LEE COUNTY TRAUMA SERVICES DISTRICT BOARD OF DIRECTORS MEETING. THURSDAY, May 23, 2013

Transcription

1 LEE COUNTY TRAUMA SERVICES DISTRICT BOARD OF DIRECTORS MEETING THURSDAY, May 23, 2013 GULF COAST MEDICAL CENTER - Boardroom Doctors Way, Fort Myers, FL 339 (Held concurrently with the Lee Memorial Health System Board of Directors Meeting)

2 LEE COUNTY Trauma Services District BOARD of DIRECTORS OFFICE FAX: P.O. BOX 2218 FORT MYERS, FLORIDA AGENDA LEE COUNTY TRAUMA SERVICES DISTRICT BOARD OF DIRECTORS MEETING May 23, *1:00 p.m. *Held concurrently with Lee Memorial Health System Board Meeting Gulf Coast Medical Center (Medical Office Building) Boardroom Doctors Way, Ft. Myers, FL Call To Order (Richard Akin, Board Chairman) Lee County Trauma Services District Board of Directors Meeting 2. Public Input Agenda Items: Any Public Input is limited to three minutes and a Request to Address the Board of Directors card must be submitted to the Board Administrator prior to meeting. BOARD OF DIRECTORS DISTRICT ONE Stephen R. Brown, M.D. Marilyn Stout DISTRICT TWO Richard B. Akin Nancy M. McGovern, RN, MSM 3. Meeting Minutes of December 6, 20, January 8, 2013, February 28, 2013 (Approval) (Diane Champion, Board Secretary) 4. Operations Report (Acceptance) (Dr. Ernst Vieux, Medical Director, Trauma) 5. Trauma District Financials (Acceptance) (Ben Spence, Controller Acute Care/Reimbursement) DISTRICT THREE Sanford N. Cohen, M.D. David Collins DISTRICT FOUR Diane Champion Chris Hansen DISTRICT FIVE Jessica Carter Stephanie Meyer, BSN, RN 6. Regional Advisory Committee on Trauma Services (Chris Hansen, Board Member, RAC Co-Chair) A Additional Appointments (Approval) 7. Other Items (Sally Jackson, System Director/Government & Community Relations) A. Legislative Questions (Update) 8. Date of the next REGULAR LEE COUNTY TRAUMA SERVICES DISTRICT MEETING: August 22, 2013, *1:00p.m. Gulf Coast Medical Center Boardroom (Medical Office Building) *held concurrently with Lee Memorial Health System Board Meeting. 9. ADJOURN (Richard Akin, Board Chairman) TRAUMA DISTRICT - Trauma Agenda.doc

3 LEE COUNTY TRAUMA SERVICES DISTRICT BOARD OF DIRECTORS 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 Administrator 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.

