3.0 CONSENT AGENDA On a motion moved by W. Rogers, seconded by H. Marshall and carried, the GBHS Board of Directors approved:

Transcription

1 GREY BRUCE HEALTH SERVICES BOARD OF DIRECTORS Committee of the Whole ACTION SUMMARY 0900 hrs Board Room, GBHS Owen Sound Regional Hospital PRESENT REGRETS GUESTS STAFF Mark Ostland, Chair Brenda Kearney, Vice Chair (joining remotely) Sue Carruthers Ron Goldsmith Harry Marshall Gail Robinson (joining remotely) Martha Rogers Will Rogers Paul Sinclair Patsy Taylor Bill Van Wyck Lance Thurston, President and Chief Executive Officer Judy Shearer, VP Clinical Services & Chief Nursing Executive Dr. Michael Marriott, Chief of Staff Dr. Elaine Blau, President, Medical Staff Rural Dr. Neil Lamont, President, Medical Staff - Urban Lori Ledingham, Director, GBHS Board Susan Pugh, Director of Laboratory Services Aman Sidhu, Director, GBHS Board Michele Turcotte, Director of Surgical Services Dr. Todd Webster, CMIO No guests in attendance Mary Margaret Crapper, Director Communications and Public Relations Rebecca Cummings, Chief Human Resources Officer Ryan Gonsalves, VP Information Technology, Chief Information Officer Martin Mazza, VP Corporate and Diagnostic Services, Chief Financial Officer Diana Ryman, Director of Patient Relations and Patient Safety Sarah Cunningham, Executive Assistant 1.0 CALL TO ORDER M. Ostland called the meeting to order at 0905 hrs. 2.0 ANNOUNCEMENTS / CORRESPONDENCE No announcements made. 3.0 CONSENT AGENDA On a motion moved by W. Rogers, seconded by H. Marshall and carried, the GBHS Board of Directors approved: 3.1 Information Technology

2 3.2 Resources MOTION to recommend to the Board of Directors approval of the January 2017 Withholding and Remittance of Payments under the Income Tax Act 3.3 Quality 3.4 Planning 3.5 Audit MOTION to approve Audit Plan for 2016/ Board Governance & Development 3.7 Committee Meeting Survey Results 4.0 APPROVAL OF THE AGENDA MOVED BY R. Goldsmith, seconded by M. Rogers, that the agenda be approved as circulated. CARRIED 5.0 DECLARATION OF CONFLICT OF INTEREST M. Ostland invited Board members who may have a conflict of interest to so declare it. No declarations heard. 6.0 BUSINESS ARISING FROM THE MINUTES No business arising. 7.0 MOTION to move to the Committee of the Whole meeting Motion to Move to Committee of the Whole At 0907 hrs it was MOVED BY W. Rogers, seconded by S. Carruthers, to move into Committee of the Whole. CARRIED 1.0 APPROVAL OF THE AGENDA COMMITTEE OF THE WHOLE MOVED BY M. Ostland, seconded by P. Taylor, to approve the agenda as circulated. CARRIED 2.0 DECLARATION OF CONFLICT OF INTEREST M. Ostland invited Board members who may have a conflict of interest to so declare it. No declarations heard. 3.0 PLANNING 3.1 GBHS STRATEGIC PLANNING L. Thurston explained that we are moving into our annual planning process as an organization; need to ensure that the Strategic Plan is still on point. Please refer to the attached presentation. The floor was opened to Directors, giving opportunity for them to provide feedback on current approach, issues, and a variety of suggestions were denoted in the circulated file:

