Board of Directors Meeting Thursday, August 29, 2019 1:00 p.m. · BOARD OF DIRECTORS & TRAUMA DISTRICT MEETING will be held on August 29, 2019, at 1:00 p.m. in the Gulf Coast Medical

Board of Directors Meeting

Thursday, August 29, 2019 1:00 p.m.

AGENDA BOARD OF DIRECTORS MEETING AUGUST 29, 2019 AT 1:00 p.m.

Gulf Coast Medical Center – Boardroom (Medical Office Building)

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

Time Action

1.00 p.m. 1. Call to Order – Stephen Brown, MD, Board Chairman

The Board of Lee Memorial Health System, doing business as Lee Health, Gulf Coast Medical Center & Lee Memorial Hospital/HealthPark Medical Center and the Board of Directors of its subsidiary corporations, including but not limited to Cape Memorial Hospital, Inc. doing business as Cape Coral Hospital; Lee Memorial Home Health, Inc.; and HealthPark Care Center, Inc.

1.05 p.m. 2. Invocation & Pledge of Allegiance (Rev. Johanna Kiefner, MDiv., LCSW)

3. Public Input

1.10 p.m. 4. Consent Agenda

a. Board Meeting Minutes of 6/27/19 b. Risk Management Report

Approve

1.15 p.m. 5. President’s Report – (Larry Antonucci, President/CEO) Discuss

1.30 p.m. 6. Physician Leadership Council Update – (William Hearn, D.O., PLC Chairman) Discuss

1.45 p.m. RECESS to CALL TO ORDER Lee County Trauma Services District Board of Directors Meeting (Stephen Brown, MD, Board Chairman)

RECONVENE LEE MEMORIAL HEALTH SYSTEM BOARD MEETING (Stephen Brown, MD, Board Chairman)

2.20 p.m.

7. Medical Staff Credentialing a. Lee Memorial Hospital b. Cape Coral Hospital c. Gulf Coast Medical Center d. HealthPark Medical Center e. Golisano Children’s Hospital of SWFL

Approve

2.25 p.m. 8. IT Update – (Ben Spence, Chief Financial Officer, and Rick Schooler, Chief Information Officer)

Discuss

3.00 p.m. 9. Committees’ Summaries and Recommendations

a. Quality, Safety & Patient Experience Committee Verbal Update

AGENDA BOARD OF DIRECTORS MEETING 8/29/19

3.15 p.m.

10. Governance Task Force/Governance Committee Update (Stephen Brown, MD, Board Chair & GTF Chair, Donna Clarke, Board Vice Chair, Governance Committee Chair)

a. Governance Committee Verbal Update b. Recommended Action

1. Policy Review 2. President/CEO Evaluation Tool

Approve Approve

3.25 p.m. 11. Board Meeting Evaluation

3.30 p.m. 12. Adjourn

Date of the next Meeting:

September 26, 2019 at 1:00 p.m.

Board of Directors

Gulf Coast Medical Center – Boardroom

13685 Doctors Way, Ft. Myers, FL 33912

Lee Memorial Health System Board of Directors

BOARD OF DIRECTORS

Invocation &

Pledge of Allegiance


BOARD OF DIRECTORS

PUBLIC INPUT AGENDA ITEMS:

Any public input pertaining to items on the Agenda 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.

Refer to Board Policy: 10:15H: Public Addressing the Board Non-Agenda Item: Individuals wishing to address the Board on an item NOT on the Agenda, the Board office must be notified of subject matter at least three (3) days prior to the meeting to allow staff time to prepare and to insure the matter is within the jurisdiction of the Board.

BOARD OF DIRECTORS

CONSENT AGENDA

(APPROVE)

a) Board meeting Minutes of 6/27/19

b) Risk Management Report


BOARD OF DIRECTORS MEETING MINUTES

Thursday, June 27, 2019

LOCATION: Gulf Coast Medical Center, Medical Office Building, Board of Directors Boardroom, 13685 Doctors Way, Fort Myers, FL 33912 MEMBERS PRESENT: Stephen Brown, M.D., Board Chairman; Therese Everly, Board Secretary; Sanford N. Cohen, M.D., Board Member; Stephanie Meyer, BSN, RN, Board Member; Nancy McGovern, RN, MSM, Board Member; Diane Champion, Board Member, Jessica Carter Peer, Board Member MEMBERS ABSENT: Donna Clarke, Board Vice Chairman, David Collins, Board Treasurer; Chris Hansen, Board Member;

NOTE: Documents referred to in these minutes are on file by reference to this meeting date in the Office of the Board of Directors and on the Board of Directors website at www.leehealth.org/boardofdirectors, for public inspection.

SUBJECT DISCUSSION ACTION FOLLOW-UP

MEETING CALLED TO ORDER

FULL BOARD OF DIRECTORS MEETING was CALLED TO ORDER at 1:00 p.m.

by Stephen Brown, M.D., Board Chairman.

INVOCATION AND PLEDGE OF

ALLEGIANCE

Tim Griffis, MDiv, gave the Invocation, followed by the Pledge of Allegiance.

PUBLIC INPUT None

CONSENT AGENDA Dr. Brown asked for approval of the Consent Agenda. A motion was made by Therese Everly to approve the Consent Agenda consisting of:

a. Board Meeting Minutes of 05/30/19 The motion was seconded by Nancy McGovern and carried with no opposition.

PRESIDENT’S REPORT

Larry Antonucci, M.D., President & CEO presented the President’s Report.

PHYSICIAN LEADERSHIP COUNCIL

UPDATE

No report to present.

MEDICAL STAFF CREDENTIALING

Dr. Brown asked for approval of the Medical Staff Credentialing. Discussion ensued with Mark Greenberg, MD, about resignations.

A motion was made by Nancy McGovern to approve the Medical Staff Credentialing.

The motion was seconded by Jessica Carter Peer and carried with no opposition.

LEGISLATIVE UPDATE Michael Nachef presented a legislative update. Topics included the Federal Government Outlook, 2019 Florida Legislative Session Overview, 2019 Session Appropriations Summary, 2019 Session Legislation Summaries and 2020 Legislative Session Outlook.

COMMITTEES’ SUMMARIES AND

RECOMMENDATIONS

Nancy McGovern, Audit Committee Chair, gave a verbal update from the Audit Committee Meeting. The main topics covered were:

A motion was made by Nancy McGovern to approve that PWC conduct the FY 2019 financial audit for Lee Memorial Health System, Lee

LEE HEALTH BOARD OF DIRECTORS MEETING MINUTES

Thursday, June 27, 2019 Page 2 of 2


SUBJECT DISCUSSION ACTION FOLLOW-UP

Education, where Mary McGillicuddy covered the new board structure and reiterated the importance of the Sunshine Act. Price Waterhouse Coopers (PWC) Audit Planning, covering the methodology of PWC to develop their audit plans, the technology utilized by PWC in their audits and PWC’s collaboration with Lee Health staff. Compliance and Audit Plans, with updates given by the Compliance team, regarding development of the Compliance Work Plan, the health system’s Internal Audit Program and the Health System’s Privacy Program. Dr. Cohen asked how long had PWC been doing the audit and the possibility of conducting an RFP in the future for financial audit companies. Discussion ensued. Mary McGillicuddy reaffirmed that the Board reviews this contract for financial audit each year.

County Trauma Service District and Lee Memorial Health System Foundation, Inc. in the manner as outlined in the engagement letter. The motion was seconded by Diane Champion and carried with no opposition.

Audit Committee will review possibility of conducting an RFP re: financial audit companies.

BOARD MEETING EVALUATION

Great meeting. Thanks expressed to Nancy McGovern for chairing the Audit committee and to Jeff Pigott’s team for their assistance. Dr. Brown chaired an informative Trauma meeting and Michael Nachef was thanked for his clear presentation regarding the legislative update. Dr. Cohen reminded Board members on the need to follow Robert’s Rules of Order with regard to speaking at the meeting and wait to be recognized by the Chair.

NEXT REGULAR MEETING

The next LEE HEALTH BOARD OF DIRECTORS & TRAUMA DISTRICT MEETING

will be held on August 29, 2019, at 1:00 p.m. in the Gulf Coast Medical Center, Medical Office Building, Boardroom

13685 Doctors Way, Fort Myers, FL 33912

ADJOURNMENT The LEE HEALTH SYSTEM BOARD OF DIRECTORS MEETINGS

ADJOURNED at 2:38 p.m. by Stephen Brown, M.D., Board Chairman.

Minutes were recorded by Laura Reynolds, Board of Directors Assistant

________________________________________ Therese Everly Date approved

Board Secretary

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

BBBOOOAAARRRDDD OOOFFF DDDIIIRRREEECCCTTTOOORRRSSS 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.

DATE: 8/29/2019 LEGAL SERVICE REVIEW? YES_X_ NO__ SUBJECT: Quarterly Risk Management Report REQUESTOR & TITLE: Mary McGillicuddy, Chief Legal Officer and Mary Lorah, Risk Manager

PREVIOUS BOARD ACTION ON THIS ITEM (IF ANY) (justification and/or background for recommendations – internal groups which support the recommendation) The Board of Directors reviews the Quarterly Risk Management Report on a quarterly basis. SPECIFIC PROPOSED MOTION: Motion to approve the Quarterly Risk Management Report as presented.