4 LEE COUNTY TRAUMA SERVICES DISTRICT BOARD OF DIRECTORS MEETING MINUTES Thursday, December 6, 20 LOCATION: Gulf Coast Medical Center, Medical Office Building, Board of Directors Boardroom, Doctors Way, Fort Myers, FL 339 MEMBERS PRESENT: Richard Akin, Board Chairman; Steve Brown, M.D., Board Vice Chairman; Marilyn Stout, Board Treasurer; Nancy McGovern, RN, MSM, Board Secretary; Linda Brown, MSN, ARNP, Director; Jason Moon, Director; Chris Hansen, Director; Donald Brown, Director; James Green, Director MEMBERS ABSENT: Diane Champion, Director (Excused) OTHERS PRESENT: Jim Nathan, President/Chief Executive Officer; Cathy Stephens, Board Administrator; Jim Humphrey, Board Counsel; Thomas Presbrey, M.D., Chairman/Physician Leadership Council, Mary McGillicuddy, Chief Legal Officer; Larry Antonucci, M.D., Chief Operating Officer/Hospital & Physician Services; Mike German, Chief Financial Officer; Jon Cecil, Chief Human Resources Officer; Scott Nygaard, M.D., Chief Medical Officer/Physician Services; Chuck Krivenko, M.D., Chief Medical Officer/Clinical and Quality Services; Mike Smith, Chief Information Officer; Joshua DeTillio, Chief Administrative Officer/Gulf Coast Medical Center; Scott Kashman, Chief Administrative Officer/Cape Coral Hospital; Donna Giannuzzi, Chief Administrative Officer & Chief Nursing Officer/Health Park Medical Center; Kevin Newingham, Vice President/Strategic Services; Marjory May, Vice President/Acute Care; Ernst Vieux, M.D., Medical Director/Trauma; Regina Eberwein, System Director/ Planning & Market Research; Sally Jackson, System Director/Government & Community Relations; Mary Briggs, System Director/Media Relations; Kristy Rigot, System Director/Recruitment & Retention; Catherine Kahle, Senior System Counsel; Debbie Wiles, Risk Manager II; Cynthia Brasher, System Director/Spiritual Services; Ben Spence, Controller Acute Care & Reimbursement; Nelayde Fonte, D.O., Medical Staff President/Lee Memorial Hospital; Marliese Mooney, RN, MS, PLC Consultant to Planning Board;; David Berger, M.D., Board Quality Community Representative; Reverend Bill Miller; Kim Gaide, Ambulatory Operations Manager I; Michael Marcus, Manager/Trauma Program; Laurie Gretten, Executive Secretary/Board of Directors, Tamra Ellsworth, Administrative Secretary/Board of Directors GUESTS: Dave Whatmore, Lee County Sheriff s Department; Sanford Cohen, M.D., Board member elect; Stephanie Meyer, Board member elect; David Collins, Board member elect; Tom Olivo; Frank Gluck, News-Press Reporter; Melinda Black, Family Health Centers 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 for public inspection. SUBJECT DISCUSSION ACTION FOLLOW- UP MEETING CALLED TO ORDER PUBLIC INPUT There was none at this time. The Lee County Trauma Services District Board of Directors Meeting was CALLED TO ORDER at 3:45 p.m. by Richard Akin, Board Chairman. MEETING MINUTES OPERATIONS REPORT TRAUMA DISTRICT FINANCIALS OTHER ITEMS DATE OF THE NEXT MEETING Nancy McGovern asked for approval of the Trauma District Meeting Minutes of August 23, 20. Dr. Ernst Vieux presented the Trauma District Operations Report (Exhibit 1) which consisted of the Trauma registry entries, Trauma alerts, Trauma alerts by county of injury, Trauma service admissions, and the Trauma registry data for the year. Ben Spence reviewed the Trauma District Financials (Exhibit 2) which consisted of Trauma volumes, expected payment, payor mix comparison, red light bill funds, and the Trauma District income statement. Sally Jackson submitted an article, titled: Trauma Rule Tossed Out in Hospital Industry Battle (Exhibit 3). The date of the next regular meeting of the Lee County Trauma Services District is Tuesday, January 8, 2013, at 1:00 pm, in the Gulf Coast Medical Center Boardroom (held concurrently with the Lee Memorial Health System Board Meeting). A motion was made by Steve Brown to approve thetrauma District Meeting Minutes of August 23, 20. The motion was seconded by Don Brown and it carried with no opposition. A motion was made by Linda Brown to accept the Trauma District Operations Report (Exhibit 1). The motion was seconded by Don Brown and it carried with no opposition. A motion was made by Chris Hansen to accept the Trauma District Financials (Exhibit 2). The motion was seconded by Don Brown and it carried with no opposition.

5 LEE COUNTY TRAUMA SERVICES DISTRICT BOARD OF DIRECTORS MEETING MINUTES Thursday, December 6, 20 Page 2 of 2 FOLLOW- SUBJECT DISCUSSION ACTION UP ADJOURNMENT The Lee County Trauma Services District Board of Directors meeting was ADJOURNED at 3:59 p.m. by Richard Akin, Board Chairman. Minutes were recorded by Laurie Gretten, Executive Secretary/Board of Directors Office Diane Champion Board Secretary

