TBRHSC Board of Directors Open Meeting Thursday, April 17, 2014 – 5:00 pm Boardroom, Level 3, TBRHSC 980 Oliver Road, Thunder Bay AGENDA Vision: Healthy Together Mission: To advance world-class Patient and Family Centred Care in an academic, research-based, acute care environment Values: Patients ARE First (Accountability, Respect and Excellence)
# Time Presenter Item & Purpose (Y) Expected (X) Outcome (Z) R / e D c I e n o D E c f m d i i o s s u i c m r o c u m n a e s a t / n s i t A i o d o i o c n a n t n t i i o o n n
1.0 CALL TO ORDER 2.0 PATIENT STORY – Peter Myllymaa 3.1 1 S. Fraser Quorum (7 members total required, 5 being voting) 3.2 1 S. Fraser Conflict of Interest 3.3 1 S. Fraser Approval of the Agenda X 3.4 3 S. Fraser Chair’s Remarks X 4.0 PRESENTATIONS 4.1 20 G. Ferguson Accreditation* X X X C. Freitag 4.2 10 R. Morrison CEO Evaluation Process* X X 5.0 CONSENT AGENDA 5.1 Board of Directors: Approval of Minutes (March 19, 2014)* X X 5.2 TBRHS Foundation* X 5.3 Volunteer Association X 5.4 Professional Staff Association X 5.5 Thunder Bay Regional Research Institute* X 5.6 Quality Committee Minutes (March 18, 2014)* X 6.0 REPORTS AND DISCUSSION 6.1 5 Report from Senior Management* X X X 6.2 10 A. Robichaud Report from the President and CEO X X 6.3 5 Dr. G. Porter Report from the Chief of Staff* X X 6.4 5 Dr. Crocker Report from the Chief Nursing Executive* X X Ellacott 6.5 5 Dr. R. Strasser Northern Ontario School of Medicine (NOSM)* X X 7.0 BUSINESS/COMMITTEE MATTERS 7.1 Corporate Membership* X 8.0 FOR INFORMATION 8.1 Board Comprehensive Work Plan* X 8.2 Volunteer Association Corporate Membership List* X 8.3 Foundation Board Corporate Membership List* X
Page 1 of 2 # Time Presenter Item & Purpose (Y) Expected (X) Outcome (Z) R / e D c I e n o D E c f m d i i o s s u i c m r o c u m n a e s a t / n s i t A i o d o i o c n a n t n t i i o o n n
9.0 BOARD MEMBER COMMENTS X 10.0 DATE OF NEXT MEETING – Wednesday, May 7, 2014 – 5:00pm X 11.0 ADJOURNMENT Ethical Framework TBRHSC is committed to ensuring decisions and practices are ethically responsible and align with our mission/vision/values. All leaders should consider decisions from an ethics perspective including their implications on patients, staff and the community. The following questions should be reviewed for each decision.
1. Does the course of action put ‘Patients First’ by responding respectfully to needs & values of patients and families? 2. Does the course of action demonstrate ‘accountability’ by advancing quality, safety and Patient and Family Centred Care & delivering fiscally responsible services? 3. Does the course of action demonstrate ‘respect’ by honouring the uniqueness of every individual? 4. Does the course of action demonstrate ‘Excellence’ by reinforcing that we are recognized leaders in Patient and Family Centered Care through the alignment of Academics and Research with Clinical Services?
For more detailed questions to use on difficult decisions, please refer to TBRHSC’s Framework for Ethical Decision Making located on the Quality and Risk Management page of the Internet. http://intranet.tbrhsc.net/Site_Published/i5/render.aspx?DocumentRender.IdType=5&DocumentRender.Id=110784
Page 2 of 2 BOARD OF DIRECTORS (Open) April 17, 2014 Agenda Committee or Report Motion or Recommendation Approved or Item Accepted by:
3.3 Agenda – April 17, 2014 “That the Agenda be approved as circulated.” Moved by: Seconded by:
5.0 Consent Agenda “That the Board of Directors: Moved by: 5.1 Approves the Board of Directors Minutes of March 19, 2014, Seconded by: 5.2 Receives the TBRHS Foundation Report – dated March, 2014, 5.3 Receives the Volunteer Association Report – n/a, 5.4 Receives the Professional Staff Association Report – n/a, 5.5 Receives the TBRRI Report dated April, 2014, 5.6 Receives the Minutes of the Quality Committee of March 18, 2014,
as presented.”
6.0 Reports and Discussion “That the Board of Directors: Moved by: 6.1Accepts the Report from Senior Management, Seconded by: 6.2 Accepts the Report from the President and CEO, 6.3 Accepts the Report from the Chief of Staff, 6.4 Accepts the Report from the Chief Nursing Executive, 6.5 Receives the Report from the NOSM,
dated April , 2014 as presented.”
7.1 Corporate Membership “That the Board of Directors accepts the applications for membership to the Corporation received for the period March 1 to April 4, 2014 as per the attached listing.”
1 of 1 Board Accreditation Update 2014 Gary Ferguson April, 2014
1 TBRHSC Surveyor Team
Board Session with Surveyors • Monday May 26, 2014 from 1600-1700 • During this time the Surveyors will review Priority Processes related to the Governance Standards • This session will include all 4 Surveyors
TBRHSC Surveyors • TBRHSC has been assigned 4 Surveyors. There will also be an Observer present (Training). • The team consists of a Physician as well as individuals with nursing and administrative background. • The Surveyors bring a variety of Clinical and Administrative experience to the process.
2 Governance Discussion Group
Priority Process
A priority process is a system or process that Accreditation Canada has identified as having a significant impact on patient safety and quality of care or service. Surveyors assess priority processes using Tracers (a systematic method of inquiry).
Topics/Priority Process for review: -Planning and Service Design -Communication -Human Capital -Resource Management -Integrated Quality Management
3 Planning and Service Design
The purpose of this tracer is to determine how the organization develops and implements the infrastructure, programs and service to meet the needs of the community and populations served.
Questions Surveyors may ask about this PP
• What is the mission of your organization? • What are the priorities of your organization for next five years? • How do you incorporate the values of the organization in your daily practice? • The strategic and operational planning process • Review Strategic Plan
4 Communication
The Surveyors may:
• Review of Information/Communication Plan • Ask how does the Board communicate with staff. • Discuss Board Communication among various layers of the organization, and with external stakeholders.
5 Human Capital
The Surveyors may:
Review Human Resource Plan
Questions surveyors may ask about this PP
1. Questions related to recruitment, retention and succession planning ? CEO 2. Concerns or challenges related to this are 3. What is the Board interaction with Staff in the organization?
6 Resource Management
During this tracer the surveyors will be monitoring, administration, and integration of activities involved with the appropriate allocation and use of resources.
The Surveyors may ask:
• What is the Boards involvement in finance, capital planning, and resources allocation. • Review Operational Plans
7 Integrated Quality Management
The purpose of this priority process is to review the continuous, proactive and systematic process. To understand, management and communicative qualities from a system-wide perspective to achieve goals and objectives
The Surveyors may:
• Review the Quality Improvement Initiatives in relation to the Governance Standards. • Review how Integrated Quality Management is implemented into the Board’s operation.
8 Accreditation Canada Reports, Follow- up and Awards
General Debriefing is held once the surveyors have completed their initial on site survey. Prior to leaving the site the Surveyors will hold an hour meeting with interested staff, board members, volunteers, clients and family members to highlight their findings.
Surveyors will also leave a brief preliminary report on-site which includes accreditation findings and results of the surveyor ratings
After the survey, TBRHSC will be given time to review and verify the accuracy of survey findings and submit organization commentary
6-8 weeks after the on-site survey Accreditation Canada will issue the final report. This report includes Surveyor commentary, Organization commentary and the Award forecast
9 Questions?
10 Surveyor Profile Doris Cassan has been a registered nurse for 37 years and a surveyor with Accreditation Canada since 2009. She is currently the Patient Care Manager for Emergency, Surgical Suite and Central Service Department at Groves Memorial Hospital in Fergus, a busy small hospital in southern Ontario. Doris has held leadership positions in many other programs in community hospitals including Women's & Children's Health, Dialysis, Ambulatory Care and Chronic Care.
Doris is a member of the RNAO and Nursing Leadership Network. She has enjoyed teaching nursing at times, and is a strong advocate for ongoing professional education. She has completed her Masters in Nursing as well as the Nursing Leadership Institute (Dorothy Wylie). In 2012, Doris attained the Canadian Patient Safety Officer designation and CSAO certification in medical device reprocessing.
1 / 2 2 / 2 Surveyor Profile Patti Cochrane is accountable for clinical operations and programs at the Trillium Health Partners - Mississauga Hospital.
During the merger of the Credit Valley Hospital and Trillium Health Centre, Patti was Vice President, Patient Services, Quality and Practice and Chief Nursing Officer at the organization’s Trillium sites. Previous to that, Patti was Vice President, Patient Services and Quality and Chief Nursing Officer at Trillium Health Centre. She has also held a wide range of clinical roles including Associate Vice President, Performance Excellence and Director of a number of health systems since the creation of Trillium Health Centre in 1998, and other roles with the Mississauga Hospital starting in 1991.
Patti is a registered nurse with a Bachelor’s Degree and a Masters in Health Science in Health Administration and has recently completed her Canadian Health Executive program designation.
Her accomplishments over the years have been numerous and have included leading patient-centredness initiatives, the design of the decentralized inpatient tower, advancing innovative models of care and quality improvement engagement and adoption. In 2006, she was the recipient of the Innovation Award from the Society of Graduates at the University of Toronto for her inpatient design work. Patti is currently a board member for the Cardiac Care Network, Quality Health Network and is a healthcare speaker on various topics such as quality.
1 / 2 2 / 2 Surveyor Profile Kevin Gough MD is head of the Division of Infectious Diseases and Medical Director of the HIV Service at St. Michael’s Hospital in Toronto, Ontario. He served as Interim Medical Director of Casey House Hospice in Toronto and is a past member of their Board of Directors. He continues to sit on the Quality Committee of the Board and provides Infectious Diseases consultation to the residential program at the House.
Kevin trained as a Medical Laboratory Technologist before gaining his medical degree at McMaster University. He went on to complete specialist training in Internal Medicine and sub-specialist training in Infectious Diseases. He is a fellow of the Royal College of Physicians and Surgeons of Canada.
Kevin completed a Master of Education degree (Health Professional Education) at the Ontario Institute for Studies in Education at the University of Toronto (OISE-UT). He is the educational representative for the Division of Infectious Diseases at St. Michael’s Hospital and sits on the University of Toronto Infectious Diseases Residency Training Program Committee. Kevin is the recipient of Outstanding Teacher Awards from the Department of Medicine for his teaching excellence and serves as Chief Examiner for the Medical Council of Canada.