FINANCIAL IMPLICATIONS Budgeted Account ____ Non-Budgeted ____ (Annual Project Budget and Total Project Budget) None STAFFING & OPERATIONAL IMPLICATIONS (including FTEs, facility needs, etc.) None PURPOSE/REASON FOR RECOMMENDATION See Presentation. This request supports the following Strategic Initiative(s): Excellent Health Outcomes and Strong Financial Results

SUMMARY (including alternatives considered, Pros and Cons) This Quarterly Risk Management Report provides a summary of information about activities of the Risk Management program, including the following:

Incident and Safety Reporting rate per 1,000 patient days Impact per 1,000 patient days Categories of reports Risk Management participation in LMHS System Committees and Education Liability Summary Goals

PATIENT SAFETY WORK PRODUCT: CONFIDENTIAL AND PRIVILEGED INFORMATION CREATED AS PART OF LPSES – LEE HEALTH’S PATIENT SAFETY EVALUATION SYSTEM

#3400.159 Rev. 10/16

Risk Management Report to the Board of Directors

April – June 2019

The disclosure of this document and the contents herein does not constitute a waiver of any and all protections afforded PatientSafety Work Product under the Patient Safety Quality Improvement Act of 2005 and implementing regulations.


Risk Management Program Elements

The Risk Management Program is designed to identify, evaluate and reduce the risk of injury to the patients, personnel, visitors and to reduce the risk of loss to the health system. Risk Managers:

Review reports, conduct investigations and analyze events in an effort to reduce risks to patients and the frequency and severity of medical malpractice claims; and

Investigate patient care complaints, provide education, and provide direction in regards to regulatory compliance.

This report includes Risk Management activities for the quarter and includes a summary of patient safety events and reporting rates; adverse incidents under Florida law; impact analysis; report categories; education; claims; general activities; and goals.

1


Patient Safety Evaluation System

Please Note: Separate from Florida law program requirements, Risk Managers play an integral role in the health system’s Patient Safety Evaluation System, a voluntary program created by federal law. Employees are encouraged to report patient safety or quality concerns by filing a Patient Safety Report which are utilized by Risk Managers who participate in health system patient safety initiatives

2


Patient Safety Reporting RatesThis graph shows event and report rates for the system for the last 12 months. The following page shows the reporting rates for each facility.

3

Total Number of reports for the third quarter FY2019 was 3597

0

5

10

15

20

25

30

35

40

45

50

Jul‐18 Aug‐18 Sep‐18 Oct‐18 Nov‐18 Dec‐18 Jan‐19 Feb‐19 Mar‐19 Apr‐19 May‐19 Jun‐19

Rate per 1000 Patient Days

Lee Health System

LMHS Linear (LMHS)


4

Reporting Rate (continued)


AnalysisThis graph reflects the percentage of reports that have no impact on the patient.

The graph for the fourth quarter indicates that 84.01% (3022) of the reports received involve situations which had no impact on the patient.

Reporting “near misses” is highly encouraged to identify potential areas of improvement. This information allows us to provide data used in our quality improvement activities throughout the system.

5

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Percent of reports without im

pact

LMHS Linear (LMHS)


AnalysisThis graph reflects the reporting rate per 1000 patient days and the rate of

patient impact for the five facilities during the quarter.

6

0.00

5.00

10.00

15.00

20.00

25.00

30.00

35.00

40.00

45.00

CCH HPMC LMH GCMC GCHSWF

Reporting Rate Impact Rate


CategoriesThis table shows the rate for the categories of reports from April through June 2019 at all five facilities. Rates per 1000 Patient Days are utilized to be consistent with other system reporting. 95% of all reports fall under the Patient Safety Taxonomy. The top five reports in this taxonomy are related to Care, IV Complications, Medication/Other Substance, Conduct, and Patient Falls.78% of all reported occurrences fall within one of these five categories

7During this quarter there were two adverse incidents reported to AHCA

Taxonomy / Occurrence Type Total Rate

ADR, confirmed 20 0.19

ADR, suspected 18 0.17

Adverse Drug Reaction Total 38 0.35

HIPAA 31 0.29

Conduct 458 4.24

Blood or Blood Product 41 0.38

Care 831 7.69

Device or Medical/Surgical Supply... 68 0.63

Environment 20 0.19

Fall 377 3.49

IV Complication 612 5.66

Laboratory 199 1.84

Medication or Other Substance 531 4.91

Other 9 0.08

Perinatal 114 1.06

Pressure Injury/Ulcer 11 0.10

Radiology 20 0.19

Surgery or Anesthesia 119 1.10

Venous Thromboembolism 2 0.02

LH - Patient Safety Total 3412 31.58

Security, Operations and Environment Total 84 0.78

Visitor Safety Total 32 0.30

Grand Total 3597 33.29


Safety Classification

8

Safety Classification Occurrence Type APR MAY JUN Total Rate

Near Miss Blood or Blood Product 3 5 5 13 0.12Care 45 66 56 167 1.55Device or Medical/Surgical Supply... 5 6 8 19 0.18Environment 1 1 1 3 0.03Fall 0 0 1 1 0.01IV Complication 1 0 1 2 0.02Laboratory 42 47 39 128 1.18Medication or Other Substance 73 68 57 198 1.83Perinatal 2 0 4 6 0.06Radiology 4 6 1 11 0.10Surgery or Anesthesia 6 10 13 29 0.27Venous Thromboembolism 0 0 1 1 0.01Near Miss Total 182 209 187 578 5.35

Precursor Conduct 2 0 0 2 0.02Blood or Blood Product 8 1 1 10 0.09Care 125 117 91 333 3.08Device or Medical/Surgical Supply... 7 4 6 17 0.16Environment 1 0 2 3 0.03Fall 2 0 0 2 0.02IV Complication 2 0 1 3 0.03Laboratory 12 11 8 31 0.29Medication or Other Substance 90 72 58 220 2.04Other 0 1 1 2 0.02Perinatal 1 0 0 1 0.01Pressure Injury/Ulcer 3 0 0 3 0.03Radiology 2 0 2 4 0.04Surgery or Anesthesia 6 2 4 12 0.11Precursor Total 261 208 174 643 5.95


LiabilityThe Third fiscal quarter 2019 (April - June, 2019) ended with 39 pending claims. The quarter saw 10 claims closed and 9 claims opened. Malpractice prevention, patient safety and quality of care improvement continue to be the primary focus of the Health System’s risk managers.

9


10

Risk Management Orientation for new hires

Defensible Documentation

Risk Presentation for Registration

Clinical Practice Council Presentations

Risk Education for Pre‐Procedure Testing

Education Activities


11

Risk Management Activities

Continued participation in system patient safety activities including:

System Medication Safety Committee Campus Specific Medication Safety Work Teams Participated in various Root and Apparent Cause

Analysis Teams Telemetry Leadership Team Transport Directors and Role in Safety Executive Quality Safety Management Council Policy & Procedure Committee GCHSWF Leadership Quality Council Diversions Operations Committee New Employee Orientation Workgroup Customer Improvement Team Safety Governance Council HIV Consent Process Change


Risk Management Goals

12

• Continue to track and trend patient safety events, adverse incidents, provide summary data and work closely with various departments and committees engaged in performance improvement and patient safety activities.

• Continue to work with Education and Organizational Development and management staff to assure that all employees are meeting the annual education requirement for risk management and to provide a module to meet the annual requirement.

• Continue to utilize pre‐litigation procedures to resolve meritorious claims in a timely manner.

• Continue to collaborate with others in the Health System with regard to patient safety initiatives and make recommendations based on trends.


Thank You


BOARD OF DIRECTORS

PRESIDENT’S REPORT

Larry Antonucci, MD, President & CEO

Lee Health

Board of Directors Meeting

August 29, 2019

President’s Report

FHA Board Retreat

Meeting with Governor DeSantis

FHA Trustee of the Year

Leadership Update

Passion For The Promise Finalists

LPG Provider Update

Physician Leadership Program

CMS Star Rating Update

Health Care Costs and Politics

Medicare for ALL?

HAC Program FY 2020

Lee Telehealth Update

Highlights and Updates

PHYSICIAN LEADERSHIP COUNCIL UPDATE

(William Hearn, D.O, PLC Chairman)

Physician Leadership Council Report

08/29/19

Flow Project

MS members are collaborating with Administration (Dr. Wolf) to identify

points of barriers and develop process improvements to relieve these

barriers.

Go Live: LMH‐ Pilot program is active. GCMC‐Dec 2019. HPMC and CCH‐

June 2020.

ExceptionalLEE Performance Excellence

Currently in Phase I‐ defining and evaluating processes.

Selected Independent and Employed MS members are participating at all

levels to set the groundwork for broader MS, Administration and front line

employee recruitment into this enterprise wide effort. Kickoff planned for

November 2019.

Clinical Collaboration Council

Pulmonary embolism and Deep Venous Thrombosis

i. PE/DVT performing at 4 star level

ii. Mandatory education model to assess risk and appropriate

prophylaxis.

iii. 1st line providers: Surgeons, Hospitalists and Advanced providers

introduced to the new system now.

iv. Phase II providers: Ortho, Thoracic Surgeons, GYN‐Oncology and OB

will be introduced to the program by January 2020.

v. Item referred to all CME’s to develop a process for corrective action

for non‐compliant providers.

Diagnosis Improvement

i. Owner: Dr. de la Torre

ii. MS working to evaluate how we make decisions. Goal is to prevent

the major forms of medical errors such as wrong, missed and delayed

diagnosis.

iii. Decision making is the number 1 factor leading to patient harm.

iv. We are early in this project that will ultimately lead to better, safer

care.

v. Next PLC update will be November 2019

Board Committee Structure

All FMEC’s support Lee Health’s BOD’s efforts to incorporate the Medical

Staff’s voice into relevant Board business.

