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Board of Commissioners Meeting March 5, 2018 4:00 Pm

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Board of Commissioners Meeting March 5, 2018 4:00 Pm Board of Commissioners Meeting March 5, 2018 4:00 p.m. - France Tower Conference Room A Page 1 of 294 HALIFAX HEALTH BOARD OF COMMISSIONERS MEETING 303 No. Clyde Morris Boulevard, Daytona Beach, FL France Tower Conference Room A 4:00 p.m., March 5, 2018 AGENDA Call to Order Invocation & Pledge of Allegiance Roll Call Mission Statement Page 4 Approval of Minutes (Action) Board of Commissioners Meeting – January 8, 2018 Page 5 Board of Commissioners Meeting – February 5, 2018 Page 13 Approval of Agenda (Action) Medical Staff Report – Dan Miles, MD (Action) Credentials Committee Actions – January & February 2018 Page 15 Management Report – Jeff Feasel Page 26 Strategic & Community Health Planning Committee – Jeff Feasel Page 31 Audit & Finance Committee Report – Eric Peburn (Information only) FY 2018A Floating Rate Notes Page 35 Audit & Finance Committee Minutes – January 2018 Page 36 Investment Committee Minutes – November 2017 Page 39 Investment Performance Report – December 2017 & January 2018 Page 41 Schedule of Uses of Property Taxes – December 2017 Page 51 Capital Expenditures ($25,000 - $50,000) (Working Capital) Page 52 Neonatal Incubator - $43,651 Page 53 Network Access Control Ports - $42,331 Page 55 EEG Cart - $42,177 Page 57 Omnicell Medication Dispensing Cabinet - $31,884 Page 59 Box Truck w/Lift Gate - $26,500 Page 61 Affiliate Activity (Information Only) Sale of Portion of Deltona Parcel (4.888 Acres) Page 63 120 Howland Boulevard - $1,666,000 (cost basis $1,148,876) Deltona Road & Utility Infrastructure (Phase I) Page 63 120 Howland Boulevard - $787,000 ($430,000 to be paid By HH Holdings and $357,000 to be paid by buyer) Consent Agenda (Action) Healthy Communities Board Appointment Page 66 Financial Statements Ended December 2017 Page 67 Financial Statements Ended January 2018 Page 91 Capital Expenditures - $50,000 and Over (Working Capital) Page 116 Cardiac Cath Lab Replacement - $1,488,698 Page 117 Pediatric Telemetry Monitoring System - $428,641 Page 119 Merge Hemodynamics System - $348,604 Page 121 Emergency Power Connection at HHPO - $300,000 Page 123 Access Control - $118,687 Page 125 Hemodialysis & Disinfection Equipment - $57,369 Page 127 Disposals – January & February 2018 Page 128 Audit Reports Page 131 Page 1 of 2 Page 2 of 294 HALIFAX HEALTH BOARD OF COMMISSIONERS MEETING 303 No. Clyde Morris Boulevard, Daytona Beach, FL France Tower Conference Room A 4:00 p.m., March 5, 2018 AGENDA Old Business (Information Only) CIA Dashboard / Update December 2017 & January 2018 Page 133 New Business CIA Resolution Page 137 2018 Infection Control & Risk Assessment Plan Page 140 2018 Performance Improvement Plan Page 162 2017 Performance Improvement Evaluation of Effectiveness Page 186 2018 Patient Safety Plan Page 189 2017 Environment of Care Summary Page 201 Additional Information Deltona Ambulatory Surgery Center (ASC) Update Page 224 Human Resources Reports December 2017 & January 2018 Page 225 Affiliate Minutes Page 227 Public Participation Presentation(s) HBS – Community Action Team (CAT) Program Page 238 Quality Update – 4th Quarter FY 2017 Page 248 HR Turnover / Generational Influence & Workforce Strategy Page 272 Next Meetings – May 7, 2018 - France Tower Conf. Room A 4:00 p.m. - Regular HH Board Meeting Closed Strategic Planning and Litigation meetings to follow (Pursuant to FS 395.3035 & FS 286.001) Adjourn Page 2 of 2 Page 3 of 294 OUR MISSION is to be the community healthcare leader through exceptional talent and superior patient centered service delivered in a financially sustainable manner. OUR VISION is to develop talented teams dedicated to providing competent, accountable patient centered healthcare in a financially sustainable manner. OUR VALUES: Halifax Health will cultivate a positive workplace in which each team member is valued, respected, and has an opportunity for personal and professional growth. We will develop patient centered systems of care. OUR SERVICE PHILOSOPHY: Halifax Health will ensure that those we serve are treated with courtesy and respect in a safe, compassionate, and professional environment. Halifax Health will provide exemplary medical, emotional, and spiritual care for each of our patients and their families. Adopted 7/14/10 4 halifaxhealth.org 9 0 1 - 0 1 5 0 Page 4 of 294 HALIFAX HOSPITAL MEDICAL CENTER BOARD OF COMMISSIONERS MEETING Held at 303 North Clyde Morris Boulevard, France Tower, Daytona Beach, FL January 8, 2018 __________________________________________________________________ Present: Ed Connor, Assistant Secretary (via phone) Dan Francati, Vice Chairman Harold Goodemote, Chairman Carl W. Lentz, M.D., Member Tom McCall, Secretary Glenn