governance committee meeting thursday, march 12, 2020 10:30 … · 2020-03-12 · meeting minutes...

Governance Committee Meeting

Thursday, March 12, 2020 10:30 a.m.

AGENDA GOVERNANCE COMMITTEE MEETING MARCH 12, 2020 AT 10:30 a.m.

Gulf Coast Medical Center – Boardroom (Medical Office Building)

13685 Doctor’s Way, Ft. Myers, FL 33912

1) Call to Order | Donna Clarke, Committee Chair 2) Public Input

3) Consent Agenda

a. Minutes of October 17, 2019 Governance Committee Meeting (Approve) b. Policies (Recommendation to Board) (Approve)

4) Committee Assignment Process Overview and Feedback Results | Tracy Pyles –

(Informational)

5) Board Committee Assignment (Approve)

a. Board Member Assignment (Recommendation to Board Chair) b. Community Members (Recommendation to Board) c. Physician Members (Recommendation to Board)

Community Health Improvement and Finance & Investment Committees

Quality, Safety & Patient Experience Committee

6) Board Agenda - Medical Staff Credentialing | Mary McGillicuddy - (Recommendation to

Board) (Approve)

7) Board Team Building | Genny White, Carol Simonds and Amy Webb – (Discussion)

8) Adjourn

Date of Next Meeting June 11, 2020 at 9:00 a.m. Board of Directors Gulf Coast Medical Center – Boardroom 13685 Doctors Way, Ft. Myers, FL 33912

Statement regarding

PUBLIC INPUT

All public input will take place at the Board of Directors Meetings, (not Committee Meetings).

At that time input is limited to three minutes and a “Request to Address the Board of Directors” card should be completed and submitted to the Board Staff prior to meeting.

Non-Committee members are present to observe only and not to participate.

Please contact the Board Office with any questions. (239) 343-1500

Consent Agenda

Minutes of October 17, 2019 Governance Committee Meeting

a)

b) Policies

Lee Memorial Health System Board of Directors

GOVERNANCE COMMITTEE MEETING MINUTES October 17, 2019

LOCATION: Gulf Coast Medical Center, Medical Office Building, Board of Directors Boardroom, 13685 Doctors Way, Fort Myers, FL 33912 MEMBERS PRESENT: Donna Clarke, Board Vice Chair, Committee Chair; Sanford N. Cohen, M.D., Board Member; Diane Champion, Board Member

MEMBERS ABSENT: Jessica Carter Peer, Board Member

OTHERS PRESENT: Genny White, Board Office Coordinator; Tracy Pyles, Senior Associate Attorney; Mike Wukitsch, Chief Human Resources Officer; Mary McGillicuddy, Chief Legal

Officer, Administrative Sponsor

NOTE: Documents referred to in these minutes are on file in the Office of the Board of Directors and available for public inspection.

SUBJECT DISCUSSION ACTION FOLLOW-UP MEETING

CALLED TO ORDER The GOVENANCE COMMITTEE MEETING

was CALLED TO ORDER at 1:06 p.m. by Donna Clarke, Committee Chair

PUBLIC INPUT STATEMENT

Donna Clarke acknowledged the Public Input Statement.

CONSENT AGENDA The Consent Agenda including the August 1, 2019 Governance Committee Meeting Minutes and proposed Committee Charter revisions and Omnibus Board Policy Revision 10.56 were presented for approval.

The Committee discussed revisions to the Governance Committee Meeting Minutes regarding Policy 10.55 and agreed to revise the minutes so that the second sentence will read as follows: “The Committee requested that Board Counsel review policy 10.55 and provide guidance on incorporating language regarding the Board Chair’s ability to take action on behalf of the Board and inform the Board after such action has occurred.”

A motion was made by Dr. Cohen to approve the Consent Agenda with the exception of the August 1, 2019 Governance Committee Meeting Minutes.

The motion was seconded by Diane Champion and carried with no opposition.

A motion was made by Dr. Cohen for approval of the August 21, 2019 Governance Committee Meeting Minutes with the modification as discussed.


ANNUAL SHORT TERM INCENTIVE PLAN

Michael Wukitsch, Chief Human Resources Officer, presented the Annual Short Term Incentive Plan of the CEO/President for FY2020.

