BOARD OF DIRECTORS

GOVERNANCE Committee of the Whole

MEETING

February 5, 2009, 1:00pm Lee Memorial Hospital Boardroom

2776 Cleveland Ave, Ft. Myers, FL 33901

ELECTRONIC BOARD PACKET

ALL MEETINGS ARE OPEN TO THE PUBLIC AND THE PUBLIC IS INVITED TO ATTEND Any Public Input pertaining to an agenda item is limited to three minutes and a

“Request to Address the Board of Directors” card must be completed and submitted to the Board Assistant prior to the meeting.

LEE MEMORIAL HEALTH SYSTEM BOARD OF DIRECTORS

GOVERNANCE COMMITTEE OF THE WHOLE

MEETING

Thursday, February 5, 2009 1:00 p.m.

Lee Memorial Hospital Boardroom

AGENDA

1. CALL TO ORDER (Lois Barrett, MBA, Governance Chair) The meeting of the Governance Committee of the Whole of the Lee Memorial Health System Board of Directors will be called to order. Matters concerning the business of Lee Memorial Health System consisting of Southwest Florida Regional Medical Center/Gulf Coast Hospital & Lee Memorial Hospital/HealthPark Medical Center and its subsidiaries (HealthPark Care Center, Inc., Lee Memorial Home Health, Inc., Cape Memorial Hospital, Inc. doing business as Cape Coral Hospital, and Lee Memorial Medical Management, Inc.) may be reported, discussed and recommended by the Committee of the Whole, then referred to the full Board of Directors for final action.

2. PUBLIC INPUT: Any public input pertaining to items on the Agenda is limited to three minutes and a “Request to Address the Board of Directors” card must be completed and submitted to the Board Assistant prior to meeting.

3. Consent Agenda (Approval) A. October 2, 2008 Governance Committee Meeting Minutes B. FY 2009, 1st Quarter Board of Directors Budget

4. Smoke-Free/Tobacco Free LMHS Campuses/Properties (Approval) (Jon Cecil, Chief Human Resources Officer - 30 min)

5. FY 2008, 4th Quarter Compliance Report (Accept) (Charles Swain, Chief Compliance and Internal Audit Officer – 10 min)

6. Board of Directors Policies: (Cathy Stephens, Board Liaison – 10 min) • 10.10D Orientation of New Directors (Adoption)

• 10.27D Reporting and Accreditation of System Entities (Adoption)

• 10.52B Community Representatives (Adoption)

7. LMHS CEO/President Contract (Approval) (Jim Humphrey, Board Counsel - 30 min)

8. 2009 Board of Directors Liaison and Committee Appointments (Accept) (Richard Akin, Board Chairman - 15 min)

9. Full Board Meeting Location (Lois Barrett, MBA, Governance Chair) (Discuss)

10. Other Items (Cathy Stephens, Board Liaison) • Public Request – Teleconference • Board Representation at System Events

11. Date of the next REGULAR Governance Committee of the Whole: Thursday, May 7, 2009, 1:00 p.m. Lee Memorial Hospital Boardroom, 2776 Cleveland Avenue, Fort Myers

12. ADJOURNMENT of GOVERNANCE COMMITTEE

Bf/BOD/PRESENTATIONS/2009/020509 Governance Committee Agenda

___________________ L E E M E M O R I A L HEALTH SYSTEM

BBBOOOAAARRRDDD OOOFFF DDDIIIRRREEECCCTTTOOORRRSSS

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 must be completed and submitted to the Board Assistant

prior to meeting.

Refer to Board Policy: 10:15E: 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 seven (7) days prior to the meeting to allow staff time to prepare and to insure the matter is within the jurisdiction of the Board.

Governance Committee of the Whole

February 5, 2009

3. Consent Agenda: (Approval)

A. October 2, 2008 Governance Committee Meeting Minutes

B. FY 09 1st Quarter

Board of Directors Budget

LEE MEMORIAL HEALTH SYSTEM BOARD OF DIRECTORS GOVERNANCE COMMITTEE MEETING MINUTES

Thursday, October 2, 2008 LOCATION: Lee Memorial Hospital Boardroom, 2776 Cleveland Avenue, Fort Myers, FL 33901 MEMBERS PRESENT: Nancy McGovern, RN, MSM, Vice Chairman/Governance Chairman; John Donaldson, M.D., Board Chairman; Richard Akin, Board Treasurer; Lois C. Barrett, MBA, Board Secretary; Linda L. Brown, MSN, ARNP, Director; Marilyn Stout, Director; Kerry Babb, Director; James Green, Director; Jason A. Yost, Director; Frank T. La Rosa, Director OTHERS PRESENT: Jim Nathan, CEO/President; Jim Humphrey, Board Counsel/Fowler, White, Boggs, Banker; Alison Ash, Esq./Fowler, White, Boggs, Banker; Cathy Stephens, Board of Directors’ Liaison; Mary McGillicuddy, Chief Legal Officer; Jon Cecil, Chief Human Resources Officer; Dawson McDaniel, Guest (incoming Board member); Lynn Rosko, Guest; Bob Johns, Guest; Isabel Firth, Administrative Secretary/Board of Directors; Beth Finney, Executive Secretary/Board of Directors

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.lememorial.org/boardofdirectors, for public inspection.

SUBJECT DISCUSSION ACTION FOLLOW-UP MEETING CALLED

TO ORDER The meeting of the Governance Committee of the Whole

of the Lee Memorial Health System (LMHS) Board of Directors was CALLED TO ORDER by Vice Chair Nancy

McGovern, RN, MSM at 1:13 p.m.

The Board sits as the Lee Memorial Health System Board of Directors of Southwest Florida Regional

Medical Center (SWFRMC)/Gulf Coast Hospital (GCH) & Lee Memorial Hospital (LMH)/HealthPark Medical Center

(HPMC) and its subsidiaries (HealthPark Care Center, Inc., Lee Memorial Home Health, Inc., Cape Memorial Hospital, Inc. doing business as Cape Coral Hospital (CCH), and Lee Memorial Medical Management, Inc.)

may be reported, discussed and recommended by the Committee of the Whole, then referred to the full Board

of Directors for final action.

