Norman Regional Hospital Authority Meeting

NORMAN REGIONAL HOSPITAL AUTHORITY Board Meeting February 22, 2021 MINUTES The Norman Regional Hospital Authority met in monthly session Monday, February 22, 2021 at 5:30p.m. in the Porter Auditorium. The meeting Agenda was posted February 18, 2021 on the NRHS and City of Norman websites and at the entrance to Norman Regional Hospital. Members Present: Doug Cubberley, Chairman Jerome (Jerry) Weber, Ph.D. Tom Sherman Muhammad Anwar, MD Mary Womack James Chappel Joan Greenleaf Diane Chambers, MD Kevin Pipes Others Present: Richie Splitt, President & CEO John Manfredo, COO Paula Price, VP Strategy & Growth Meegan Carter, VP Population Health & Wellness Brittni McGill, CNO Ken Hopkins, CFO Dr. Farhan Jawed, MD, Chief of Medical Staff Dr. Joe Voto, MD, Chief of Medical Staff-elect Jenny Anderson, Administrative Director Quality & Performance Larry Harden, Administrative Director, Compliance Karen Rieger, Attorney, Crowe & Dunlevy Kelly Wells, Calvin Bohanan, Shane Cohea, Kenneth Fertitta, Clerk Lab Registrar Kourtney Bell, Manager Lab Outreach and Outpatient Services Eddie Sims, Manager, EMSStat Jan Emmons, Director, Emergency Services Andrew Minnich, Paramedic, EMSStat Michaela Vaughn Jeffrey Neeley, EMT, EMSStat William Krull, Paramedic, EMSStat Bryan McVea, EMT recruit Recorder: Claudia Todd, Executive Assistant  NRHA Board Minutes 2 February 22, 2021 Agenda Item I. Meeting Called to Order Mr. Cubberley called the February 22, 2021, Norman Regional Hospital Authority meeting to order at 5:39p.m. Agenda Item II. Introduction and Recognition of Outstanding Healers A. March 2021 Healer of the Month – Kenneth Fertitta, Clerk Lab Registrar Mr. Cubberley introduced Kourtney Bell, Manager Lab Outreach and Outpatient Services who presented Mr. Fertitta. Ms. Bell shared Mr. Fertitta is originally from Longview, Texas but has lived in Oklahoma City for 33 years. Mr. Fertitta has worked for Norman Regional for 9 years and shared that his coworkers are what he enjoys most about his job. Ms. Bell shared comments from his peers revealing Mr. Fertitta makes a great impact on patients and their experiences while visiting our health system. He is always kind and helpful, patients love him, and he never has an off day. He goes above and beyond for patients and coworkers, answering questions until they are all satisfied. He is the essence of the Norman Way and the laboratory is blessed to have him in their department. Mr. Fertitta thanked everyone for the opportunity for the honor. He stated he tries to ease the worries of those he encounters, knowing they are under stress or aren’t feeling well and wants them to feel comfortable and safe. Mr. Cubberley congratulated and thanked Mr. Fertitta on behalf of the Board for his outstanding dedication, professionalism, compassion, and positive attitude that continues to make Norman Regional Health System a caring, high quality system. Ms. Bell left the meeting at 5:45pm. B. EMSStat Crimestoppers Paramedic of the Year 2020-2021 Andrew Minnich, Paramedic and EMT of the Year 2020-2021 Jeffrey Neeley, EMT Mr. Cubberley introduced Mr. Sims, Manager EMSStat. Mr. Sims introduced Jeffrey Neeley who has been with Norman Regional EMSStat since September 2019 and will be completing Paramedic school soon. Mr. Neeley endured a personal tragedy recently and was able to use that experience to comfort a patient who was going thru a similar incident. Mr. Sims introduced Andrew Minnich, Paramedic. Mr. Minnich has been with Norman Regional EMSStat since July 2018. Mr. Minnich volunteered to work a transfer on a very busy day and was able to assist a patient in an embarrassing situation with compassion, dignity and grace. Mr. Minnich is also currently in the Oklahoma City fire academy. Mr. Minnich and Mr. Neeley thanked everyone for allowing them to work at such a wonderful health system.  