The Committee discussed and recommended to amend the evaluation measurement for the Readmission Rate Goal of the FY 2020 Short Term Incentive Plan from 4th quarter to either fiscal year or 4th quarter whichever is lowest for a more fair performance measure.

A motion was made by Dr. Cohen to recommend for approval to the full Board of Directors the Annual Short Term Incentive Plan of the CEO/President for FY2020 with the revision to the Readmission Rate measure as follows: The Goal Measurement is the Medicare all Cause 30-Day readmission rate average for the 4th Quarter OR the average for FY2020.


Board of Directors

LEE HEALTH GOVERNANCE TASK FORCE MEETING MINUTES

Thursday August 1, 2019 Page 2 of 3


SUBJECT DISCUSSION ACTION FOLLOW-UP BOARD AND

COMMITTEE MEETING 2020 CALENDAR

Genny White, Board Office Coordinator, presented a draft 2020 Board and Committee Meeting Calendar.

After discussion, it was determined that Genny White will revise the 2020 Board and Committee Meeting Calendar to reflect Strategic Planning as “To Be Determined” (TBD) as to the specific date those meetings will be held.

A motion was made by Dr. Cohen to recommend for approval to the full Board of Directors the schedule for the Board and Committee Meetings in 2020 as revised to reflect the Strategic Planning dates as “To Be Determined”.


Board of Directors

BOARD RESOLUTIONS Kristie A. Scott, Board Counsel, presented the proposed adoption of certain resolutions and to retire policies related to the proposed resolutions.

The Committee discussed the difference between a policy and a resolution. A policy is in a Policy & Procedure manual and reviewed on a predetermined schedule. A resolution remains in effect until a change is needed; thus is more efficient while having the same legal impact. Dr. Cohen inquired why the word “sunset” was used. It was discussed that the word “sunset” is basically shorthand for dropping or ending the policy. The Committee concluded “retire” is a more appropriate word.

Authorized Signers of Financial Instruments & Petty Cash Funds: After discussion, the Committee concluded the policy will remain in effect as a policy in order to research whether the policy or possible resolution should address the number of signatures needed for checks. Mary McGillicuddy will review with the Finance Department and place the item on a future Committee agenda.

A motion was made by Donna Clarke to recommend to the Board of Directors the adoption of a resolution pertaining to litigation management.


A motion was made by Donna Clarke to recommend to the Board of Directors to retire Board Policy 20.20 entitled Litigation Management.


A motion was made by Dr. Cohen to recommend to the Board of Directors the adoption of a resolution pertaining to Lee Health’s Safety Program, as presented.


A motion was made by Dr. Cohen to recommend to the Board of Directors the adoption of a resolution pertaining to the Risk Management Program.

Mary McGillicuddy / Finance

Board of Directors

Board of Directors

Board of Directors

Board of Directors

LEE HEALTH GOVERNANCE TASK FORCE MEETING MINUTES

Thursday August 1, 2019 Page 3 of 3


SUBJECT DISCUSSION ACTION FOLLOW-UP The motion was seconded by Diane Champion and carried with no opposition.

A motion was made by Dr. Cohen to recommend to the Board of Directors to retire Board Policy 20.19 entitled Risk Management and Safety.


Board of Directors

COMMUNICATION PLAN FOR MEDICAL

EXECUTIVE COMMITTEES

Mary Briggs, System Director Strategic Communications & Public Relations, presented an overview of a Communication Plan she is working with Dr. Hearn for the Medical Executive Committees (MECs). The goal is to provide consistent messaging across all MECs that is relevant, easy to access and understand. Messages will be mobile friendly and contain interactive links to additional information.

Discussions ensued. Mary Briggs acknowledged the need for appropriate editing and will assign a member of her team to be responsible for grammar and content.

Informational.

BOARD OF EDUCATION OPPORTUITIES

Genny White, Board Office Coordinator, presented information regarding education programs Board members attended since 2016, as well as upcoming opportunities. After the informational document is revised to clearly identify historic programs and future programs, Genny White will share the list with Board Members.

Informational.

STOP REVIEW The Committee discussed the “stop review” of the Board’s governance structure previewed by Donna Clarke in her last verbal report to the Board and acknowledged that much of the Committee’s work has been a continuation of implementing governance best practices identified by the Governance Task Force.

