December 13, 2019 NOTICE The Board of Directors of the Kaweah Delta Health Care District will meet in an open Board of Directors meeting at 4:15PM on Wednesday, December 18, 2019 in the Memory Care Center at Quail Park at Shannon Ranch – 3440 W. Flagstaff, Visalia. The Board of Directors of the Kaweah Delta Health Care District will meet in a closed Board of Directors meeting at 5:30PM on Wednesday, December 18, 2019 in the Memory Care Center at Quail Park at Shannon Ranch – 3440 W. Flagstaff, Visalia pursuant to Government Code 54956.9(d)(2) Health and Safety Code 32155, 1461, and 32106. The Board of Directors of the Kaweah Delta Health Care District will meet in an open Board of Directors meeting at 6:00PM on Wednesday, December 18, 2019 in the Memory Care Center at Quail Park at Shannon Ranch – 3440 W. Flagstaff, Visalia. The Board of Directors of the Kaweah Delta Health Care District will meet in a closed Board of Directors meeting following the 6:00pm meeting on Wednesday, December 18, 2019 in the Memory Care Center at Quail Park at Shannon Ranch – 3440 W. Flagstaff, Visalia pursuant to Government Code 54956.9(b)(1). All Kaweah Delta Health Care District regular board meeting and committee meeting notices and agendas are posted 72 hours prior to meetings (special meetings are posted 24 hours prior to meetings) in the Kaweah Delta Medical Center, Mineral King Wing entry corridor between the Mineral King lobby and the Emergency Department waiting room. The disclosable public records related to agendas are available for public inspection at the Kaweah Delta Medical Center – Acequia Wing, Executive Offices (Administration Department) {1st floor}, 400 West Mineral King Avenue, Visalia, CA and on the Kaweah Delta Health Care District web page http://www.kaweahdelta.org. KAWEAH DELTA HEALTH CARE DISTRICT Nevin House, Secretary/Treasurer Cindy Moccio - Board Clerk / Executive Assistant to CEO DISTRIBUTION: Governing Board Legal Counsel Executive Team Chief of Staff www.kaweahdelta.org 400 West Mineral King Avenue · Visalia, CA · (559) 624 2000 · www.kaweahdelta.org 1/241 KAWEAH DELTA HEALTH CARE DISTRICT BOARD OF DIRECTORS MEETING Quail Park at Shannon Ranch 3440 W. Flagstaff, Visalia www.KaweahDelta.org Wednesday, December 18, 2019 OPEN MEETING AGENDA {4:15PM} 1. CALL TO ORDER 2. APPROVAL OF AGENDA 3. PUBLIC PARTICIPATION – Members of the public may comment on agenda items before action is taken and after the item has been discussed by the Board. Each speaker will be allowed five minutes. Members of the public wishing to address the Board concerning items not on the agenda and within the subject matter jurisdictions of the Board are requested to identify themselves at this time. 4. APPROVAL OF THE CLOSED AGENDA – 5:30PM 4.1. Approval of closed meeting minutes – November 25, 2019. 4.2. Conference with Legal Counsel – Anticipated Litigation – Significant exposure to litigation pursuant to Government Code 54956.9(d)(2) – 11 Cases – Ben Cripps, Compliance & Privacy Officer and Dennis Lynch, Legal Counsel 4.3. Credentialing pursuant to Health and Safety Code 1461 and 32155, medical staff privileges – Dennis Lynch, Legal Counsel 4.4. Credentialing - Medical Executive Committee requests that the appointment, reappointment and other credentialing activity regarding clinical privileges and staff membership recommended by the respective department chiefs, the credentials committee and the Medical Executive Committee be reviewed for approval pursuant to Health and Safety Code 1461 and 32155 – Byron Mendenhall, MD, Chief of Staff. 4.5. Quality Assurance pursuant to Health and Safety Code 32155 and 1461, report of quality assurance committee – Byron Mendenhall, MD, Chief of Staff 5. TOUR OF QUAIL PARK AT SHANNON RANCH 6. ADJOURN Wednesday, December 18, 2019 Page 1 of 6 Herb Hawkins – Zone I Lynn Havard Mirviss – Zone II John Hipskind, MD – Zone III David Francis – Zone IV Nevin House – Zone V Board Member President Vice President Board Member Secretary/Treasurer MISSION: Health is our Passion. Excellence is our Focus. Compassion is our Promise. CLOSED MEETING AGENDA {5:30PM} 1. CALL TO ORDER 2. APPROVAL OF CLOSED MEETING MINUTES – November 25, 2019 Action Requested – Approval of the closed meeting minutes – November 25, 2019. 3. CONFERENCE WITH LEGAL COUNSEL – ANTICIPATED LITIGATION – Significant exposure to litigation pursuant to Government Code 54956.9(d)(2) – 11 Cases Ben Cripps, Compliance & Privacy Officer and Dennis Lynch, Legal Counsel 4. CREDENTIALING pursuant to Health and Safety Code 1461 and 32155, medical staff privileges. Dennis Lynch, Legal Counsel 5. CREDENTIALING - Medical Executive Committee requests that the appointment, reappointment and other credentialing activity regarding clinical privileges and staff membership recommended by the respective department chiefs, the credentials committee and the Medical Executive Committee be reviewed for approval pursuant to Health and Safety Code 1461 and 32155 – Byron Mendenhall, MD, Chief of Staff. 