NRHA Board Minutes 3 February 22, 2021 Agenda Item III. Board Education A. A Black History Moment Mr. Chappel shared February is designated as Black History Month. This month is reserved to teach, honor, encourage and motivate our youth to learn about and highlight the accomplishments of black Americans. For this is a time to recognize, celebrate, honor and appreciate all Americans, and especially black Americans as we work toward the goal of making the United States the “GOAT” or Greatest of All Time of all nations. Mr. Chappell stated it seems impossible to achieve “GOAT” status on the contributions of one group of people, but seems more probable and sustainable from the contributions of many people. Dr. Martin Luther King Jr. is quoted as saying “We have a power that can change conditions, change the southland and change our nation. If we will but use that power, we will see a better day.” Today we are not helpless and have the power to change conditions and change our nation to see a better day. At 100 years old, Brigadier General Charles E. McGee, 30 years US Air force and Tuskegee Airman, flew over 409 missions in 3 wars, was awarded the “Key to Life” award at the 2020 NAACP Image Awards. In his acceptance speech, he used Hyundai’s Sponsorship slogan “Taking Technology to a New Level” to say his hope was “we” would use the work “we” are doing to get “us” to a new level and a better America. Rotary International President Sakuji Tanaka once quoted from the Declaration of Independence “We hold these truths to be self-evident, that all men are created equal, that they are endowed by their Creator with certain unalienable rights, that among these are Life, Liberty and the pursuit of Happiness.” Looking back at 2020’s civil unrest and looking forward to 2021 – what if it is not about who is a patriot and who is not, what if it is not about which lives matter and which lives don’t, but what if our continuing civil unrest is all about life, liberty and the pursuit of happiness? These are rights endowed to everyone and impossible to give up. B. Community and Board Education: COVID/Lab Services Mr. Calvin Bohanan, Director Laboratory Services presented an overview of Clinical Lab Services at NRHS. Over the past 2 fiscal years, the board has approved $596,707 in capital items for the lab. This funding has assisted in serving the Norman community by providing state of the art equipment and earning the title of national Runner Up for the Lab of the Year 2020. Norman Regional has 3 main campus labs, 7 patient service centers in NRHA Board Minutes 4 February 22, 2021 Norman/Moore and 2 COVID sites (Drive-thru and Pre-Op). At those locations, we hold 5 CLIA certificates. The Clinical Laboratory Improvement Amendments (CLIA) regulate laboratory testing and require clinical laboratories to be certified by the Center for Medicine and Medicaid Services (CMS) before they can accept human samples for diagnostic testing – NRHS also enjoys 3 College of American Pathology (CAP) certificates, employs 190 healers, 4 Board Certified Pathologists and 60 Board Certified Medical Technologists. NRHS labs produce over 1,600,000 test annually or 4,384 tests per day on average. Our labs play an integral role in delivering high quality and trusted health care:  According to the CDC, 70% of today’s medical decisions depend on lab test results.  