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TBRHSC Board of Directors Open Meeting Thursday, April 17, 2014

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TBRHSC Board of Directors Open Meeting Thursday, April 17, 2014 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 Information X Discussion X Page 2 of 2 Education Expected Recommendation Outcome (Z) /Decision/Action Item & Purpose (Y) Ethical Framework – Wednesday, May 7, 2014 – 5:00pm Presenter (X) Does the course of action demonstrateDoes ‘respect’ the by course honouring of the action uniqueness demonstrate ofCentered ‘Excellence’ every Care by individual? through reinforcing the that alignment we of are Academics recognized and leaders Research in with Patient Clinical and Services? Family & delivering fiscally responsible services? Does the course of action putDoes ‘Patients the First’ course by of responding action respectfully demonstrate to ‘accountability’ needs by & advancing values quality, of safety patients and and Patient families? and Family Centred Care Time BOARD MEMBER COMMENTS DATE OF NEXT MEETING ADJOURNMENT http://intranet.tbrhsc.net/Site_Published/i5/render.aspx?DocumentRender.IdType=5&DocumentRender.Id=110784 For more detailed questions to use onlocated difficult on decisions, the please Quality refer and to Risk TBRHSC’s Management Framework page for of Ethical the Decision Internet. Making 3. 4. 1. 2. All leaders should consider decisions from ancommunity. ethics The perspective following including questions their should implications be on reviewed patients, for staff each and decision. the TBRHSC is committed to ensuring decisions and practices are ethically responsible and align with our mission/vision/values. # 9.0 10.0 11.0 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.
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