Fraser Health Authority Medical Advisory Committee (HAMAC) Minutes of Meeting 2012 March 14 Central City Cedar/Dogwood Rooms

Transcription

1 Fraser Health Authority Medical Advisory Committee (HAMAC) Minutes of Meeting 2012 March 14 Central City Cedar/Dogwood Rooms To strive for quality, safety and professionalism in the health of our communities and the medical care of individual patients throughout Fraser Health MEMBERS Dr. Peter Doris HAMAC Chair PD Dr. Dayan Muthayan Med Coordinator ARH DM Dr. David Jones (by phone) Med Coordinator BH DJ Dr. Richard Schwarz Med Coordinator CGH RS Dr. Dan Rubin Med Coordinator DH DR Dr. Dave Konkin Med Coordinator - ERH DK Dr. Larry Kehler Med Coordinator FCH LK -- vacant -- Med Coordinator LMH Dr. Andrew Edelson Med Coordinator MMH AE Dr. Dorothea Bergen Med Coordinator PAH DB Dr. Winston Gittens Med Coordinator RCH WG Dr. Greg Harrington Med Coordinator RMH GH Dr. Urbain Ip Med Coordinator SMH UI Dr. Allan Holmes Medical Coordinator JPOCSC AH Dr. Sean Keenan RDH Critical Care SK Dr. Anne Clarke RDH Emergency/HAMAC Vice Chair AC Dr. Arun Garg RDH Lab Med & Path AG Dr. Terry Isomura RDH - Mental Health & Addictions TI Dr. Gerald Simkus RDH Cardiology GS Dr. Peter Beresford RDH - Ob/Gyn. PB Dr. John Ramsden RDH Anesthesia JR Dr. Spencer Lister RDH Medical Imaging SLis Dr. Jean Lauzon RDH Surgery JL Dr. Steve Ligertwood RDH Hospitalists SLig Dr. Anne McNamara RDH Medicine AM Dr. Yusuf Bawa RDH Family Practice YB Dr. Mark Sorial I-RDH - Pediatrics MS Present Absent/ Regrets Nigel Murray ( ) President and CEO NJM Dr. Andrew Webb VP, Medicine AW Dr. Tom Ward Executive Medical Director TW Dr. Roy Morton Executive Medical Director RM Dr. Darryl Samoil Executive Medical Director DS Dr. Paul Van Buynder Chief Medical Health Officer PV ( ) Dr. Jan Kornder Medical Director Quality and Patient Safety JK Dr. James Zacharias Medical Staffs presidents Council rep JZ Dr. Mike Newton MN Dr. Luay Dindo LD ADMIN SUPPORT Shirley Hoffman Recording Secretary sh Peter Owen Director, Medical Affairs PO GUESTS Cathy Weir Tammy Simpson Dawn Drummond Director, Director, Quality Improvement and Patient Safety Coordinator, Patient Safety & Learning System, QI & PS Medical Staff Assistant, PAH 1

2 1.0 CALL TO ORDER Dr. Doris called the meeting to order at 1730 hours. 1.1 Introduction of Guests Tammy and Cathy were introduced Approval of Agenda It was MOVED and SECONDED: That the agenda of the HAMAC meeting of March 14, 2012 be accepted as circulated. 1.3 Approval of Minutes It was MOVED and SECONDED: That the minutes of the HAMAC meeting of February 8, 2012 be accepted as circulated. 1.4 Chair Remarks The Chair moved the meeting in-camera at this point of the meeting following the PSLS presentation by PSLS Coordinator. 2.0 PRESENTATIONS 2.1 PSLS Tammy Simpson, PSLS Coordinator, reviewed a typical PSLS (Patient Safety Learning System) report and circulated graphs and charts. The report will be posted on the HAMAC SharePoint Site for members to have a closer look at. sh Discussions points included: Programs (PMDs) get these reports on a regular basis; Dept. Heads can receive the reports if they wish Surgery events are not separated (i.e. Anesthesia is part of Surgery) Each event is assigned to a manager for review and the loop closed. It would be helpful if the initiator of the event would identify themselves rather than remain anonymous (which is an option) to enable further dialogue between manager and initiator. What do members want to see on a regular basis? These requests should be funnelled through JK; who will liaise with Tammy. It was noted that one useful report would be the number of preventable harm events. Also, HAMAC would like to see the top 10 events reported out. JK will report to HAMAC on a regular basis around PSLS. The PSLS support staff are available to speak to Regional Departments if requested. JK (at a later time in the meeting) ran through his PowerPoint presentation PSLS, A Physicians Guide. The presentation included: History of Safety Reporting Systems Patient Safety PSLS the Whys, the Hows, the Issues How to initiate a report JK emphasized that quality is what we do and that medical Leaders need to encourage the use of this tool by medical staff it is simple to use. Challenges of the system include: Interpretation of category when entering the data Recording facts (not opinions) Confusion on what events should be initiated It is unclear whether these reportings are S. 51 protected The presentation will be posted on the HAMAC SharePoint Site for members. 3.0 Business Arising 3.1 HAMAC Mission Statement Deferred to the next meeting. sh HAMAC/April 2