PUBLIC INPUT ITEMS Nancy McGovern announced Lynn Rosko has submitted a “Public Request to Address the

Board of Directors” card (Exhibit 1) and then invited Lynn to speak. Lynn Rosko introduced herself and said she has an ongoing issue with LMHS regarding the use of her husband’s social security number as a form of patient identification and she is concerned with the possibility of identity theft. Lynn said she has made several attempts through phone calls and letters to address her issue and received no response until recently; in a letter sent by Cathy Stephens on behalf of Stanley Padfield which addresses the standard use of her husband’s social security number as a patient identifier. Additionally, Lynn said she has been in contact with the Agency for Healthcare Administration (AHCA) and they informed her there is no legal requirements stating that LMHS must use a social security number as a form of identification. Lynn said as a result of her conversation with AHCA, she is requesting her husband’s social security number be removed from all patient information and files. Members of the Board and Jim Nathan apologized for the lack of communication however explained to Lynn the process for addressing such matters were followed correctly. Mary McGillicuddy assured Lynn this information has been referred to the legal department and they are currently in the process of researching the legal requirements for using a patient’s social security number as a method of identification. There was further discussion with regard to handling complaint letters in the Board office and distribution methods to Board members. Mary McGillicuddy returned to the meeting to advise Mrs. Rosko that LMHS has just clarified with AHCA that upon signature of her request, Lynn and her husband may remove their Social Security number from all future medical records. Mary said in addition, LMHS will request the Rosko’s to sign a release relinquishing LMHS being liable for any patient identification issues in the future. Lois Barrett requested additional information regarding patient social security numbers being used on medical bills.

Legal follow up with the Board regarding patient social security numbers as identifiers.

LEE MEMORIAL HEALTH SYSTEM BOARD OF DIRECTORS GOVERNANCE COMMITTEE OF THE WHOLE MEETING MINUTES Thursday, October 2, 2008 Page 2 of 3

SUBJECT DISCUSSION ACTION FOLLOW-UP MEETING MINUTES Lois Barrett asked if anyone wished to make any corrections or deletions to the

August 14, 2008 Governance Committee of the Whole Meeting Minutes. A motion was made by Lois Barrett to approve the August 14, 2008 Governance Committee of the Whole Meeting Minutes. The motion was seconded by Jason Yost and it carried with no opposition.

FY 2008 CEO/ PRESIDENT

EVALUATION RESULTS

Jon Cecil reviewed the FY 2008 CEO/President Evaluation Results (Exhibit 2).

A motion was made by Jason Yost to accept the FY 2008 CEO/President Evaluation Results (Exhibit 2). The motion was seconded by Linda Brown and it carried with no opposition.

2008 BOARD

COUNSEL EVALUATION

RESULTS

Cathy Stephens reviewed the 2008 Board Counsel Evaluation Results (Exhibit 3). A motion was made by Jason Yost to accept the 2008 Board Counsel Evaluation Results (Exhibit 3). The motion was seconded by Linda Brown and it carried with no opposition.

BOARD

SELF-EVALUATION RESULTS

Cathy Stephens reviewed the 2008 Board Self-Evaluation Results (Exhibit 4). Discussion ensued with regard to the scoring system and using ‘neutral’ as a choice for scoring.

There was also discussion regarding the electronic board packets. John Donaldson said for those who do not wish to access their Board packet electronically from the LMHS website they can request a hard copy from the Board office.

A motion was made by John Donaldson to accept the 2008 Board Self-Assessment Results (Exhibit 4). The motion was seconded by Linda Brown and it carried with no opposition.

AMERICAN HOSPITAL

ASSOCIATION UPDATE

Linda Brown reviewed highlights of the American Hospital Association Journal, Trendwatch (Exhibit 5), which provides information regarding the excessive administrative costs associated with quality surveying and certifications. She said much of the information being gathered through these expensive surveys is being duplicated through various surveying groups. She said in response, the American Hospital Association (AHA) is working toward consolidating this mass amount of information into one single program. She said this consolidation of information will cut costs and improve quality and outcome measurement on a national level. Discussion ensued.

BOARD POLICIES

10.15E:

PUBLIC ADDRESSING THE BOARD

40.10G: BOARD LIAISON/

ASSISTANT TO BOARD EVALUATION

Cathy Stephens reviewed proposed revisions being made to Board Policy 10.15E: Public Addressing the Board (Exhibit 6). Discussion ensued with regard to increasing length of time allowed for the public to address the Board on items pertaining to the agenda and relevance of public input. Frank La Rosa said it is important for members of the community to be able to address their concerns openly during Board meetings. John Donaldson said the Board’s role is to provide policy and oversight rather than managing day-to-day issues. He said LMHS has a great management team in place to handle issues and channel problems and issues to the appropriate people to handle.

Cathy Stephens reviewed revisions made to Board Policy 40.10G: Board Liaison/Assistant to the Board Compensation and Performance Review (Exhibit 7).

A motion was made by Marilyn Stout to adopt revised Board Policy 10.15E: Public Addressing the Board (Exhibit 6). The motion was seconded by Linda Brown and it carried with no opposition. A motion was made by Marilyn Stout to adopt revised Board Policy 40.10G: Board Liaison/Assistant to the Board Compensation and Performance Review (Exhibit 7). The motion was seconded by James Green and it carried with no opposition.

DISCUSSION ITEMS:

BOARD POLICY 20.14E: TRAVEL

EDUCATION EXPENSES

GULF COAST “MEDICAL CENTER”

Cathy Stephens said at the August 14th Governance meeting the Board discussed the allocation of funds for Board travel. She submits said Board Policy 20.14E: Travel Education Expenses (Exhibit 8) to the Board, which explains the allocation of funds for individual and group travel. Discussion ensued.

Marilyn Stout said she was made aware of a “Gulf Coast Medical Center” in Panama City, FL and is concerned with possible legal issues that may occur with using this name for the

LEE MEMORIAL HEALTH SYSTEM BOARD OF DIRECTORS GOVERNANCE COMMITTEE OF THE WHOLE MEETING MINUTES Thursday, October 2, 2008 Page 3 of 3

SUBJECT DISCUSSION ACTION FOLLOW-UP NAMING COINCIDENCE

TELECONFERENCING INTO BOARD AND

COMMITTEE MEETINGS

FACILITY NAMING UPDATES

BOARD ANNUAL ORGANIZATIONAL

MEETING LOCATION

‘DRAFT’ BIO/QUESTIONNAIRE FOR BOARD OFFICER POSITION INTEREST

new Gulf Coast facility on Metro Parkway. Mary McGillicuddy said the legal name on the license will be “Gulf Coast Medical Center Lee Memorial Health System” therefore eliminating any legal issues and LMHS has already clarified any naming issues with the Agency for Healthcare Administration (AHCA). Further discussion ensued regarding naming and branding of LMHS facilities; Anne Rose added this topic is being brought back to the November 13th Planning Committee of the Whole Meeting for further discussion.