3 M. Rogers commented on the Strategic Management Framework - suggested to include strategic priorities and how they get woven into the Board Committees. R. Cummings reported that staff members show engagement with the Strategic Directions, from a Human Resources perspective. R. Goldsmith and Dr. N. Lamont identified the Strategic Plan is very much people focused. In spite of financial hardship, must re-invite staff to connect with and embody fundamentals of this plan. Reviewed previous work that was done on the Corporate Operating Plan before put on hold due to Transformation implementation. More information on this will be shared with the Board in near future, after we revisit metrics such that all areas can see themselves represented through various initiatives. The Mission, Vision and Values were reviewed and deemed acceptable as is by all no changes to be made at the current time; however promoting our next level of oneness across the organization is desired. B. Van Wyck commented on the need for the Board to place its trust in L. Thurston and his Executive staff with operational matters and to maintain governance level view as a Board. P. Sinclair and P. Taylor expressed that their newness on the Board somewhat affects their ability to comment on issues (lack of background information). L. Thurston summarized by saying there is a need to define the role of the Board and its relationship with senior staff. Fundamental discussions to occur about the organization s direction for the future and ways to achieve greater oneness at GBHS. Spoke to the need for continued advocacy with the SWLHIN and Ministry. ACTION: S. Cunningham will circulate a link to the Georgian College Strategic Plan video and document. Time will be set aside at future Planning Committee meeting to speak to GBHS Relationship with Foundations and Auxiliaries. Operations versus Governance will be added as a topic on a future BGDC Agenda. Generative Governance Article by Cathy Trower will be discussed at an upcoming meeting. 4.0 QUALITY BOARD SCORECARD J. Shearer shared the draft Board Scorecard and spoke to its concept: snapshot of indicators/trends the Board may want to look at over a year long period; discussed how and when to present this, what to do if not meeting targets upon monitoring, engaging front-line staff through quality and safety teams that are being initiated. R. Cummings mentioned that a scorecard is effective in lean rollout, for example, as it can live on huddle boards and help drive change on inpatient units. W. Rogers made the request to have HSMR (Hospital Mortality Rate) numbers presented regularly and for added definition behind numbers on the scorecard so understanding why they are important. M. Rogers spoke to quality reporting (to various governing bodies) and the need to put together an integrated framework which will inform responsibility at different levels (Committee, Board), and at what frequency. Development of such a framework is underway and will be brought up to the Board through the Board Quality Committee. The scorecard appears in a new layout than used in the past; more work is required before bringing back to the Board. ACTION: Invite J. Carter to present on huddle boards at an upcoming meeting, as a quality tracer. Board Committees asked to delve deep at their meetings, to flush out specific scorecard indicators.

4 /18 QUALITY IMPROVEMENT PLAN (QIP) Diana Ryman, Director of Patient Relations and Patient Safety, was introduced as she plays an instrumental role in conducting quality work. Together she and J. Shearer delivered a presentation on this year s QIP, which they brought forward for review / approval of the Board. Please refer to the attached presentation which outlines the indicators in detail. Interesting discussion ensued regarding medication reconciliation, patient compliance and slow process improvement with respect to this - with input from Dr. N. Lamont, R. Goldsmith, and others. A question was posed by B. Kearney about wait times in the Emergency Department. Noting some issues in this area are related to adolescent mental health patients (delays in moving them), flu outbreaks (closure of unit to admissions). MOVED BY M. Rogers, seconded by W. Rogers, to approve the Quality Improvement Plan for 2017/18 GBHS as presented. CARRIED 5.0 RESOURCES 5.1 FINANCIAL STATEMENTS M. Mazza spoke to the previously circulated financial statements, focusing primarily on results from February As such, the year-to-date net result from hospital operations reflects a deficit of -$1.7M. By far the most significant circumstance has been the decrease in Ministry revenue due to funding formula results, due to the HBAM reset. Despite the sizeable year-end loss that GBHS is facing this year, the outcome is favourable relative to budget. Recent information on patient activity and statistics were described. G. Robinson stated that it is great to see an improvement; posed a question as to what initiative from Back to Balance has had the most impact on the numbers. The single biggest is funds received from the Ministry, followed by retail Pharmacy net profit ($500K), some of our own revenue charges (such as room billings) and staffing level changes. MOVED BY B. Kearney, seconded by H. Marshall, to accept the Financial Statements from November and December 2016, and January and February 2017, as presented. 5.2 H-SAA ACCOUNTABILITY AGREEMENT M. Mazza referred the Board to the attached Briefing Note regarding the 2017/18 HAPS and H-SAA and was able to speak to deliberations to date. GBHS was not asked to submit a revised HAPS. MOVED BY P. Taylor, seconded by R. Goldsmith, for the Board Chair and President & CEO to sign the H-SAA and HAPS agreements. CARRIED 6.0 INFORMATION TECHNOLOGY 6.1 GBIN UPDATE R. Gonsalves provided the Board with an update on GBIN and status on the Partnership Agreement. The shared lawyer has been contacted to determine next best steps and M. Fecenko s advice to GBHS is to make final changes to the agreement for presentation to partners. Those organizations that wish to proceed will move forward and those who do not may opt to begin a 2-year (assisted) off-boarding. Feedback has been compiled from all partners, including that from newest organization (Almonte), and the legal team is doing a final review and clean-up of the document. H. Marshall asked if we are limiting expansion / ensuring that no other partner organizations be onboarded during this time which is correct. Also, asked if there have been updates from OSMH as they revealed a plan to do an independent review of the agreement. There has been no news on this.