Dr. Cohen brought attention to the importance of Board Members establishing working relationships and that the new meeting schedule may result in Board members spending less time together. The Committee recognized that this could impact the Board’s ability to work together and discussed scheduling a Board Retreat in FY 2020 for team building. The Board Office will reach out to the Leadership and Organizational Department to discuss a potential retreat.

Informational.

NEXT REGULAR MEETING

The next LEE HEALTH GOVERNANCE COMMITTEE MEETING will be held on a date to be determined

in the Gulf Coast Medical Center, Medical Office Building, Boardroom 13685 Doctors Way, Fort Myers, FL 33912

ADJOURNMENT The GOVERNANCE COMMITTEE MEETING ADJOURNED at 2:22 p.m.

by Donna Clarke, Governance Committee Chairman.

Minutes were recorded by Josephine Desibia

________________________________________

Donna Clarke Date approved Committee Chair

Lee Memorial Health System Board of Directors Updated 3/2/17

BBBOOOAAARRRDDD OOOFFF DDDIIIRRREEECCCTTTOOORRRSSS

Keep form to one page, EMAIL to: [email protected] by Noon Eight (8) days PRIOR to presenting.

DATE: March 12, 2020 LEGAL SERVICE REVIEW? YES X NO__

SUBJECT: Routine Review of Board Policies

REQUESTOR & TITLE: Donna Clarke, Governance Committee Chair

PREVIOUS BOARD ACTION ON THIS ITEM (IF ANY) (justification and/or background for recommendations – internal groups which support the recommendation)

See each policy for previous reviews and actions by the Board of Directors.

SPECIFIC PROPOSED MOTION:

Motion to recommend approval of combining, revising, reviewing without revising, and retiring Board policies as presented.

FINANCIAL IMPLICATIONS Budgeted Account ____ Non-Budgeted ____ (Annual Project Budget and Total Project Budget) None

STAFFING & OPERATIONAL IMPLICATIONS - Not applicable (including FTEs, facility needs, etc.) None

PURPOSE/REASON FOR RECOMMENDATION

To periodically review the Board of Directors’ policies and make recommendations to the Board of

Directors to ensure its policies reflect the Board’s with current practices

SUMMARY (including alternatives considered, Pros and Cons)

The Governance Committee is reviewing 22 Board policies and considering the following

recommendations to the Board of Directors:

(1) to combine three policies (10.01, 10.02, 10.03) into one policy entitled Mission, Vision and Value (10.01);

(2) to combine two policies (10.10, 10.12) into one policy entitled Orientation of New Board Members and Board Member Education (10.10);

(3) to approve six policies (10.49, 20.12, 20.15, 20.16, 20.17, 40.11) with revisions;

(4) to approve eight policies (10.15, 10.21, 10.22, 10.28, 10.29, 30.01, 40.01, 40.09) without revisions;

(5) to retire one policy (10.37); and

(6) to refer two policies (20.01, 20.09) to the Finance and Investment Committee for review and

recommendation to the Board of Directors

See the detailed summary included in the meeting packet.

mailto:[email protected]

Policy

NumberPolicy Title

Date of Last

Review

Date of Next

Review Suggested Action

COMBINE POLICIES

10.01E Mission Statement 5/18/2017 5/18/2020 Combine Policies 10.01, 10.02, 10 .03

10.02D Lee Memorial Health System Values 4/27/2017 4/27/2020 Combine Policies 10.01, 10.02, 10 .03

10.03D Vision Statement 4/27/2017 4/27/2020 Combine Policies 10.01, 10.02, 10 .03

10.10H Orientation of New Board Members 4/27/2017 4/27/2020 Combine Policies 10.10 and 10.12

10.12C Continuing Education for Directors 4/27/2017 4/27/2020 Combine Policies 10.10 and 10.12

REVIEW WITH REVISIONS

10.49B E-mail Communications for Board Members 4/27/2017 4/27/2020 Updated - Clarity to email storage retention policies

20.12C Evaluation of Banking Services 4/27/2017 4/27/2020

Updated - Clarity on person responsible and how often

evaluation of banking services should occur

20.15D Design-Build Contracts Policy (Rule) 4/27/2017 4/27/2020 Updated - Clarity on Selection Committee Members