6 LEE COUNTY TRAUMA SERVICES DISTRICT BOARD OF DIRECTORS ANNUAL ORGANIZATIONAL MEETING MINUTES Tuesday, January 8, 2013 LOCATION: Gulf Coast Medical Center, Medical Office Building, Board of Directors Boardroom, Doctors Way, Fort Myers, FL 339 MEMBERS PRESENT: Richard Akin, Board Chairman; Sanford Cohen, M.D., Board Vice Chairman; Marilyn Stout, Board Treasurer; Diane Champion, Board Secretary; Steve Brown, M.D., Director; Nancy McGovern, RN, MSM, Director; David Collins, Director; Chris Hansen, Director; Jessica Carter, Director; Stephanie Meyer, BSN, RN, Director OTHERS PRESENT: Jim Nathan, President/Chief Executive Officer; Cathy Stephens, Board Administrator; Jim Humphrey, Board Counsel; Mary McGillicuddy, Chief Legal Officer; Larry Antonucci, M.D., Chief Operating Officer/Hospital & Physician Services; Mike German, Chief Financial Officer; Jon Cecil, Chief Human Resources Officer; Mike Smith, Chief Information Officer; Chuck Krivenko, M.D., Chief Medical Officer Clinical and Quality Services/Chief Patient Safety Officer; Scott Nygaard, M.D., Chief Medical Officer/Physician Services; Donna Giannuzzi, Chief Administrative Officer & Chief Nursing Officer/Health Park Medical Center; Dan Fink, Chief Administrative Officer/The Children s Hospital; Joshua DeTillio, Chief Administrative Officer/Gulf Coast Medical Center; Scott Kashman, Chief Administrative Officer/Cape Coral Hospital; Lisa Sgarlata, Chief Administrative Officer/Lee Memorial Hospital; Kristin Fay, Chief Administrative Officer/Lee Physician Group; Sharon MacDonald, Chief Foundation Officer; Catherine Kahle, Senior System Counsel/Interim Corporate Compliance Officer; Dave Kistel, Vice President/Facility Management/Support; Kevin Newingham, Vice President/Strategic Services; Roger Chen, Vice President/Organization Transformation; Mary Briggs, System Director/Media Relations; Suzanne Bradach, System Director/Special Projects; Bill Silverman, M.D., Board Quality/Education Community Representative; Marliese Mooney, RN, MS, PLC Consultant to Planning Board; Jack Eikenberg, Finance Community Representative; Donald Brown, Finance Community Representative; Mitchell Cordova, PhD., Board Quality/Safety Community Representative; Reverend Israel Suarez., Board Planning Community Representative; Angela D Anna, System Director/Internal Audit; Kim Gaide, Ambulatory Operations Manager I; Susan Crowley, MA, BCC, Chaplain; Laurie Gretten, Executive Secretary/Board of Directors; Tamra Ellsworth, Administrative Assistant/Board of Directors GUESTS: Jeff Dektas, Lee County Sheriff Office, Angelo Vaughn, Lee County Sheriff Office, Honorable John Carlin, Judge; Cecil Pedergrass, Lee County; Neil LeClair; Dave Arter; Sean Hartman; Frank Gluck, NewsPress; Lena Brown; Cindy Castorica; Robert McDonald; Amanda Carter; Vic Carter; Rosario Matos; Sandra Matos; Dougles Peer; Stelsa Carter; Glenda Akin; Levi Bentley; Judy Bentley; Richard Hardin; Cindy Hardey; Doug Meurer, Lee County Manager; Sandra Cohen; Brittany Cohill; Tina Parker; Clif Parker; John Fritts; Raj Mahadevan, M.D.; Victor Mahadevan; Vincen Mahadevan; Christin Collins; Andrew Williams; John Grey; Andrew Malach; Susan Malach; Alexander Keeley; Mike Ellis 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 for public inspection. SUBJECT DISCUSSION ACTION FOLLOW-UP MEETING CALLED TO ORDER The Lee County Trauma Services District Board of Directors Annual Organization Meeting was CALLED TO ORDER at 1:59 p.m. by Richard Akin, Board Chairman. PUBLIC INPUT AGENDA ITEMS CONFIRMATION OF 2013 BOARD OFFICERS OLD BUSINESS There were No Public Input Agenda Items. Jim Humphrey confirmed the 2013 Board Officer positions: Richard Akin, Board Chairman; Sanford Cohen, Board Vice Chairman; Marilyn Stout, Board Treasurer; and Diane Champion, Board Secretary. Jim Humphrey recommended a motion consistent with the Special Act establishing the Lee County Trauma Services District. Chris Hansen is working with Lee County Government to evaluate the current Emergency Medical Service (EMS) helicopter situation. A motion was made by Chris Hansen to approve, consistent with the Special Act establishing the Lee County Trauma Services District, that the Governing body of the Trauma Services District be composed of the members of the Board of Directors of the Lee Memorial Health System and shall also be called the Board of Directors of the Lee County Trauma Services District; and the Board of the Trauma Services District shall have the same officers as the Board of Directors of the Lee Memorial Health System. The motion was seconded by David Collins and it carried with no opposition. NEW BUSINESS There was no NEW Business at this time. NEXT REGULAR SCHEDULED MEETING The date of the next meeting of the Lee County Trauma Services District Board of Directors is on Thursday, May 23, 2013, *1:00pm, in the Gulf Coast Medical Center, Medical Office Building, Board of Directors Boardroom. *(Meeting concurrent with the Lee Memorial Health System Meeting)