Clinical lab testing helps maximize effective patient care delivery  Enhances the ability of clinicians to make evidence-based diagnostic and therapeutic decision  Essential in providing care that is safe, effective, patient-centered, timely, efficient and equitable The Lab focuses on three key areas:  Customer Service: o The Norman Way o ICARE Values o ICARE with Heart  Quality o Data-driven and evidence-based decisions o Perform clinical validations of ALL in house testing o Work with elite reference labs for send-out testing o Review 44 quality Key Performance Indicators. (KPIs)  Timeliness o Utilize automation whenever possible to optimize turnaround times o 9 total PDSA’s in process (5 include timeliness) Mr. Bohanan reviewed a departmental timeline beginning January 30, 2020 when the World Health Organization declared SARA-CoV-2 (Coronavirus, COVID-19) a global health emergency - December 4, 2020 when the labs helped launch the NRHS COVID Vaccination Clinic. NRHS labs have completed over 65,000 PCR COVID tests in-house. Teaming up with our Clinics and Transitions of Care Team, NRHS has documented over 19,000 calls to the COVID-19 hotline and over 12,000 sick patient visits through the COVID drive-thru clinic. According to Hospital Pricing Specialists, NRHS provided one of the most cost- friendly COVID-19 testing fees in the nation with only Rhode Island and Maryland offering COVID tests at a lower cost. Mr. Bohanan shared the Lab will offer faster molecular testing as it becomes available and change testing needs as determined by COVID-19 variants and mutations. The team also plans to lose the “runner up” title this year by becoming the Medical Laboratory Observer (MLO) Lab of the Year 2021.  NRHA Board Minutes 5 February 22, 2021 Agenda Item IV. Approval of January 25, 2021, Norman Regional Hospital Authority Board Meeting Minutes Mr. Cubberley asked for approval of the January 25, 2021 Board Meeting Minutes ACTION TAKEN: Dr. Weber made the motion to approve the January 25, 2021 Board Meeting Minutes, with the spelling corrections of ET3 on Agenda Item III, paragraph 1, CMS correction on Agenda Item III, paragraph 2. Ms. Greenleaf seconded the motion, and the motion was approved unanimously with aye votes from Mr. Cubberley, Dr. Weber, Ms. Womack, Mr. Chappel, Dr. Anwar, Ms. Greenleaf, Mr. Pipes, Dr. Chambers and Mr. Sherman. Agenda Item V. Trustee Conflict of Interest Mr. Larry Harden, Director of Compliance and Risk, reviewed the Conflict of Interest Policy, Conflict of Interest Disclosure Statement and Oath of Office for the Norman Regional Hospital Board of Trustees. Mr. Harden asked each Board member to review, sign and date the Conflict of Interest Disclosure Statement and return to Claudia Todd once completed. Agenda Item VI. The Environment of Care Management Plan - 2020 Annual Evaluation Mr. Shane Cohea, Director Safety & Security presented the annual Evaluation of The Environment of Care Management Plan for review and approval. The Environment of CARE (EOC) refers to any site where patients are treated, including inpatient and outpatient setting. The main objective of the EOC is to provide a safe, functional and effective environment for patients, staff members and others. The program also helps to ensure compliance with applicable safety codes and regulations. The safety team conducted 145 tours and visits looking for potential hazards and improvement opportunities. ACTION TAKEN: Mr. Pipes made the motion to approve the Environment of Care Management Plan – 2020 Annual Evaluation. Dr. Weber seconded the motion, and the motion was approved unanimously with aye votes from Mr. Cubberley, Dr. Weber, Ms. Womack, Mr. Chappel, Dr. Anwar, Ms. Greenleaf, Mr. Pipes, Dr. Chambers and Mr. Sherman. Mr. Sims, Mr. Minnich, Ms. Vaughn, Mr. Neeley, Mr. Krull, Mr. Fertitta, Mr. Bohanan left the meeting at the meeting at 6:32pm. Agenda Item VII. Performance Update Ms. Anderson, Administrative Director, Quality & Performance presented an update on Quality and Data Overview.  