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El Camino Hospital Board of Directors and Invited Hospital Staff Only

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El Camino Hospital Board of Directors and Invited Hospital Staff Only EL CAMINO HOSPITAL BOARD AMENDED AGENDA AND SPECIAL MEETING OF THE BOARD Wednesday, September 11, 2013 5:30 p.m. Location: El Camino Hospital, Conference Rooms, E, F & G, ground floor 2500 Grant Road Mountain View, California and via teleconference: 4100 Lake Tahoe Blvd. South Lake Tahoe, CA 96150 MISSION: To be an innovative, publicly accountable and locally controlled comprehensive healthcare organization which cares for the sick, relieves suffering, and provides quality, cost competitive services to improve the health and well-being of our community. A copy of the amended agenda for the Special Meeting will be posted and distributed at least twenty-four (24) hours prior to the meeting. In observance of the Americans with Disabilities Act, please notify us at 650-988-7504 twenty-four (24) hours prior to the meeting so that we may provide the agenda in alternative formats or to make disability related modifications and accommodations PRESENTED BY I. CALL TO ORDER/ROLL CALL Neal Cohen, MD 5:30 p.m. Board Chair II. POTENTIAL CONFLICT OF Neal Cohen, MD 5:31-5:32 INTEREST DISCLOSURES Board Chair III. BOARD RECOGNITION Resolution 2013-7 Pat Wolfram, VP, public motion The Board will recognize individual(s) who ECH, Los Gatos comment required enhance the experience of the Hospital’s patients and the community. 5:32-5:37 ATTACHMENT 1 IV. PUBLIC COMMUNICATION Neal Cohen, MD 5:37-5:42 A. Oral Comments Board Chair This opportunity is provided for persons in the audience to make a brief statement, not to exceed 3 minutes on issues or concerns not covered by the agenda. B. Written Correspondence V. ACTION Neal Cohen, MD public motion A. Consent Calendar Board Chair comment required All items listed on the Consent Calendar are 5:42-5:44 considered to be routine matters or are considered formal documents covering previous Board instructions. One motion, a second and a vote may enact all of the items listed on the Consent Calendar. There will be no separate discussion of Consent Calendar items unless members of the Hospital Board, Hospital staff or the public request discussion Page 1/534 El Camino Hospital Board Regular Board Meeting September 11, 2013 Page 2 on a specific item at the beginning of the consideration of the Consent Calendar. Approval: Minutes of the Board Meetings: a. Regular Meeting of the Board – July 10, 2013 b. FY 2013 Community Benefit Report Committee Updates: c. Quality, Patient Care, and Patient Experience (David Reeder, Chair) Reviewed and Recommended for Approval by the Finance Committee d. May and June 2013 Financials e. Simplee Agreement f. Travel Policy g. Medical Director, Digestive Health h. Medical Director, Geriatric Psychiatry i. Medical Director, Wellness and Associated On-Call Panel j. Medical Director, Information Technology k. On-Call Panel, Plastic Surgery l. Medical Director, Transcatheter Aortic Valve Replacement m. Surgical Robot Purchase Reviewed and Recommended for Approval by the Investment Committee n. Revised Cash Balance Investment Policy o. Revised Surplus Cash Investment Policy Reviewed and Recommended for Approval by the Medical Staff p. Medical Staff Report (open) Information: q. LG IT Post Activation Review r. July 2013 Financials Acceptance: Committee Minutes (open): s. Finance Committee (May 28, 2013) t. Governance Committee (July 2, 2013) u. Investment Committee (May 13, 2013) v. Quality Committee (June 17, 2013) w. Auxiliary Report x. Foundation Report ATTACHMENT 2 VI. DISCUSSION ITEMS (for possible action): A. Quality Update: Preventable Harm Eric Pifer, MD, Chief Medical information – Infection Control and Antimicrobial Officer 5:44-5:54 Stewardship Dan Shin, MD, Medical ATTACHMENT 3 Director, Antimicrobial PageStewardship 2/534 El Camino Hospital Board Regular Board Meeting September 11, 2013 Page 3 B. Governance Committee Report: Julia Miller, Chair public possible Chair and Vice Chair in Governance Committee comment motion(s) Committees; 5:54-6:04 Revised Agenda Format; Considerations for Closed Session Minutes; Considerations for Executive Sessions in Committee; and Appointment of Ad Hoc Committee ATTACHMENT 4 C. Annual Board Meeting Schedule – Patricia A. Einarson, MD public possible Dark Months Secretary/Treasurer comment motion ATTACHMENT 5 6:04-6:09 D. CEO Report Tomi Ryba information ATTACHMENT 6 President and CEO 6:09-6:14 E. Board Comments Neal Cohen, MD information Board Chair 6:14-6:24 VII. ADJOURN TO CLOSED SESSION 1. Conflict of Interest disclosures relating to Items 2-11 on the Closed Session agenda pursuant to the code provisions listed below. 