7 LEE COUNTY TRAUMA SERVICES DISTRICT BOARD OF DIRECTORS ANNUAL ORGANIZATIONAL MEETING MINUTES Tuesday, January 8, 2013 Page 2 of 2 SUBJECT DISCUSSION ACTION FOLLOW-UP ADJOURNMENT The Lee County Trauma Services District Board of Directors meeting was ADJOURNED at 2:02 p.m. by Richard Akin, Board Chairman. Minutes were recorded by Laurie Gretten, Executive Secretary/Board of Directors office Diane Champion Board Secretary

8 LEE COUNTY TRAUMA SERVICES DISTRICT BOARD OF DIRECTORS MEETING MINUTES Thursday, February 28, 2013 LOCATION: Gulf Coast Medical Center, Medical Office Building, Board of Directors Boardroom, Doctors Way, Fort Myers, FL 339 MEMBERS PRESENT: Richard Akin, Board Chairman; Sanford N. Cohen, M.D., Board Vice Chairman; Marilyn Stout, Board Treasurer; Diane Champion, Board Secretary; Steve Brown, M.D., Board Member; Nancy McGovern, RN, MSM, Board Member; David Collins, Board Member; Chris Hansen, Board Member; Jessica Carter, Board Member; Stephanie Meyer, BSN, RN, Board Member; David Berger, M.D., Board Quality/Safety Community Representative; Bill Silverman, M.D., Board Quality/Safety Community Representative; Mitch Cordova, PhD, Board Quality/Safety Community Representative OTHERS PRESENT: Jim Nathan, President/Chief Executive Officer; Cathy Stephens, Board Administrator; Jim Humphrey, Board Counsel; Mary McGillicuddy, Chief Legal Officer; Jon Cecil, Chief Human Resources Officer; Scott Nygaard, M.D., Chief Medical Officer/Physician Services; Chuck Krivenko, M.D., Chief Medical Officer/Clinical and Quality Services; Mike German, Chief Financial Officer; Donna Giannuzzi, Chief Nursing Officer & Chief Administrative Officer/Health Park Medical Center; Lisa Sgarlata, Chief Administrative Officer/Lee Memorial Hospital; Joshua DeTillio, Chief Administrative Officer/Gulf Coast Medical Center; Scott Kashman, Chief Administrative Officer/Cape Coral Hospital; Daniel Fink, Chief Administrative Officer/The Children s Hospital; Wendy Piascik, Vice President/Patient Care Services/CCH; Avra Bowers, M.D., System Medical Director/Primary Care Services; Mary Briggs, System Director/Media Relations; Sally Jackson, System Director/Government & Community Relations; Suzanne Bradach, System Director/Special Projects; Stephen Streed, System Director/Epidemiology & Infection Control; Sandy Wharton, System Director/Medical Staff Services; Ben Spence, Controller/Acute Care & Reimbursement; Catherine Kahle, Senior System Counsel; Eric Anderson, Senior Project Manager; Joan Odorizzi, Nursing Director/CCH; Marliese Mooney, RN, MS, PLC Consultant to Planning Board; Donald Brown, Board Finance Community Representative; Denise Sawyer, MDiv, Chaplain; Laurie Gretten, Executive Secretary/Board of Directors, Tamra Ellsworth, Executive Secretary/Board of Directors GUESTS: Jim Drzymala, Lee County Sheriff s Department; Allison Ash, Fowler White; Frank Gluck, News-Press Reporter; Liz Freeman, Naples Daily News Reporter; Donald Eslick; Nicholas Batos; L.E. Scotty Wood; Melinda Black, Family Health