Fraser Health Authority Medical Advisory Committee (HAMAC) Minutes of the Meeting May 9 Central City Cedar and Dogwood Rooms

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1 Fraser Health Authority Medical Advisory Committee (HAMAC) Minutes of the Meeting May 9 Central City Cedar and 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. Anne Clarke HAMAC Co-chair AC Dr. Dayan Muthayan Med Coordinator ARH DM Dr. David Jones 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 Dr. Phil Cilliers (Interim) Med Coordinator LMH PC 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. 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 SL Dr. Jean Lauzon RDH Surgery JL Dr. Steve Ligertwood RDH Hospitalists SLi Dr. Anne McNamara RDH Medicine AMc Vacant RDH Family Practice Dr. Mark Sorial I-RDH - Pediatrics MS Nigel Murray President and CEO NM 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 PVB Dr. Jan Kornder Medical Director Quality and Patient Safety JK Dr. James Zacharias Dr. Mike Newton Dr. Luay Dindo Medical Staffs presidents Council rep ADMIN SUPPORT Dawn Drummond Recording Secretary dd Peter Owen Director, Medical Affairs PO Present JZ MN LD Absent/ Regrets GUESTS Sharmen Lee Petra Welsh Consultant Administrative Director, Infection Control, FH

2 1.0 CALL TO ORDER Dr. Peter Doris called the meeting to order at 1750 hours. 1.1 Introduction of Guests PD introduced the guests, as noted above (1) (2) 1.2 Approval of Agenda MOVED: AC SECONDED: SL That the agenda of the HAMAC meeting of May 9, 2012, be accepted as distributed. 1.3 Approval of Minutes **x2 MOVED: AH SECONDED: DB That the minutes of the HAMAC meeting of April 11, 2012 be accepted as circulated. 1.4 Chair Remarks - none 2.0 PRESENTATIONS 2.1 Infection Prevention and Control - Quality Performance Committee; FH Hand Hygiene Report Quarter 4, 2011/12 ** Petra presented an overview of the attached report. FH Pulse is a good resource for accessing audit reports that show levels of hand washing compliance, they can be printed off for posting on units. Compliance reports as well as trend reports are also available by program or facility. PW will provide the link to the audit report site. There was general discussion of having easy access to hand washing tools such as antimicrobial gels available for physicians and within three feet of each bedside. JZ noted that as well as fixed stations with hand sanitizers there are also portable versions available to order. The order sheet will be distributed to HAMAC members. AC noted that she participated in the hand hygiene audit course and felt that it targeted behaviour change by raising awareness of your hand hygiene practice. It also provided positive reinforcement for others to observe physicians participating in the audits and practicing preferred hand hygiene protocol. AW confirmed that it will be policy for all new physicians to complete the hand hygiene course. (3) MOVED: AC SECONDED: SL That HAMAC recommends that every member of HAMAC complete the hand hygiene audit training program within the next two months. CARRIED Page 2 of 7

3 2.2 Physician Engagement in Advanced Clinical Information Systems PIAC ** DS provided a presentation as detailed in the Briefing Note circulated with the agenda package. Physician engagement is required to support the deployment of advanced clinical information systems in FH. The Health Care Informatics Strategy Council has endorsed the proposed Physician Informatics Advisory Committee, and requested that discussions begin with HAMAC for the purpose of forming this committee. (4) MOVED: SL SECONDED: JZ That HAMAC supports in principle the creation of a Physician Informatics Advisory Council (PIAC) as a standing subcommittee of HAMAC that will advise the HAMAC, MSFAC, CIEC and HCISC, on physician and clinical aspects of information technology and the development and implementation of an electronic health record. ACTION: DS to provide draft Terms of Reference to next HAMAC meeting June 13, 2012 for approval. 3.0 BUSINESS ARISING 3.1 Medical Staff Consultation on Rules Changes JZ circulated a document reflecting the results of the consultation with the Medical Staff over the proposed changes to the Medical Staff Rules. From the list of proposed changes, 2 issues were identified: The involvement of the RDH in the search and selection of an HDL involvement of both in each other s selection process could lead to real or perceived conflict Meeting attendance requirements are not realistic because it is not possible for some Regional Depts to hold meetings of the whole. The feedback from the Medical Staff will be provided to the Board, as presented, along with HAMAC s recommendation for the changes. 3.2 MRP Policy/Motion from Surgical Program Council ** In February 2012 the Surgical Program Council discussed issues with interpretation of the MRP Policy in regard to responsibility for (long stay) medical patients with minor or major surgical needs. A two part recommendation from the Council was forwarded to HAMAC for adoption. It was noted that the Council Motion was not unanimous, that there are two subspecialities with a specific interest in a change. Page 3 of 7