5 The future vision for GBIN and IT at GBHS is being contemplated, mapped, in keeping with LHIN and Ministry mandates. A variety of questions and comments were posed by M. Ostland, Dr. E. Blau, W. Rogers, G. Robinson - related to maintenance / support agreements, upgrades, risks and timelines. 7.0 TRANSFORMATION (PLANNING) 7.1 TRANSFORMATION UPDATE L. Thurston gave the Board an update on Transformation activities: shared learnings from recent stakeholder outreach, information about Back to Balance initiatives and estimated cost savings. A public forum meeting is set for March 28 th in Meaford; additional meetings are being set up in Southampton and Markdale in April to garner input from those communities as well. Scheduled to make a final decision on surgical services consolidation and initial Back to Balance initiatives at the April 26 th Board meeting. L. Thurston is hopeful that we will have received an announcement from the Ministry regarding funding by that time. M. Rogers inquired if there are any further updates related to the new Markdale Hospital. Detailed plans are being developed. A question was posed by S. Carruthers about the surgical services review and what change potential Ministry funding might mean for consolidation options under consideration. The answer: this service shift must be uncoupled from the funding formula change as the review began beforehand. 8.0 BOARD GOVERNANCE AND DEVELOPMENT 8.1 ANNUAL BOARD PERFORMANCE & DEVELOPMENT SURVEY RESULTS R. Cummings shared background information and excellent results from both our GBHS Annual Board Performance and Development Survey (2017) and from GCE-issued Board Self-Assessment (2016). Some comments reveal a lack of understanding related to Board policies and procedures and this is. There is need to review the length of time Board members spend on committees; term could be extended to 2 years to allow for better movement/continuity on issues. Take this into consideration for Committee Chairs as well. Intelligent consideration to be given to learning curves, skills and experience of members. ACTION: At next BGDC meeting, address comments related to frequency of Board meetings. 8.2 BOARD MEMBER VACANCY / RECRUITMENT R. Cummings spoke about Board Member recruitment and the timeline for this. One individual has indicated they are not planning to return. As this was indicated anonymously and/or may have been a misunderstanding of the survey question, asked that this person please identify themselves to the Board Chair if it is taking effect end of this year. The necessary paperwork has been prepared to advertise a position, though there may not actually be any vacancy this year. 8.3 INITIATE BOARD OFFICER SELECTION PROCESS As per Policy VI-5: Board Officer Selection Process, there are 3 elected Board Officer positions identified as Board Chair, Vice Chair of the Board and Officer At-Large. The past Board Chair is usually included as well. An opportunity was provided, via survey, for Board members to indicate their interest in becoming a Board Officer. ACTION: an annual re-appointment meeting will be scheduled for Board Officers.