Centers; Dave Elias, NBC-2; Matt Apthorp, NBC-2; Linda Adams; Katlyn Vanderhoof; Ben Nelson, Mayor/City of Bonita Springs; John Roemer 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 for public inspection. SUBJECT DISCUSSION ACTION FOLLOW-UP MEETING CALLED TO ORDER The Lee County Trauma Services District Board of Directors Meeting was CALLED TO ORDER at 5:08 p.m. by Richard Akin, Board Chairman. PUBLIC INPUT AGENDA ITEMS REGIONAL ADVISORY COMMITTEE ON TRAUMA SERVICES A ADDITIONAL APPOINTMENTS None at this time. Chris Hansen asked for approval of the 2013 Additional Appointments to Regional Advisory Committee (RAC) on Trauma Services (Exhibit 1). Chris announced the additional appointments of Lee County Commissioner, Cecil Pendergrass, Paige Kreegel, M.D., and Michael V. Reagen, Ph.D. and said the appointees have agreed to offer their experience to the committee. A motion was made by Steve Brown to approve the 2013 Additional Appointments to the Regional Advisory Committee on Trauma Services (Exhibit 1). The motion was seconded by David Collins and it carried with no opposition. OTHER ITEMS None at this time. NEXT REGULAR SCHEDULED MEETING The date of the next meeting of the Lee County Trauma Services District Board of Directors is Thursday, May 23, 2013 at *1:00pm, in the Gulf Coast Medical Center Boardroom *Held concurrently with Lee Memorial Health System Board of Directors Meeting. ADJOURNMENT The Lee County Trauma Services District Board of Directors meeting was ADJOURNED at 5:09 p.m. by Richard Akin, Board Chairman. Minutes were recorded by Tamra Ellsworth, Executive Secretary/Board of Directors office Diane Champion, Board Secretary

9 Board of Directors Trauma Report May 23, 2013

10 LMH Trauma Statistics CY 20 Total Trauma Registry entries = 2057 Trauma alerts = 1025 Trauma consults = 414 Majority of our trauma alert patients are between the ages of 1-44 (52%).

11 Trauma Registry Data Trauma Alerts CY # Trauma Alerts

12 Statistics - continued Counties most frequently served: Lee 57% Collier 18% Charlotte 16% Hendry 6% Glades 1% Average Hospital LOS = 1 to < 6 days (72%) but ranged from 1d to 92d

13 Mechanism of Injury Trauma Alerts CY 20 N=1025 Trauma alerts Blunt % MVC 353 (34.44%) Fall 180 (17.56%) MCC 90 (8.78%) Ped vs Auto 81 (6.09%) Assault 41 (4.00%) Bike vs Auto 24 (2.34%) Bicycle 16 (1.56%) Other Blunt 22 (2.15%) Other 37 (4.31%) Penetrating 157 (15.32%) Stab Wound 78 (7.61%) GSW 79 (7.71%) Burns 16 (1.56%)

14 Trauma Alerts/Downgrades CY 20 Trauma Alerts: 1025 Downgrades: 298 (29% overall D/G Rate) Downgraded and admitted: 108 Downgraded and discharged: 190 Downgrades by MOI (top 3) MVC 115 Car looked bad Fall 73 Syncope/CVA/dysrhythmia vs CHI Stab Wound 26 Unable to determine depth of wound

15 CY 20 Trauma Alert ED Dispositions 35% 30% 25% % Patients 20% 15% 10% 5% 0% Floor ICU OR Morgue TSFR Home/Jail

16 Trauma Registry Data Trauma Service Admissions # Trauma Svc. Admits 20 0 Jan- Feb- Mar- Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec-