NRHA Board Minutes 6 February 22, 2021 The purpose of data collection is to make informed decisions in improving the quality and safety of patient care, improve efficiency and patient satisfaction. Various data such as Hospital Acquired Infections or Harm and Mortality is collected several ways including chart reviews and data mining systems. The data is analyzed to determine how NRHS is performing, how we compare to others and where we need to be. One of our most important measures is against ourselves, as we strive for continuous improvement. We routinely ask “Are we better than last year? and “Are we approaching the targets?” Data is used in multiple ways, and is displayed on department NEWs Walls. There are three things any data display should have:  Where are we now? (Data Points),  Where do we need to be? (Targets/Benchmarks)  Are we improving? (Moving in the right direction). To improve interpretation with Board Patient Quality and Safety Committee, we will begin using 3 data classifications:  Needs Improvement – 2 Calendar Years not reaching target – all have PDSA’s or other ongoing process improvement teams  Improving – Most recent Calendar Year improved or improving to better than target  Better Than – 2 Calendar Years better than target Agenda Item VIII. Approval of the January 2021 Norman Regional Health System Financial Statements Mr. Hopkins presented the January 2021 Norman Regional Health System Financial report: January 2021 Financial Performance  Gross Revenues .................................. (Budget $211,994,526)............ $188,840,225  Net Patient Revenue .............................. (Budget $44,129,063).............. $42,827,405  Total Operating Expenses ..................... (Budget $44,112,575).............. $42,673,887  Total Operating Revenues ...................... (Budget $44,560,676).............. $43,199,742  Operating Income ....................................... (Budget $448,101)................. ($525,855)  Non-Operating Revenues (Expenses) ..... (Budget $1,901,252)............ ($17,602,546)  Excess Revenues over Expenses ............ (Budget $1,539,353)............ ($18,128,401) Year-to-Date  Operating Income .................................. (Budget $45,062,639)................. ($685,706)  Non-Operating Revenues (Expenses) ..... (Budget $7,638,764).............. $40,798,146  Excess Revenues over Expenses .......... (Budget $12,701,403).............. $40,112,440  Accounts Receivable Days ............................ (Budget 43 Days).................. 49.1 Days  Days Cash on Hand…………………………………………………………….207.9 Days ACTION TAKEN: Mr. Weber motioned to approve the January 2021 NRHS Financial Statements. Ms. Greenleaf seconded the motion. January Financials  NRHA Board Minutes 7 February 22, 2021 were approved unanimously with aye votes from Mr. Cubberley, Dr. Weber, Mr. Chappel, Dr. Anwar, Ms. Greenleaf, Mr. Sherman, Mr. Pipes, Dr. Chambers and Ms. Womack. Agenda Item IX. Medical Staff A. Dr. Jawed presented the Medical Staff report. He stated the Medical Executive Committee (MEC) met on February 10, 2021. Old Business: Mr. Hopkins provided a financial update over the past year sharing the COVID-19 impact. New Business:  COVID-19: Open discussion was held covering COVID-19 cases in Cleveland County and across the state; focus remains on patent and healer safety.  Ms. McGill provided a hospitalization update. COVID-19 hospitalizations continue to decline. The Incident command center has been deactivated. Patient visitation limitations are being erased somewhat.  Mr. Bohanan reviewed information covering the COVID-19 variants.  Mr. Manfredo presented an Inspire Health update on HealthPlex Exterior Design, the Freestanding ED+, Behavioral Medicine and Senior Wellness Center. Creditials Report:  Dr. Mullins presented the credential report for recommended approval. Department Reports:  Reports were provided by Emergency Medicine, Hospital Medicine, Hospital Quality Patient Safety Committee (HQPSC), Infection Committee, Medicine Department, OB/GYN, Pathology, Pediatric Department, Pathology, Pediatrics, Pharmacy & Therapeutics, Physician Advisory Committee and Radiology. Medical Staff Report:  Dr. Boyd reported Doctor’s Day is March 30th. He provided an update on COVID-19. Administrative Reports:  Ms. McGill announced unused patient rooms were reserved for healers to utilize during inclement weather. An update was provided on the recent The Joint Commission recertification surveys for Total Hip Replacement/Total Knee Replacement/Hip Fracture. The TJC surveyor was very complimentary of the program.  