Kevin has chaired the Infection Control Committee at St. Michael’s Hospital and sat on the Pharmacy and Therapeutics, and Post-Graduate Medical Education Committees, as well as the Physician Informatics Advisory Group to advance information technology initiatives for medical staff. He has also co-chaired the Toronto Central Local Health Integration Network High Cost Drug Review Committee for the Ministry of Health and Long-Term Care, Ontario.
Kevin is a member of the Faculty of Medicine at the University of Toronto, with research and clinical interests in Infectious Diseases, HIV, and Medical Education. He also serves as an Investigating Coroner for the Province of Ontario.
Kevin is a member of the Accreditation Canada Surveyor Certification Education Advisory Committee, the International Education Advisory Group, and has served as a mentor for new surveyor training.
1 / 2 2 / 2 Surveyor Profile Gil Vergilio is currently employed as a Quality Improvement and Patient Safety Consultant. He works with clinical leadership teams on regional improvement initiatives and activities related to patient safety. In addition, he consults on accreditation, IQM activities and organization reviews.
Throughout his career, Gil has held several leadership positions in both health care and health education. He has worked as a Program Director for paramedic training at the Justice Institute of British Columbia where he supported efforts in obtaining accreditation with CMA Conjoint accreditation. Earlier in his career Gil has held several leadership positions with respiratory therapy in both British Columbia and Alberta.
Gil holds a Master of Education, with a major in Administrative Leadership from Simon Fraser University. He has completed formal studies in quality management through CHA, and health administration studies at the University of Saskatchewan.
Gil has recently served on the Board of Directors for the Society of Christian Schools in British Columbia. He is also an Education Consultant with the Canadian Healthcare Association, working on their continuing education programs. In addition, he is past president of both the Canadian and British Columbian Societies for Respiratory Therapists.
Gil has authored several articles on patient-focused care, multi-skilling in health professions and accreditation.
1 / 2 2 / 2 Thunder Bay Regional Health Sciences Centre CEO PERFORMANCE EVALUATION Presentation to TBRHSC Board of Directors
Presented by Rod Morrison April 17, 2014
1 Board Policy BD-05 CEO Performance and Evaluation
Key Elements:
1) Chair Responsibility • To initiate the process on behalf of the Executive Committee of the Board
2) Two aspects of performance evaluation
page 2 Performance and Evaluation
CEO Goals and Objectives/ CEO Work Plan Competencies - Reviewed and -Input from Board assessed by Executive Committee
Board Assessment of CEO Performance
page 3 Competencies
Definition: A competency is any knowledge, skill, trait, motive, attitude, value or other personal characteristic that is essential to perform the job and that differentiates good from superior performance.
page 4 Competencies
• Achieving Results • Leading Effectively • Thinking Critically • Personal Effectiveness
page 5 The Performance Evaluation Tool: 20/20 Insight
page 6 20/20 Insight - Features
• Performance management/evaluation software
• Web based survey completion, data collection, reporting
• Fully customizable: respondent selection process, notices, instructions, reporting
page 7 20/20 Evaluation Participants/Respondents
In addition to Board members, input will be sought from:
• 2 external leaders • 4 internal leaders/direct reports • CEO self evaluation
page 8 Confidentiality
• Participants are not identified by name.
• Numeric ratings are combined to produce an average score.
• Feedback comments are confidential.
page 9 Process
• All Participants will be notified via email on April 22, 2014.
• The email contains a link to the evaluation with instructions, username and deadlines. Participants will create their own password.
• Deadline for completion will be May 8, 2014. A reminder email is sent to those who have not completed their evaluation one week before the deadline.
• Respondents can change their rating or comments at any time during this timeframe.
• Performance report is prepared and sent to the Executive Committee.
page 10 Sample Report – Category View
page 11 Timeline
Work plan established in May 2013 for 2013/2014
April 22,2014 • Evaluation open to participants. • (Notification via e-mail)
May 8, 2014 • Deadline for evaluation to be completed.
May 2014 • Performance evaluation report to CEO Evaluation & Compensation Committee • Progress on Strategic Plan Achievements related to the job description May 2014 • Finalize evaluation and May 14/15 work plan – CEO Evaluation & Compensation Committee • (President & CEO in attendance)
June 2014 • Report to the Board (in camera)
page 12 Review of Process and Criteria
Following completion of the 2014 Evaluation, the Committee will meet to consider input from Board and CEO on changes to the process and criteria
page 13 Questions?
14 Thunder Bay Regional Health Sciences Centre Board of Directors Wednesday, March 19, 2014 Boardroom – 5:00 p.m. Present: Nadine Doucette, Acting Chair Andrée Robichaud* Grant Walsh ACTION Sharon Cole Paterson Anita Jean Doug Shanks Jay Storeshaw Dr. Gordon Porter* Dick Mannisto Dr. Rhonda Crocker Ellacott*
By Invitation – Senior Management Team: Dr. Stewart Kennedy Cathy Covino Janet Northan Peter Myllymaa Dr. Mark Henderson Glenn Craig Dr. Roxanne Deslauriers Rod Morrison
By Invitation: Jessica Nehrebecky, Rec Sec. Renée Laakso Aaron Skillen Miranda Figliomeni, Student Katrina Sutton
Regrets Susan Fraser Dr. Roger Strasser Tracie Smith Dr. Suzanne Allain* Dawn Bubar Carolyn Freitag
1.0 CALL TO ORDER - The Chair called the meeting to order at 5:02 p.m.
The Chair welcomed the web audience, Board members, Senior Management and guests.
2.0 PATIENT STORY – Dr. Gordon Porter
Dr. Gordon Porter, Chief of Staff, shared a patient story.
3.1 Quorum – Quorum was attained.
3.2 Conflict of Interest – None.
3.3 Approval of the Agenda Motion Moved by: Grant Walsh Seconded by: Jay Storeshaw
“That the Agenda be approved, as circulated.”
CARRIED
3.4 Chair’s Remarks – for information
Board of Director’s Meeting – March 19, 2014 Page 1 of 4
* Denotes Non-Voting Member 4.0 PRESENTATIONS
4.1 ALC Update – Aaron Skillen
Mr. Aaron Skillen, Program Director, Chronic Disease Prevention & Management and Medicine Services, provided an overcapacity and Alternate Level of Care (ALC) update. The following points were highlighted: The average daily admitted patient census in 2014 is 425, whereas TBRHSC is funded for only 396 beds. There have only been two days in 2014 whereTBRHSC has had less than 396 patients. The ALC rate in 2013/14 was 16%. TBRHSC has been in gridlock for 52 consecutive days (December 30, 2013 – February 19, 2014). The Minister of Health’s recent announcement of $14M in funding is expected to bring some relief to the ALC issue. It is still unclear as to exactly when TBRHSC will begin to feel the impact of the funding. Further details are expected in the near future on how the beds will be allocated.
It was asked if the number of visits that TBRHSC receives in their Emergency Department (ED) is congruent with cities of the same population. It was estimated that it is likely much lower in cities of the same population, however further investigation will be done and will be reported back to the Board for their information.
Mr. Skillen was excused from the meeting.
5.0 CONSENT AGENDA
On page 2 of 5 of the February 5, 2014 minutes, “TBRHSC had 1,2000,000 kg of waste” should read “TBRHSC had 1,200,000 kg of waste”.
Moved by: Doug Shanks Secondedby: DickMannisto Motion
“That the Board of Directors: 5.1 Approves the Board of Directors Minutes of February 5, 2014, as amended, 5.2 Receives the TBRHS Foundation Report dated March , 2014, 5.3 Receives the Volunteer Association Report dated March, 2014, 5.4 Receives the Professional Staff Association Report – n/a, 5.5 Receives the TBRRI Report dated March, 2014, 5.6 Receives the Minutes of the Quality Committee of February 11, 2014.”
CARRIED
6.0 REPORTS AND DISCUSSION
Board of Director’s Meeting March 19, 2014 Page 2 of 4
* Denotes Non-Voting Member 6.1 Report from Senior Management TBRHSC recycles some of its plastics through a company in the United States and receives payment for the material that is recycled. More information will be sought regarding which types of plastics are currently being recycled. The organization was applauded for the significant drop in lost time days and the Workplace Safety and Insurance Board (WSIB) refund. A very well attended emergency preparedness exercise was held in January, 2014. The table top focused on a code orange (external disaster). The scenario consisted of an ice storm and lack of staff and supplies. Lessons learned from the exercise were: when to actually call the code and the lack of agreements that TBRHSC has with some external organization (i.e. Snowmobile Club, Army, etc). The City By-Laws relating to the Smoke Free Grounds on TBRHSC property have been approved. Ticketing for infractions have been approved, however will begin after the proper training has been provided. Patients, family members and staff members are asked to stop smoking when they are seen on TBRHSC’s ground. It was clarified that anyone is able to ask someone to not smoke on property grounds.
6.2 Report from the President and CEO The President and CEO reported on the following: Members of Senior Management travelled to Ottawa on February 10, 2014 to meet with Dr. Jack Kitts, President and CEO and members of Ottawa Hospital to learn about the Studer Concept. The concept is a care model that can improve the quality of care of patients. More information will be forthcoming on multiple options on how TBRHSC can enhance patient experiences. On March 31, 2014, the President and CEO, along with Mr. Anthony Dale, President and CEO of Ontario Hospitals Association (OHA) will be presenting the Local Health System Integration Act (LHSIA) review to the Standing Committee on Social Policy.
6.3 ReportfromtheChiefofStaff - for information
6.4 Report from the Chief Nursing Executive – for information TBRHSC has successfully hired 63 new graduate nurses that will begin to work in May, 2014. The new hires will assist with summer relief needs. As requested by the Board of Directors, the Chief Nursing Executive will source information regarding the demographic on the nurses that are hired. Action 6.5 Report from the Dean, Northern Ontario School of Medicine – for information
Moved by: Grant Walsh Seconded by: Jay Storeshaw Motion “That the Board of Directors: 6.1 Accepts the Report from the President and CEO, 6.2 Accepts the Report from the Chief of Staff,
Board of Director’s Meeting March 19, 2014 Page 3 of 4
* Denotes Non-Voting Member 6.3 Accepts the Report from the Chief Nursing Executive, 6.4 Receives the Report from the NOSM,
Dated March, 2014 as, presented.”