Cathy Stephens said in the past we have made arrangements for Board members to participate in meetings via teleconference if unable to attend. She said she has received several complaints from Board members who have felt the teleconferencing is a distraction during the meeting. Cathy asked the Board to discuss their opinions on this matter. James Green said teleconferencing provides accessibility to those who may not be able attend meetings due to scheduling issues. He said the ability for those to teleconference is essential to maintaining an active and engaged Board. Discussion ensued with regard to improving teleconferencing communication and future possibilities of video conferencing. John Donaldson said he will work with Mike Smith to discuss for possible networking changes and improvements. Lois Barrett said she is concerned with the naming and labeling of LMHS facilities. Jim Nathan reminded the Board that Marketing will be providing an update on the facility naming and labeling project each month during the Planning Committee meeting. He said there will not be a report provided at the September Planning meeting since the entire meeting is devoted to the facility planning however if time allows, Marketing could provide a brief update on the project.

Cathy Stephens announced the LMHS Board of Directors Annual Organizational meeting will be held Tuesday, January 6, 2009 at the Lee County Public Education Center. She said due to scheduling conflicts we will not be able to hold this meeting at its normal 3:00pm time. She said if we choose to use this facility for this meeting we will need to change the meeting time to 12:00pm. All members of the Board agreed on changing the time for the Annual Organizational meeting to 12:00pm. Cathy reminded the Board in August they requested a survey be created to gather information from the Board with regard to those wishing to run for an officer position. She requested the Board review the ‘Draft’ Board Officer Position Survey (Exhibit 9) submitted for suggestions and/or changes before being submitted to the Board for completion by December 15, 2008. The committee agreed this document is fine.

Mike Smith research possibilities to improve teleconferencing in Board meetings.

TIME SENSITIVE

ISSUES Cathy Stephens reminded the Board of the upcoming Doc Coggins Award Gala on Saturday, October 4th. She asked for all Board members to arrive at the Gulf Harbour Clubhouse by 5:00pm to greet the Doc Coggins winners as they arrive by limousine.

OTHER ITEMS There were NO “Other Items” to be discussed.

ADJOURNMENT The Governance Committee of the Whole meeting

was ADJOURNED by Governance Chairman Nancy McGovern, RN, MSM at 2:51pm.

Minutes were recorded by Beth Finney, Executive Secretary/ Board of Directors Office ___________________________________________ Lois C. Barrett, MBA Board Secretary

BOARD OF DIRECTORS QUARTERLY BUDGET REPORTFY2009 1st Quarter Oct - Dec, 2008 Manager: Stephens

Expenses YTD ACTUAL 2009 BUDGETSalaryProductive Salary 32,959 135,944NonProductive Salary (Benefits & Vacation) 33,978 159,494

Total Salaries 66,937 295,438Supplies (Variable)

840000 Office/Copy/Photo/Computer 1,872 6,000843000 Education Supplies/Books 2 150850000 Raw Food Costs - Catering Charges* 639 3,000850000 Raw Food Costs - Meal Tickets* LEE MEMORIAL HOSP ONLY *N/A at this time

Total Supplies (Variable) 2,513 9,151Other (Fixed)

822000 Legal Exp-Non Professional - Legal Fees 465 400825000 Legal Exp - Professional Attorney Fees 10,658 40,000846000 Adv/Mktg-Production 0 200858000 Special Events-Doc Coggins 8,834 14,000864000 Subscriptions 50 200865000 Scholarships/Donations 0 500868100 Cellular Phone 162 700880000 Education & Travel 4,191 49,500880100 Mileage Reimbursement 24 1,500881200 Business Meeting & Expense 1,919 8,000960000 Postage Expense 152 600

Total Other (Fixed) 26,455 115,600Purchased Services (Fixed)

845700 Purchased Svs - Printing 67 350845950 Purchased Svs - Courier 1,030 5,000

Total Purchased Services (Fixed) 1,097 5,350Purchased Services (Variable)

845800 Purchased Svs - Equip Rental 24 111 Total Purchased Services (Variable) 24

Total Expenses 97,026 425,650Budget/2009 Presentation Board Budget YTD/1st Qtr presented to Governance Committee 02/05/09

______________ L E E M E M O R I A L HEALTH SYSTEM

BBBOOOAAARRRDDD OOOFFF DDDIIIRRREEECCCTTTOOORRRSSS RECOMMENDED ACTION FOR BOARD APPROVAL

(Action includes Acceptance, Approval, Adoption, etc)

Keep form to one page, SUBMIT (thru SLC Member) ELECTRONICALLY to L Drive – Miscellaneous - BOD Presentations by Noon the Friday before you’re scheduled on agenda.

DATE: February 5, 2009 LEGAL SERVICE REVIEW? YES____ NO__X__

SUBJECT: Smoke-Free Campuses/Properties

REQUESTOR & TITLE: Jon Cecil, CHRO

PREVIOUS BOARD ACTION ON THIS ITEM (IF ANY) (justification and/or background for recommendations – internal groups which support the recommendation i.e. SLC, Operating Councils, PMTs, etc.)

Board discussion with several board members expressing desire to pursue system-wide Smoke-Free (Tobacco-Free) campuses and properties. Board tabled further action for approximately 6 months to the February 2009 Governance Committee meeting while requesting Administration continue its efforts to reduce smoking use among LMHS employees.

SPECIFIC PROPOSED MOTION:

Establish a system-wide committee to develop a plan for Tobacco-Free campuses/properties. Tobacco-free includes all uses of tobacco whether smoked or chewed. The planning process would include a board member, physician, management, clinical and non-clinical staff, Auxilian (volunteer) and community representatives. Report back to the LMHS Board of Directors through either the Quality or Planning Committee no later than March with a specific recommendation including a date for implementation.

PROS TO RECOMMENDATION

Based on research of other health system successful implementation of tobacco-free campuses/properties requires a well designed, comprehensive program with adequate time to implement and stakeholders input to assure program acceptance and sustainability.

CONS TO RECOMMENDATION

Program planning will result in a time period that may or may not be acceptable to board members.

LIST AND EXPLAIN ALTERNATIVES CONSIDERED

LMHS has done considerable research of other health care organizations’ tobacco free campuses/properties reviewing the pros and cons and opportunities for success. Rapid or not well planned/communicated tobacco-free programs have resulted in a high degree of failure.