4 MOVED: JL SECONDED: JZ That the Motion from the Surgical Program Council meeting of February recommending two amendments to the Most Responsible Physician Policy be adopted. DISCUSSION: Although there was an initial focus on a need for defining minor surgery, further discussion revealed that this is a somewhat more complex issue. MOTION WITHDRAWN: ACTION: JL will take the recommendation back to the Surgical Program Council for further review and re-wording. 3.3 Hospitalists Admitting privileges DEFERRED to next meeting. 3.4 Obstructive Sleep Apnea Patient Policy JR provided an update. In terms of HAMAC s concern about impact on patient safety in the absence of policy direction, he clarified that patients who would be covered by a OSAP are currently being identified in the Pre- Anesthesia Clinics. There will be no policy until all parties (hospitalist) have been consulted. A trial has been underway at ARH. The data received is currently being collated. A draft policy will be forwarded to HAMAC within the next couple of months. 3.5 Pending Items Tracking Document DEFERRED to next meeting. 4.0 MEDICAL STAFF CREDENTIALING (5) 4.1 A. Recommendations for Board Approval 1. Applications for Appointments and Privileges Recommended Page 13, Line 2, Pediatrics DEFERRED (6) 3. Applications for Review/Renewal of Membership Recommended 5. Applications for Changes of Category, Hospital and/or Privileges (7) Page 10, Line 1 and 2, Anesthesiology DEFERRED Page 13, Line 31, Pediatrics DEFERRED 6. Leave of Absence (8) In Camera minuted discussion regarding an application for Leave. Page 4 of 7

5 (9) (10) B. C. 8. Leadership Appointments Temporary Appointments/Privileges for Ratification Page 16, Line 1,2,3, Anesthesiology DEFERRED.For Board Information 1. Separations - noted for information. MOVED: AM SECONDED: WG That it be recommended the Board... - grant the appointments and privileges applied for as noted in the reports 4.1 (A)(1-8) - ratify the Temporary Appointment/Privileges in the report 4.1 (B), and - accept for information the report 4.1( C )(1) 4.2 Other (11) MOVED: SL SECONDED: GH That the meeting move In Camera. (1845 hours) 5.0 QUALITY IMPROVEMENT AND PATIENT SAFETY IN CAMERA 6.0 REGIONAL DEPARTMENT REPORTS IN CAMERA (12) MOVED: AM SECONDED: AC That the In Camera session be concluded. (1905 hours) 7.0 MEDICAL STAFF FACILITIES ADVISORY COMMITTEE 7.1 Report None 8.0 NEW BUSINESS (30 mins.) 8.1 Director Designations under MHA & PPA ** (13) MOVED: DB SECONDED: WG That, consistent with the Mental Health Act, HAMAC recommend to the Board of Directors the appointment of the medical staff members as directors of the FHA designated facilities as noted below: Page 5 of 7

6 1. Timber Creek - SITE/UNIT LISTED IN THE REGULATIONS TO THE MENTAL HEALTH ACT Board Appointed Director: Dr. Brian Guan Site Designation: Provincial Mental Health Facility Mission Mental Health Centre - SITE/UNIT LISTED IN THE REGULATIONS TO THE MENTAL HEALTH ACT Board Appointed Director: Dr. Pieter Strauss Site Designation: Provincial Mental Health Facility Clostridium difficile Infection CDI Pre-printed Orders BN** DS spoke to the recommendation in the Briefing Note regarding immediate implementation of prescribing guidelines which include the automatic hold by pharmacy after 72 hours for antibiotics that have been ordered without a specified duration of treatment. Also presented was a regional pre-printed order sheet for C. difficile infection. Members agreed with the stop order notion but noted there needed to be clearly entrenched practices of Pharmacy notifying the physician whenever this occurred. (14) MOVED: RS SECONDED: AC That HAMAC supports immediate adoption of the new prescribing guidelines for C. difficile treatment, which include an automatic hold by Pharmacy after 72 hours for antibiotics prescribed without a specified duration of treatment, and the provision of education to medical staff to support the guidelines. 8.3 Standardized Physician Implementation Regional CDI Pre-printed Orders (15) MOVED: RS SECONDED: WG That the Regional Pre-printed Order for CDI be adopted. CARRIED General Admission Pre-Printed Orders Provided for information. 8.4 Advancing Clinical Information Systems Workshops ** DS asked for volunteers or designates to attend these workshops scheduled for June and July Regional Department of Geriatric Medicine ** DEFERRED Page 6 of 7

7 9.0 OTHER REPORTS 9.1 CEO 9.2 VP Medicine Quality Performance Committee BN ** 9.3 Chief Medical Health Officer no report 9.4 Medical Staff Association Presidents (3) Item Executive Medical Directors (3) no reports 10.0 Next Meeting June 13, Adjournment the meeting was adjourned at 2020 hours. Page 7 of 7