20.16G Consultants Competitive Negotiation Act Policy 4/27/2017 4/27/2020 Updated - Clarity on Selection Committee Members

20.17S Financial Goal Policy 5/18/2017 5/18/2020

Updated - Clarity on Moody's medians, ratio titles and

clarify that Operating margin driver for budget

40.11A Board Attorney Performance Review 6/29/2017 6/29/2020 Updated to include Board feedback to Attorney

REFER TO COMMITTEE FOR REVIEW

20.01H Investment Management 4/27/2017 4/27/2020 Refer to Committee - Finance and Investment

20.09L Capital Assets: Authorization, Expenditures and Disposal 4/27/2017 4/27/2020 Refer to Committee - Finance and Investment

REVIEW WITH NO REVISIONS

10.15H Public Addressing the Board 6/29/2017 6/29/2020 Review - No Revisions

10.21C Public Notice of Bid Requests 4/27/2017 4/27/2020 "

10.22D Appointment of Board Members for Public Bid Openings 4/27/2017 4/27/2020 "

10.28C Medico-Administrative Duties Protection 4/27/2017 4/27/2020 "

10.29A Peer Reviewer Protection 4/27/2017 4/27/2020 "

30.01C Organized Medical Staff 4/27/2017 4/27/2020 "

40.01E Pay Policy Statement 4/27/2017 4/27/2020 "

40.09D President and Chief Executice Officer (CEO) Succession Process 8/10/2017 8/10/2020 "

RETIRE

10.37C Display of System Name and Logo 4/27/2017 4/27/2020 Outdated

Committee Assignment Process Overview and

Feedback Results(Tracy Pyles, Senior Managing Attorney)

1

COMMITTEE ASSIGNMENT PROCESS

BOARD MEMBER ASSIGNMENT PROCESS

1. Governance Chair sends a memo to Board Committee Chairs first week of February:

a. Input from Board Member regarding preferred Committee Assignmentb. Include summary of Committee Member Skills and Characteristicsc. Do they wish to remain Chair?d. Committee Member Attendance and Contributionse. Committee Reflections

2. Governance Chair sends a memo to non-Chair Board Committee Members during the first weekof February.

a. Input from the Board Members regarding preferred Committee Assignment

3. Compile information for Governance Committee meeting on 3/12/2020.

4. Governance Committee makes recommendation to the Board Chairman.

5. Board Chairman will appoint.

6. Board Chairman sends communication to Board Members (plan to send before 3/26 BoardMeeting unless otherwise determined by Board Chair).

COMMUNITY MEMBER ASSIGNMENT PROCESS

1. Governance Chair sends memo to Committee Chairs re Community Members.

2. Compile information for Governance Committee meeting on 3/12/2020.

3. If the Board Committee Chairs recommend reappointment, and the Governance Committeeconcurs, Governance Committee recommends reappointment to the full Board of Directors forapproval.

a. Plan on presenting at 3/26 Board Meeting

4. If a Board Committee Chair does not recommend reappointment, or if the GovernanceCommittee does not concur, the Governance Committee will start new appointment process.

2

PHYSICIAN MEMBER ASSIGNMENT PROCESS

1. Governance Chair sends memo to Committee Chairs re Physician Members.

2. Governance Chair sends memo after receiving input from Committee Chairs to PLC (Meets3/30/20) (CHI & Finance) and MECs (meets 3/9, 10, 11, 16 and 17) (QSPE).

3. Compile information from PLC and MECs.

4. Governance Committee reviews and if Board Committee Chair and PLC/MECsrecommendations align, Governance Committee recommends reappointment to the full Boardof Directors for approval.

5. If the Governance Committee, PLC/MEC and/or the Board Committee Chair do not agree thenstart new appointment process.

Board Member Committee Feedback

Committee Preference Committee Chair Reflections / Recommendations Steve Brown Yes, would want to remain serving on the same

committee (QSPE) and in addition, would like to serve on Governance.

Diane Champion Yes, would want to remain serving on the same committees (Audit & Governance).

Sandy Cohen Yes, would want to remain serving on the same committees (QSPE and Governance).