FINANCIAL IMPLICATIONS Budgeted ____ Non-Budgeted _X___ (including cash flow statement, projected cash flow, balance sheet and income statement) Program recommendation will include a financial analysis, budget proposal, and educational and preliminary promotional plan.

OPERATIONAL IMPLICATIONS (including FTEs, facility needs, etc.)

A system wide program plan will take considerable time and resources to develop.

SUMMARY

A comprehensive program plan is needed for the Board of Directors to decide if, when and how LMHS is to achieve Tobacco-Free Campuses and all health system properties. Approval of a process to finalize this plan is requested at the Governance Committee.

BOD/Forms/Board (Action) Reporting Form - revised 6/16/08 cs

LEE MEMORIAL HEALTH SYSTEM BOARD OF DIRECTORS POLICY MANUAL no. 10.25B supersedes no. 10.25A ------------------------------------------------------------------------------------------------------------------------------------- category: General Operations

title: No Smoking Policy ------------------------------------------------------------------------------------------------------------------------------------- original adoption: 01/08/91 review date: 08/02/07

revision date: 07/31/98, 07/26/02 -------------------------------------------------------------------------------------------------------------------------------- PURPOSE: To promote a healthful environment by limitation of smoking in the Health System. -------------------------------------------------------------------------------------------------------------------------------- POLICY: The Board of Directors of Lee Memorial Health System directs there be no smoking in any System facility As a healthcare institution, Lee Memorial Health System has a responsibility to encourage good health practices, to protect the lives and well-being of its patients and to respect the rights of non-smokers to breathe smoke-free air. Policy: - Smoking is prohibited indoors in all Health System facilities. - Smoking is permitted only in designated areas outside of Health System facilities.

Smoking is prohibited in all other exterior areas. - An employee who smokes in an unauthorized area, but not an unsafe or hazardous

area, is subject to the progressive corrective action process. - Smoking is prohibited in any room, ward or compartment where oxygen, flammable

liquids, or combustible gases are used or cylinders (E) stored, and in any other hazardous location. An employee who smokes in a hazardous area is subject to immediate termination, since this is deemed to be outrageous conduct.

This policy is adopted and in conjunction with and does not replace the general smoking policies of the Health System.

V:\PRESENTATIONS\2009\Governance\020509 Governance\10.25B POLICY 10.25B No Smoking Policy Appr 7-26-02.doc Page 1 of 1

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

Keep form to one page, SUBMIT (thru SLC Member) ELECTRONICALLY to L Drive – Miscellaneous - BOD Presentations by Noon the Friday before you’re scheduled on agenda.

DATE: January 30, 2009 LEGAL SERVICE REVIEW? YES____ NO____

SUBJECT: Quarterly Compliance Report

REQUESTOR & TITLE: Charles Swain, Chief Compliance and Internal Audit Officer

PREVIOUS BOARD ACTION ON THIS ITEM (IF ANY) (justification and/or background for recommendations – internal groups which support the recommendation i.e. SLC, Operating Councils, PMTs, etc.) The Compliance Program Board Policy 10.47A requires quarterly updates summarizing compliance activities. SPECIFIC PROPOSED MOTION: Acceptance of the Quarterly Compliance Report for period October 1, 2008 – December 31, 2008. PROS TO RECOMMENDATION

CONS TO RECOMMENDATION

LIST AND EXPLAIN ALTERNATIVES CONSIDERED N/A

FINANCIAL IMPLICATIONS Budgeted ____ Non-Budgeted ____ (including cash flow statement, projected cash flow, balance sheet and income statement) N/A OPERATIONAL IMPLICATIONS (including FTEs, facility needs, etc.) N/A SUMMARY This report highlights the Compliance Department activities for the quarter. There were no significant compliance issues or concerns that needed to be brought specifically to the attention of the LMHS Board. The compliance activities are organized under the seven elements of a compliance program as contained in the guidelines issued by the Department of Health and Human Services, Office of Inspector General.

BOD/Forms/Board (Action) Reporting Form - revised 6/16/08 cs

Compliance Report

Reporting Period: October 1, 2008 – December 31, 2008 Status of the Seven Compliance Elements

Element # 1: Written Policies and Procedures.

• There were no policies due for revision or update by Compliance in the online Policy and

Procedure Manual during this reporting period, and no new policies were added.

Element # 2: Compliance Officer and Compliance Committee.

• Compliance Officer’s activities and accomplishments are contained in other compliance elements that follow.

Element #3: Education.

• Compliance training including the LMHS Standards of Conduct continues to be part of new employee On-Boarding Orientation and is part of the orientation offered to volunteers and by Medical Staff Services to new physicians.

• The Compliance Program Guidelines section in the Mandatory Education Module was

updated for 2009.

Element #4: Communication.

A total of 81 issues came to the Compliance Department during the quarter. • Seventeen of the 81 issues were calls that came to the LMHS Hotline. The allegations

involved 11 Human Resource matters, two Legal, Risk and Safety issues, and two Timekeeping matters. Two additional calls were informational (Callers seeking clarification regarding various issues). One of the 17 calls reporting issues was substantiated.

• Sixty-four of the 81 issues came directly to the Compliance Department.

o Fifty three issues categorized as Guidance were inquiries from employees

who wanted to verify that they were doing the right thing before proceeding with an action. Nineteen of these inquiries involved questions regarding the Employee Conflict of Interest Questionnaire.

o Eleven issues that came to the Compliance Department potentially involved

compliance violations.

1

A breakdown of the 11 issues received during the quarter October 1, 2008 – December 31, 2008 is as follows: Issue Category

Brought Forward

Received

Resolved

Carried Forward

Billing, Documentation and Coding 0 1 0 1 Conflict of Interest/Inducements 0 1 1 0 HIPAA/Patient Confidentiality 0 0 0 0 Human Resources/Benefits/Miscellaneous 0 1 1 0 Human Resources/Employee Relations 0 4 4 0 Legal Interpretations/Risk and Safety 2 2 1 3 Other 0 2 2 0 Patient Care 0 0 0 0 Payroll/Timekeeping 0 0 0 0 Physician Matters 0 0 0 0

TOTAL 2 11 9 4

Appendix I contains a summary, by category, of the issues received directly by Compliance during the quarter.

Element #5: Enforcement/Disciplinary Actions.

• Excluded Party Search System (EPSS) – The Compliance department screened all new employees against the Office of Inspector General and the U.S. General Services Administration databases to be certain they are eligible for participation in Federal healthcare programs. The screening revealed an exclusion for a sanctioned individual who had not applied for reinstatement. Corrective action was taken resulting in the employee’s termination. During this period, a semi-annual exclusion check was also completed for all employees. Medical Staff Services performed a monthly screen of physicians and provided the results to the Compliance Department.