MS leadership at multiple campuses has expressed reservations regarding

the discontinuation of direct BOD representation at FMEC meetings.

FMEC Actions (attached)

Multiple LEE County Residence Waivers

Approved to allow Associate Staff to serve on FMEC at GCHSWF

Revised the Pediatric Emergency Medicine delineation of privileges with

removal of ACLS certification

MS Elections (results maintained in MS Office)

i. FMEC membership resulted ratified

ii. Department Chairmanships were ratified

iii. Surgical Section Chiefs were ratified

Approved MS rule 3 regarding consultations

CCH IM Residency as sponsoring institution

FMEC ACTION TABLE Page 1

Date approved by: CCH GCMC HPMC LMH GCHSWF ITEM APPROVED (KEY WORDS) 06/17/19 06/10/19 06/11/19 06/12/19 Approved: Lee County Residence waiver for Gary P.

Colon, M.D. (Neurosurgery) meets requirement. 06/11/19 06/18/19 Approved: Lee County residence waiver for Douglas

Brian Keck, D.M.D. (Pediatric Dentist) based on institutional need.

06/11/19 Approved Krunal Patel, M.D. as a Nominee of Associate category to be placed on the upcoming ballot.

06/12/19 LMH Hospitalist Service line: Acknowledge the plan to reduce the level of coverage provided by the Cape Coral Hospitalists at LMH.

06/12/19 Approved: Lee County Residence waiver for David C. Ritter, M.D. (Vascular & Oncologic Surgery) as presented with a stipulation that he complies with exemption/waiver criteria set-up by LMH MEC for privileges and membership based on institutional needs.

06/18/19 Approved to accept Associate staff category to serve on the FMEC on an ongoing basis.

06/18/19 Approved the revised Pediatric Emergency Medicine delineation of privileges with the modification to remove ACLS certification.

08-19-19 08-12-19 08-13-19 08-14-19 08-20-19 FMEC Election results ratified 08-19-19 08-12-19 08-13-19 08-14-19 Dept. Chairs ratified 08-19-19 08-12-19 08-13-19 08-14-19 Surgical Section Chiefs ratified 08-19-19 08-12-19 08-13-19 08-14-19 Approved the M.S. General Rules & Regs.- Rule #3

Consultations, 3. c.i. Routine Inpatient Consultations i. Routine Inpatient Consultations 1. Routine inpatient consultations are consultations requested for inpatients that do not require urgent intervention by the consulting physician. Inpatients with routine consultations shall be seen within 24 hours after the order for consultation is made. The official time of the consultation request will be the electronic record generated time for placement of the patient’s name on the specialist’s EPIC consultation list.

08-19-19 Approved the Internal Medicine Residency Program as CCH sponsoring institution.

08-13-19 Approved to Appoint Dr. Azam to the Credentials Committee as a HPMC representative.

08-14-19 Approved Christopher N. Conner, M.D. as LMH Radiology Chairman effective 09-01-19


BOARD OF DIRECTORS

MEDICAL STAFF CREDENTIALING

(APPROVE)

a) Lee Memorial Hospital

b) Cape Coral Hospital

c) Gulf Coast Medical Center

d) HealthPark Medical Center

e) Golisano Children’s Hospital of SWFL


LEE HEALTH Lee County, Florida

#1 M E M O R A N D U M

To: Board of Directors

From: Nancy A. Taylor, CPMSM, CPCS Director, Centralized Credentialing Services

Date: August 21, 2019

Subject: Lee Memorial Hospital Medical Staff Recommendations

The Facility Medical Executive Committee of the Medical Staff recommends the following physicians and allied health practitioners and certifies they have met the requirements set forth in the bylaws:

1. Associate Staff Appointment:

a. Patrick Bartholomew, Jr., D.P.M. – Podiatry b. Dustin Begosh-Mayne, M.D. – Internal Medicine c. Jonathan Benaknin, D.O. – Psychiatry d. Drew Bienvenu, M.D. – Emergency Medicine e. Ashley Chatigny, D.O. – Psychiatry f. Gary Colon, M.D. – Neurosurgery g. Joseph D’Alonzo, M.D. – Diagnostic Radiology h. Alexander Damron, M.D. – Pathology i. Sourab Dhungel, M.D. – Nephrology j. Kristen Dimas, M.D. – Family Medicine k. Eric Feinberg, M.D. – OB/Gyn l. Christina Garcia, D.P.M. – Podiatry m. Samuel Giles, M.D. – Neurology n. Michael Horowitz, M.D. – Neurosurgery o. Zachary Hothem, D.O. – Trauma Surgery p. Aruna Khan, M.D. – Family Medicine q. Sergey Kozyr, M.D. – Trauma Surgery r. Jimmy Liu, M.D. – Internal Medicine s. Adina Logan, M.D. – Internal Medicine t. Solange Marte Estevez, M.D. – Internal Medicine u. Tyler McKinnon, M.D. – Diagnostic Radiology v. Stephen Moenning, M.D. – Addiction Medicine w. Juliana Odetunde, M.D. – Family Medicine x. Aastha Parsa, M.D. – Nephrology y. Daniel Reikher, M.D. – Internal Medicine z. Francisco Ruiz, M.D. – Gastroenterology aa. Roberto Rupcich, M.D. – Family Medicine bb. Nelson Smith, M.D. – Internal Medicine cc. W. Zachary Stone, M.D. – Orthopedic Surgery dd. John Thompson, D.O. – Orthopedic Surgery ee. Laura Veras Mena, M.D. – Allergy & Immunology ff. Erin Ward, M.D. – OB/Gyn gg. Lori Williams, M.D. – Internal Medicine hh. Hailon Wong, M.D. – Family Medicine

Memorandum to Board of Directors - LMH August 21, 2019 Page 2 of 3


2. Privileges Only Appointment: a. Jennifer Carrion, M.D. – Family Medicine b. Jason Hughes, M.D. – Teleradiology c. Deb Mojumder, M.D. – Teleneurology d. Richard Pacini, M.D. – Teleradiology e. Brett Searcey, M.D. – Teleradiology f. Ayesha Waheed, M.D. - Teleradiology

3. Intrasystem Application:

a. Gautham Mogilishetty, M.D. – Nephrology b. Shalini Saith, M.D. – Nephrology

4. Temporary Privileges:

a. Hamid Nawaz, M.D. – Cardiology, 08-14-19 – 09-12-19 5. Resignations:

a. Puja Aggarwal, M.D. – Teleneurology, effective 06-11-19 b. Michael Bloss, M.D. – Teleradiology, effective 06-23-19 c. Eve Bowers, M.D. – Internal Medicine, effective 06-12-19 d. Gerald Fitzpatrick, M.D. – Family Medicine, effective 06-03-19 e. Klaus Freeland, M.D. – Ophthalmology, effective 07-15-19 f. Roger Hirchak, D.O. – Family Medicine, effective 06-01-19 g. Peter Lewis, M.D. – Internal Medicine, effective 06-01-19 h. Walter Morgan, M.D. – Teleneurology, effective 07-10-19 i. Javed Qureshi, M.D. – Teleradiology, effective 06-14-19

6. Leave of Absence :

a. Charles Boggs, M.D. – General Surgery, military leave 06-01-19 – 09-30-19 b. Ronald Delans, M.D. – Nephrology, personal leave 07-01-19 - 09-30-19 c. Zachary Garner, D.O. – Gastroenterology, educational leave 07-01-19 – 10-01-19 d. Marc Rosenblatt, D.O. – Physical Medicine & Rehab/Pain Management, personal

leave 07-06-19 – 07-05-20 7. Privilege Requests:

a. Gilbert Abou-Lahoud, M.D. – Robotic Surgery b. Craig Barkley, M.D. – Robotic Surgery c. Peter Denk, M.D. – Robotic Surgery d. Rishi Ramlogan, M.D. – Robotic Surgery e. Samith Sandadi, M.D. – Robotic Surgery f. Moses Shieh, M.D. – Robotic Surgery

8. Change of Status:

a. George Ball, M.D. – Internal Medicine, Honorary, 06-28-19 b. Bruce Berget, M.D. – Pediatrics, Honorary 07-01-19 c. William Evans, M.D. – Urology, Honorary 09-05-19 d. Clifford Thacker, M.D. – Addiction Medicine, Privilege Only to Associate 07-09-19

Memorandum to Board of Directors - LMH August 21, 2019 Page 3 of 3


9. Advanced Practice Providers:

a. Alina Adams, CRNA – US Anesthesia Partners b. Brittany Adams, APRN – Florida Cancer Specialists c. Jessica Bartalino, APRN – Florida ID Care d. Aimiee Cruz, APRN – Allergy, Sleep & Lung Care e. Michelle Daddario, APRN – LPG Adult Hematology & Oncology f. Aileen Fiallo, PA – 21st Century Oncology – ENT g. Kellie Girnys, APRN – Gulf Coast Vascular Surgeons h. Vivanne Kateregga, APRN – LPG Complex Care Center i. Nicole Outten, PA – LMHS ER Physicians j. Stacy Parker, APRN – Lee Convenient Care k. Leslie Romersberger, PA – Colorectal Institute l. Nadege Sanon, APRN – LPG Complex Care Center m. Nicole Scott, PA – Florida Cancer Specialists n. Melissa Shockey, APRN – Lee Community Healthcare – Dunbar o. Julie Taylor, APRN – LPG Family Medicine at Plantation p. Diane Thompson, APRN – Dr. Shetty q. Rupert Valbuena, CRNA – US Anesthesia Partners