6. QUALITY ASSURANCE PURSUANT TO HEALTH AND SAFETY CODE 32155 AND 1461, REPORT OF QUALITY ASSURANCE COMMITTEE Byron Mendenhall, MD, Chief of Staff 7. ADJOURN OPEN MEETING AGENDA {6:00PM} 1. CALL TO ORDER 2. APPROVAL OF AGENDA 3. PUBLIC PARTICIPATION – Members of the public may comment on agenda items before action is taken and after the item has been discussed by the Board. Each speaker will be allowed five minutes. Members of the public wishing to address the Board concerning items not on the agenda and within the subject matter jurisdictions of the Board are requested to identify themselves at this time. 4. CLOSED SESSION ACTION TAKEN – Report on action(s) taken in closed session. 5. OPEN MINUTES – Request approval of the November 25, 2019 open board of directors meeting minutes. Action Requested – Approval of the open meeting minutes – November 25, 2019 open board of directors meeting minutes. Wednesday, December 18, 2019 Page 2 of 6 Herb Hawkins – Zone I Lynn Havard Mirviss – Zone II John Hipskind, MD – Zone III David Francis – Zone IV Nevin House – Zone V Board Member President Vice President Board Member Secretary/Treasurer MISSION: Health is our Passion. Excellence is our Focus. Compassion is our Promise. 6. RECOGNITIONS – John Hipskind, MD 6.1. Presentation of Resolution 2061 to Karen Bontekoe - Service Excellence Award – December 2019. 6.2. Presentation of Resolution 2062 to Mary Sisto, RN, Director of Nursing – Rehabilitation and Skilled Nursing retiring from Kaweah Delta – 12 years of service. 6.3. Presentation of Resolution 2063 to Mike Varela, Environmental Services Aide retiring from Kaweah Delta – 19 years of service. 6.4. Presentation of Resolution 2064 to Rose Newsom, RN Director of Nursing Practice retiring from Kaweah Delta – 42 years of service. 6.5. Presentation of Resolution 2065 to John Hipskind, MD in appreciation of his service to the Kaweah Delta Health Care District Board, 2008-2019. 7. STREET MEDICINE - Presentation relative to the Street Medicine Program. Omar Guzman, MD, Director of Undergraduate Medical Education, Department of Emergency Medicine 8. CONSENT CALENDAR - All matters under the Consent Calendar will be approved by one motion, unless a Board member request separate action on a specific item. 8.1. REPORTS A. Medical Staff Recruitment B. Environment of Care C. Compliance 8.2. POLICIES A. HUMAN RESOURCES 1. Special Pay Practices New 2. Standby and Callback Pay 72 Revised 3. Differential Pay-Shift, Holiday, and Weekend 75 Revised 4. Performance Management and Competency Assessment Program 213 Revised 5. Transfers 31 Revised 6. Education Assistance 61 Revised 7. Professional Certification Bonus 50 Deleted 8. Education Assistance and Loan Repayment Awards 51 Deleted 9. Education Programs and Compensation Practice 246 Deleted 10. Educational Leave of Absence 150 Deleted B. COMPLIANCE 1. Physician Contracts and Relationships CP.03 Revised 2. Federal and State False Claims Act and Employee Protection Provisions CP.13 Revised Wednesday, December 18, 2019 Page 3 of 6 Herb Hawkins – Zone I Lynn Havard Mirviss – Zone II John Hipskind, MD – Zone III David Francis – Zone IV Nevin House – Zone V Board Member President Vice President Board Member Secretary/Treasurer MISSION: Health is our Passion. Excellence is our Focus. Compassion is our Promise. 8.3. Recommendation from the Medical Executive Committee (DECEMBER 2019) A. Medical Staff Policy 1) MS45 Initial FPPPE (Proctoring) - Revised B. Privilege Criteria – Revised 1) Anesthesia 2) Nurse Practitioner / Physician Assistant 3) Certified Registered Nurse Anesthetist 4) Emergency Medicine 8.4. The Kaweah Delta Health Care District Board of Directors supports verification as a Level III trauma center by the American College of Surgeons. Kaweah Delta commits to maintain the high standards needed to provide optimal care of all trauma patients. The multidisciplinary trauma performance improvement program has the authority to evaluate care across disciplines, identify opportunity for improvement, and implement corrective actions. 8.5. BOARD BYLAWS – Annual review and approval of amendments to the Board Bylaws. 8.6. Professional Services Agreement second addendum regarding Pediatric Services Agreement and Professional Services Agreement regarding Neonatology and Pediatric Specialty Services effective January 1, 2020. Recommended Action: Approve the December 18, 2019 Consent Calendar. 9. COMMUNITY ENGAGEMENT - Report on the Kaweah Delta Community Engagement Initiative groups. Deborah Volosin, Director of Community