Ritchey, Member Susan Schandel, Treasurer Also Present: Mary Jo Allen, Executive Director, Halifax Hospice Kent Bailey, Director of Finance Mark Billings, Exec. VP/Chief Operating Officer Jeanne Connelly, Exec. Director, Physician Services Margaret Crossman, MD, Sr. VP/Chief Medical Officer Ben Eby, Director of Finance, Halifax Hospice Jeff Feasel, President & Chief Executive Officer Kim Fulcher, VP/Chief Human Resource Officer Vivian Gallo, Sr. VP/General Counsel Bill Griffin, Director, System Research & Planning John Guthrie, Director, Communications Ginny Kwong, MD, VP/Chief Medical Information Officer Arvin Lewis, Sr. VP/Chief Revenue Officer Catherine Luchsinger, Chief Nursing Officer Ann Martorano, Chief Communication Officer Dan Miles, MD, President, Medical Staff Steve Miles, MD, Sr. VP/Chief Quality Officer Jacob Nagib, Director, Engineering, Design & Construction Eric Peburn, Exec. VP/Chief Financial Officer Andy Pollock, Chaplain Raphael Ramirez, Market Development Specialist Dee Schaeffer, Executive Director, Healthy Communities Shelly Shiflet, VP/Corporate Compliance Officer Tom Stafford, VP/Chief Information Officer Lisa Tyler, Corporate Controller Alberto Tineo, VP Operations Bob Wade, Board Compliance Expert, Barnes & Thornburg, LLP Raul Zimmerman, MD, Medical Director, Halifax Hospice Mike Finch, Daytona News Journal ____________________________________________________________________________ Chairman Goodemote called the meeting to order at 4:00 p.m. The invocation was given, the Pledge of Allegiance recited, the Mission Statement read, and the roll recorded. ELECTION OF OFFICERS Discussion: Following the Governor’s reappointment of Commissioners Goodemote, Ritchey and McCall to the Halifax Board of Commissioners, Mr. Goodemote advised that election of offices would be held. Halifax Health Board of Commissioners – January 8, 2018 - Page 1 Page 5 of 294 Action: Mr. Ritchey moved to keep the current slate of officers (see below). Mr. Francati seconded the motion. Carried unanimously. Chairman, Harold Goodemote Vice Chairman, Dan Francati Treasurer, Susan Schandel Secretary, Tom McCall Assistant Secretary, Ed Connor APPROAL OF MINUTES Discussion: Mr. Goodemote requested approval of the minutes from the November 6, 2017 Board of Commissioners Meeting. Action: Mrs. Schandel moved to approve minutes as presented. Mr. McCall seconded the motion. Carried unanimously. APPROVAL OF AGENDA Action: Mr. Ritchey moved to approve the agenda. Mrs. Schandel seconded the motion. Carried unanimously. MEDICAL STAFF REPORT Credentials Committee Actions – November & December 2017 Discussion: Dr. Miles advised that the following physicians were in attendance to satisfy the personal appearance requirement and that each had been approved previously by the board: John Conboy, MD Uril Greene, MD Ameigh Worley, MD Discussion: Dr. Miles requested approval of the following physician applications as recommended by the Credential Committee: Michael Black, Anesthesiology, Associate Action: Mr. Francati moved to approve application for Dr. Michael Black. Mrs. Schandel seconded the motion. Carried unanimously. Gary DeCesare, Plastic & Reconstructive Surgery, Associate Action: Mr. Francati moved to approve application for Dr. Gary DeCesare. Mrs. Schandel seconded the motion. Carried unanimously. Michael Harrington, MD, General Surgery, Associate Action: Mr. Ritchey moved to approve application for Dr. Michael Harrington. Mr. Francati seconded the motion. Carried unanimously. William Kendall, MD, Transplant Surgery, Associate Action: Mrs. Schandel moved to approve application of Dr. William Kendall. Mr. Francati seconded the motion. Carried unanimously. Jennifer Kirkman, MD, Medicine/Family Medicine, Associate Action: Dr. Miles advised that Dr. Kirkman was unable to attend and requested board approval with the understanding that Dr. Kirkman will make a future appearance before the board. Mr. Ritchey moved to approve Halifax Health Board of Commissioners – January 8, 2018 - Page 2 Page 6 of 294 application of Dr. Kirkman. Mr. Francati seconded the motion. Carried unanimously. Samuel Miller, MD, Family Medicine, Associate Action: Mrs. Schandel moved to approve application of Dr. Samuel Miller. Mr. Francati seconded the motion. Carried unanimously. Jessica Popelka, MD, Surgery/Podiatry, Associate Action: Mrs. Schandel moved to approve application of Dr. Jessica Popelka. Mr. Francati seconded the motion. Carried unanimously. Zachary Tyser, MD, OB/GYN, Associate Action: Mr. Ritchey moved to approve application of Dr. Zachary Tyser. Mr. Francati seconded the motion. Carried unanimously. Karl Unkenholz, MD, Emergency Medicine, Associate Action: Mrs. Schandel moved to approve application of Dr. Karl Unkenholz. Mr. Francati seconded the motion. Carried unanimously. H. Cory Weitzner, MD, Anesthesiology,
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