10. Advanced Practice Providers – Sponsor Change:

a. Flavio Jamur, APRN – Millennium Hospitalist Group b. Jennifer Perkins, APRN –Employee Health c. Andrea Sensecqua, PA – LPG Associates in Cardiac Care

11. Advanced Practice Providers – Additional Sponsor:

a. Brittany Adams, APRN – Heart & Vascular Institute b. Jaclyn Wise, PA – LPG General & Vascular Surgery

12. Advanced Practice Providers – Privilege Request:

a. Justin Harlacher, PA – Central Line Placement b. Robert Haynes, Jr., PA – Central Line Placement c. Joshua Lomen, PA – Arterial Line Placement

Approved by the Board of Directors – August 29, 2019

________________________________________________ Stephen R. Brown, M.D., Chairman - Board of Directors


LEE HEALTH

Lee County, Florida




Subject: Cape Coral Hospital Medical Staff Recommendations




a. Charles Alakija, M.D. – Emergency Medicine b. Patrick Bartholomew, Jr., D.P.M. – Podiatry c. Christopher Beechy, M.D. – Emergency Medicine d. Dustin Begosh-Mayne, M.D. – Internal Medicine e. Oscar Busso, M.D. – Internal Medicine f. Ashley Chatigny, D.O. – Psychiatry g. Gary Colon, M.D. – Neurosurgery h. Joseph D’Alonzo, M.D. – Diagnostic Radiology i. Alexander Damron, M.D. – Pathology j. Sourab Dhungel, M.D. – Nephrology k. Kristen Dimas, M.D. – Family Medicine l. Harshit Doshi, M.D. - Neonatology m. Tyler Ensley, D.O. – Emergency Medicine n. Christina Garcia, D.P.M. – Podiatry o. Samuel Giles, M.D. – Neurology p. Michael Horowitz, M.D. – Neurosurgery q. Jimmy Liu, M.D. – Internal Medicine r. Adina Logan, M.D. – Internal Medicine s. Solange Marte Estevez, M.D. – Internal Medicine t. Tyler McKinnon, M.D. – Diagnostic Radiology u. Stephen Moenning, M.D. – Addiction Medicine v. Aastha Parsa, M.D. – Nephrology w. Daniel Reikher, M.D. – Internal Medicine x. Francisco Ruiz, M.D. – Gastroenterology y. Syed Sher, D.O. – Family Medicine z. Nelson Smith, M.D. – Internal Medicine aa. W. Zachary Stone, M.D. – Orthopedic Surgery bb. John Thompson, D.O. – Orthopedic Surgery cc. Price Ward, M.D. - Neonatology

Memorandum to Board of Directors - CCH August 21, 2019 Page 2 of 3


2. Privileges Only Appointment: a. Jason Hughes, M.D. – Teleradiology b. Deb Mojumder, M.D. – Teleneurology c. Richard Pacini, M.D. – Teleradiology d. Brett Searcey, M.D. – Teleradiology e. Ayesha Waheed, M.D. - Teleradiology


a. Mina Elnemr, M.D. - Gastroenterology b. Salomon Levy Miranda, M.D. – General Surgery c. Gautham Mogilishetty, M.D. – Nephrology d. Shalini Saith, M.D. – Nephrology

4. Resignations:

a. Puja Aggarwal, M.D. – Teleneurology, effective 06-11-19 b. Michael Bloss, M.D. – Teleradiology, effective 06-23-19 c. Peter Lewis, M.D. – Internal Medicine, effective 06-01-19 d. Walter Morgan, M.D. – Teleneurology, effective 07-10-19 e. Faullin Paletsky, M.D. – Internal Medicine, effective 03-01-19 f. Javed Qureshi, M.D. – Teleradiology, effective 06-14-19



leave 07-06-19 – 07-05-20 6. Change of Status:

a. Bruce Berget, M.D. – Pediatrics, Honorary 07-01-19 b. William Evans, M.D. – Urology, Honorary 09-05-19 c. Clifford Thacker, M.D. – Addiction Medicine, Privilege Only to Associate 07-09-19


a. Alina Adams, CRNA – US Anesthesia Partners b. Brittany Adams, APRN – Florida Cancer Specialists c. Jessica Bartalino, APRN – Florida ID Care d. Michelle Daddario, APRN – LPG Adult Hematology & Oncology e. Aileen Fiallo, PA – 21st Century Oncology – ENT f. Kellie Girnys, APRN – Gulf Coast Vascular Surgeons g. Leslie Romersberger, PA – Colorectal Institute h. Nicole Scott, PA – Florida Cancer Specialists i. Diane Thompson, APRN – Dr. Shetty j. Rupert Valbuena, CRNA – US Anesthesia Partners k. Heidi Zielinski, CNM – Premier Women’s Care of SWF

Memorandum to Board of Directors - CCH August 21, 2019 Page 3 of 3


8. Advanced Practice Providers – Sponsor Change: a. Flavio Jamur, APRN – Millennium Hospitalist Group b. Rita Kelly, APRN – LPG General Surgery Cape Coral c. Jennifer Perkins, APRN –Employee Health d. Andrea Sensecqua, PA – LPG Associates in Cardiac Care


a. Brittany Adams, APRN – Heart & Vascular Institute b. Jennifer Moss, APRN – CCH ER Physicians c. Jaclyn Wise, PA – LPG General & Vascular Surgery

10. Advanced Practice Providers – Privilege Request:

a. Justin Harlacher, PA – Central Line Placement b. Joshua Lomen, PA – Arterial Line Placement








Subject: Gulf Coast Medical Center Medical Staff Recommendations




a. Erin Barth, M.D. - Gastroenterology b. Patrick Bartholomew, Jr., D.P.M. – Podiatry c. Dustin Begosh-Mayne, M.D. – Internal Medicine d. Ashley Chatigny, D.O. – Psychiatry e. Gary Colon, M.D. – Neurosurgery f. Lawrence Coryell, M.D. – Diagnostic Radiology g. Alexander Damron, M.D. – Pathology h. Sourab Dhungel, M.D. – Nephrology i. Kristen Dimas, M.D. – Family Medicine j. Harshit Doshi, M.D. - Neonatology k. Thomas Elkins, M.D. – Diagnostic Radiology l. Viviana Freire-Florit, M.D. - Anesthesiology m. Christopher Fernandez, M.D. - Gastroenterology n. Christina Garcia, D.P.M. – Podiatry o. Samuel Giles, M.D. – Neurology p. Michael Horowitz, M.D. – Neurosurgery q. Paul Hurd II, M.D. – Physical Medicine & Rehab r. Helen Jaramillo Gutierrez, M.D. – OB/Gyn s. Seth Jelinek, M.D. – Internal Medicine t. Kevin Kadakia, M.D. – Diagnostic Radiology u. Jimmy Liu, M.D. – Internal Medicine v. Adina Logan, M.D. – Internal Medicine w. Juan Loor Tuarez, M.D. – Internal Medicine x. Pankaj Malik, M.D. - Anesthesiology y. Solange Marte Estevez, M.D. – Internal Medicine z. Stephen Moenning, M.D. – Addiction Medicine aa. Aastha Parsa, M.D. – Nephrology bb. Sebastian Puig, M.D. – Internal Medicine cc. Daniel Reikher, M.D. – Internal Medicine dd. Lucia Reyes, M.D. – Family Medicine ee. Nelson Smith, M.D. – Internal Medicine

Memorandum to Board of Directors - GCMC August 21, 2019 Page 2 of 3


ff. W. Zachary Stone, M.D. – Orthopedic Surgery gg. John Thompson, D.O. – Orthopedic Surgery

2. Privileges Only Appointment:

a. Jason Hughes, M.D. – Teleradiology b. Deb Mojumder, M.D. – Teleneurology c. Richard Pacini, M.D. – Teleradiology d. Brett Searcey, M.D. – Teleradiology e. Ayesha Waheed, M.D. - Teleradiology



a. Puja Aggarwal, M.D. – Teleneurology, effective 06-11-19 b. Michael Bloss, M.D. – Teleradiology, effective 06-23-19 c. Stella Bulengo, M.D. – Dermatology, effective 07-28-19 d. Klaus Freeland, M.D. – Ophthalmology, effective 07-15-19 e. Roger Hirchak, D.O. – Family Medicine, effective 06-01-19 f. Walter Morgan, M.D. – Teleneurology, effective 07-10-19 g. Javed Qureshi, M.D. – Teleradiology, effective 06-14-19 h. Michael Worobel, D.O. – Physical Medicine & Rehab, effective 06-05-19


a. Ronald Delans, M.D. – Nephrology, personal leave 07-01-19 - 09-30-19 b. Zachary Garner, D.O. – Gastroenterology, educational leave 07-01-19 – 10-01-19 c. Fred Liebowitz, M.D. – Pain Management, 30 day extension through 08-15-19 d. Marc Rosenblatt, D.O. – Physical Medicine & Rehab/Pain Management, personal


a. Greg Pound, D.P.M. – Inpatient Podiatry privileges b. Constantine Plakas, M.D. – TCAR


a. William Evans, M.D. – Urology, Honorary 09-05-19 b. Clifford Thacker, M.D. – Addiction Medicine, Privilege Only to Associate 07-09-19


a. Brittany Adams, APRN – Florida Cancer Specialists b. Dawn Arrand, CNM – Family Health Centers c. Jessica Bartalino, APRN – Florida ID Care d. Aimiee Cruz, APRN – Allergy, Sleep & Lung Care e. Michelle Daddario, APRN – LPG Adult Hematology & Oncology f. Aileen Fiallo, PA – 21st Century Oncology – ENT g. Kellie Girnys, APRN – Gulf Coast Vascular Surgeons