Element #6: Auditing and Monitoring.

• Several items on the Compliance Work Plan are in progress. No reports were issued during the quarter.

Element #7: Pending Actions/Initiatives and Corrective Actions.

• A Hotline allegation regarding timekeeping resulted in corrective action. • A sanctioned employee was terminated. • A vendor’s business privileges were reinstated at LMHS following corrective action by

the vendor’s company.

2

3

APPENDIX I Summary of 11 Cases Received by Category: Billing, Coding and Documentation 1 issue received regarding improper billing is being investigated. This issue remains open.

Conflict of Interest/Inducements 1 issue involved a potential conflict of interest regarding a hospital bill. This issue was unsubstantiated. Health Insurance Portability and Accountability Act (HIPAA) - Patient Confidentiality There were no issues reported to Compliance. Human Resources/Benefits/Miscellaneous 1 issue received involved the process for validating information submitted to the Employee Crisis Fund. This issue was substantiated. Human Resources/Employee Relations 4 issues received involved allegations regarding wrongful termination, solicitation, preferential treatment, and falsification of records. Three of the issues were substantiated. Legal Interpretations, Risk Management and Safety 2 issues received involved an allegation of inappropriate marketing practices by a Home Health Agency (HHA) and HHA regulations regarding remuneration. An issue regarding compliance with Fair and Accurate Credit Transaction Act/Red Flag Rules brought forward from the previous quarter was closed as substantiated. An issue regarding recruiting invoices from an independent contractor brought forward from the previous quarter remains open. 3 issues remain open and will be closed next quarter. Other 2 issues involved unethical conduct by vendor and use of classroom space. Both issues were substantiated. Patient Care There were no reported issues. Payroll/Timekeeping There were no reported issues. Physician Matters There were no reported issues.

BdRpt 100108 - 123108.doc

10.10D - DRAFT - Orientation of New Directors.doc Page 1 of 4

LEE MEMORIAL HEALTH SYSTEM BOARD OF DIRECTORS POLICY MANUAL no. 10.10 D C Supersedes 10.10C

------------------------------------------------------------------------------------------------------------------------- category: General Operations

title: Orientation of New Directors ------------------------------------------------------------------------------------------------------------------------- original adoption: 01/08/91 review date: 02/05/09

revision date: 03/27/92, 07/31/98, 07/26/02, 02/26/09 ------------------------------------------------------------------------------------------------------------------------- PURPOSE: To ensure proper orientation of new Board members. ------------------------------------------------------------------------------------------------------------------------- POLICY: The following Board Member Orientation program will be provided new members of the Board of Directors (Attachment 1 & 2).

10.10D - DRAFT - Orientation of New Directors.doc Page 2 of 4

Attachment #1

BOARD MEMBER ORIENTATION Who? Date Completed

/Comments Upon election these should be completed by BOARD ASSISTANT:

Board Assistant

Contact New Member, schedule orientation Schedule swearing-in ceremony Oath of Office Letter of Acceptance 4. Commission Fee & Bond. Personnel Advice Form (PAR) W-4 Photo identification badge Order business cards/e-mail address Order nameplate & decorative badge Order stationery Photo placed in facilities 13. Parking sticker Schedule of meetings Board Assistant WEB Sign Up – Email policy/training BOARD MEMBER: 15. Curriculum Vitae or Resume Board Member 8. Professional photo appointment. New Board Member Materials (Board Assistant): The following should be given to Board Member:

1. 3 ring Binder containing: Board Assistant Enabling Legislation Board Bylaws Medical Staff By-laws Organization Chart Policy Manual Conflict of Interest Statement Strategic Plan Document with Service Line Plans

2. Publications Board Assistant Government in Sunshine Manual Order form for Periodicals Healthcare Acronyms Booklet Phone Directory Library Information Liaison List Minutes from previous 3 months Board Goals List **B.O.-Board Assistant Staff **B.M.=Board Member

10.10D - DRAFT - Orientation of New Directors.doc Page 3 of 4

Attachment #2 BOARD MEMBER ORIENTATION

Board Member should schedule the following meetings (with assistance of Board Assistant Staff where needed preferably within six months of election or appointment):

Date Completed

CONTACT INFO

Board Liaison/Assistant to the Board – Review the documents and information which is given to Board Member by the Board Assistant Staff per list. Brief new member on any current issues before the Board. Assist in any way possible. Provide an introduction to facilities.

Cathy Stephens 334-5370 Assistants:

Isabel Firth & Beth Finney Chief Executive Officer (CEO)– Organization’s history. Role of Board and

Board Members. Healthcare nationally and locally – key challenges facing Lee Memorial Health System, leadership structures, relationship with Lee Healthcare Resources, Naples Community Hospital, Sarasota Memorial Health System and others.

Jim Nathan Office: 985-3500

Assistant: Heidi MacLean

Chief Financial Officer (CFO) – Copies of budget, most recent audit report, three (3) months financial and statistical reports. Discuss performance relative to budget, major financial issues, investment policies, etc.

John Wiest 772-6542

Assistant: Cathy Adorno Chief Human Resources Officer – Discuss current issues with staffing,

recruitment, confidentiality and any other areas of concern. Provide information on employee benefits available to Board Members.

Jon Cecil 772-6597

Assistant: Sue Gillish Chief Patient Care Officer – Discuss areas of responsibility including patient

care organization and structure, staffing, clinical specialties, challenges and successes.

Donna Giannuzzi, RN 343-5473

Assistant: Angie Barroso Chief Medical Officer, Clinical & Quality Service – Provide Performance

Improvement update Manual and documents Describe describing the Performance Improvement System, explaining the purpose of same and including a description of the WAVE initiative. Discuss Medical Staff Services and Credentialing function as it relates to the Board’s role.

Chuck Krivenko, MD 985-3572

Assistant: Sherri Brusco

Chief Ambulatory (Outpatient) & Strategic Services – Review and discuss Strategic Plan. Provide information on Lee Physician Group, Lee Physician Services, Bonita Community Health Center, Outpatient Services. , and any other areas.

C.B. Rebsamen, MD 985-3510

Assistant: Vickie Lane

Chief Administration Officers (CAO): All Facilities Tour facility and review any pertinent information related to specific acute care facility.

HP – Donna Giannuzzi, RN 343-5473 LMH – Gaile Anthony, RN 334-5364

CCH – Larry Antonucci MD 573-5630 SWR/GCMC – Doug Luckett 939-8430

Chief Legal Officer – Discuss any ongoing litigation and provide background information. Review Government in the Sunshine Manual and Conflict of Interest Policy.