3 3.2 Anesthesia Job Action Update Dr. Ramsden reported that as far as he was aware, the intended job action by Anesthetists across the province in early April was still planned to occur. Recent correspondence from the VP Medicine s office to Anesthetists outlined rules under the PMA and College regarding withdrawal of service. Apparently BCAS has communicated with administration at each site reading the specifics of the job action and the impact at the site. A BC Media Statement of December, 2011 from the BC Anesthesiologists Society explaining issues will be posted on the HAMAC SharePoint sight for information. sh 3.3 Amendments to the Rules - Process JZ noted the Medical Staff Associations will be meeting throughout March to consult on the proposed changes to the Rules. The Presidents expect to report back to the April HAMAC meeting. HAMAC/April 4.0 MEDICAL STAFF CREDENTIALING Prior to this section getting started, PO introduced and welcomed Dawn Drummond, dawn.drummond@fraserhealth.ca who will be taking over the role of secretarial support for HAMAC following this March meeting as well as functioning as a Credentials Coordinator for the Regional Departments of Paediatrics, Medical Imaging and Lab Medicine. Dawn has extensive experience in Medical Affairs; she has worked at Peace Arch Hospital since 1998; and prior to that was an office manager in clinical office practice. Shirley Hoffman, current secretarial support for HAMAC since its inception, will be continuing on in Fraser Health in her support role to the Vice Presidents of Clinical Operations/Strategic Planning and Information Management. Members requested to record a vote of great appreciation to Shirley for her many years of high quality, invaluable support to HAMAC. A Recommendations for Board Approval 1. Applications for Appointments and Privileges Recommended Recommendations from the Departments of Cardiology, Obs/Gyn and Pediatrics were deferred due to the absence of the RDHs That it be recommended the Board grant the appointments and privileges applied for as noted on the report Applications for Appointments and Privileges Recommended as amended. 3. Applications for Review/Renewal of Membership - Recommended Delete: (18) GC (Emergency) Reported by RDH as resigned Clarification: (75) CP (Lab Med) additional information was highlighted That it be recommended the Board grant the renewal of membership applied for as noted on the report Applications for Review/Renewal of Membership Recommended as amended. 5. Applications for Change of Category, Site and /or Privileges Recommendations from the Departments of Hospitalists, Obs/Gyn, and Pediatrics were deferred due to the absence of the RDHs That it be recommended the Board approve the changes for category, site and/or privileges of membership as noted on the report Applications for Changes of Category, site and/or Privileges as amended. 6. Leave of Absence That it be recommended the Board approve the leaves of absence as noted on the report Leave of Absence as circulated. 3

4 8. Leadership Appointments Added: Dr. Dennis Janzen, HDL, Medical Imaging, SMH Dr. Michael Curry, HDL, Emergency, DH Recommendations from the Department of Obs/Gyn were deferred due to the absence of the RDH That it be recommended the Board approve the Leadership appointments as noted on the report Leadership Appointments as amended. B Temporary Appointments/Privileges for Ratification AE requested an extension to a midwife s temporary privileges beyond March 31. TW will follow. TW That it be recommended the Board ratify the temporary appointments with temporary privileges in the report Temporary Appointments/Privileges for Ratification as amended. 8 It was MOVED and SECONDED That it be recommended the Board approve the report as noted above (4A and B). CARRIED C For Board Information Separations noted for information 3 It was MOVED AND SECONDED That the meeting move in camera. (1745 hrs.) 5.0 QUALITY AND PATIENT SAFETY IN CAMERA 5.1 Approval of In Camera Minutes 5.2 FH Quality Performance Committee 5.3 Board 5.4 Other 6.0 REGIONAL DEPARTMENT REPORTS IN CAMERA 6.1 Anaesthesia 6.2 Cardiology 6.3 Critical Care 6.4 Emergency 6.5 Family Practice 6.6 Hospitalist 6.7 Laboratory Medicine and Pathology 6.8 Medical Imaging 6.9 Medicine 6.10 Mental Health and Addictions 6.11 Obstetrics/Gynecology 6.12 Pediatrics 6.13 Surgery It was MOVED and SECONDED That the in camera session be concluded (1840 hrs.) 7.0 MEDICAL STAFF FACILITIES ADVISORY COMMITTEE REPORT 7.1 Report RM reported: DR to clarify regional anesthesia clinical practice guidelines w. JR on obstructive sleep apnoea; this quality issue is impacting on ORs at DH. 4