Mr. Splitt shared several points of recognition: o Congratulations to the Ortho ream for their recent TJC reaccreditation of the total hip, total knee and hip fracture program.  NRHA Board Minutes 8 February 22, 2021 o The Nurse Residency Program has been certified – first in the state o The Perinatal Care Program received TJC Certification  Mr. Splitt shared Griffin Memorial Hospital submitted a Request for proposal (RFP) for an architectural firm to design/build a new 305-bed inpatient facility.  There will be four celebratory occasions approaching this year: o Groundbreaking for the FSED is slated for May 20, 2021 o 75th Anniversary of the Health System in June - 2021 o Foundation Gala will be in June - 2021 o HelathPlex expansion groundbreaking in July - 2021 Hospital Board Chair Report:  Mr. Cubberley announced the move to approve the acquisition of property for the HealthPlex expansion. B. Approval of Radiology Special Request Form ACTION TAKEN: Mr. Weber motioned to approve the Radiology Special Request Form. Mr. Pipes seconded the motion. The request was approved unanimously with aye votes from Mr. Cubberley, Dr. Weber, Mr. Chappel, Dr. Anwar, Ms. Greenleaf, Mr. Sherman, Mr. Pipes, Dr. Chambers and Ms. Womack. Agenda Item X. Patient Quality and Safety Committee Ms. Joan Greenleaf presented a report from the February 1st webex meeting. Ms. Annette Troxell, Labor, Delivery & Recovery presented the TJC Perinatal Certification journey that NRHS began in 2016, but in earnest, in May 2019. The TJC survey was completed virtually; this had never been done before. The teams were developed according to the following core indicators:  PC-01 – Early Inductions – decrease the rate of patients with elective vaginal delivers or cesarean births before 39 weeks  PC-02 – Cesarean Births – decrease the rate of nulliparous women with a term and singleton baby in the vertex position delivered by cesarean birth by 10%  PC-05 – Exclusive Breastfeeding – maintain exclusive breastfeeding rate > 70%  PC-06 – Unexpected Complications of the Newborn – decrease the rate of newborns with moderate and severe unexpected complications  Reduce cesarean section infection rate by 10% The Perinatal Quality Council was established in September 2019 to help teams collaborate with physicians and to review progress. Ms. Karen Brazeal, Nurse Manager NICU presented information on the new Baby Monitor Program. The NRHS Foundation provided 10 NICView camera systems to  NRHA Board Minutes 9 February 22, 2021 assist with family bonding when separated and to help build trust and confidence in the NICU staff. This system allows the family to view the baby visually from any location where Wi-Fi connections are available. Ms. Meg Belford, Director Clinic Operations & Growth, presented a Primary Care Accountable Care Organization (ACO) Quality update. This is a group of providers who voluntarily come together to provide coordinated, high-quality care to Medicare patients. The focus of the ACO is to improve the individuals overall health in 10 quality measures, while reducing expenses. Mr. Toby Branum, Director Ambulatory Services & Wellness, provided an update on the Outpatient COVID Infusion Center. As of January 15th, 430 high-risk, COVID positive patients have been treated with monochlonal antibodies from 65 referring providers. Ms. Jenny Anderson provided an update on the FY2020 Focus Priorities for Board Quality. The Core Sepsis Bundle compliance will remain a high focus for the next year with continued PDSA’s. Agenda Item XI. Finance Committee A. Mr. Hopkins reported