CARRIED
7.0 BUSINESS/COMMITTEE MATTERS - none
8.0 FOR INFORMATION - none
8.1 Board Comprehensive Work Plan – for information
9.0 BOARD MEMBER COMMENTS - none The organizers of TBRHSC’s 10th anniversary were commended on a wonderful event. On average, there are about 30 viewers for the Open Board sessions. It was suggested to do more promotion for the monthly webcasts in order to increase the number of viewers. Action
10.0 DATE OF NEXT MEETING – April 17, 2014– 5:00 p.m.
11.0 ADJOURNMENT
There being no further business, the meeting adjourned at 5:50 p.m.
______Chair Board Secretary
______Recording Secretary
Board of Director’s Meeting March 19, 2014 Page 4 of 4
* Denotes Non-Voting Member
Thunder Bay Regional Research Institute Report for TBRHSC Board – April, 2014
Submitted by: Dr. Roxanne Deslauriers – April 8th, 2014
Visitors and Announcements
March was a busy month for TBRRI as we hosted several tours of our research spaces at 980 Oliver Road and took part in two important announcements.
Throughout the month, staff conducted tours for four groups including Thunder Bay Regional Health Sciences Foundation staff; candidates for the Associate Dean of Research position at the Students visit the TBRRI wet lab. Northern Ontario School of Medicine; as well as Grade 7 & 8 students from Pic Mobert, Pic River and Rocky Bay First Nations communities which was organized through the Nokiiwin Tribal Council Inc. A similar tour took place in February for 7 Savant Lake First Nations Grade 6-8 students.
We were also pleased to host a tour and meeting with the Honourable Dr. Eric Hoskins, Economic Development, Trade and Employment Minister who was in Thunder Bay on March 25th and requested an opportunity to visit the Research Institute. During his visit Minister Hoskins was able to speak with Dr. Zehbe regarding her work related to HPV and with Drs. Curiel and Jumah regarding their work related to HIFU and uterine fibroids. Hon. Dr. Eric Hoskins
Surgeon Group Invests $2M in Local Orthopedic Research
On March 17th, a group of orthopedic surgeons at Thunder Bay Regional Health Sciences Centre announced that they are donating $2M over 10 years to fund a local orthopedic research program. The six surgeons making the donation are: Dr. Peter Clark, Dr. Claude Cullinan, Dr. Kurt Droll, Dr. Jubin Payandeh, Dr. David Puskas and Dr. Tracy Wilson. The group wanted to establish a sustainable orthopedic research program and hopes that their announcement will highlight the need for more community investment in health research. One of the projects they will undertake is a study into higher amputation rates in Northwestern Ontario related to patient complications from diabetes. TBRRI commends this group for their commitment to advancing patient-centred care at TBRHSC and looks forward to collaborating with them on their research program.
Dr. Jumah is Officially Welcomed
On March 20th, TBRRI held a media event to officially announce our newest addition to the scientist team, Dr. Naana Jumah. It was also an opportunity for TBRHSC to welcome her as a member of the Women & Children’s Program in Obstetrics and Gynaecology. Dr. Teresa Bruni, Medical Director of the Women’s & Children Program, and Dr. Henry Fairley, Gynaecologist, addressed the group and added their enthusiastic acceptance of this talented individual.
Brenda Mason, a member of the Aboriginal Advisory Committee and St. Joseph’s Care Group, noted how pleased she is that Dr. Jumah will be focusing on the health of Aboriginal women in the region. As a Clinician Researcher with TBRRI, Dr. Jumah will work collaboratively with TBRRI Scientists on various projects in her areas of interest including Aboriginal women’s health, substance use in pregnancy and cervical cancer screening. Her PSI Dr. Naana Jumah with Brenda Mason, Aboriginal Graham Farquharson Knowledge Advisory Committee Member, & Dr. Roxanne Translation Fellowship award will also give Deslauriers, Acting CEO, TBRRI her the opportunity to develop a rsearch program related to the non-invasive treatment of uterine fibroids.
Research is Important to the Canadian Cancer Society
In January, 2013, the Canadian Cancer Society awarded TBRRI Scientist, Dr. Chris Phenix with a Canadian Cancer Society Innovation grant. The grant program supports unique and creative research ideas that will impact cancer. This year, the Canadian Cancer Society noted Dr. Phenix’s work at TBRRI in their public campaign. The article talks about his work to develop a new imaging agent for Positron Emission Tomography (PET) that gives off a signal only when activated by a specific protein that is suspected of playing a role in the spread of cancer and chemotherapy resistance. By imaging the activity of the protein, Dr. Phenix hopes to develop PET as a method to not only detect the presence of cancer but also indicate the cancer’s potential to spread or resist treatment.
The importance of cancer research; the advancement in cancer treatment and detection in Thunder Bay; and the work of TBRRI was also mentioned by Melanie Mathieson when she spoke at the Canadian Cancer Society’s survivors luncheon in Thunder Bay on April 5th.
Thunder Bay Regional Health Sciences Centre Quality Committee of the Board Tuesday, March 18, 2014 Administrative Boardroom – 4:00 – 6:00 p.m.
Present: Sharon Cole-Paterson, Cathy Covino, R. Crocker Ellacott, Miranda Figliomeni (4th year nursing student with Rhonda Crocker Ellacott, Susan Fraser, Dr. Gordon Porter, Doug Shanks, Keith Taylor, Grant Walsh
Regrets: Georgia Carr, Anita Jean, Andrée Robichaud
By Invitation: Michael Del Nin, Manager, Decision Support, Carolyn Freitag, Director, Strategy and Performance Management, Michelle Allain, Bioethicist
1. CALL TO ORDER – The Chair called the meeting to order at 4:00 p.m.
2.0 QUORUM – Quorum was attained.
2.1 CONFLICT OF INTEREST – None.
2.2 APPROVAL OF AGENDA
It was noted that the date of the next meeting should read, “April 15, 2014”.
Moved by: Doug Shanks Seconded by: Keith Taylor
“That the Agenda be approved, as amended”. Motion
CARRIED
3. REPORTS
3.1 Quality Improvement Plan
Cathy Covino, Senior Director, Quality and Risk Management, Michael Del Nin, Manager, Decision Support, and Carolyn Freitag, Director, Strategy and Performance Management gave an update on the 2014/15 Quality Improvement Plan (QIP).
The 7 Priority Indicators of the 2014/15 QIP are C-Difficile Infection, Medication Reconciliation on Admission, Total Margin, Emergency Department Wait Times, Alternate Level of Care, Readmissions, and Patient Satisfaction.
Quality Committee of the Board Page 1 of 6 March 18, 2014 The indicators linked to executive compensation are as follows:
Access: 90th percentile ER length of stay (hours) for admitted patients Current Performance (Q3) = 29.16 Target = 29.0
Effectiveness: Gross Margin Current Performance (Q3) = 0.72% Target = 0.0%
Patient Centred: Patient Satisfaction Percentage positive NRC+Picker Responses for "Overall, How Would You Rate the Care and Services you Received at the Hospital?" In-Patient: Current Performance (Q2) = 94.4% Target = 94.8% ED: Current Performance (Q2) = 86.5% Target = 87.1%
Safety: Medication Reconciliation Percentage of Eligible Patients for Whom Medication Reconciliation was Performed on Admission Current Performance (Jan – Feb 2014) = 50% Target = 80%
The QIP has been reviewed extensively by Senior Management Council and is in compliance with the Excellent Care for All Act.
Discussion took place regarding TBRHSC’s engagement with their community partners with respect to the QIP. There was not a five partner engagement prior to formulating the QIP due to time constraints but will be included in the engagement for the next Strategic Plan. How we engage our 5 partners either through a letter or the Strategic Plan engagement sessions will be discussed with the President and CEO.
Discussion took place regarding including the word “gridlock” to the Priority Indicators in the narrative report as it resonates with the public. It was noted that with the upcoming revisions to the Bed Management Policy, the number of days in gridlock may initially increase, as gridlock days are currently understated.
Staff and physician satisfaction was removed from the QIP but will be on the Board Scorecard.
Quality Committee of the Board Page 2 of 6 March 18, 2014 Discussion took place regarding the data for Falls Prevention. Currently data for falls are being tracked but there is no hard target available for the QIP. The target would be 100% adherence to the process measures.
Suggested revisions to the 2014/15 QIP:
1. Information with respect to the recent media announcement and interim plan that has been established and supported will be added in the “Challenges, Risks, and Mitigation Strategies” section of the narrative report.
2. Both the Deputy Minister of Health Ontario and the Minister of Health will be noted in the “Challenges, Risks, and Mitigation Strategies” section of the narrative report.
3. The five partner’s engagement session in April will be noted in the “Integration and Continuity of Care” section of the narrative report.
4. Under the heading, “What Are the Objectives of Our QIP” in the narrative report, “and decrease organizational gridlock” will be added to the end of the last bullet and the last bullet will be moved to the top of the bullets.
5. The 2013/14 Year-to-Date value of 4.5 for Falls Prevention will be removed from the spreadsheet.
A further suggestion was made for consideration for the next QIP regarding factoring in points for varying target degrees for executive compensation indicators.
Moved by: Doug Shanks Seconded by: Keith Taylor
“The Quality Committee of the Board recommends that the Board of Directors approve the 2014/15 Quality Improvement Plan submission package as revised.” Motion
CARRIED
3.2 QIP Excerpt from Board Scorecard Report
The QIP Excerpt from the Board Scorecard was included in the agenda package with the 2014/15 QIP spreadsheet.
3.3 Compliments/Concerns/Comments
Cathy Covino, Senior Director, Quality and Risk Management gave a report on the Compliments, Concerns, and Comments data.
Quality Committee of the Board Page 3 of 6 March 18, 2014 The following graphs were reviewed: 2014 Compliments by Category, 2014 Compliments by Department, 2013 Compliments by Category, 2013 Compliments by Department, 2014 Concerns by Category, 2014 Concerns by Department, 2013 Concerns by Category, 2013 Concerns by Department, January to March Comment Categories Graph.
The comments were included in the agenda package.
Improvements have been made to the Receipt of Concern Letter that thanks the complainant for giving the feedback and asks that they call Quality and Risk Management if they have not received a response back in 45 days.
The shadowing of a patient during their journey to help improve satisfaction and quality improvement, much like an accreditation tracer was discussed. Patient shadowing will be added to a future Patient Family Advisor agenda.
Currently Patient Experience Advisors are available in the Emergency Department. Patient call backs have also begun.
The Emergency Department has Patient Experience Advisors available to help with immediate concerns.
4. PRESENTATIONS
4.1 Ethics Presentation
Michelle Allain, Bioethicist gave a presentation on clinical ethics.