Memorandum to Board of Directors - GCMC August 21, 2019 Page 3 of 3


h. Leslie Romersberger, PA – Colorectal Institute i. Milver Salinas, CRNA – Anesthesia & Pain Consultants j. Nicole Scott, PA – Florida Cancer Specialists k. Diane Thompson, APRN – Dr. Shetty


a. Flavio Jamur, APRN – Millennium Hospitalist Group b. Jennifer Perkins, APRN –Employee Health c. Andrea Sensecqua, PA – LPG Associates in Cardiac Care


a. Brittany Adams, APRN – Heart & Vascular Institute 11. Advanced Practice Providers – Privilege Request:

a. Keith Gillis, APRN – Critical Care b. Stephen Hagewood, PA - Intubation c. Jenene Knowles, PA – Intubation and Critical Care d. Jeilena Krill, PA – Removal of tunnel catheter e. Joshua Lomen, PA – Arterial Line Placement f. Mini Mathew, APRN – Critical Care g. David Merkle, PA – Removal of tunnel catheter h. Emily Randall, PA – Removal of tunnel catheter i. Aleisha Rees, PA – Removal of tunnel catheter





#4

M E M O R A N D U M




Subject: HealthPark Medical Center Medical Staff Recommendations



a. Patrick Bartholomew, Jr., D.P.M. – Podiatry b. Dustin Begosh-Mayne, M.D. – Internal Medicine c. Shauna Berry, D.O. – Pediatric Ophthalmology d. Drew Bienvenu, M.D. – Emergency Medicine e. Ashley Chatigny, D.O. – Psychiatry f. Gary Colon, M.D. – Neurosurgery g. William Cutting, M.D. – Cardiology h. Joseph D’Alonzo, M.D. – Diagnostic Radiology i. Alexander Damron, M.D. – Pathology j. Sourab Dhungel, M.D. – Nephrology k. Kristen Dimas, M.D. – Family Medicine l. Harshit Doshi, M.D. – Neonatology m. Eric Feinberg, M.D. – OB/Gyn n. Christina Garcia, D.P.M. – Podiatry o. Samuel Giles, M.D. – Neurology p. Chris Grevengood, M.D. – OB/Gyn q. Michael Horowitz, M.D. – Neurosurgery r. Zachary Hothem, D.O. – Trauma Surgery s. Helen Jaramillo Gutierrez, M.D.t. Sergey Kozyr, M.D. – Trauma Surgery u. Jimmy Liu, M.D. – Internal Medicine v. Adina Logan, M.D. – Internal Medicine w. Juan Loor Tuarez, M.D. – Internal Medicine x. Solange Marte Estevez, M.D. – Internal Medicine y. Tyler McKinnon, M.D. – Diagnostic Radiology z. Stephen Moenning, M.D. – Addiction Medicine aa. Aastha Parsa, M.D. – Nephrology bb. Sebastian Puig, M.D. – Internal Medicine cc. Daniel Reikher, M.D. – Internal Medicine dd. Francisco Ruiz, M.D. – Gastroenterology ee. Nelson Smith, M.D. – Internal Medicine

Memorandum to Board of Directors - HPMC August 21, 2019 Page 2 of 4


ff. W. Zachary Stone, M.D. – Orthopedic Surgery gg. Karysse Trandem, D.O. – OB/Gyn hh. Erin Ward, M.D. – OB/Gyn ii. Price Ward, M.D. - Neonatology


a. Jason Hughes, M.D. – Teleradiology b. Deb Mojumder, M.D. – Teleneurology c. Richard Pacini, M.D. – Teleradiology d. Brett Searcey, M.D. – Teleradiology e. Ayesha Waheed, M.D. - Teleradiology


a. Gautham Mogilishetty, M.D. – Nephrology b. Shalini Saith, M.D. – Nephrology



a. Puja Aggarwal, M.D. – Teleneurology, effective 06-11-19 b. Frances Arrillaga, M.D. – Pediatric Cardiology, effective 07-10-19 c. Michael Bloss, M.D. – Teleradiology, effective 06-23-19 d. Klaus Freeland, M.D. – Ophthalmology, effective 07-15-19 e. Roger Hirchak, D.O. – Family Medicine, effective 06-01-19 f. Peter Lewis, M.D. – Internal Medicine, effective 06-01-19 g. Walter Morgan, M.D. – Teleneurology, effective 07-10-19 h. Javed Qureshi, M.D. – Teleradiology, effective 06-14-19 i. Gary Stapleton, M.D. – Pediatric Cardiology, effective 12-31-18




a. Craig Barkley, M.D. – Robotic Surgery b. Constantine Plakas, M.D. – TCAR


a. George Ball, M.D. – Internal Medicine, Honorary, 06-28-19 b. Bruce Berget, M.D. – Pediatrics, Honorary 07-01-19 c. William Evans, M.D. – Urology, Honorary 09-05-19 d. Clifford Thacker, M.D. – Addiction Medicine, Privilege Only to Associate 07-09-19



9. Advanced Practice Providers: a. Alina Adams, CRNA – US Anesthesia Partners b. Brittany Adams, APRN – Florida Cancer Specialists c. Marcela Alvarez-Lazo, APRN – LPG Adult Gastroenterology d. Dawn Arrand, CNM – Family Health Centers e. Jessica Bartalino, APRN – Florida ID Care f. Aimiee Cruz, APRN – Allergy, Sleep & Lung Care g. Michelle Daddario, APRN – LPG Adult Hematology & Oncology h. Aileen Fiallo, PA – 21st Century Oncology – ENT i. Kellie Girnys, APRN – Gulf Coast Vascular Surgeons j. Susan Mallone-Stead, APRN – LPG Associates in Pediatrics k. Karen Mikol, PA – LPG Adult Gastroenterology l. Nicole Outten, PA – LMHS ER Physicians m. Leslie Romersberger, PA – Colorectal Institute n. Nicole Scott, PA – Florida Cancer Specialists o. Julie Taylor, APRN – LPG Family Medicine at Plantation p. Diane Thompson, APRN – Dr. Shetty q. Rupert Valbuena, CRNA – US Anesthesia Partners


a. Flavio Jamur, APRN – Millennium Hospitalist Group b. Susan Nolan, PA – LPG Pediatric Gastroenterology c. Jennifer Perkins, APRN –Employee Health d. Andrea Sensecqua, PA – LPG Associates in Cardiac Care


a. Brittany Adams, APRN – Heart & Vascular Institute b. Jaclyn Wise, PA – LPG General & Vascular Surgery

12. Advanced Practice Provider – Privilege Request:

a. Robert Haynes, Jr., PA – Central Line Placement 13. Advanced Practice Providers for LPG Pediatric Intensivists– Privilege Requests:

a. Lilian Barroso, APRN Central Venous Catheter, Chest Tube and Arterial Line Amy Mayhugh, APRN Central Venous Catheter, Chest Tube, Arterial Line and Peripheral IV Central Catheter Sharon Osinski, APRN Code Blue, Central Venous Catheter, Chest Tube, Arterial Line and Peripheral IV Central Catheter Patricia Rountree, APRN Chest Tube, Arterial Line and Peripheral IV Central Catheter



Caline Wills, APRN Central Venous Catheter, Chest Tube, Arterial Line and Peripheral IV Central Catheter





#5

M E M O R A N D U M To: Board of Directors From: Nancy A. Taylor, CPMSM, CPCS Director, Centralized Credentialing Services Date: August 21, 2019 Subject: Golisano Children’s Hospital of Southwest Florida

Medical Staff Recommendations The Facility Medical Executive Committee of the Medical Staff recommends the following physicians and allied health practitioners and certifies they have met the requirements set forth in the bylaws:


a. Syeda Basith, M.D. – Pediatric Ophthalmology b. Shauna Berry, D.O. – Pediatric Ophthalmology c. Ashley Chatigny, D.O. – Psychiatry d. Joseph D’Alonzo, M.D. – Diagnostic Radiology e. Alexander Damron, M.D. – Pathology f. Harshit Doshi, M.D. – Neonatology g. Eric Feinberg, M.D. – OB/Gyn h. Tyler McKinnon, M.D. – Diagnostic Radiology i. Joseph Peter, M.D. – Pediatrics j. Farhan Rashid, M.D. – Pediatrics k. Freddy Solano, M.D. – Pediatrics l. Patricia Subnaik, D.O. – Pediatric Gastroenterology m. Jennifer Walls, M.D. – Pediatric Emergency Medicine n. Erin Ward, M.D. – OB/Gyn o. Price Ward, M.D. – Neonatology


a. Deb Mojumder, M.D. – Teleneurology 3. Intrasystem Application:

a. William Kokal, M.D. – Wound care consults b. Christopher Ponder, M.D. – Emergency Medicine c. Jeremy Tamir, M.D. – Wound care consults

Memorandum to Board of Directors August 21, 2019 Page 2 of 2

4. Temporary Privileges: a. Konstantin Denev, M.D. – Pediatric Emergency Medicine, 07-29-19 – 08-28-19;

08-31-19 – 09-30-19 b. Kimberly Massey, M.D. - Pediatric Emergency Medicine, 08-05-19 – 09-04-19