Mary McGillicuddy 334-5382

Assistant: Josephine Desibia Corporate Compliance Officer – Copy of most recent Compliance Report.

Explain role within system, list of regulatory agencies. Discuss any current issues.Charles Swain

335-7112 Assistant: Linda Ives

Foundation Board President &/or Director – Discuss role of Foundation and current activities. How a board member can support and promote the Foundation. Copy of most recent report to the Board.

Sharon MacDonald 985-3550

Assistant: Shelley Hughes Vice President Facility & Support Services – Comprehensive report on

current construction, rehab projects. Future plans. Schedule tours of each facility including the three acute care hospitals, Bonita Community Health Center, HealthPark Care Center, LeeSar, a Lee Convenient Care Center, a Physician Office, and any others.

Dave Kistel 574-0341

Assistant: Sue Thomas

The Children’s Hospital of Southwest Florida – Tour & Overview of services. John Iacuone, MD 432-3237

Kathy Bridge-Liles 432-3698

Board Legal Counsel – Consult with the Board’s legal counsel reference any questions you might have concerning Sunshine Laws, Public Boards, services provided under retainer agreement, and any other matters of concern.

Jim Humphrey 985-4855

Assistant: Michele

10.27D -DRAFT- Reporting and Accreditation of System Entities.doc Page 1 of 1

LEE MEMORIAL HEALTH SYSTEM BOARD OF DIRECTORS

POLICY MANUAL no. 10.27 D C supersedes no. 10.27 C B -------------------------------------------------------------------------------------------------------------------------------- category: General Operations

title: Reporting and Accreditation of System Entities -------------------------------------------------------------------------------------------------------------------------------- original adoption: 01/08/91 review date: 02/05/092/12/04

revision date: 07/31/98, 07/26/02, 2/26/04, 02/26/09 -------------------------------------------------------------------------------------------------------------------------------- PURPOSE:

To provide a mechanism for reporting of System entities and their accreditation. -------------------------------------------------------------------------------------------------------------------------------- POLICY: The Board of Directors shall periodically review and accept a report regarding the operation and accreditation of the following entities: Subsidiaries (Board reporting as required in Bylaws): Cape Memorial Hospital, Inc. d/b/a Cape Coral Hospital; HealthPark Care Center, Inc. Lee Memorial Home Health, Inc.; Lee Memorial Medical Management, Inc. Subagencies, Service Lines: Areas to report are outlined in the CURRENT Strategic Plan Model Outline (attached), as Key Strategy Areas &/or Core Clinical Services. Reports are to be submitted on the Entity Reporting Executive Summary annually. February – Lee Physician Group, Ambulatory (Outpatient Services); March – Oncology; April – Children’s Services, Women’s Services; May – Orthopedics, The Rehab Hospital; June – Facility Planning; NO MEETINGS IN JULY; August – General/Vascular Surgery, Cardiology; September – Marketing/Public Image; October – Neuroscience Supporting Agencies (report biannually) Lee Healthcare Resources – (February & July) LMHS Foundation – (Board Policy requires semi-annual report to Board) Auxiliaries – reports annually at Board meetings LMHS Joint Ventures – (report biannually) Joint with Naples Community Hospital - Bonita Community Health Center (January & July) Joint with Sarasota Memorial - LeeSar Purchasing Cooperative (March & September) Joint with Sarasota Memorial - Cooperative Services of Florida (CSF) (March & September) Joint with Morton Plant Hospital Association, Inc. - Access Medical South (April & October) Joint with ProHealth Medical, Inc - Access Infusion Partners (April & October) Joint with Central Fort Myers Resources, Inc. - LMR Imaging (April & October) Accreditation for System subsidiaries and sub-agencies shall be obtained and maintained from at least one nationally or regionally recognized organization approved by the Board and related to the major work of the unit when such an accreditation program exist.

10.52B DRAFT Community Representatives Appointed to Committee.doc Page 1 of 2

LEE MEMORIAL HEALTH SYSTEM BOARD OF DIRECTORS

POLICY MANUAL no. 10.52 BA supersedes no. 20.19/10.52A ----------------------------------------------------------------------------------------------------------------------------------- category: General Operations

title: Community Representatives/Physician Leadership Council (PLC) Representative - Appointed to a Committee of the Whole

----------------------------------------------------------------------------------------------------------------------------------- original adoption: 5/30/03 (Board Policy 20.19) review date: 02/05/09 08/02/07 revision date: 5/31/07, 08/30/07, 02/26/09 ----------------------------------------------------------------------------------------------------------------------------------- PURPOSE:

To provide for the appointment of community representatives/PLC representative to serve in an advisory capacity on a Committee of the Whole of the Board of Directors. ----------------------------------------------------------------------------------------------------------------------------------- POLICY:

Board members, CEO, Senior Leadership Council (SLC) members shall have the authority to recommend persons for appointment to serve on a Committee of the Whole who are not Directors of the Lee Memorial Health System. Such persons shall be entitled to vote at the Committee level. -----------------------------------------------------------------------------------------------------------------------------PROCEDURE:

1. Lee Memorial Health System Directors, the Health System President and members of the Senior Leadership Council of Lee Memorial Health System, as well as any person from the community may nominate a qualified person or persons for appointment as a community representative to serve on a Committee of the Whole. All nominations must be accompanied by a written resume of the nominee’s education, training and experience.

2. From the nominees, the Committee Chair, CEO and SLC Designated Representative shall recommend the persons to be appointed. They shall appoint not less than one nor more than three (3) qualified persons to serve as community representatives. The PLC shall appoint one (1) representative. The recommended appointments will be submitted to the designated Committee of the Whole, and then to the Full Board of Directors for approval.

3. Community representatives so appointed shall serve a term of three (3) fiscal years, and may be reappointed if recommended by the Committee Chair, CEO and SLC designated representative. A community representative appointed after October 1 of any year shall serve until the 30th of September of three (3) years following such appointment. The PLC appointee term will be at the discretion of the PLC.

10.52B DRAFT Community Representatives Appointed to Committee.doc Page 2 of 2

4. Community Representatives/PLC Representative shall receive no compensation for their services. With the approval of the Board of Directors, Community Representative/PLC Representative may be reimbursed for travel expenses in accordance with the provisions of section 112.061, Fla. Stat., and the Lee Memorial Health System Policy on travel reimbursement, when traveling to meetings or functions outside Lee County at the direction or invitation of the Committee Chair or CEO.