6 8.4 INITIATE PROCESS FOR REAPPOINTMENT AND NEW DIRECTOR INTERVIEWS R. Cummings gave an update on the process for reappointment / New Director interviews. As part of evaluation processes in place, will meet with new Board Members and those seeking reappointment. ACTION: a survey will go out this week for all Board Members to complete and meetings to be arranged in April, to occur immediately before the Board Meeting in Wiarton. 8.5 ORIENTATION FEEDBACK & COMMITTEE CHAIR ORIENTATION Good feedback about New Director Orientation and Hospital Tours was received. ACTION: at next BGDC meeting will discuss how we can improve Committee Chair Orientation. 8.6 GOVERNANCE ACCREDITATION R. Cummings shared results from the GBHS Governance Tool and plans for upcoming Accreditation. Results were very positive overall, with only 4 flags identified. ACTION: To address each flag, will bring this to next BGDC meeting for discussion. 9.0 COMMUNICATION / REPORT OUT FROM THE COMMITTEE OF THE WHOLE SESSION MOTION to approve the Quality Improvement Plan for GBHS as presented MOTION to accept the Financial Statements from November and December 2016, and January and February 2017 as presented MOTION for the Board Chair and President & CEO to sign the H-SAA and HAPS agreements MOVED BY M. Rogers, seconded by R. Goldsmith, to move back to the Board meeting. CARRIED 8.0 APPROVE REPORT FROM THE COMMITTEE OF THE WHOLE SESSION MOTION to approve the report out as outlined / highlighted above MOVED BY S. Carruthers, seconded by P. Sinclair, to receive the report from the Committee of the Whole session. CARRIED 9.0 REPORT FROM THE CHIEF OF STAFF Dr. Marriott shared his first report with the Board and the floor was opened up for any questions. He has enjoyed his first few months, is deep in learning and appreciates the support of the Executive Team. A question was posed regarding the regional sexual assault program, which was discussed at an MAC meeting, and it was confirmed this has become a 24/7 operation. The Board reviewed Medical Staff Policy VII-30 as previously circulated, with revisions tracked. MOVED BY B. Van Wyck, seconded by P. Taylor, to receive the Chief of Staff Report. CARRIED MOVED BY W. Rogers, seconded by P. Taylor, to approve the revised policy: VII-30 Temporary Medical Staff Credentialing BOARD MEMBER EDUCATION FEEDBACK M. Rogers and S. Carruthers each shared a summary regarding the OHA Health Achieve conference which they attended in early November: they both found the mental health presentation to be exceptional and thought it nice to join for dinner outing with staff. Due to financial constraints not many GBHS staff were able to attend. Also, many attendees were not from the Hospital sector seen as a valuable conference to bridge gaps to other industries, such as IT. It is felt that one day attendance at

7 this event is enough for Board members and that we can limit to 1 or 2 individuals. R. Goldsmith then shared his summary of the Governing for the Future event put on by the SWLHIN that he attended end of November. About 40 individuals were there, some from other Hospital Boards (SBGHC, HDH). And members of the LHIN were present, however in a listening only capacity. Worthwhile event, in that in generated thoughts about collaboration. Pre-reading material can be browsed on the Board portal. In future, have at least 2 members of the GBHS Board present. All three were thanked for their involvement at education sessions and for today s presentations. Board Chair, Mark Ostland, recapped the meeting and asked new Board members to provide some input: P. Sinclair stressed importance of keeping a long-term view on issues. B. Van Wyck liked the format of the Committee of the Whole meeting. It is expected the focus at April s Board Meeting will be on Back to Balance discussions and making a decision on surgical services with a staff report and recommendation for the Board to consider DATE, TIME & LOCATION OF NEXT MEETINGS New Director & Reappointment Interviews and Board Meeting Wednesday, April 26 th Wiarton Hospital, Board Room followed by Board Meeting Wednesday, April 26 th Wiarton Hospital, Board Room Board Committee Day Wednesday, May 24 th Owen Sound Regional Hospital, Board Room 12.0 ADJOURNMENT There being no further business, on a motion by B. Kearney the meeting adjourned at 1350 hrs. Chair, Board of Directors Secretary, Board of Directors /SC Thank You