5. Resignations:

a. Puja Aggarwal, M.D. – Teleneurology, effective 06-11-19 b. Frances Arrillaga, M.D. – Pediatric Cardiology, effective 07-10-19 c. Walter Morgan, M.D. – Teleneurology, effective 07-10-19 d. Gary Stapleton, M.D. – Pediatric Cardiology, effective 12-31-18


a. Bruce Berget, M.D. – Pediatrics, Honorary 07-01-19 7. Advanced Practice Providers:

a. Alina Adams, CRNA – US Anesthesia Partners b. Rupert Valbuena, CRNA – US Anesthesia Partners

8. Advanced Practice Provider – Sponsor Change/Intrasystem:

a. Susan Nolan, PA – LPG Pediatric Gastroenterology 9. Advanced Practice Providers for LPG Pediatric Intensivists– Privilege Requests:

a. Lilian Barroso, APRN Central Venous Catheter, Chest Tube and Arterial Line Amy Mayhugh, APRN Central Venous Catheter, Chest Tube, Arterial Line and Peripheral IV Central Catheter Sharon Osinski, APRN Code Blue, Central Venous Catheter, Chest Tube, Arterial Line and Peripheral IV Central Catheter Patricia Rountree, APRN Chest Tube, Arterial Line and Peripheral IV Central Catheter Caline Wills, APRN Central Venous Catheter, Chest Tube, Arterial Line and Peripheral IV Central Catheter



STRATEGY

DISCUSSION

#3400.159 Rev. 10/16

August 29, 2019

IT Update

Brian Zegers, System DirectorInformation Security Officer

Rick SchoolerChief Information Officer

William Carracino, MD Vice PresidentMedical Informatics

1

Agenda

Information and Systems Security

What’s Trending in Healthcare IT

Epic Update

Information and Systems Security

2

3

Information & Systems SecurityHealthcare Events, Trends, and Threats

Top Threats to Lee Health…...Phishing and Password Management!

Phishing is the #1 delivery method for ransomware and other malware Over 90% of breaches involve the use of compromised accounts

Phishing emails account for 98% of social engineering attacks

59% of workers reuse their passwords everywhere – at home and at work

Average individual has 100-200 accounts that require some sort of password identification

4

Information & Systems SecurityEmail Metrics – Phishing/Malware

Email StatsMonthly Average of Total Emails sent to Lee Health: ~10,000,000Percentage of Emails blocked as Spam/Malware/Bulk/etc: 88%Percentage of Emails delivered to Lee Health mailboxes: 12%

5

Information & Systems SecurityCybersecurity Metrics – External Threats

Blocked internet attempts to access Lee Health network Average Firewall Deny Attempts - Month: 70,000,000Average Firewall Deny Attempts – Minute: 1,620

Security offenses researched (July) 151Research performed by 24x7 Managed Services and IS Cybersecurity Team

Top 5 Attack Sources1. USA2. Russia3. China4. Romania5. Netherlands

6

Information & Systems Security

Proper password management is critical in todays security landscape – the impact of breaches can be significant

Many of these breaches shown have lead to exposed passwords

Individuals often reuse passwords and if disclosed can be used to attempt unauthorized access to other online services and company resources

7

Information & Systems SecurityProtection & PreparednessContinued investment in top security products and services

Network Perimeter protectionEmail filtering, firewall/intrusion prevention systems, intrusion detection systems/web filtering

Data protectionEncryption, two-factor user authentication, secure communications, data loss prevention, account takeover protection

Constant security review of the enterpriseVulnerability scans, 3rd party security assessments, application security testing, security log reviews, security exercises and roundtables

Increased staff for IS Security TeamIncreased staff to focus on researching and responding to daily security events along with managing new security solutions that have been implemented

What’s Trending in Healthcare IT

8

9

Top of Mind Healthcare Provider Priorities

A vast spectrum of technologies have been deployed over the past 30 years targeting healthcare provider top-of-mind priorities

o Care quality, safety and costo Access to careo Patient engagement, satisfaction and experienceo Reimbursement, revenue and market shareo Consumerismo Physician alignment and satisfactiono Population health management and assumption of risko Operational efficiency and productivity

However, recent technology innovations are enabling significant and often disruptive change

10

Technology Platforms Changing Healthcare

Four such technologies are…Digital Health (eHealth)

Artificial Intelligence

Predictive and Prescriptive Analytics

The Cloud and Mobility

11

The Five Domains of Digital Health

Virtual Care - Care delivery at a distance enabled by communication technologies (Ex: Lee Telehealth)

Patient Self-Service - Service model enhancements empowering patients to manage their health and treatment (Ex: Epic MyChart, Self Schedule, On My Way)

Connected Solutions -Smart devices driving real-time decision support, monitoring and interventions

Personalized Care - Augmented patient profiles supporting more tailored, effective treatments and customized experiences

Operation Automation - Re-engineering using data and analytics to drive quality and efficiency (Ex: Analytics Center of Excellence dashboards, Epic Caboodle, Baldrige Patient Flow)

Source: Chartis “Five Key Domains in the Provider Digital Health Landscape”

12

Artificial Intelligence

AI is poised to deliver transformational impact, but many claim to have what may not be ready to bring value

The future holds possibilities across many, if not most, areas of healthcare delivery, management and payment

AI’s current primary focus is condition prevention or treatment techniques and patient outcomes

The 2018 World Medical Innovation Forum on artificial intelligence (presented by Partners Healthcare) showcased twelve areas of healthcare that are most likely to see a major impact from AI within the next decade

Source: Jennifer Bresnick, Health IT Analytics, April 2018

13

2018 World Health Medical Innovation ForumAI Applications Unifying mind and machine

through brain-computer interfaces

Developing the next generation of radiology tools

Expanding access to care in underserved regions

Reducing the burdens of electronic health record use

Containing the risks of antibiotic resistance

Creating more precise analytics for pathology images

Source: Jennifer Bresnick, Health IT Analytics, April 2018

Bringing intelligence to medical devices and machines

Advancing cancer treatment

EMR as a reliable risk predictor

Monitoring health through wearables and personal devices

Making smartphone selfies into powerful diagnostic tools

Revolutionizing clinical decision making with artificial intelligence at the bedside

14

Predictive and Prescriptive Analytics

15

Mobility and The Cloud

Across industries, the expectation for information search and “doing business” is anytime, anywhere and mobile – the same is now expected from healthcare

The advent of smartphone apps has enabled innovation opportunities for those building software solutions for healthcare as well as consumers and patients

The application and infrastructure technologies that have historically been installed and maintained in corporate data centers are now being offered “In The Cloud”

These three realities are fundamentally and permanently changing the experience and operations of those consuming as well as delivering healthcare services

16

mHealth App Facts…

There are more than 97,000 health and fitness applications available for download to mobile or tablet devices

52% of smartphone users collect health-associated information on their devices

15% of 18 to 29-year olds have health apps already installed on their cell phones

8% of smartphone users between the ages of 30 to 49 have medical app downloads

40% of doctors trust that these mobile tools can lessen the number of on-site clinical visits

More than 25% of American physicians are using at least one mHealth app

93% of doctors say mobile apps can enhance the quality of patient health

Source: Andy Edwards, Ortholive website, Feb 2019

17

Staying in The Game: The New Normal

Growing needs and rising expectations

Maturing IT Governance

Innovation while avoiding “Bright Shiny Objects”

Talent management, recruiting and retention

Funding levels

Epic Update

18

Update Topics

Cognitive Computing

Provider Well Being

Interoperability & MyChart

TeleHealth

Cosmos

20

Cognitive Computing

© 2019 Epic Systems Corporation. Used with permission.

22

Provider Well Being

Provider Well Being @ Lee Health

Provider/Staff Well-Being Workgroup (Cardiology)Maslach Burnout Inventory Survey

Physician recognition program for LPG Consultant Review

Divurgent Surveys

Joy in Practice Survey (LPG)Medical Staff Survey (Medical Staff)

Expanding the Epic Training Team for provider satisfaction

25

Interoperability and MyChart

Care Everywhere Stats

26© 2019 Epic Systems Corporation. Used with permission.

On My Way

Help patients find closest Urgent care where they can be seen as soon as possible

Patients can let Urgent Care department know that they’re on their way

Patients must have a MyChart account

Live 10/21/2019

© 2019 Epic Systems Corporation. Used with permission.

Proxy Invites in MyChart

28

Patients can give family members or other caregivers who are also patients at your organization proxy access to their MyChart accounts without any intervention from clinic staff, so it's easier for everyone involved to share in the patient's care.

Live 8/26 with Upgrade

Send Documents Directly to Patients in MyChart Messages

Clinicians and staff can attach documents directly to MyChart messages and patients can see the attachments directly in the message.


Automatically add to Wait ListAutomatically add appointments to the wait list for patients who have opted to receive Fast Pass offers in MyChart.


29

Patient Estimates

Patients can view estimates generated by staff via MyChart.


Insurance Updates/Card Photos

Patients can update their insurance information through MyChart including uploading of insurance card images.