17 Trauma Registry Data ISS > # ISS> Jan- Feb- Mar- Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec-

18 Trauma District Financials FISCAL YEAR TO DATE as of December 31, 20

19 Trauma Volumes Inpatient Discharges: 390 vs. 422 prior year Decrease of 32 cases or -8% Trauma Surgeon Visits: 2,984 vs. 2,257 prior year 32% increase from prior year, 727 visits

20 Expected Payment Expected Inpatient Payment per Case Hospital DEC 11 FYTD $17,875 Hospital DEC FYTD $17, %

21 Trauma District Quarter End /31/ Inpatient Discharges 9 Auto/PIP 33% 102 Medicare/Mcare HMO 26% 60 Private Insurance 15% 43 Medicaid, Medicaid HMO 11% 43 Self Pay or Charity 11% 13 Other Government, 4% 390 Total Discharges 100%

22 Payments from Fines Special Trauma Funding 11/30/20 1/31/2013 Extra Court Fines $ 2,437 $ 1,951 Red Light Running $ 30,085 $ 24,425 Enhanced Speed Zones $ 65 $ 13 Improper passing a school bus $ 14,072 $ 9,209 Racing on highways & reckless driving $ 44,762 $ 40,233 Camera Bill $ 109,596 $ 102,697 Total $ 201,017 $ 178,527

23 Trauma District 1 st Quarter Financial Report Professional Technical Total Revenues 667,000 7,041,300 7,708,300 Expenses 1,874,000 6,726,000 8,600,000 Loss from Operations Trauma Readiness Costs -1,207, , , , ,000 Net Loss -1,207, ,700-1,391,700

24 L E E M E M O R I A L HEALTH SYSTEM BOARD OF DIRECTORS REGIONAL ADVISORY COMMITTEE ON TRAUMA SERVICES A Additional Appointments (Approval)

25 LEE COUNTY TRAUMA SERVICES DISTRICT BOARD OF DIRECTORS M E M O R A N D U M TO: FROM: Directors, Lee County Trauma Services District Richard Akin, Board Chairman & Jim Nathan, President DATE: May 23, 2013 SUBJECT: Additional Appointments to the FY 2013 Regional Advisory Committee on Trauma ========================================================================== = Below is the list of additional appointments to the Regional Advisory Committee on Trauma Services for Board approval: Co-Chair: Chris Hansen Co-Chair: Carol Barclay Members: Lee County: Carol Barclay (Co-Chair) Sal Grosso Dick Helms, CPA David Ciccarello, Esq. Cecil Pendergrass Glades County: Bob Jones (CV/Resume not available) Donna Storter Long Hendry County: Charlotte County: Collier County: At Large: Patricia Harrington, Ph.D Janet Taylor Debbie Harrington Paige Kreegel, M.D. Pat Barton Robert B. Tober, M.D. Michael V. Reagen, Ph.D. Joe Flint (previously representing Glades County) Trauma Policy states appointments are approved to serve a term of one calendar year. Five of the fifteen members appointed shall come from each of the following counties in Southwest Florida: Charlotte, Collier, Glades, Hendry, and Lee. The remaining ten members shall be at-large appointees and shall reside in any one of the five counties = 15 total. \\IS033780\Backup Drive\PRESENTATIONS\2013\ TRAUMA DISTRICT & FULL BOARD - TAMRA\Trauma\ FY 2013 RAC Appointments for Approval - UPDATED.doc

26 LEE COUNTY TRAUMA SERVICES DISTRICT BOARD OF DIRECTORS OTHER ITEMS A. Legislative Questions

27 ADJOURNMENT LEE COUNTY TRAUMA SERVICES DISTRICT DATE OF THE NEXT REGULARLY SCHEDULED LEE COUNTY TRAUMA SERVICES DISTRICT MEETING: Thursday, August 22, :00pm* GULF COAST MEDICAL CENTER - Boardroom Doctors Way, Ft. Myers, FL 339 *(Held concurrent with the Lee Memorial Health System Board of Directors Meeting)