Bioethics is a reasoned and systematic approach to deciding what is the right thing to do in a situation. Ethical dilemmas can arise at any point along the continuum of care and at each level within the organization. They are often complex and value laden.
The goal of the ethics portfolio is to support the improvement of patient care by assisting patients, families, staff, physicians, students and volunteers resolve ethical issues.
Clinical and organizational ethics at Thunder Bay Regional Health Sciences Centre have undergone many structural changes over the past year. The former Ethics Team was dissolved and replaced with a new framework which includes the Operational Ethics Committee as well as bi-annual Ethics Engagement Forums to ensure broad based discussion and engagement on ethical issues.
The Operational Ethics Committee reports to the Senior Management Council, Medical Advisory Committee, and the Board of Directors.
Quality Committee of the Board Page 4 of 6 March 18, 2014 Member duties and responsibilities are to regularly attend Operational Ethics Committee meetings and actively participate in facilitating the overall goals and work of the committee. They are also to regularly attend Ethics Engagement Forum meetings and actively participate in facilitating the overall goals and objectives designated for these meetings. They serve as ambassadors for ethics within the organization.
Members participate in sub-committees as necessary and contribute to the work of these groups and address ethical issues that arise through discussion in a collaborative, supportive, and sensitive manner that upholds the standards of professionalism, respect, and dignity.
Confidentiality is maintained within the limits of the law and as outlined in the confidentiality agreement signed by Operational Ethics Committee members.
The Ethics Portfolio and Operational Ethics Committee ensure quality of care by providing a mechanism for hospital staff, patients, and families to identify and discuss ethical issues of importance to the institution. They are compliant with Accreditation Canada Standards. They may recommend changes that improve the quality of care and services delivered but the decisions themselves are left up to the individuals.
The Ethics Plan is reviewed and updated yearly and aligned with the TBRHSC Strategic Plan.
The roll out of the Ethical Decision Making Framework is currently taking place.
Ethics was added as a check off box along with the selection of committees to review prior to passing policies at Policy and Procedure and has had recent input in the Code Status Policy, Management of Abuse of Patients by Other Patients, Visitors, or Employees Policy, Disagreeing with Multidisciplinary Plan of Care Policy, and the Infective Endocarditic Pathway. The Ethics Consultation Policy is currently being reviewed and updated.
Ethics consultation services are available 24 hours a day, 7 days per week. Formats include confidential bioethicist or committee consultations. There were 9 consultations from January - March 2014 which included both discussions of organizational and clinical ethics.
A suggestion was made to invite Michelle to a future Patient Family Advisor meeting.
4.2 Risk Management Presentation
The Risk Management presentation was included in the agenda package.
The representatives from Marsh Risk Consulting will be invited to attend the April 15, 2014 Quality Committee of the Board meeting by videoconference to report on the Risk Register prior to the full Board meeting on May 7, 2014.
Quality Committee of the Board Page 5 of 6 March 18, 2014 5. CONSENT AGENDA
Moved by: Doug Shanks Seconded by: Sharon Cole-Paterson
“That the Quality Committee of the Board: 5.1 Approves the Quality Committee of the Board Minutes of February 11, 2014, 5.2 Receives the Research Ethics Board Minutes of January 27, 2014." Motion
CARRIED
6. DATE OF NEXT MEETING
The next Quality Committee of the Board meeting will take place on April 15, 2014 at 4:00 p.m. in the Administrative Boardroom.
7. ADJOURNMENT
The Quality Committee of the Board meeting adjourned at 6:00 p.m.
Quality Committee of the Board Page 6 of 6 March 18, 2014 Senior Management Report to the Board of Directors Thunder Bay Regional Health Sciences Centre April, 2014
Academics, Interprofessional Education, Medical Affairs and Pharmacy
Academic Affairs Implementation of a web based database, HSP Net, for managing learner placements is under way. The database will allow for the collection of information on the name and discipline of the student being placed, the location of the placement and who is teaching the student (i.e., the preceptor).
Interprofessional Education Seven new instructors have been trained to deliver the Neonatal Resuscitation Program (NRP). The added resources will contribute to the attainment of goals around staff/physician/learner certification and recertification goals.
Medical Affairs The Standard Admission and Discharge working groups continue to meet and work on reviewing, revising and updating current policies and processes.
Recruitment The Chiefs of departments have been asked to work with the Program Medical Directors on updating their human resource plan. Recent site visits include a psychiatrist, a family physician, a radiologist, and a medical oncologist.
Pharmacy Medication Reconciliation (Med Rec) implementation is in progress. Discharge Medication Reconciliation Pharmacist efforts are focused on surgical patients for Accreditation 2014. Phase 2 of the discharge Med Rec will focus on medical patients. Safer Healthcare Now audits are ongoing. The audits will assist in determining the quality of our Medication Reconciliation processes and aid in determining areas for ongoing education. 980 Oliver Road A 4th year Pharmacy student from Dalhousie University was on site for a 6 week Thunder Bay, ON P7B 6V4 placement. Preparation began for physical inventory on March 31, 2014. Phone: 684-6007 Website: Research www.tbrhsc.net Visitors and Announcements
Page 1 of 12 TBRRI hosted a number of tours of the Oliver Road research spaces during the month of March. Tours were conducted for four groups including Thunder Bay Regional Health Sciences Foundation staff; candidates for the Associate Dean of Research position with NOSM; and for a group of Grade 7 & 8 students from Pic Mobert, Pic River and Rocky Bay First Nations. TBRRI also hosted a special tour and meeting with the Honourable Dr. Eric Hoskins, Minister of Economic Development, Trade and Employment – Minister Hoskins requested an opportunity to tour the Research Institute while in Thunder Bay on March 25th. On March 17th a group of 6 TBRHSC Orthopedic Surgeons announced a donation of $2M to fund a local orthopedic research program – one of their first projects will be to study higher amputation rates in Northwestern Ontario related to patient complications from diabetes – TBRRI looks forward to working with this group, and others, on their research program. Dr. Naana Jumah was officially welcomed at a media event on March 20th – Dr. Jumah will be working collaboratively with TBRRI Scientists on projects in her areas of interest including Aboriginal women’s health, substance use in pregnancy and cervical cancer screening – the 2013 PSI Graham Farquharson Knowledge Translation Fellowship award which she received will help her to develop a research program related to the non-invasive treatment of uterine fibroids using High Intensity Focused Ultrasound.
Research Strategic to TBRHSC Over the coming year, focus will be put on research initiatives strategic to TBRHSC including but not limited to the following areas: Aboriginal Health; Clinical Trials; Research Program – growing the program to facilitate research through provision of advice and services (i.e. support for clinicians, learners, hospital researchers, ethics, experimental design, grant support, and statistical support) Moving research into the Hospital through participation in such groups as the Medical Advisory Committee, Medical Education Committee, Professional Staff Association and in Physician recruitment visits.
TBRRI Management & Scientific Direction TBRRI is currently in the process of recruiting a new Director of Clinical Business 980 Oliver Road Development. Thunder Bay, ON Efforts continue to seek out and sponsor new Clinical Trial opportunities. P7B 6V4 The Institute will continue to work on implementing its 2012-16 Strategic Plan and Phone: functioning as TBRHSC’s research arm. 684-6007 Infrastructure and research development priorities continue to focus on 3 areas Website: including: www.tbrhsc.net cyclotron; microPET (Dr. Phenix & Advanced Medical Research Institute of Canada [AMRIC] re personalized medicine) Page 2 of 12 HIFU (Drs. Jumah, Curiel, Rubel & Pichardo) The Institute and its staff are working on research collaboration opportunities with Sunnybrook in Toronto and AMRIC in Sudbury.
Human Resources, Organizational Development and Library Services HR Skills for New Leaders program was launched with great reviews. This training will be held every six months. Over 80 leaders attended the Change Management workshop facilitated by iLearn2 on March 26. RPN Spring hire interviews are taking place this month. 31 applicants will be interviewed.
Labour Relations ONA Current Term: April 1, 2011 - March 31, 2014 ONA and the Hospitals’ Negotiating Team have completed their third week of central bargaining. Arbitration Hearing has taken place and award is pending. Local negotiations for the 2014 collective agreement have been completed and awaiting ratification. OPSEU Current Term: April 1, 2011 - March 31, 2014 OPSEU and the Hospitals’ Negotiating Team met from March 4th to 10th, where they were joined by mediator Gerry Lee on March 7th. The mediation process proved to be unsuccessful thus the parties will be proceeding to interest arbitration. Local negotiations have begun. OPSEU-Maintenance Current Term: September 29, 2011 - September 28, 2013 Negotiations will commence in spring 2014, however no dates have been scheduled at this time. SEIU Current Term: October 12, 2013 - December 31, 2017 The current central contract was negotiated for a term of four years, 2013-2017. Local negotiations are expected to begin in May/June 2014. COPE Current Term: April 1, 2011 - March 31, 2013 This contract is entirely local. The Hospital and Union went to conciliation; however no new term was negotiated. Interest arbitration dates have not been set at this time. PIPSC Medical Physicists Current Term: July 1, 2010 - June 30, 2013 Central negotiations have commenced with future bargaining dates to be scheduled. Radiation Therapists Current Term: Oct 1, 2011 – Sept 30, 2014 No update since the previous negotiations. 980 Oliver Road Thunder Bay, ON P7B 6V4 Phone: 684-6007 Website: www.tbrhsc.net
Page 3 of 12 2014 Grievance Activity As at March 31, 2014 TOTAL GRIEVANCES ARBITRATION # of Filed since Employees Jan 1, 2014 by Union Active Resolved Active Award ONA 4 4 6 0 0 1018 COPE 3 3 1 1 0 329 OPSEU 3 3 9 0 0 406 OPSEU - Mtc. 1 1 1 0 0 20 SEIU 2 2 3 0 0 561 PIPSC 0 0 0 0 0 2 PIPSC - 0 0 0 0 0 22 Assoc. TOTALS 13 13 20 1 0 2358
Strategy & Planning
Strategy and Performance Management The Strategy & Performance department participated in the Change Management Workshop March 26. We look forward to applying critical techniques and developing new tools for leadership to support them in effective change management. Accreditation preparation ramps up in the month of April beginning with a widespread staff communication strategy and individual and team prep meetings with the Accreditation Coordinator. The Accreditation surveyors are known and the schedule is set to go. Following the completion of the fiscal year, a debrief of the budget planning and process will be conducted in collaboration with finance and COO. This will inform revisions to the upcoming annual planning, budget, and QIP cycle schedule.