5. Community Representatives shall be qualified by reason of training or experience in the

fields of Finance, Planning, Quality & Education, business management, or healthcare administration; or by reason of possessing a similar or related occupational background.

6. This Policy shall not be construed to require that any individual who is nominated be recommended or appointed as a Community Representative, and all recommendations of community representatives shall be at the discretion of the Committee Chair, CEO and SLC designated representative, and appointments at the discretion of the Chair and Board of Directors.

7. Community representatives shall serve at the pleasure of the Chair, and may be dismissed by the Chair from service on the Committee of the Whole at any time, with or without cause, without recourse.

8. Community representatives/PLC Representative serving on a Committee of the Whole are subject to Florida’s Sunshine Law and any documents, including emails, prepared or received in their role as committee members are subject to the Public Records Law.

______________

L E E M E M O R I A L HEALTH SYSTEM BBBOOOAAARRRDDD OOOFFF DDDIIIRRREEECCCTTTOOORRRSSS

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

Keep form to one page, SUBMIT (thru SLC Member) ELECTRONICALLY to L Drive – Miscellaneous - BOD Presentations by Noon the Friday before you’re scheduled on agenda

DATE: Feb 2, 2009 LEGAL SERVICE REVIEW? YES_XX_ NO__

SUBJECT: Extension of Employment Agreement with the President and Chief Executive Officer (CEO)

PRESENTED BY: James T. Humphrey, Board Counsel

PREVIOUS BOARD ACTION ON THIS ITEM (IF ANY) (justification and/or background for recommendations – internal groups which support the recommendation i.e. SLC, Operating Councils, PMTs, etc.) Prior Employment Agreement with James R. Nathan, President and Chief Executive Officer dated June 28, 2000, term of Agreement was Five (5) years. The present Employment Agreement with James R. Nathan, President and Chief Executive Officer dated May 3, 2004 which also has a five (5) year term.

SPECIFIC PROPOSED MOTION: To extend the term of the Employment Agreement for a period of five (5) years, beginning April 1, 2009. PROS TO RECOMMENDATION

Insures the continued employment of Mr. Nathan in the capacity of President and CEO pursuant to the existing written Employment Agreement and is consistent with Board Policy 40.02G.

CONS TO RECOMMENDATION None

LIST AND EXPLAIN ALTERNATIVES CONSIDERED FINANCIAL IMPLICATIONS Budgeted ____ Non-Budgeted ____ (including cash flow statement, projected cash flow, balance sheet and income statement) OPERATIONAL IMPLICATIONS (including FTEs, facility needs, etc.) SUMMARY

BOD/Forms/Board (Action) Reporting Form - revised 6/16/08 cs

Memorandum TO: Lee Memorial Health System Board of Directors FROM: James T. Humphrey, Board Counsel

DATE: January 27, 2009

RE: Extension of Employment Agreement with the President and Chief Executive Officer (CEO)

Consistent with the existing employment agreement between the Board and Jim Nathan,

the prior Chairman, with my assistance, had been negotiating both the renewal of the existing agreement as well as a new agreement. The Chairman initially desired to have a new agreement which recognized the significant increase in Jim’s responsibility as well as his accomplishments on behalf of the System. However, during the negotiations Jim indicated a willingness to extend the existing agreement for a term of five (5) years. He is agreeable to keeping the supplemental benefits at the same amounts as set forth in Section 4.5 of the agreement.

During the term of the existing agreement, Jim has met or exceeded the performance expectations set forth by the Board and has performed all of the duties required of him by reason of his employment as President and CEO. He also has served as President and CEO of all subsidiary corporations and promoted a positive image of the System within the Community. As with all LMHS management this year due to the economic challenges of our community, there has been no authorization of any increase in Jim’s compensation.

A copy of the existing Employment Agreement is enclosed together with a proposed Renewal of Employment Agreement for the Board’s consideration.

Renewal of Employment Agreement

JAMES R. NATHAN

President and Chief Executive Officer

This renewal of Employment Agreement is entered into this ________ day of

_____________________, 2009 by and between Lee Memorial Health System Board of

Directors (“System”) and James R. Nathan (“Employee”).

WHEREAS, the Employee, James R. Nathan, is serving as President and Chief Executive

Officer (CEO) of Lee Memorial Health System and all of its subsidiary entities; and

WHEREAS, the System and the Employee entered into an Employment Agreement with

respect to the duties and responsibilities of the Employee which agreement began on April 1,

2004 and extends for a period of five (5) years; and

WHEREAS, both parties to the Employment Agreement desire to have it continue in full

force and effect for an extended period of five (5) years.

NOW, THEREFORE, in consideration of the mutual covenants and agreements

contained in the Employment Agreement the parties agree as follows:

1. To extend the Employment Agreement, a copy of which is attached and made a

part hereof, for a period of five (5) years from April 1, 2009.

2. As with the existing Employment Agreement, this extension shall not affect any

fund and or benefits established under either the pre-existing or the present

Employment Agreement. The Employee shall continue to have such rights or

obligations and be entitled to payment of the same in accordance with the terms

and opinions issued in regards to the present and prior Employment Agreements.

3. This Renewal Agreement may not be amended, changed or modified except by a

writing signed by the parties to this Agreement.

IN WITNESS WHEREOF, the parties have executed this Agreement as of this ______

day of _____________________, 2009

EMPLOYER: LEE MEMORIAL HEALTH SYSTEM By: __________________________________ Richard Akin Chair, Board of Directors EMPLOYEE: JAMES R. NATHAN ______________________________________ James R. Nathan

LEE MEMORIAL HEALTH SYSTEM BOARD OF DIRECTORS

POLICY MANUAL no. 40.02G supersedes no. 40.02F

------------------------------------------------------------------------------------------------------------------------- category: Employee Relations

title: President/CEO Compensation & Performance Review ------------------------------------------------------------------------------------------------------------------------- original adoption: 01/8/91 last review date: 02/09/06

revision date: 4/05/91, 3/27/92, 7/31/98, 8/25/00, 7/26/02, 1/6/04, 02/23/06 -------------------------------------------------------------------------------------------------------------------------

PURPOSE:

To provide for the establishment and periodic review of the compensation of the President/CEO of the Lee Memorial Health System and for an annual review of his or her performance. -------------------------------------------------------------------------------------------------------------------------

POLICY: 1. The Board shall conduct a review on at least an annual basis of the compensation of

the President/CEO. 2. In establishing the compensation of the President/CEO, the following shall apply:

a. In evaluating the compensation of the President/CEO, it shall be the Board's goal that the base pay compensation shall be no less than the 50th percentile or median base pay compensation for chief executive officers of health care systems of similar size as reported by a recognized national survey of health care executive salaries and compensation. The survey data will provide for a geographic weight equal to the following: national data (2/3 weight) and southeastern United States data (1/3 weight). Human Resources is responsible for compiling competitive market compensation information and data for the Board.

b. No System leadership or management employee, as such positions are

defined by System policy, shall receive total cash compensation in excess of 80% of the President/CEO’s total cash compensation.

c. If the President/CEO is employed pursuant to a written contract, the provisions

of that contract related to compensation shall prevail and supersede this Policy during the term of the contract.