Live 10/15/2019

30

TeleHealth

31

Inpatient Ambulatory HomeConsumer/Retail

• Stroke• Neurology• Genetics• Oncology• Neonatology

Intervention• Skilled NursingOn Hold• NeurosurgeryIn Development• Cardiothoracic• Substance Abuse• Psychiatry

• Palliative Care• Behavioral Health

(LCH)• Residency Clinic

(Babcock)• Pediatric

NeurologyOn Hold• COPD• Surgery• Post-Discharge

• TeleHealth (Home Health)

• 24/7 Urgent Care

Contracted PhysiciansLPG PhysiciansLPG & Contracted Physicians

MEASURES• Patient Experience

MEASURES• Revenue Generation• Cost Reduction

MEASURES• Patient impact• Readmission rate• Time to consult

MEASURES• Patient Access• Reduced transports

AMBULATORY

• Palliative Care• LCH Behavioral Health• #Surgery

INPATIENT

• Oncology• #Neurosurgery

AMBULATORY

• Lee TeleHealth• Residency Clinic• *Remote Patient

MonitoringINPATIENT

• *Virtual Sitting

INPATIENT

• Neurology Rounding• Genetics• *Neonatal Intervention• * Substance Abuse• * CTC Surgery• * Psych Consults

AMBULATORY

• HH Telehealth• #Discharge Clinic• #COPD

INPATIENT

• Stroke• SNF Urgent Consults

Telehealth as part of LH Strategic Plan

#Program on hold*In Process

• LeeTeleHealth.org

• Partnership with American Well

• Launched 5/7/2019

• Phase 1 – American Well physicians

• Phase 2 – Incorporate LPG providers

• Data:• Visits: 34 visits

• Enrollments: 275

• Wait time: 5.5 min

• Visit length: 6.2 min

• Average Age: 46

• Chief Complaints (by frequency):

Respiratory, Rash, GI, UTI

24/7 Urgent Care

34

Cosmos

35© 2019 Epic Systems Corporation. Used with permission.

Thank You

COMMITTEES’ SUMMARIES & RECOMMENDATIONS

Quality Safety and Patient Experience Committee

COMMITTEES’ SUMMARIES & RECOMMENDATIONS

GTF/Governance Committee Update

a) Verbal Update b) Recommended Action

1. Policy Review 2. CEO/President Performance Review


BBBOOOAAARRRDDD OOOFFF DDDIIIRRREEECCCTTTOOORRRSSS


DATE: August 29, 2019 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 approve the recommendations of the Governance Committee relating to 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 to ensure its policies reflect the Board’s with current practices

SUMMARY (including alternatives considered, Pros and Cons) The Governance Committee reviewed a number of Board policies and determined to recommend to the Board of Directors the following:

(1) to combine eleven policies into one policy entitled “Conduct of Board Business” (10.06);

(2) to approve eight policies without revisions;

(3) to approve nine policies with revisions; and

(4) to sunset eight policies

See the detailed summary included in the Board’s meeting packet.

The Governance Committee notes it referred one policy to the Audit Committee for review and comment back to the Governance Committee relating to the Evaluation of the Auditing Firm (20.11).




DATE: August 29, 2019 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) The Board approved the Omnibus Policy on Committees on March 21, 2019 and added an Appendix on April 29, 2019. SPECIFIC PROPOSED MOTION:

Motion to approve the recommendations of the Governance Committee to revise the Board of Directors Omnibus Policy on Committees (10.56) as presented.


To incorporate additional best practices

SUMMARY (including alternatives considered, Pros and Cons) The Governance Committee recommends revisions to the Board of Directors Omnibus Policy on Committees (10.56):

to add Committee Rules of Engagement to the Appendix based on best practices suggested by the Governance Task Force and Board Members, and

to revise the quorum requirement for committees to be a majority of committee members.

Policy

NumberPolicy Title

Date of Last

Review

Date of Next

Review Suggested Action

COMBINE POLICIES

10.06C Conduct of Board Business 5/26/2013 5/26/2019

Combine Policies 10.06, 10.07,10.09,

10.16, 10.11, 10.16, 10.31,

10.34,10.38, 10.46, 10.48 and 10.50

10.07D

Ex-Officio Membership by System President on Board

Committees 9/8/2016 9/8/2019 Combine as above

10.09F Agenda Item Background Materials 8/24/2017 8/24/2020 "

10.11H Board Member Attendance 6/23/2016 6/23/2019 "

10.16D Recording of Committee Action & Board Votes in Minutes 6/23/2016 6/23/2019 "

10.31B Appointment of Acting Committee Chairman 6/23/2016 6/23/2019 "

10.34D Regular Meetings of the Board of Directors 11/3/2016 11/3/2019 "

10.38B Consent Agenda 6/23/2016 6/23/2019 "

10.46B Attendance & Voting at Meetings by Teleconference 6/23/2016 6/23/2019 "

10.48A Decorum During Meetings and Disciplinary Procedures 6/23/2016 6/23/2019 "

10.50 Board Meeting Audio/Video Recordings & Retention 6/23/2016 6/23/2019 "

REFER TO COMMITTEE FOR REVIEW

20.11E Evaluation of Auditing Firm 4/14/2016 4/14/2019 Refer to Committee (Audit)

REVIEW WITH NO REVISIONS

10.20D Litigation Management 8/11/2016 8/11/2019 Review - No Revisions

10.24G Lee Memorial Health System Foundation 1/5/2017 1/5/2020 "

10.43F Board Member Standards 12/1/2016 12/1/2019 "

10.54A Grievance Process 3/31/2016 3/31/2019 "

20.02D Conflict of Interest 12/1/2016 12/1/2019 "

20.08C

Authorized Signers for Financial Instruments and Petty Cash

Funds 11/17/2016 11/17/2019 "

20.13H Compensation and Benefits for Board Members 12/1/2016 12/1/2019 "

40.06C Reporting Unlawful Acts 9/8/2016 9/8/2019 "

Policy

NumberPolicy Title

Date of Last

Review

Date of Next

Review Suggested Action

REVIEW WITH REVISIONS

10.00G

Initiation & Maintenance of the Board of Directors Policy Manual

11/3/2016 11/3/2019 Updated

10.05G Duties and Responsibilities of Board of Directors 12/1/2016 12/1/2019 Updated

10.19F Risk Management and Safety 8/11/2016 8/11/2019 Updated

10.35C Organizational Code of Ethics 9/22/2016 9/22/2019 Updated

10.47E Compliance Program 1/17/2019 1/17/2022 Updated

10.55A Board Officers - Duties and Election 11/3/2016 11/3/2019 Updated

10.56 Board of Directors Omnibus Policy on Comittees 4/25/2019 4/25/2022 Updated

20.14G

Board Use of Funds for Education, Travel and Business Meeting/

Special Event Expenses 3/31/2016 3/31/2019 Updated

30.03C Medical Credentialing 9/22/2016 9/22/2019 Updated

SUNSET

10.13E Self-Evaluation/Review of Performance 4/27/2017 4/27/2020 Covered in Gov. Comm. Charter

10.36C System Marketing Program 9/22/2016 9/22/2019 Operations

10.45B Awards and Recognition Policy 9/22/2016 9/22/2019 Operations

10.51B Liaison Assignment, Role & Responsibility 6/29/2017 6/29/2020 Outdated

10.52G Community Consultants Apppointment 6/28/2018 6/28/2021 Outdated

30.04 Medical Staff Representation 2/25/2016 2/25/2019 Covered in Board Policy 30.05

40.05D Staffing Reductions 3/10/2016 3/10/2019 Operations

40.10J Board Office Coordinator Compensation & Performance Review 9/8/2016 9/8/2019 Operations

Once this policy is printed, it is not considered a controlled document. Please review electronic version of this policy for the most current document.

10.56 Board of Directors Omnibus Policy on Committees Page 1 of 4

LEE MEMORIAL HEALTH SYSTEM BOARD OF DIRECTORS

POLICY MANUAL no. 10.56 Supersedes no.

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category: General Operations title: Board of Directors Omnibus Policy on Committees ---------------------------------------------------------------------------------------------------------------------------------

Date Originated: 3/21/19

Reviewed/No Revision:

Dates Revised: 4/25/19; 8/29/2019

Next Review Date: 4/25/228/29/2022

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PURPOSE: To set forth the operational principles and policies for Lee Memorial Health System Board Committees. ---------------------------------------------------------------------------------------------------------------------------------

POLICY:

1. Authority: Board Committees serve in an advisory role to the Board, with the Board ultimately making final decisions.

2. Quorum: A majority of the members of the Committee plus one (1) shall constitute a quorum for a meeting. The affirmative vote of a majority of Board Members serving on the Committee and the affirmative vote of all Committee members present at the meeting shall be required to constitute action of the Committee.

3. Committee Member Terms: Except as otherwise directed by the Board, a Committee Member

shall serve a one year term unless appointed to fill a vacancy; in either case, the term shall expire at the Board’s annual meeting. Any Committee member may be removed from the Committee by the Board Chair with or without cause at any time.

4. Attendance Expectations: Committee members are expected to attend 75% or more of the meetings for the Committees on which they serve and will personally perform their Committee obligations.

5. Participation by Teleconference: In an emergency situation, and with prior Board Chair approval, a Committee member may participate in a meeting of the Committee by means of teleconference or similar communications equipment as long as all persons participating in the meeting can speak to and hear each other at the same time and each member can participate in all matters before the Committee, including, without limitation, the ability to propose, object to and vote upon a specific action to be taken by the Committee. Participation by such means shall constitute presence at a meeting.



6. Committee Chair Selection: Committee Chairs will be appointed by the Board Chair, unless otherwise delineated in the Committee Charter. Committee Chairs will be members of the Board of Directors.

7. Information Flow: Committee Chairs will present reports that will include recommended action, if any, at the next Board meeting following the Committee meeting. The Committee will keep minutes of its meetings and such minutes will be available for review on the LH Board’s website following the Committee’s approval of the minutes. The Committee will utilize executive dashboards at Board meetings to communicate relevant information to the Board as appropriate.

8. Administrative Sponsors: Each Committee shall have an Administrative Sponsor who will be a member of the Administration’s Senior Leadership team. The Administrative Sponsor will work together with the Committee Chair to develop agendas and materials for Committee meetings.