Stephanie Meyer Yes, would want to remain on the same committees (Finance & Investment and QSPE). Willing to switch if someone would prefer these committees. Any committee works.

Jessica Carter Peer Yes, would want to remain on the same committees (Audit and Governance). However, if Audit Committee meetings are added, may not be able to attend committee meetings.

COMMITTEE CHAIRS

Donna Clarke Governance

Yes, would want to remain on the same committees (Finance & Investment and Governance).

Recommended continued service: Sanford Cohen, Jessica Carter Peer, Diane Champion

David Collins Finance & Investment

Yes, would want to remain on the same committees (Finance & Investment and Community Health Improvement)

Recommended continued service: Donna Clarke, Chris Hansen, Stephanie Meyer, Peter Andruszkiewicz, David Klein, William Hearn

Therese Everly Quality, Safety & Patient Experience

No. I would like to remain on QSPE and switch to Governance. However, it will be fine if I remain on CHI. Order of Preference: 1. QSPE, 2. Governance, 3. CHI, 4. F&I, 5. Audit

Recommended continued service: Stephen Brown, Sanford Cohen, Stephanie Meyer, Asif Azam, Keri Mason, Larry Hobbs, Eric Eason, Mitko Badov. The QSPE committee continues to evolve as a committee. The physician members have been engaged. I look to the PLC, MEC's feedback in regards to committee's work

Chris Hansen Community Health Improvement

Yes, would want to remain on the same committees (Finance & Investment and Community Health Improvement).

Recommend continued service: David Collins, Therese Everly, Nancy McGovern, David Berger, Minnie Jackson, Joanna Carioba. We have only met once so would like to see all current committee members remain on the CHI.

Nancy McGovern Audit Yes, would want to remain on the same committees (Community Health Improvement and Audit).

Recommend continued service: Jessica Carter Peer, Diana Champion, Tami Cindrich, Bill Foster

Board Committee Assignment

a) Board Member Assignment

b) Community Members

c) Physician Members

Lee Health LEE HEALTH

Board of Directors

Finance & Investment Committee (4)

Audit Committee (2)

Quality, Safety & Patient Experience

Committee (4)

Community Health Improvement Committee (2)

Governance Committee (2)

MEMBERS (7) MEMBERS (9) MEMBERS (7) MEMBERS (5) MEMBERS (4)

Board Members: Donna Clarke David Collins Chris Hansen

Stephanie Meyer

2 Community Members:

Peter Andruszkiewicz David Klein

1 Physician Member: William Hearn, DO

Board Members: Therese Everly, BS, RRT

Sanford Cohen, MD Stephanie Meyer, BSN, RN

Stephen Brown, M.D.

5 Physician Members: Asif Azam, MD Keri Mason, DO

Larry Hobbs, MD Eric Eason, DO

Mitko Badov, MD

Board Members: Chris Hansen David Collins

Therese Everly Nancy McGovern

2 Community Members:

David Berger, MD Minnie Jackson, BSN, MS

1 Physician Member: Joanna Carioba, MD

Board Members: Nancy McGovern, RN, MSM

Diane Champion Jessica Carter Peer

2 Community Members: Tami Cindrich, CPA, CHBC

Bill Foster, CPA

Board Members: Donna Clarke

Diane Champion Sanford Cohen, MD Jessica Carter Peer

Administrative Sponsor Chief Financial Officer

Administrative Sponsor Chief Operating Officer

Administrative Sponsor Chief Foundation &

Development Officer

Administrative Sponsor VP Compliance & Internal

Audit

Administrative Sponsor Chief Legal Officer

Committee Composition February 2020



RECOMMENDED FOR BOARD ACTION (Action includes Acceptance, Approval, Adoption, etc)

Keep form to one page, EMAIL to: [email protected] by Noon

Eight (8) days PRIOR to presenting.


SUBJECT: Board Member Committee and Committee Chair Assignments to Board Committees



On March 21, 2019, the Governance Task Force presented to the full Board of Directors the Board Member and Committee Chair assignments to Board Committees, as appointed by the Board Chair or required by Committee Charter. SPECIFIC PROPOSED MOTION: [A Motion to Recommend to the Chairman of the Lee Health Board of Directors the Board Member and Committee Chair Assignment will be determined by the Governance Committee.]