5 Program Management specific issue at SMH revealed communication from Programs to other related parts of the organization is critical when implementing service changes; PMDs should not be making decisions in isolation. How can Program Management be improved upon? What needs refining? How can we fix the issues; suggestions would be welcomed. We are now two years into the process of change. Evidence of divergence between the interests of a particular site and the position of the Regional Dept/Program in regard to manpower plans, recruitment and credentialing of (required) staff. 8.0 NEW BUSINESS 8.1 Designation of Directors under the Mental Health Act and Patients Property Act TI had pre-circulated a BN. Board appointment of directors under the Mental Health Act & the Patients Property Act need to be updated and approved and the Ministry of Health notified. 9 It was MOVED and SECONDED: That, consistent with the Mental Health Act, HAMAC recommends to the Board of Directors the appointment of the Medical Staff members as directors of the FHA designated facilities as noted in the table below: SITE/UNIT DIRECTOR SITE DESIGNATION per Mental Health Act Reg Burnaby Hospital Dr. Nirmal Kang Psychiatric Unit Burnaby Mental Health Centre Dr. Nirmal Kang Chilliwack General Hospital Dr. Anette Brink Psychiatric Unit Chilliwack Mental Health Centre Dr. Anette Brink Langley Memorial Hospital Dr. Shilpa Shete Psychiatric Unit Langley Mental Health Centre Dr. Shilpa Shete Peace Arch District Hospital Dr. Doug Maskall Psychiatric Unit White Rock/South Surrey Mental Health Centre Dr. Doug Maskall Ridge Meadows Hospital and Dr. Biju Mathew Psychiatric Unit Health Care Centre Maple Ridge Mental Health Centre Dr. Biju Mathew Royal Columbian Hospital Dr. Anson Koo Psychiatric Unit Connolly Lodge / Cottonwood Lodge Dr. Nigel Fisher New Westminster Mental Health Centre Dr. Anson Koo Tricities Mental Health Centre Dr. Anson Koo Developmental Disabilities Mental Health Services Dr. Robin Friedlander Surrey Memorial Hospital Dr. Marietta Van Den Berg Psychiatric Unit Surrey Mental Health & Addiction Dr. Marietta Van Den Berg Delta Mental Health Centre Dr. Atul Nanda Abbotsford Regional Hospital Dr. Pieter Strauss Psychiatric Unit Abbotsford Mental Health Centre Dr. Pieter Strauss 5 To Board

6 TI noted there is a designate delegation list in each of the local mental health inpatient units to cover absences of the Directors. 8.2 MRP Policy Motion from Surgical Program Council JL asked that this item be deferred to the April meeting as DS was not present. DS has sent regrets to the April meeting so this item will be deferred to May. HAMAC/May 9.0 OTHER REPORTS 9.1 CEO no report 9.2 VP Medicine no report 9.3 Chief Medical Health Officer PVB reported: Pertusus: cases have been reported from Fraser East. The infection has spread to other parts of the HA. No deaths have been reported. He encouraged HAMAC members to get their boosters; particularly if they had not been boosted over the past five years as the vaccines are not of permanent efficacy and appear to be effective for 5 years only.. Vaccines are available in community pharmacies and in GP offices free of charge. Flu vaccine: the flu is considered a quality and safety issue in the USA. NJM will be championing provincial support at the Leadership Council in April to make immunizations mandatory for all health authority employees in hopes of increasing the compliance rates to at least 90% (this year the rate was only 30%). Better Health Program: encouragement of all, particularly seniors, to keep fit and stay healthy in the community. Prevention of injuries and a healthy lifestyle is crucial to keeping down the numbers of in-patients. 9.4 Medical Staffs Association Presidents LD advised that vascular SMH will discontinue at the end of March; the Surgical Program will not renew this MOCAP contract. There was speculation as to the reasons for this. He also stated his concerns for the SMH site; particularly with the expansion of the Critical Care Tower. MOTION PROPOSED BY LD: That HAMAC support the continued existence of a vascular surgery service at SMH at its current funding level (including a MOCAP funded call group). Discussion: Issue had not been pursued through appropriate organizational channels and insufficient information had been presented to HAMAC Defeated by Vote 9.5 Executive Medical Directors TW noted: PMI leadership courses for up to 40 Medical Staff leaders are now available for registration; the first module is Conflict and Negotiation. 9.0 ADJOURNMENT/NEXT MEETING The meeting adjourned at 2005 hours. The next regular meeting of HAMAC will be held on April 11, 2012 in the Dogwood and Cedar Rooms at Central City SUMMARY OF ACTION ITEMS TO THE BOARD TO THE BOARD (8) Credentials/Recommendations (9) Directors Under the MHA and PPA 6