the Finance Committee met on Wednesday, February 17 due to weather conditions. Ms. Porter provided a health needs assessment update. The Most Favored Nation Drug Pricing Rule was reviewed. Mr. Harden provided a Risk Management Report. B. Mr. Hopkins presented for approval 1 capital request item totaling $72,811: a. Quality Assurance Device for Stereotactic Radiation: $72,811 ACTION TAKEN: Dr. Weber made a motion to approve the Capital Equipment Requests at a total cost of $72,811 as recommended by the Finance Committee. Mr. Sherman seconded and the motion was approved unanimously with votes from Mr. Cubberley, Dr. Weber, Mr. Chappel, Dr. Anwar, Mr. Sherman, Ms. Greenleaf and Ms. Womack. Agenda Item X. Old Business Mr. Cubberley reminded Board members the Board Trustee Advance is scheduled for March 6 at the Norman Regional Moore Conference Center. Agenda Item XI. New Business A. The Resolution for the Proposed Norman Regional Sports & Human Performance Center inside the Norman Forward Multi-Sports & Indoor Aquatics Facility was reviewed. Ms. Price presented information related to the proposed NRHS clinical space located inside the (Norman Forward) Aquatics and Multi- Sports Facility. This project is the result of a public-private partnership between the City of Norman, the Trae Young Family Foundation and Norman Regional  NRHA Board Minutes 10 February 22, 2021 Health System. ACTION TAKEN: Dr. Weber made a motion to approve the Resolution for the Proposed Norman Regional Sports & Human Performance Center inside the Norman Forward Multi-Sport & Indoor Aquatics Facility. Dr. Anwar seconded and the motion was approved unanimously with votes from Mr. Cubberley, Dr. Weber, Mr. Chappel, Dr. Anwar, Mr. Sherman, Dr. Chambers, Mr. Pipes, Ms. Greenleaf and Ms. Womack. Agenda Item XII. Administrative Report A. Mr. Splitt provided an update on the ongoing vaccination efforts in the Norman community. NRHS recently partnered with IMMY Labs to provide ~10,000 vaccines in one day. 20 NRHS healers assisted with the vaccine process. NRHS will present the HealthPlex expansion Planned Unit Development (PUD) Amendment to City Council on February 23rd. The amendment modernizes an existing PUD for the campus and provides updates for the expanded facility and services. B. Ms. McGill provided a COVID-19 update: o NRHS has been at a Tier 1 level for 2 weeks o COVID vaccine clinic each Friday o Efforts to address healer wellness continue o IMMY’s Mega POD Vaccination event at Embassy Suites on February 22 o Healer Accommodations due to Winter storm – meals, transportation, a place to stay, downtime activities o Public Safety Coordination with EMS groups Ms. McGill reported NRHS is awaiting final Joint Commission approval for Perinatal Care and Total Joint programs. A Joint Commission virtual site visit in December for Perinatal Care resulted in only 2 minor recommendations for Improvement. In February, a second Joint Commission virtual visit occurred for re-certification of the Total Knee, Total Hip and Hip Fracture program. Ortho is also awaiting final approval from TJC. The Nurse Residency Accreditation has been approved. NRHS has the only program of its kind and certification in the State of Oklahoma. C. Mr. Manfredo provided an update on The “Snowvid” preparations and status of the hospital grounds and property after a weeks’ worth of extreme weather. Agenda Item XIII. Proposed Executive Session A. Proposed Vote to Convene an Executive Session Pursuant to 25 Okla. Stat. Section 307 B.4. to Discuss with Legal Counsel Pending Internal Peer Review/Credentialing Investigation Regarding the Medical Staff Members/Applicants Listed Below; NRHA Board Minutes 11 February 22, 2021 ACTION TAKEN: Dr. Weber made a motion to adjourn into Executive Session. Mr. Sherman seconded and the motion was approved unanimously with aye votes from Mr. Cubberley, Dr. Weber, Mr. Chappel, Mr. Sherman, Dr. Anwar, Ms. Greenleaf, Mr. Pipes, Dr. Chambers and Ms. Womack. B. Medical Staff Recommendations Regarding the Medical Staff Members/ Applicants as Listed in XIII.B 1-4 Below. 