FINANCIAL IMPLICATIONS Budgeted Account ____ Non-Budgeted ____ (Annual Project Budget and Total Project Budget) – None identified

STAFFING & OPERATIONAL IMPLICATIONS - Not applicable(including FTEs, facility needs, etc.)


Pursuant to the Board Member Committee Assignments Process, the Governance Committee Chair collected feedback from Board Members regarding their current service on Board Committees and preferred assignments. A Motion to Recommend assignments will be determined after the feedback

is considered by the Governance Committee.


Board Committee Chair Considerations: Donna Clarke, who is already a member of the Finance

and Investment Committee, will serve as the Committee Chair for the Finance and Investment

Committee pursuant to the Committee’s Charter.

Board Member Feedback: Generally, most Board Members indicated a desire to remain on their

existing Committees. A few Board Members provided additional specific feedback:

Board Member Steve Brown said: Yes, would want to remain on the QSPE. In addition, would

like to serve on Governance.

Board Member Therese Everly said: “I would like to remain on QSPE and switch to

Governance. However, it will be fine if I remain on CHI.” Preference order: 1. QSPE, 2.

Governance, 3. CHI, 4. F&I, 5. Audit

Board Member Jessica Carter Peer said: “… if Audit Committee meetings are added, I may

not be able to attend Committee meetings.”

Board Member Stephanie Meyer said: Yes, would want to remain on same committees (F&I

and QSPE). “Willing to switch if someone would prefer these Committees.”








SUBJECT: Community Member Assignment to Board Committees



On May 30, 2019, the Governance Task Force presented its recommendations to the full Board of Directors for Community Member assignments to Board Committees, which the Board discussed

and approved. SPECIFIC PROPOSED MOTION:

Motion to recommend to the full Board of Directors for approval that all Community Members continue serving on the Committees to which they are currently assigned until the next Community

Member reappointment cycle.

FINANCIAL IMPLICATIONS Budgeted Account ___ Non-Budgeted ____ (Annual Project Budget and Total Project Budget) – None identified

STAFFING & OPERATIONAL IMPLICATIONS - Not applicable

(including FTEs, facility needs, etc.)


Pursuant to Board Policy 10.57, Board Committee Community and Physician Member Appointment Process, the motion reflects a recommendation based upon feedback from the current Committee

Chairs regarding the Community Members serving on Board Committees. All of the current Committee Chairs recommended that the Community Members continue serving on the Committees to which they are currently assigned. Current Community Members serving on Board Committees

include:

Finance & Investment: Peter Andruskiewicz and David Klein Community Health Improvement: David Berger, MD and Minnie Jackson, BSN, MS Audit: Tami Cindrich, CPA, CHBC and Bill Foster, CPA


The Governance Committee may consider alternative action as part of its review at the Committee

meeting.








SUBJECT: Physician Member Appointment to Board Committees



On May 30, 2019, the Board of Directors approved the appointment of the following members of the Medical Staff to serve as Physician Members of the Community Health Improvement Committee

of the Board and Finance & Investment Committee of the Board, respectively: Joanna Muller Carioba, MD and William Hearn, DO.

SPECIFIC PROPOSED MOTION:

1. Motion to recommend to the full Board of Directors for approval for the following Physician

Member to continue to serve on the Community Health Improvement Committee of the Boarduntil the next Physician Member reappointment cycle, contingent upon a favorablerecommendation from Physician Leadership Council:

Joanna Muller Carioba, MD

2. Motion to recommend to the full Board of Directors for approval for the following PhysicianMember to continue to serve on the Finance & Investment Committee of the Board until the next

Physician Member reappointment cycle, contingent upon a favorable recommendation fromPhysician Leadership Council:

William Hearn, DO

FINANCIAL IMPLICATIONS Budgeted Account ___ Non-Budgeted ____ (Annual Project Budget and Total Project Budget) – None identified

STAFFING & OPERATIONAL IMPLICATIONS - Not applicable (including FTEs, facility needs, etc.)


Pursuant to Board Policy 10.57, Board Committee Community and Physician Member Appointment

Process, the motion reflects a recommendation based upon feedback from the current Committee Chairs regarding the Physician Members serving on Board Committees. The Physician Leadership Council is expected to consider its recommendation to the Board on March 30, 2020.