2. Approval of: - Minutes of the closed session of the Special Meetings of the Board (July 30, 2013), motion required Govt. Code Section 54957.2; Acceptance of: - Minutes of the closed session of the Finance Committee (May 28, 2013), Governance motion required Committee (July 2, 2013), Investment Committee (May 13, 2013), and Quality Committee (June 17, 2013), Govt. Code Section 54957.2. 3. Report of Medical Staff Quality Assurance Committee, Health and Safety Code Section 32155. - Deliberations concerning reports on Medical Staff quality assurance matters motion required - Medical Staff Report 4. Health and Safety Code Section 32106(b) for a report involving health care facility trade secrets. - IT Case for Change information 5. Health and Safety Code Section 32106(b) for a report involving health care facility trade secrets. - FY 2013 Organizational Goal Achievement information 6. Report involving Govt. Code Sections 54957 and 54957.6 for discussion and report on personnel matters. - FY 2014 Foundation President Base Pay information 7. Report involving Govt. Code Sections 54957 and 54957.6 for discussion and report on personnel matters. - Employee Recognition Bonus information 8. Conference with Legal Counsel – pending or threatened litigation, Govt. Code Section 54956.9(d)(1) - Tamara vs. El Camino Hospital, et al. information 9. Health and Safety Code Section 32106(b) for a report involving health care facility trade secrets - Development of New Services and Programs – Continuum of Care Update. information 10. Health and Safety Code Section 32106(b)Page for a report3/534 involving health care facility trade secrets; El Camino Hospital Board Regular Board Meeting September 11, 2013 Page 4 report involving Govt. Code Section 54957 for discussion and report on personnel performance matters; and report of Medical Staff Quality Assurance Committee, Health and Safety Code Section 32155. - CEO Report information 11. Report involving Govt. Code Section 54957 for discussion and report on personnel performance matters. - Executive Session possible motion 12. Adjourn to Open Session ATTACHMENTS 7-16 VIII. RECONVENE OPEN SESSION Neal Cohen, MD 8:33-8:34 To report any required disclosure regarding Board Chair permissible actions taken during Closed Session. IX. FY 2014 Foundation President Base Pay Tomi Ryba, public possible President and CEO comment motion Julie Johnston, Director, 8:34-8:37 Compensation and Benefits X. Service Animal Policy Sheetal Shah, Manager, Risk public possible ATTACHMENT 17 Management and Patient Safety comment motion 8:37-8:40 XI. IT Case for Change Tomi Ryba, public possible President and CEO comment motion Eric Pifer, MD, CMO 8:40-8:45 Greg Walton, CIO XII. ADJOURNMENT Neal Cohen, MD 8:46 p.m. Board Chair PLEASE NOTE: The CLOSED SESSION is limited to the El Camino Hospital Board of Directors and invited Hospital staff only. Page 4/534 Separator Page Att 1 - Resolution 2013-7.pdf Page 7/534 RESOLUTION 2013 - 7 RESOLUTION OF THE BOARD OF DIRECTORS OF EL CAMINO HOSPITAL REGARDING RECOGNITION OF SERVICE TO THE COMMUNITY WHEREAS, the Board of Directors of El Camino Hospital values and wishes to recognize on an ongoing basis the contribution of individuals who enhance the experience of the Hospital’s patients, their families, the community and staff, as well as individuals who in their efforts exemplify El Camino Hospital’s mission and values. WHEREAS, the Board wishes to honor and express heartfelt gratitude to the Los Gatos multi- disciplinary team that worked diligently to become the youngest Primary Certified Stroke Center in Santa Clara County. Achieving Primary Stroke Center Certification signifies an organization’s dedication to fostering better outcomes for stroke patients when every second counts. Because of the persistence and innovation of this team, El Camino Hospital has demonstrated that our Los Gatos campus now meets these critical elements of performance to treat patients suffering from stroke who need immediate assessment and treatment. WHEREAS, the Board would like to recognize these employees who showed unwavering dedication to patient care by working together in a concerted effort to achieve a common goal. This ambitious task took more than a year to complete. Tomi Ryba, Eric Pifer, Michelle McGowFn, Pat Wolfram, and Martin Lesica provided incredible leadership, commitment, and support for the project. Five members of the stroke neurology team graciously monitored the 24 hour coverage, collaborating with other units across campus. The eagerness from nurses throughout the hospital to learn about stroke care was impressive. One Joint Commission Certification reviewer lauded staff for their engagement, describing the level of stroke education they received as phenomenal. Your diligence and attention to detail in your work is commendable. WHEREAS, the Board acknowledges the service of this special group, whose work resulted in elevating our standard of care to the community we
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