Decision Support Work has begun on development of key performance indicators for inclusion on programs/service balanced scorecards. The first release of the 2014-15 BSC package (including April 2014 results) will be release in late May. Select Decision Support staff are undergoing detailed training on Health System 980 Oliver Road Thunder Bay, ON Funding Reform and Quality-based Procedures in order to better support strategic P7B 6V4 and operational decision-making. Phone: 684-6007 Health Records Website: Coders began training for the new 3M encoding and abstracting software. www.tbrhsc.net Analysts and management participated in a Ministry of Health session promoting the importance of quality data and the impact to the health based allocation model.
Page 4 of 12 Occupational Health & Safety (OHS) Lost Shifts due to WSIB 2008 2009 2010 2011 2012 2013 2014 TotalNumberofIncidents 637 515 537 688 757 762 104 WSIB Health Care Claims 115 118 111 115 108 117 35 WSIB Lost Time Claims 92 48 47 12 6 5 1 WSIB Lost Time 13 4 11 6 7 2 0 Recurrences LostTimeDays 3842 2359 1615 593 278 105 11 Near misses/hazardous 312 305 388 74 situations 2008 – 2010 Near Misses captured in different form and therefore not included
WSIB claims management has been and continues to be a priority for the OHS department. OHS, through a long-term action plan focusing on better management of WSIB claims and recovering costs from previous years, eliminated the surcharge for 2012 and 2013, as well as a refund. Once our efforts to reclaim previous surcharge payments are exhausted, refunds will no longer be received. However, the goal for the surcharge will remain at $0.00.
Current Initiatives Annual TB surveillance – April / May, 2014. Ergonomic Blitz – 29 new computer chairs were purchased and delivered to staff in areas of need.
Volunteer Services National Volunteer Week April 6-12, 2014. Celebrating 10 Years of Volunteer Service. Look for the following activities designed to honour volunteers: iNformed articles, Chronicle Journal feature article, cake served on Wednesday, April 9 at 2:15 pm, lobby display and photos. 2014 Ontario Volunteer Services Awards: 7 adults and 2 youth will be honoured at a ceremony on May 29, 2014 in Thunder Bay. Recipients are: Mariyln Chisholm (25 Years), Connor Ferguson (2 Years Youth- PFA), Jacequeline Harvey 2 Years Youth, Marilyn Hay (25 Years), Kathryn Hughes (20 Years), Dorothy Martell (20 Years), Christian O’Brien (2 Years Youth), Laurette Patriquin (25 Years) and Linda Sargent (20 Years). 980 Oliver Road City of Thunder Bay Citizen of Exceptional Achievement Award – Kevin Herman. Thunder Bay, ON Fourteen Volunteers attended a training session for the new Tea Time Volunteer P7B 6V4 Visiting program for ALC patients located in the Surgical Day Care Unit. The training Phone: included a presentation from the Alzhiemer’s Society on Communications. 684-6007 TBRHSC Board members are welcome to attend the Volunteer Appreciation and Website: th www.tbrhsc.net Awards Dinner 10 Anniversary Celebration on May 1, 2014 at the Victoria Inn at 6pm.
Page 5 of 12 PFCC Grants - Volunteer Services is thankful for the acceptance of two PFCC Grants: 2 STAXI (Blue Wheelchairs) and 2 Beverage Carts for Cancer Care. The Volunteer Association is focusing on Board Governance and has been working with consultant, Diane Walker.
EVP, Patient Services & CNE
Driving Health Care System Transformation: Dialogue on Moving Forward Conversation on Championing Quality / Patient Family Centred Care – Presented at OHA Conference Sudbury, April 7, 2014 – and Chatham, April 10, 2014.
12th Annual Nursing Scholarship Forum – Keynote Address: Nurse Comportment: Nurse, Patient and Family Surveys: Keynote Address Nursing Leadership Creating Healthy Work Environments, Lakehead University & Confederation College BScN Programs, April 4, 2014.
QBP / Wait Time Funding We realized 99% of our available funding for 2013 / 2014 for surgery. Out of $ 6,182,861 available we will realize $ 6,082,861.
Pediatric Tour Video Filming of the pediatric tour is completed and will be available on the web site shortly for those patients and families from the region and those who can not make it to TBRHSC for the tour.
Hippest Party in Town The fundraiser held in March was a great success and just under $ 30,000 was raised to purchase equipment for the joint centre on 3A.
ED Volumes & Overcapacity Impacts At year end for 13-14, ED had a total of 106,536 visits which is down by 4.6% (5121 visits) from the previous year. Volume decreases were primarily seen in the non-admitted low acuity category, 73% of all visits were high acuity patients with 10% admission rate. ED continues to exceed provincial targets for non-admitted high acuity patients with a length of stay (LOS) of 6.5 hours ( target 7 hours) and low acuity LOS 3.3 hours ( target 980 Oliver Road 4 hrs) for the month of March. Thunder Bay, ON Over the past year improvement in LOS targets for admitted patients (target 25-27 P7B 6V4 hours) has been recognized with the utilization of temporary overflow areas. The LOS Phone: for this category has gone from an average of 35.3 hours last year to 29 hours in 13-14 . 684-6007
Website: ED Dedicated Offload Delay Nurse Focus Group www.tbrhsc.net Participated in a provincial focus group via teleconference to discuss practices across Ontario related to the Dedicated Offload Nurse position. Outcomes, impacts, performance metrics and partnerships were shared Page 6 of 12 TBRHSC has been funded by MOHLTC- Superior North EMS, for the Offload Delay Nurse position since 2010. Over the past year offload delay times have decreased from 36 to 6 minutes and patient satisfaction scores have improved substantially.
Diagnostic Wait Times MRI Priority 4 (routine) wait times sustaining well above target (LHIN target 30%) with 93% complete in February. CT Priority 4 wait times slightly improved in February with 55% complete in 28 days over (LHIN target 85%) – expect further improvement in March with additional 150hrs approved. Pathology report turnaround times show sustained improvement in February with 69% complete within 10 days (target 90%).
Corporate Services & Operations
Financial Services The financial position of TBRHSC as at February 28, 2014 is a $3,217,901 deficit compared to a budgeted surplus of $144,085 and prior year deficit of $3,446,825 Overall unfavourable revenue variances of $4 million are offset with favourable expense variances of $626k. The most significant favourable expense variance of $2.2M (million) is in supplies and other expenses including course registration, travel, minor equipment, building/grounds maintenance and professional fees. Unfavourable variances are in drugs $1.3M, salaries $1.1M and capital amortization $0.7M. Earned hours of 3,647,191 are 23,987 over budget and 45,699 more than the prior year and include paid sick hours and overtime that exceeds the prior year. February inpatient days of 132,801 are 2,460 more than budget and 2,090 more than prior year and Emergency visits of 97,792 are 1,185 less than budget and 4,551 less than prior year.
Capital Planning and Operations Fire Inspection • TBRHSC has received a Summons in regards to the use of the Alcoves. • Work is ongoing on deficiencies identified by Fire Department regular inspections. 980 Oliver Road Education and auditing tools have been rolled out to the departments – audits and Thunder Bay, ON monitoring is ongoing. P7B 6V4 Capital Projects Phone: • Health Services Building is on schedule for early summer occupancy; 684-6007 • Parking Lot B expansion – MOE approval has been received – tender being Website: issued for early April. www.tbrhsc.net • The Noise Abatement project was completed and are awaiting the MOE’s feedback.
Page 7 of 12 • Functional planning and budgetary costing is ongoing for the Cardio-Vascular Surgery program. • Our energy retrofit project received significant incentive money from the OPA. Northwest Supply Chain Collaboration • Year 3 projected savings based on most recent awards tops the $2.5 million annual threshold for the 13 member hospitals. Nutrition and Food Services • In early March, the new CBORD menu system was installed and went live. N&FS Hostesses are now using this more efficient computer program while taking patient meal preferences. This is enabling more patients to be seen to collect meal preferences, as one of N&FS's PFCC initiatives.
Chronic Disease Prevention & Management
Cardiovascular & Stroke Program Cardiovascular Program representatives visited Lake of the Woods District Hospital’s leadership team on March 28th in Kenora. The visit highlighted acute cardiovascular patient services, including: Stroke and STEMI care, plans for a future Cardiovascular Surgical Program, improved patient transport guidelines, and opportunities for collaboration. Feedback from the Kenora team will support our ongoing collaboration around quality improvement activities. The Healthy Rehabilitation Program is pleased to announce Sioux Lookout as their newest partner in cardiac rehabilitation programming. With support from Dr. Ellen Melton, Rehab Lead, and Kyle Baysarowich, Program Coordinator, the Sioux Lookout team is bringing services to the community to improve the health of regional patients at risk for cardiac events. The Comprehensive Cardiovascular Surgical Proposal development process is near completion. Through extensive engagement with the University Health Network’s Peter Munk Cardiovascular Centre and internal stakeholders, a framework for a high quality cardiovascular surgical program was created. Submission anticipated in early April 2014.
Regional Cancer Program An interdisciplinary team from TBRHSC attended a Nursing Models of Care workshop with Cancer Care Ontario. The goal of the workshop was to look at alternative models of care where RN's are working to the full scope of their practice. We are looking forward to 980 Oliver Road hearing the provincial recommendations. Thunder Bay, ON The QBP for Systemic Therapy began April 1st. The Systemic Therapy disease site P7B 6V4 working groups are currently reviewing 10 months of 13/14 data to ensure that we are Phone: using treatment regimes that match the disease and intent to ensure funding will be 684-6007 secured. Each Medical Oncologist will review their patient registers for patients that are Website: potential candidates for discharge based on the funding model for follow-up care. The www.tbrhsc.net Transition Clinic will help process these program discharges so the follow-up plan is clearly outlined for both the patient and the primary care providers. Patients without a
Page 8 of 12 primary care provider will not be discharged, but rather followed by a Nurse Practitioner or GPO within the cancer program.
Corporate Patient Flow Services John Ross is the Manager of Corporate Patient Flow Services as of March 17th, replacing Karen Rybak. John has had multiple roles in the Emergency Department at TBRHSC since 2001.
Renal Program Discussions with Lake of the Woods District Hospital’s Renal Service have begun. Transition of their Renal Service to become part of TBRHSC’s Renal Program is planned for 14/15. The first vascular access surgery will occur this month with Dr. Lindsay (University Health Network). Initiating use of Nursing Resource Team to back-fill for vacation, sick time, etc. in hemodialysis Will be hiring for staff in Sioux Lookout and Fort Frances hemodialysis to open an evening shift.
Mental Health Program
Adult Mental Health Services Confirmation letter from the LHIN regarding the Phase One Implementation of the Mental Health Emergency Service and Urgent Care Clinic received. Hiring and training process has started. AMH Interprofessional team had two team building retreats. The unit continues to operate in an overcapacity state.