SUMMARY

(including alternatives considered, Pros and Cons)

The Governance Committee may consider alternative action as part of its review at the Committee meeting.








SUBJECT: Physician Member Appointment to the Quality, Safety & Patient Experience Committee of the Board



On April 25, 2019, the Board of Directors approved the appointment of the following members of the Medical Staff from each Lee Health hospital to serve as Physician Members of the Quality, Safety & Patient Experience Committee of the Board: Asif Azam, MD, Keri Mason, DO, Larry Hobbs,

MD, Eric Eason, DO and Mitko Badov, MD. SPECIFIC PROPOSED MOTION:

Motion to recommend to the full Board of Directors for approval for the following Physician

Members to serve on the Quality, Safety, & Patient Experience Committee until the next Physician Member reappointment cycle, contingent upon favorable recommendations from each of the Medical Executive Committees:

Asif Azam, MD, Lee Memorial Hospital

Keri Mason, DO, Cape Coral Hospital, Larry Hobbs, MD, Gulf Coast Medical Center Eric Eason, DO, Golisano Children’s Hospital

[To be determined] HealthPark Medical Center

FINANCIAL IMPLICATIONS Budgeted Account ___ Non-Budgeted ____

(Annual Project Budget and Total Project Budget) – None identified

STAFFING & OPERATIONAL IMPLICATIONS - Not applicable (including FTEs, facility needs, etc.)


Pursuant to Board Policy 10.57, Board Committee Community and Physician Member Appointment Process, the motion reflects a recommendation based upon feedback from the current Committee

Chair regarding the Physician Members serving on the Board Committee. The current Physician Member from HealthPark Medical Center requested the MEC consider a new Physician Member due

to a change in the member’s practice location.


The Governance Committee may consider alternative action as part of its review at the Committee meeting.


Board Agenda Medical Staff Credentialing

(Mary McGillicuddy, General Counsel)

Lee Health Board of Directors

INFORMATIONAL / DISCUSSION SUMMARY

DATE: March 12, 2020

BOARD COMMITTEE: Governance Committee

OVERSIGHT DISCUSSION TOPIC: Medical Staff Credentials Recommendation

Consent Agenda Item

DISCUSSION FACILITATOR(s) (Name and Title): Mary McGillicuddy, General Counsel

SUMMARY OF KEY FOCUS POINTS:

Background: During the Board of Directors meeting held on November 21,

2019, a question was raised as to whether the Medical Staff Credentialingrecommendations should be placed on the Board of Directors Consent

Agenda. The question was referred to the Governance Committee fordiscussion, along with a suggestion for the Medical Staff Credentialing

recommendations to be accompanied by an executive summary including

trends.

FRAMING QUESTIONS:

Should the Medical Staff Credentialing Recommendations be placed on the

Board of Directors Consent Agenda?

Should the Medical Staff Credentialing Recommendations be accompanied by

an executive summary, including trends.

Does the contemplated action related to the Consent Agenda and additional

material support a well-functioning, efficient, and effective governing board?

Are there alternative approaches to achieve oversight goals?

Is additional information needed?

Recommendation Summary System Credentialing/Privileging Committee Reports

February FY 2020

Associate Staff 12 62

Privilege Only 2 14

Intrasystem 1 26

Honorary 2 3

Privilege Change 2 21

1st Year Review 8 48

Temporary (locum) 2 22

Leave of Absence 1 3

Reinstatement from Leave 0 6

Resignations 4 51

Resignations (facility specific) 1 6

Advanced Practice Providers 8 56

APP (add privileges) 2 7

APP resignations 0 8

APP Resignations (facility specific) 0 10

Totals 45 343

Trends:

______________________________________________________________________________

Board Team Building

(Genny White, Board Coordinator

Carol Simonds,

System Director Leadership & Organizational Development

Amy Webb, Leadership Development Specialist)

ADJOURNMENT

DATE OF THE

NEXT

GOVERNANCE COMMITTEE

MEETING

June 11, 2020

9:00 a.m.

Gulf Coast Medical Center

Medical Office Building

13685 Doctors Way

Ft. Myers, FL 33912