1. Recommend New Provisional Medical Staff Appointments a. Jessica Meador, DO – Emergency Medicine – Active b. David Miller, DO – Surgery – Active c. Devorah Archer-Webb, PA-C – Surgery – Allied Health d. Lori McDonald APRN-CNP – Pediatrics – Allied Health 2. Recommend Medical Staff Reappointments: a. Mason Lawrence, MD – Anesthesiologist – Active b. Shane Stidham, MD – Anesthesiologist – Active c. Jeffrey Buyten, MD – Surgery – Active d. Shannon Haenel, DO – Medicine – Active e. Patrick Cody, DO – Emergency Medicine – Active f. Daniel Kite, DO – Emergency Medicine – Active g. Marcia Hoos-Reinke, MD – Emergency Medicine – Active h. Jason Bellak, MD – Medicine – Associate i. Casey Markland, MD – Medicine – Associate j. Kevin O’Brien, MD – Medicine – Associate k. Ralph Nelson, DO – Emergency Medicine – Associate l. Dwight Thacker, APRN-CRNA – Anesthesiology – Allied Health m. Deanna Givens, APRN-CRNA – Anesthesiology – Allied Health n. Jeffrey Frederick, PA-C – Surgery – Allied Health o. Mason Lawrence, MD – Ortho Central p. Shane Stidham, MD – Ortho Central q. Josie Dean, PA-C – Ortho Central r. Dwight Thacker, APRN-CRNA – West Endoscopy and Medical Plaza Endoscopy 3. Recommend Advancement of Medical Staff from Provisional Status: a. Alexander Habashy, MD – Surgery – Active b. Robert Cunningham, MD - Emergency Medicine – Active c. Shari Jones, MD – Medicine – Active d. Rahal Kahanda, MD - Surgery – Active e. Sean Dossett, DO – Anesthesiology – Active f. Shaylea Beach, DO – Medicine – Associative g. Brandon Funk, PA-C – Surgery – Allied Health 4. Information Only: a. Jamie Steichen, PA-C – has completed required proctored cases for Paracentesis and Superficial Aspiration Biopsy privileges b. Granting proctoring temporary privileges for Jared Highley, MD.  NRHA Board Minutes 12 February 22, 2021 Alexander Jones, MD case – robotic simple prostatectomy case. C. Request to Adjourn Out of Any Such Executive Session and Return to Regular Session ACTION TAKEN: Mr. Weber made a motion to adjourn out of Executive Session. Dr. Anwar seconded, and the motion was approved unanimous aye votes from Mr. Cubberley, Dr. Weber, Mr. Sherman, Mr. Chappel, Dr. Anwar, Ms. Greenleaf, Mr. Pipes, Dr. Chambers and Ms. Womack. Mr. Cubberley noted the Board returned to regular session. There were no decisions or votes taken except to return to regular session and any information shared during the Executive Session is privileged and needs to remain in Executive Session. D. Proposed Vote to Approve or Disapprove the Medical Executive Committee Recommendations Regarding Credentialing of the Referenced Medical Staff Members as Listed in XII B 1-4. ACTION TAKEN: Dr. Weber motioned to approve credentialing items as recommended by Medical Executive Committee and Credentials Committee of all referenced Medical Staff members listed in XII B 1-4. Mr. Pipes seconded, and the motion was approved with unanimous aye votes from Mr. Cubberley, Mr. Weber, Mr. Sherman, Dr. Anwar, Mr. Chappel, Ms. Greenleaf, Mr. Pipes, Dr. Chambers and Ms. Womack. Agenda Item XIV. Board Open Discussion Mr. Cubberley described a new board tool called the board meeting mini-evaluation. He asked all Trustees to complete the survey so that the board continuously addresses concerns or questions. The goal is to continuously improve meetings and optimize board performance. Agenda Item XV. Adjournment ACTION TAKEN: Dr. Weber made a motion to adjourn the meeting at 8:13pm. Dr. Anwar seconded, and the motion passed unanimously with aye votes from Mr. Cubberley, Dr. Weber, Mr. Chappel, Mr. Sherman, Dr. Anwar, Ms. Greenleaf, Mr. Pipes, Dr. Chambers and Ms. Womack. Respectfully Submitted, Tom Sherman, Vice-Chair/Secretary