Forensic Mental Health The wait list for Forensics continues with little-to-no movement within the inpatient unit. Approval has been received from the MOH regarding the implementation plans that were submitted for the Brief Assessment Unit and the Advanced Practice Clinician for Forensic Services funding.
Prevention & Screening Services th 980 Oliver Road On March 17 a video featuring Ontario Regional Chief Stan Beardy’s personal colorectal Thunder Bay, ON cancer story was launched. The video is called ‘Early Detection: The Path to a Good Life’, P7B 6V4 and it serves to educate people, particularly First Nation people, about the importance of Phone: cancer screening. The video can be viewed by going to this link: 684-6007 www.tbrhsc.net/GoodLife. Website: The Screen for Life Coach’s travel season began on March 31st. Until October 5th, the Coach www.tbrhsc.net will be in the region providing essential cancer screening services to women from more than 35 communities.
Page 9 of 12 For 3 Wednesdays in March, the Cafeteria, TBRHSC Dietitians, local farmers and Prevention & Screening teamed-up to educate and promote health, local eating as part of Nutrition Month. Local food samples, from local farmers, were served at the Cafeteria’s Entrance with the full meals being sold in the cafeteria.
Supportive/Palliative Care & Telemedicine Services
Palliative Care Recruitment has begun for a second Palliative Care physician as we grow services for patients in our facility and community. Planning has also started for the Medically Complex Proposal for Palliative Care, a 1-year demonstration project. This project will see an outpatient advanced care and planning clinic for non-malignant diagnosed patients. Telemedicine options will be built into the program along with 24 hour supports for patients and their families who are nearing end-of-life.
Supportive Care Our Supportive Care Tele-counselling pilot has successfully connected with a patient and family in their home in a remote community for secure video connection for Supportive Care. This trial is to evaluate if this service can be an option to all patients and what the impacts are for the patient and family, as well as observing what the impact would be on Social Work, Telemedicine, and Information Technology resources.
Quality and Risk Management
Infection Prevention & Control A fact sheet and policy for Carbapenemase-Producing Enterbacteriaceae (CPE) management is presently being developed as well as an educational package for staff. CPE is highly resistant to many antibiotics. The department is taking a proactive approach to ensure a process is in place to prepare us to manage individuals with CPE when and if they begin to present at the hospital. Infection Prevention and Control (IPAC) continue to survey previous patients for the MRSA research study. The study has been extend to May 2015. There are 80 enrolled patients out of 265 positve MRSA individuals. The study reviews a broad base of risk factors such as antibiotic use, hopsitalizations, age, occupation, economic factors, surgery, immunosupressive therapy, and a selection of disease groups. An evaluation of the change in practice for patients only having to gown and glove 980 Oliver Road when they are going to areas of low risk, i.e. outside or to the cafeteria is underway. A Thunder Bay, ON survey is being completed of the staff to ensure understanding of the policy and P7B 6V4 practice changes . Phone: IPAC is participating in the RNAO Best Practice Guidelines for Central Venous Lines 684-6007 (CVL) by monitoring compliance and ensuring infection rates do not rise in this Website: patient population. www.tbrhsc.net
Page 10 of 12 Quality The 2014-15 Quality Improvement Plan has been submitted via the Navigator Tool. TBRHSC has selected 4 priority indicators, one from each dimension. The priority indicators selected are: Medicaton Reconcilliation on Admission, Financial Margin, Patient Satisfaction Overall, “How Would You Rate the Care and Services you Received at the Hospital?", and 90th Percentile ER Length of Stay (hours) for Admitted Patients. The three documents included in the submission are the Narrative, the Progress Report and the Workplan (spreadsheet) with targets and action plans. This has been posted to our website and sent to our NW LHIN and the Ontario Hospital Association. These documents represent our commitment to the community to improve the care we provide. This is a limited list of quality improvement initiatives that TBRHSC is undertaking .
Communications & Engagement (C&E)
Media Activity – March 7 – April 7, 2014 Media events/Releases = 4 o TBRHSC 10th anniversary o Ontario Regional Chief Stan Beardy Launches Cancer Screening Video o 2014 Northwestern Ontario Regional Stroke Forum o Thunder Bay Regional Research Institute brings talent back home – Dr. Jumah o Surgeon Group Invests $2-million in Local Orthopedic Research (Foundation) o Additional Media Calls = 2; cases of flesh eating disease, CIHI report on wait times Chronicle Journal feature stories = 27 Submissions to Hospital News, The Walleye, Ontario Hospital Association
10th Anniversary Celebrations: Within the first two days of its March 14 launch, the micro-website highlighting TBRHSC’s milestones of the past ten years received over 1,000 views. The 10th Anniversary Steering Committee continues to plan additional activities.
Aboriginal Health: Engagement sessions to determine the level of interest in a sweat lodge at TBRHSC are complete. Findings were reported to the Aboriginal Advisory Committee, as well as community feedback regarding translation services and traditional foods at TBRHSC. In 980 Oliver Road addition, C&E is supporting a strategy to disseminate the video produced by TBRHSC to Thunder Bay, ON P7B 6V4 promote cancer screening in First Nation communities. It has already received over 500 views. Applications for funding to support National Aboriginal Day and expanded Phone: 684-6007 Aboriginal navigator services were submitted. Finally, a student from Lakehead University’s Native Nurses Entry Program will complete a non-clinical placement with Website: www.tbrhsc.net the TBRHSC Aboriginal Engagement Lead.
Page 11 of 12 Engagement: Engagement with Francophone community members continues. With thanks to Le Réseau du Mieux-être, more feedback will be obtained. The video outlining TBRHSC’s initiatives to support Francophone health and inviting feedback will be further shared at engagement sessions and electronically with Le Réseau's network in NWO, with a request that surveys be returned by June 30. Also, C&E is working with Strategy & Performance to plan the upcoming 5 Partner Engagement session.
Annual Report 2013/14: Content for the annual report has been determined and is in development.
PFCC – Sharing Patient Stories: C&E is producing short videos that demonstrate the impaact of sharing patient stories. The first videos featuring Chief of Staff Dr. Gordon Porter were recorded and will be promoted intenrally and externally. The videos encourage more patients and families to share their experiences to support quality improvement.
Leadership Development: Communications Officer Donna Faye was selected to represent TBRHSC at Leadership Thunder Bay. The program helps participants acquire both a broader understanding of the critical issues affecting our community and the leadership skills necessary to resolve them.
Additional Support provided: Accreditation awareness; Volunteer Association donation recognition; Smoke-Free Grounds promotion; PFCC Quality Performance; Thunder Bay Symphony Orchestra performance at TBRHSC; Alternate healthcare options update; Accessibility Implementation.
980 Oliver Road Thunder Bay, ON P7B 6V4 Phone: 684-6007 Website: www.tbrhsc.net
Page 12 of 12 Chief of Staff Board Report April 2014
Credentialing We continue to wait for a response from Dr. Geoff Davis, Chief of Staff regarding their bylaw changes to align SJCG/TBRHSC bylaws to meet our current process of a common Professional Staff. The review of reappointments for the departments for 2014 should be completed in the upcoming week at the Credential committee, and MAC with completion planned this month. The Regional Credentialing working group continues to meet to support this process and work towards the beginning of the electronic application for new applicants.
Morbidity and Mortality Rounds M&M presentation schedule has begun at the MAC with Anaesthesia being the first department to present. This takes place of the previous presentations done by Quality and Risk Management
Physician Leadership Education
Information included as an additional document
Incomplete records
Meetings have occurred with several physicians in ongoing effort to complete their outstanding charts Additional information has been provided by Heidi Greenwell, regarding charts that are incomplete waiting for physician review and signature Work continues on a process to address chart deficiencies for locum physicians. Heidi Greenwell will be working with Liane MacAskill to revise current incomplete record policy.
Medical Staff policy
Revision of Medical Staff policy for Clinical Consultation (MS-23) has been completed by the MAC It has been reviewed by the Standard admission working group. Plan for it to go to Policy and Procedure committee in May with next steps to 980 Oliver Road develop an implementation strategy and data collection process Thunder Bay, ON P7B 6V4 Phone: (807) 684-6000 Respectively submitted, Website: www.tbrhsc.net Dr. Gordon Porter, Chief of Staff CANADIAN MEDICAL ASSOCATION PHYSICIAN MANAGEMENT INSTITUTE (PMI) PROFESSIONALISM AND ETHICS
On Friday, March 21st and Saturday, March 22nd, physician leaders and members of our interprofessional team at Thunder Bay Regional Health Sciences Centre participated in a course on Professionalism and Ethics. This course was held at Whitewater Golf Course.
The course was facilitated by two members of the PMI team, Monica Branigan, MD, MHSc, and Frank Wagner, MA, MHSc (Bioethics). Monica Branigan is an associate professor and the Professional Development Lead, Division of Palliative Care, Department of Family and Community Medicine, University of Toronto. With over thirty years of practice, she has a rich clinical experience including rural, urban, geriatric, student health and palliative care settings. Frank Wagner is the Bioethicist for the Toronto Central Community Care Access Centre (CCAC) and the Joint Centre for Bioethics, and an Assistant Professor in the Department of Family and Community Medicine, University of Toronto. Frank is also deeply involved in health care management and policy in Ontario. Both facilitators were well received by the participants and offered different perspectives on issues presented.
The Professionalism and Ethics course highlighted that ethical, moral and professional dilemmas arise on a daily basis in medicine and leaders play a key role in helping to prevent, identify and resolve ethical and professional conflicts on an individual and systemic level. This two day workshop aimed to provide a foundation of relevant ethical principles and commonly encountered scenarios, including a review and consideration of current issues and challenges in medical professionalism. The Thunder Bay Regional Health Sciences Centre’s Framework for Ethical Decision Making was discussed and used within the many small group sessions as a basis for decision making.
Course participants provided positive feedback following the two day course. The facilitators and participants both commented on the benefits of including both physician leaders and interprofessionals in this educational setting. Following the course, we were approached by the PMI and requested to provide statements for use in the upcoming brochure for PMI courses. Senior Management Report to the Board of Directors Thunder Bay Regional Health Sciences Centre
April 2014
EVP, Patient Services & CNE – Open Report
Nursing Resource Team: Additional RN spring hire interviews being completed 65 nurses have accepted temporary 0.8 part-time offers. Plan to recruit an additional 5-10 nurse in order to meet our summer vacation relief needs. RPN interviews in progress. Plan to hire 10 RPNs for the summer. Operationalizing the expansion of NRT to the outpatient Renal Department. Anticipated savings of $67K in year one and $122K in subsequent years.