9. Conflict of Interest: In accordance with the Florida Statutes, the LMHS Conflict of Interest Policy is designed to not unreasonably impede the recruitment and retention of those best qualified to serve.

Generally, a conflict of interest exists when a Director or committee member has any interests, financial or otherwise and directly or indirectly engages in any business transaction or professional activity or incurs any obligation of any nature which is in substantial conflict with the proper discharge of his or her duties. Directors and committee members have a duty to bring perceived conflicts of interest to the attention of Board Counsel. If a perceived conflict is brought to light, any Director, committee member or potential Director or committee member may request an opinion of Board Counsel, who will provide an opinion as to whether a conflict of interest exists.

10. Participation by Non-Committee Members: Meetings of the Committee will be noticed and conducted in accordance with Florida’s open meetings law. Any non-Committee members attending a Committee meeting will be asked to observe only and not to participate.

11. Community and Physician Members: Community and Physician Members are voting members of the Committees on which they serve. Community and Physician Members shall be nominated or recommended to the full Board for majority approval as set forth in the relevant Committee charter and/or otherwise set forth in Board policy. Community and Physician Members must have specific expertise relevant to the Committee on which they serve.

12. Education: The Governance Committee shall coordinate and oversee a robust orientation program and ongoing education for all Committee members.



13. The Sunshine Law: All members of a Committee who have voting rights are governed by the Sunshine Law. The Sunshine Law extends to the discussions and deliberations as well as formal action taken by Committee members. The Sunshine Law is applicable to any gathering whether formal or casual of two or more members of the same committee to discuss some matter on which foreseeable action may be considered by the Board.

APPENDIX Additional Information Flow Principles To ensure appropriate information flow among the Board, Board Committees, and management, the following principles will be followed: It is best practice for Committees and the Board to consider governance topics, not operational

topics. Therefore, moving forward, governance- level topics will be presented to the various Committees or the full Board.

The vast majority of governance level information will flow through Committees, and depending upon the topic (i.e., if not “strategy”) a matter needing approval will most likely first go through appropriate Committee.

Committees will focus on more detailed oversight information; ask important questions; identify issues and determine if additional information is needed. Items that require approval will come to the full Board for consideration and approval. The

Committee Chair and Administrative Sponsor will prepare a Green Sheet for any recommendations for Board action.

Items should be presented to the Board for discussion or approval. Going forward, it is unlikely that items will be presented as only “information” or for “acceptance.” The full Board is responsible for considering and approving system strategy, so strategy topics will be presented directly to the full Board (this may include dedicated sessions and closed sessions, as appropriate). Except in extenuating circumstances:

Materials coming to Committees or the Board will be provided at least 7 days prior to the relevant meeting. Neither the committees, nor the Board, will be asked to vote on major decisions during the same meeting at which the information is being received.

Committee meeting frequency and sequencing will be routinely assessed to ensure there is sufficient time to provide materials to the committee and then to the Board.

Committee Rules of Engagement

Prepare for meetings by studying all the materials provided ahead of time



Pay particular attention to the Blue Sheets (informational items) and Green Sheets (action items)

Stay at the governance level (versus asking questions about operations)

Remain focused during Committee meetings and avoid side conversations and the use of electronic devices, unless used for Committee purposes

Rely on the Board Committee Chair to facilitate discussion in meeting

Ask timely and substantive questions at Committee meetings consistent with individual conscience and convictions while at the same time supporting the recommendations of Board Committees and the majority decisions of the Board

Committee members are encouraged to participate actively during Committee meetings – both sharing ideas and listening to other members’ ideas

When asking questions of administration, Committee members should state whether the question is related to the ability to vote or is for information only

Board members should ask their questions of the CEO, COO, CFO or, for Committee related work, the Administrative Sponsor for the applicable Board Committee

Non-Board members of Committees (Community Members and Physician Members) should ask their questions of the appropriate Committee’s Administrative Sponsor




DATE: August 29, 2019 LEGAL SERVICE REVIEW? YES X NO__ SUBJECT: President and CEO Performance Evaluation REQUESTOR & TITLE: Michael Wukitsch, Chief Human Resources Officer

PREVIOUS BOARD ACTION ON THIS ITEM (IF ANY) (justification and/or background for recommendations – internal groups which support the recommendation) On August 24, 2017, the Board approved an update to Board Policy #40.02 to support the compensation plan set forth in the President & CEO’s employment agreement and a revised performance evaluation document used to measure the President & CEO’s performance. On April 26, 2018, the Board approved an amendment to the President/CEO Employment Agreement and an update to Board Policy #40.02 thereby aligning the President/CEO annual performance measurement period with the health system’s fiscal year. SPECIFIC PROPOSED MOTIONS:

Motion to approve the proposed President and CEO Performance Review document for use to review the President and CEO’s performance for Fiscal Year 2019. Motion to approve the proposed President and CEO Performance Review document for use to review the President and CEO’s performance for Fiscal Year 2020.


Annually, the Lee Memorial Health System Board of Directors reviews the President and CEO’s performance according to Board Policy #40.02.

SUMMARY (including alternatives considered, Pros and Cons) Board policy #40.02 provides for an annual review of the President and CEO’s performance and further provides that annually the Board shall determine any modifications to the President/CEO’s performance evaluation document for the next fiscal year.

DRAFT

1

PRESIDENT AND CEO PERFORMANCE REVIEW

Please rank the PRESIDENT and CEO’s performance using a scale of 1 to 5: 1 = Opportunity for Development

2 =Meets Some Expectations

3 = Meets All Expectations

4 = Exceeds Expectations

5 = Exceptional N/A = Don’t Know

Use space provided to explain feedback and add specific comments.

PERFORMANCE FACTOR FEEDBACK and COMMENTS Meeting Goals/Achieving Results

Strategic Leadership Opportunity

for Development

Meets Some Expectations

Meets All Expectations

Exceeds Expectations Exceptional Don’t Know/

No Answer

Develops strategies and plans that set clear goals, timetables, and priorities for the organization as a whole. Ensures timely and steady progress toward strategic objectives. Obtains and allocates resources consistent with strategic priorities.

1 2 3 4 5 N/A

Comments:

Financial Management Opportunity

for Development




No Answer

Establishes appropriate financial goals. Manages operations to achieve these goals. Allocates resources in accord with these goals. Ensures that appropriate systems are maintained to protect assets and exercise effective control of operations.

1 2 3 4 5 N/A

Comments:

Quality, Safety and Patient Experience Opportunity

for Development




No Answer

Establishes that quality, safety and patient experience are top priorities at every level of Lee Health. Prioritizes delivering patient-centered care that meets the highest patient satisfaction. Uses quality and safety outcomes to drive actionable decision-making. Meets quality, safety and patient experience goals.

1 2 3 4 5 N/A

Comments:

DRAFT

2


Board Relations Opportunity

for Development




No Answer

Keeps the Board fully informed of important developments, issues and challenges. Clearly and promptly identifies issues needing Board attention. Frames issues to facilitate decision-making. Proposes and evaluates alternatives. Implements Board policies and directives. Builds effective working relationships with all members of the Board.

1 2 3 4 5 N/A

Comments:

Community Partnerships Opportunity

for Development




No Answer

Represents the organization effectively in the community and develops community partnerships. Ensures that the organization is perceived as contributing appropriately to the well-being of the community it serves.

1 2 3 4 5 N/A

Comments:

Staff Engagement Opportunity

for Development




No Answer

Establishes and maintains a positive work environment for employees, auxilians and volunteers. Promotes learning and development. Fosters a strong performance orientation. Employee engagement yearly results reflect an engaged workforce.

1 2 3 4 5 N/A

Comments:

Physician Relations Opportunity

for Development




No Answer

Encourages open communications with physician leaders. Builds effective working relationships with physician leaders. Creates opportunities for physician participation in decision-making. Seeks out the right physicians for leadership positions and gives them opportunities to develop their administrative and leadership talents.

1 2 3 4 5 N/A

Comments:

DRAFT

3


Advocacy and Fund Raising Opportunity

for Development




No Answer

Represents and promotes the interest of Lee Health to accrediting organizations, government, the media and community at large. Works with the Foundation Board to implement a fundraising program that meets established goals. Establishes positive relationships with prospective donors.

1 2 3 4 5 N/A

Comments:

Development of the Leadership Team Opportunity

for Development




No Answer

Leads the organization through example to foster effective leadership committed to Lee Health’s mission and vision. Attracts, develops, retains and motivates a highly qualified leadership team. Builds understanding of and support for the organization’s decisions. Ensures the right leaders are in place to carry out the organization’s strategic direction.

1 2 3 4 5 N/A

Comments:

Role Model for ExceptionalLee Values Opportunity

for Development




No Answer

Demonstrates ExceptionalLee values of Respect, Excellence, Compassion, and Education. Lives the Promise to listen, communicate effectively, embrace empathy, act with compassion and continually improve a safe, caring, comforting and healing environment.

1 2 3 4 5 N/A

Comments:

DRAFT

4

PERFORMANCE FACTOR FEEDBACK and COMMENTS Overall Performance Rating Please provide your overall feedback rating of the PRESIDENT & CEO’s performance.

Opportunity for

Development




No Answer

1 2 3 4 5 N/A Signature of Board Member Date:

BOARD MEETING EVALUATION

ADJOURNMENT

DATE OF THE NEXT

BOARD OF DIRECTORS MEETING

September 26, 2019 1:00 P.M.

Gulf Coast Medical Center Medical Office Building

13685 Doctors Way Ft. Myers, FL 33912