40.02G POLICY 40.02G- President-CEO Compensation & Performance Review 022306.doc Page 1 of 2

40.02G POLICY 40.02G- President-CEO Compensation & Performance Review 022306.doc Page 2 of 2

3. The Board shall provide the President/CEO with the following incentive compensation opportunity (as a percentage of his/her base salary) utilizing the Leadership Pay Plan guidelines:

• 10% Incentive Payout based on achieving the strategic goal for Finance • 10% Incentive Payout based on achieving the strategic goal for Service

4. Annually, the Board shall review/develop and approve a set of written performance

expectations and job description for the President/CEO. The comments of the President/CEO shall be taken into consideration in the development of his or her respective expectations, but the Board shall have the final decision with regard to the performance expectations.

5. Annually, the Board shall conduct a performance evaluation of the President/CEO

using the written performance expectations previously developed and approved by the Board. The Chairman of the Board shall have the responsibility to request Human Resources to compile any factual or statistical information necessary to determining outcomes with particular performance expectations. The Board may elect to have each Director complete an evaluation form in advance and send to Human Resources for tabulation and summation. Human Resources will combine the evaluations into one document, reflecting the rating data and documents.

6. The Board shall meet with the President/CEO, discuss the results of the Board’s

evaluations and provide the President/CEO with any additional feedback on his/her annual performance. At the conclusion of such meetings, the Board shall accept the President/CEO’s evaluation and determine any changes to the President/CEO’s job description or performance evaluation document for the next fiscal year. Unless determined otherwise, compensation will be adjusted to meet the goal of #2a of this Policy and comply with the President/CEO’s contract.

2009 Liaison - Committee Appointments Presented to 0205 Gov CoW.doc Page 1 of 2 Created on 2/5/2009 12:10 PM

2009 LIAISONS & Committee Chair APPOINTMENTS

LLEEEE MMEEMMOORRIIAALL HHEEAALLTTHH SSYYSSTTEEMM BBOOAARRDD OOFF DDIIRREECCTTOORRSS

AREA BOARD MEMBER ADMINISTRATOR

Bonita Community Health Center Richard Akin CB Rebsamen, MD

Cape Coral Hospital ** Marilyn Stout

Larry Antonucci, MD

Cardiology Marilyn Stout

Cindy Brown, RN

Children’s Hospital Steve Brown, MD

John Iacuone, MD

Kathy Bridge-Liles Corporate Compliance /Risk Management

Nancy McGovern, RN, MSM

Charles Swain Mary McGillicuddy

Emergency Services /EMS Transfer Center

Frank La Rosa Lisa Sgarlata, RN

Chris Nesheim

Facilities

Dawson McDaniel Dave Kistel

Financial Operations Marilyn Stout John Wiest

Foundation Linda Brown, MSN, ARNP

Sharon MacDonald

HealthPark Medical Center** Steve Brown, MD Donna Giannuzzi, RN CAO

Human Resources James Green Jon Cecil

Information Systems Kerry Babb Mike Smith

Lee Healthcare Resources Dawson McDaniel Qtrly alternate Richard Akin

Doug Dodson

Lee Memorial Hospital ** Nancy McGovern, RN, MSM

Gaile Anthony, RN, CAO Mark Greenberg, MD

Lee Physician Group Richard Akin CB Rebsamen, MD

Marketing/Public Relations

Kerry Babb Anne Rose

Nursing Nancy McGovern, RN, MSM

Donna Giannuzzi, RN

Oncology

Linda Brown, MSN, ARNP

Sharon MacDonald

Physician Leadership Council & Credentialing

Richard Akin Chuck Krivenko, MD Sandy Wharton

Planning/Strategy

Linda Brown, MSN, ARNP

CB Rebsamen, MD

Post Acute Services Lois Barrett, MBA CB Rebsamen, MD Marjory May

Quality & Standards Kerry Babb Chuck Krivenko, MD

2009 Liaison - Committee Appointments Presented to 0205 Gov CoW.doc Page 2 of 2 Created on 2/5/2009 12:10 PM

AREA BOARD MEMBER ADMINISTRATOR

Regional Advisory Committee on Trauma Services

Frank La Rosa, Co-Chair Drew Mikulaschek, MD

Anne Rose Southwest Regional ** /Gulf Coast Medical Center

Richard Akin

Doug Luckett, CAO Marilyn Kole, MD

Supply Management Action Team (SMAT)

Steve Brown, MD Doug Luckett, CAO

Trauma Services

Frank La Rosa Anne Rose

Volunteer & Auxiliary Services Dawson McDaniel Jon Cecil Donna Bradish – LMH

Jill Palmer - HP Deb Schuyler – CCH

Sue Crowe – SWR/GCH Women’s Services

Nancy McGovern, RN, MSM

Kathy Bridge-Liles

**Note: Assignment to a hospital facility includes all aspects of that facility including Events, Medical Staff, etc and the responsible party will be both to the CAO and Medical Director.

2009 COMMITTEE OF THE WHOLE Chair/Vice Chair: APPOINTED by Board Chair

CoW MEETING

CHAIR VICE-CHAIR

GOVERNANCE

Lois Barrett Frank La Rosa

PLANNING

Linda Brown Richard Akin

QUALITY/EDUCATION

Kerry Babb Nancy McGovern

FINANCE

Marilyn Stout Dawson McDaniel

___________________ L E E M E M O R I A L HEALTH SYSTEM

BBBOOOAAARRRDDD OOOFFF DDDIIIRRREEECCCTTTOOORRRSSS

DATE OF THE NEXT REGULARLY SCHEDULED

MEETING

GOVERNANCE Committee of the Whole

MEETING

THURSDAY, May 7, 2009

1:00pm

Lee Memorial Hospital Boardroom 2776 Cleveland Ave, Ft. Myers, FL 33901