Best Practice Spotlight Organization: Best Practice Spotlight Organization (BPSO) 13/14 final report submitted to the Registered Nurses Association on Ontario. Teleconference with RNAO scheduled for September 16, 2014 to review report. Major deliverables met with plans in progress to address and bridge gaps moving forward as a BPSO.
980 Oliver Road Thunder Bay, ON P7B 6V4 Phone: 684-6007 Website: www.tbrhsc.net
Page 1 of 1
Northern Ontario School of Medicine Report Dr. Roger Strasser, Dean-CEO April 2014
Northern Constellations Conference
Over 215 health-care professionals from across the North participated in the Northern Ontario School of Medicine's (NOSM) third annual Northern Constellations 2014 Faculty Development Conference on April 4-5, 2014.
NOSM faculty members rotated through a series of four interactive workshops with a wide range of topics covering their roles and responsibilities in the areas of teaching and preceptoring; research and scholarly activities; and, educational leadership. Over 30 workshop options provided each participant with an opportunity to attend a combination of educational sessions addressing their own personal learning needs. Faculty development events, such as this, allow NOSM faculty from across the North to build relationships, collaborate on projects, and discuss future opportunities for those who are committed to the education of high quality physicians and health professionals in Northern Ontario.
“Over the past three years, Northern Constellations has continued to grow and increase its impact on the further development of NOSM faculty, educational staff, and learners,” said Dr. James Goertzen, NOSM’s Medical Director, Faculty Development. “The diverse program this year is the result of the commitment and expertise of the conference presenters along with their passion for educational excellence.”
Outstanding Faculty Members Recognized
NOSM faculty members are making outstanding contributions to research, patient care, and medical education. The Faculty Peer Awards of Excellence were developed to recognize the contributions of the School's faculty in providing Innovative education and research for a healthier North.
Five faculty members will be recognized during an awards dinner on Friday, April 4, 2014. Congratulations go to Dr. David MacLean (Academic Leader), Dr. Brent Kennedy (Clinical Teacher), Dr. Jo-Anne Clarke (Medical Educator), Ms. Kirsti Reinikka (Clinical Scholar) and, Dr. TC Tai (Scholar).
Simbulance Unveiled - Decommissioned Superior North EMS Ambulance Assists in Training Health-Professional Learners
NOSM is engaged in a pilot project to provide high- fidelity, mobile simulation to Northern Ontario. Based at NOSM’s West Campus at Lakehead University in Thunder Bay, this project uses a decommissioned Superior North EMS ambulance to transport high- fidelity, computerized mannequins and equipment to communities across Northern Ontario. This project
addresses the learning needs of health-care learners and practitioners in a cost-effective manner by removing the need to replicate expensive simulation environments and equipment in multiple communities. Transporting simulation equipment is only one of multiple approaches that NOSM wishes to use to support simulation-based education in its distributed sites.
At the Northern Constellations Conference, the Simbulance was unveiled, demonstrating a visible and tangible commitment to addressing regional learning needs. It provides safe transportation for expensive equipment and trained personnel and also can be used a realistic learning environment.
The ambulance was ‘decommissioned’ before ownership changed to NOSM: identifying words such as Superior North EMS, ambulance, 911 etc. were all removed; flashing light bars removed; siren removed; public address/annunciator removed. All this is done so that a decommissioned unit cannot be mistaken for a true ambulance. The Simbulance graphic wrap features NOSM students, and Superior North EMS and City of Thunder Bay logos appear on rear door as supporters of the Simbulance and NOSM.
NOSM Board of Directors
The next meeting of the NOSM Board of Directors the Annual Retreat to be held in Little Current, Manitoulin Island on May 8 & 9, 2014.
2020 Vision – NOSM`s Next Strategic Plan Reaching Beyond Extraordinary
As we near the end of NOSM’s 2010 to 2015 Strategic Plan, we are beginning to assess next steps. To achieve this, we are spending this year cultivating a rich dialogue within the School and with the people and communities we serve, particularly focused on educational excellence, outstanding research, relationship development, organizational effectiveness and expanded resources.
In January 2014, NOSM issued a call for expressions of interest to oversee the strategic planning process for the 2015 to 2020 Strategic Plan. To our great excitement, we were flooded with responses and established the Strategic Planning Advisory Committee (SPAC) – a group of 28 people that includes the perspectives of Board members, Academic Council members, physicians, staff, faculty, learners, academics, administrators, and community members. Those who were not selected to join SPAC have been invited for participate as Strategic Planning Reference Group members.
Your input is so very important in setting the priorities for NOSM in the second half of this decade. I invite you to submit your input and to join the conversation about NOSM’s future.
NOSM Responds to High Suicide Rates in the North
The Northern Ontario School of Medicine (NOSM) has incorporated suicide awareness training into NOSM’s MD curriculum in an effort to respond to the high rates of suicide in the region.
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First-year students at NOSM now undergo safeTALK training, a three-hour program created by LivingWorks that trains participants to identify persons with thoughts of suicide and to connect them with suicide first aid resources. NOSM is also developing and piloting other tools designed to help medical students deal with suicide in their future practice as physicians.
“The Northern Ontario School of Medicine was the first medical school in Canada established with an explicit mandate to improve the health of the people and communities that it serves,” explains Dr. David Marsh, Interim Associate Dean, Undergraduate Medical Education. “Integrating safeTALK training into our MD curriculum supports students and future health professionals of Northern Ontario in responding to the increased prevalence of suicide and self-inflicted injuries in the North.”
“As a medical school committed to improving the health of Northern Ontarians, we need to play our part in reducing the shockingly high number of deaths that occur from suicide in our region,” says Dr. Brian Ross, NOSM Professor and Phase 1 Coordinator.
For more information http://www.nosm.ca/about_us/media_room/media_releases/media_release.as px?id=18067&langtype=4105
NOSM Recognizes Dietitian Day
Across Canada, March is Nutrition Month and March 19, 2014 is designated as Registered Dietitian Day, a day that celebrates Registered Dietitians as health-care professionals, committed to using their specialized knowledge and skills in food and nutrition to improve the health of Canadians. As leaders in health and wellness, Registered Dietitians practice in many different settings, such as hospitals, family health teams, public health units, government, long-term care facilities, and educational institutions. March 19, 2014 marks the fifth anniversary of Dietitians Day. This day elevates the profession of Registered Dietitians and reminds us that dietitians are the smart choice for advice on healthy eating, separating fact from fiction, good nutrition and healthy living. The Northern Ontario Dietetic Internship Program (NODIP) at the Northern Ontario School of Medicine (NOSM) works in collaboration with multiple preceptors, communities, and facilities throughout Northern Ontario. Over 50 NODIP graduates are now practising across Northern Ontario as Registered Dietitians. http://www.dietitians.ca/Downloadable-Content/Public/Dietitians-SmartChoice- Col.aspx
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Northern Health Research Conference (NHRC)
The Northern Health Research Conference will be held June 6-7, 2014 in Sioux Lookout, ON. Dr. Sheldon Tobe, Chair of Aboriginal and Rural Health Research, is the lead for this year’s conference. Visit http://www.nosm.ca/nhrc/ for more information and to register.
For more news and information visit www.nosm.ca
Respectfully submitted,
Dr. Roger Strasser AM Dean-CEO Northern Ontario School of Medicine
pg. 4 Thunder Bay Regional Health Sciences Centre Corporate Membership List Received for the period of March 1-April 4, 2014
Presented to the Board of Directors on April 17, 2014
Surname First Name Surname First Name Arnone Margaret Mannisto Richard (Dick) Balacko Smith Cheryl Masood Khaja Boucher Josephine Mauro Sylvianne Cole Paterson Sharon McMillan Martin Covino Cathy Morrison Rod Covino Herb Murrell Donald Deslauriers Roxanne Myllymaa Peter Doucette Nadine Nehrebecky Jessica Edwards Don Northan Janet Fidler Wesley Porter Gordon Fraser Susan Powell Dawn Freitag Carolyn Pulice Suzanne Hannaford Joyce Robichaud Andrée Henderson Mark Robichaud Claude Hettenhausen William Shanks Doug Jean Anita Sidorski Stephen Johnson Rebecca Smith Tracie Kemeny Barbara Straiton Elizabeth Kennedy Stewart Sutton Bruce Knibbs Donald Tupker Jules Knibbs June Walsh Grant Laakso Renée Williamson Sara Leach Gerry Young Sophie Lynch Kathleen Zanette Helen
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Item # Accountability Activity s t e Comments u t n b M J A N c v c n
a p M e e o J o s O e F D p N A S s e R
1 Financial Oversight Initial Meeting of Audit Committee Aud x 2 Financial Oversight Review Evaluation of Auditors Aud x 3 Financial Oversight Independence Questionnaire Aud x 4 Financial Oversight Approve Audit Work Plan Aud x 5 Financial Oversight Audit Plan (Grant Thornton) Aud x
6 Performance Measurement and Monitoring Review Results of Interim Audit Conducted in January Aud x 7 Financial Oversight Review Draft Year End and Reporting Issues TITLE Aud x CHANGED FROM: Discussion of Year-end Reporting Issues 8 Financial Oversight Review Audit Statement Presentation Aud x Remove as this is a duplicate of line 9
9 Financial Oversight Individual Program Audit Reports Aud x Removed from workplan as individual reports not being conducted this year
10 Financial Oversight Presentation of PSAB Standards Aud x Remove as this is not relevant this year 11 Financial Oversight Update on New Hospital Capital Audit Aud x 12 Financial Oversight Review and Recommend Year End Financial Statements Aud x for Approval to the Board 13 Financial Oversight Audit Results (Grant Thornton) Aud x 14 Financial Oversight Management Letter Aud x 15 Risk Identification and Oversight Claims Summary Aud x 16 Financial Oversight Analysis of Legal Fees as at March 31 Aud x 17 Performance Measurement and Monitoring Evaluation of Auditors Aud x 18 Performance Measurement and Monitoring Recommend Appointment of Auditors Aud x 19 Financial Oversight Approve Year-end Financial Statements Aud x 20 Stakeholder Communication and Statements for Approval to Board Aud x Accountability
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Item # Accountability Activity s t e Comments u t n b M J A N c v c n
a p M e e o J o s O e F D p N A S s e R
21 Strategic Planning and Vision, Mission, Set up Partnership Meetings for the year BD x Values 22 Oversight of Management Monthly Education Topics for the Board BD x x x x x x x x x x 23 Oversight of Management Participate in CEO Evaluation via website BD x HR presenting the process to the Board on April 11 24 Governance Participate in COS Evaluation via website BD x Anticipated to have the review done in May. 25 Governance Approval of By-Laws BD x 26 Oversight of Management Approve Slate of Nominees to Fill Board Vacancies BD x 27 Oversight of Management Approve CEO Evaluation BD x 28 Oversight of Management Approve COS Evaluation BD x 29 Oversight of Management Preliminary Review of By-Laws BL x 30 Governance Evaluation of CEO EC x 31 Strategic Planning and Vision, Mission, Evaluation of COS EC x Values 32 Strategic Planning and Vision, Mission, Ensure Board Meeting Evaluations are Completed Gov x x x x x x x x x x Values 33 Governance Identify Education Needs for Coming Year Gov x 34 Governance Plan Annual Board Retreat Gov x y. 35 Governance Proposal re: Committee Structure/Work Plan Gov x 36 Governance Review Annual Board Evaluation and Board Self Gov x Evaluation 37 Oversight of Management Review all Board Policies - Identify Revisions Required Gov x
38 Governance Review Board Committee Terms of Reference Gov x 39 Governance Review CEO/Chief of Staff Performance Evaluation Gov x Process (subject to revised policy approval) 40 Governance Review Meeting Evaluations for the Quarter Gov x x x 41 Governance Board Self Assessment Questionnaire - Distribute to Gov x x Board Members for Completion 42 Governance Team Effectiveness Scale - Distribute to Board Members Gov x x for Completion 43 Governance Review Board Committee Attendance Summary Gov x x Will review at Feb 19 Gov meeting
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Item # Accountability Activity s t e Comments u t n b M J A N c v c n
a p M e e o J o s O e F D p N A S s e R
44 Governance Review By-Laws Gov x Had discussion with legal counsel regarding the Not- for-Profit Act changes. By-Laws review scheduled on April 28 45 Governance Annual Board Evaluation - Performance Review Gov x 46 Governance Review Orientation Program Gov x 47 Governance Review Applications for Board Vacancies Nom x 48 Governance Nominating Committee - Candidate Interviews for Nom x Interviews Board vacancy scheduled on April 28 49 Risk Identification and Oversight Review Board Composition Profiles documents for use Nom x of Nominating Committee: Policy BD-45 Preferred Selection Criteria for Board Membership Skills Matrix for Board of Directors Applicants 50 Quality Oversight Patient Safety/Public Indicators Qual x x x x 51 Quality Oversight Review Quality Terms of Reference Qual x 52 Quality Oversight Review Quality Work Plan Qual x 53 Quality Oversight Programs & Services Presentations Qual x x x x x x x x x x 54 Quality Oversight Comments/Compliments/Complaints Qual x x 55 Risk Identification and Oversight Quality Improvement Plan Except From Balanced Qual x x x x Item deferred on Scorecard agenda. 56 Risk Identification and Oversight Critical incidents/MAC recommendations Qual x x 57 Risk Identification and Oversight Risk Management Qual x x 58 Quality Oversight Emergency Preparedness Qual x x 59 Quality Oversight Accreditation Qual x x 60 Quality Oversight Quality Improvement Plan Approval Qual x 61 Risk Identification and Oversight Quality and Risk Management Policies Qual x 62 Quality Oversight Financial Pressures Relating to Risk Qual x 63 Performance Measurement and Monitoring Credentialling Process/Professional Staff & regulated Qual x licensed Professional processes 64 Financial Oversight Financial Statements and Variance Report - (Review) RP Q1 Q2 Q3 Q4
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Item # Accountability Activity s t e Comments u t n b M J A N c v c n
a p M e e o J o s O e F D p N A S s e R
65 Financial Oversight H-SAA Operating Plan Submission (Update) RP x 66 Financial Oversight Health Services Centre (Update) RP x 67 Financial Oversight Data Centre Relocation and Disaster Recovery Plan RP x Submission (Update) 68 Financial Oversight Resource Planning Work Plan RP x 69 Performance Measurement and Monitoring Financial Statements (information) RP x x x x x x x 70 Financial Oversight Corporate Balanced Scorecard - (Review) RP Q1 Q2 x Q4 71 Financial Oversight Wait Time Initiatives (Update) RP x Removed from agenda as nothing to report 72 Financial Oversight Northwest Supply Chain - Performance (Update) RP x x Deferred to May 73 Financial Oversight Medbuy - Overview and update RP x 74 Financial Oversight Funding HBAM and Qual Based Procedures (Update) RP x
75 Performance Measurement and Monitoring HAPS (Presentation) RP x 76 Financial Oversight Budget Planning Targets and Directives (Presentation) RP x
77 Financial Oversight Budget Planning Process (Presentation) RP x 78 Financial Oversight Investment Portfolio Update RP x 79 Financial Oversight Benchmarking Results RP x Removed from agenda as nothing to report 80 Financial Oversight Human Resources and Organizational Development RP x (Report) 81 Financial Oversight Health Human Resources, Planning, Recruitment RP x (Update) 82 Financial Oversight Capital Equipment and Capital Projects (Update) RP x x 83 Financial Oversight Informatics Projects and Initiatives (Update) RP x Topic was decided irrevelevant at committee Level
84 Financial Oversight Capital Budget Planning (Update) RP x 85 Financial Oversight Operating Plan (Approval) RP x Moved to March 86 Financial Oversight Capital Budget Summary RP x Moved to March
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Item # Accountability Activity s t e Comments u t n b M J A N c v c n
a p M e e o J o s O e F D p N A S s e R
87 Financial Oversight Broader Public Services (BPS) Disclosure RP x Defer to March as this should read SALARY DISCLOSURE and can't be done till post T4s 88 Financial Oversight Data Centre Disaster Recovery Plan (Update) RP x 89 Financial Oversight Physician and Health Human Resources Recruitment & RP x Amended to 2 items Retention (Update) 1)Physician Retention Upate (deferred to May) and 2) (name changed) Human Resources and Organizational Development Strategy (April) 90 Financial Oversight Labour Relations - Grievances and Arbitration (Update) RP x
91 Financial Oversight Occupational Health and Safety Program (Update) RP x 92 Financial Oversight TBRHSC Operating Plan (Update) RP x 93 Financial Oversight TBRRI Operating and Capital Budget (Report) RP x Postponed to May after TBRRI Board 94 Financial Oversight Non Patient Legal Matters (Update on Outstanding RP x Deferred to May Issues) 95 Financial Oversight Unaudited Preliminary Year End Financial Statements RP x (March 31) (Review) 96 Financial Oversight TBRRI - Financial Statements (Unaudited) (as at March RP x 31) 97 Financial Oversight Numbered Companies - Financial Statements RP x (Unaudited) (as at March 31) 98 Financial Oversight BPS Compliance Reports - Executive Office Reduction, RP x Use of Consultants, Expense Reporting 99 Risk Identification and Oversight TBRRI Audited Year End Financial Results RP x 100 Risk Identification and Oversight Insurance - Review of Coverage RP x 101 Risk Identification and Oversight Investments - Performance Review RP x 102 Governance Investments - Policy Review RP x 103 Risk Identification and Oversight Litigation Qual x x *new item added in March, 2014
Responsible Body Legend: Aud Audit Committee BD Board of Directors EC Evaluation and Compensation Committee Gov Governance Committee Nom Governance/Nominating Committee Qual Quality Committee RP Resource Planning Committee BL Governance/By-Laws Committee Colour Legend Completed by target In progress but not completed by target Not in progress, and not completed by target
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Surname Name Surname Name Surname Name Adams Joan Ewacha Diana Jane Morris Pat Aiken Penelope Farkas R. Joanne Mueller Marion Aldrich Sonja Feaver Gloria Murray Jean Allan Carol Feaver June Norman Margaret Arbour Noella Fossum Joyce Ochrymowicz Pat Armstrong Lorene Franchi Rose Panontin Anna Maria Autio Vivian Gerolami Judy Park Shirley Bakker Susanna Gibson Margaret Parks Alleyne Bates Lynda Gilbert Clora Patriquin Laurette Beauregard Devona Graba David Pereczky Marilyn Bell Rosemary Graba Shirley Perrier Ray Bodnar Jocelyn Gural Helen Power Margaret Bodnar Stan Harris Patti Pyne Darlene Bolt Jill Hay Marilyn Racco Marlene Bowles Barbara Hoover Lenore Rakshit Roopa Braun Linda Houge Johan Ranney William Britten Gladys Johnston Florence Rickards Barb Britton Carol Kauzlarick Ruth Robertson Margaret Anne Britton Randy Kearney Vera Rooney Maureen Brown Donna Kendall Rose Sargent Linda Burnside Barbara Kennedy Irene Schiewe Heather Buset Millie King Shirley Sellick Burt Cameron Joan Klanac Olive Sellick Fin Carniato Emma Kopechanski Mary Shaen Mary Carter Beverly Koropeski Ingrid Sheffield Diane Cava Sylvia Koropeski Valerie Shepherd Joan Chapman Bridgette Kowalchuck Sally Sippola Marion Chapman Jane Kreewin Leah Skea Marlene Chehowy Mary Lacey Kay Skula Pat Cherkas Natalie Leavitt Anne Slater Marilyn Chisholm Al Lieske Elli Slobojan Mary Chisholm Marilyn Lipowy Elizabeth Smith Cynthia Cocks Judy Lovis Lil Spivak Samuel Coffey Betty MacDonald Sylvia Tracz Michele Colquhoun Cappy Mackie Bernice Tremonti Marina Coulthard Tom Mallette Pat Ward Gussie Cunningham Joy Marak Marie Warwick Judith Della Vedova Dina Martell Dorothy Weston Shirley Derkacz Peggy Maslen Anne Wheeler Joan Detweiler Sharron Maydo Sue Wiljala Celia Dixon Diane McDonald Kathleen Wojciechowski Julia Donaldson Ann McKinnon Stella Wolnairski Virginia Dowhos Carole Mechtab Dolores Wood Mavis Dustin Jean Meijer Sheila Wyer Betty Elms Irene Middleton Ann Zamojski Marie Elmslie Nancy Milani Anne Zarek Fritzy Everitt Doreen Mokomela Judy Zurich Judy Thunder Bay Regional Health Sciences Foundation Board of Directors 4-Apr-14 Surname Name Knutson David McKinnon Brian Nieckarz Tracey Nesti Jody Bossio Tony Holloway Kevin Kadikoff Anthony Moses Joe Mirabelli Vince Poulter Mary Shaen Kyle Streib Barry Jones Parker Harris Clint Skula Pat Mymko Morris Craig Glenn