MINUTES. Meeting of the Board of Directors. 2015/16 Membership. Call to Order Phil Griffin. The reflection was provided by Brenda Lewis.

Transcription

1 2015/16 Membership Meeting of the Board of Directors 3:30 pm start time St. Joseph s Hospital Adams Boardroom A2-041 MINUTES Call to Order Phil Griffin The reflection was provided by Brenda Lewis. EDUCATION SESSION Ruth Bullas, Chief Privacy & Risk Officer and David Schned, Integrated Director, Infrastructure Technology led members through a PowerPoint presentation which provided detailed information on: Understanding what Cybersecurity is and why it is important; An explanation of top Cybersecurity threats including examples of breaches; The framework to address Cybersecurity; The hospital s defenses and challenges that lie ahead; Security related to privacy of information; An explanation of privacy breach management; and Key technology security initiatives. Discussion was held and the following comments noted: The top two barriers to achieving heightened Cybersecurity are resources; both financial and personnel; Cybersecurity is critical to the operation of the hospital as the reliance on technology increases; London hospitals have adequate securities in place at this time; The Cerner Millennium system has 100% redundancy, located in Toronto; London hospitals continuously assess risk and strategize on how to mitigate those risks related to Cybersecurity and privacy; Healthcare Insurance Reciprocal of Canada, the leading provider in healthcare liability insurance, uses London hospital s privacy breach management process as the gold standard for other hospitals; Collaboration between the Information Technology Services Team and the Privacy Department is strong. VOTING Phil Griffin (Chair) Margaret Kellow (Vice Chair) Jonathan Batch Brad Beattie Darcy Harris (R) Paul Kiteley Maria Knowles Ron LeClair Brenda Lewis Peter Mastorakos* Margaret McLaughlin Rev. Terrence McNamara Pat Pocock Howard Rundle Bruce Smith Bill Wilkinson NON-VOTING * Dr. Larry Allen John Callaghan Dr. Sarah Jarmain Dr. Gillian Kernaghan Karen Perkin Dr. Adam Rahman Dr. Michael Strong *ex-officios Guests St. Joseph s Senior Leaders LHSC Shaun Elliott, Vice Chair (R) Murray Glendining, President& CEO Recorder Terri-Lynn Cook R = regrets In summary, the hospitals have protection in place but must be even more vigilant through investment in staff, training and security assets and ensuring processes and policies are supported. 1. Board Minutes for Approval It was MOVED and SECONDED that the minutes of the meeting held October 26, 2015 be approved, as presented. P a g e 1

2 2. Reports 2.1 Board Chair Opening Remarks [P. Griffin] Mr. Griffin commented on the loss of a valued colleague - Kathy Burrill and commended the senior leader team for coming together to support each other and all staff at St. Joseph s during this time of loss. Kathy will remain a cherished member of the St. Joseph s family. During the month of November, Mr. Griffin had the privilege of attending numerous events including: An education session on Effective Governance for Quality & Patient Safety provided by the Canadian Patient Safety Institute. Although the Quality Committee of the Board oversees all quality matters and details relating to matters are shared with the Board through their Minutes, this learning opportunity suggests the need for greater transparency at the Board level. Therefore, a request has been made for the Chair of Quality Committee to provide the Board with verbal updates, as appropriate, so the Board has a greater awareness of the quality issues being dealt with by the Committee; HealthAchieve on November 2/3, This is a conference and exhibition show organized by Ontario Health Association (OHA). Keynote presentations were given by Captain Richard Philips, the Hero the High Seas who shared his dramatic experience with a Somali hijacking, and Martin Short, Canadian actor and comedian who shared stories from his new book and his personal connection to health care and cancer in particular; LHSC s Board recognition event; and The Remembrance Day ceremony at Parkwood Institute. 2.2 President and Chief Executive Officer [G. Kernaghan] Dr. Kernaghan responded to questions raised from the written report that had been pre-circulated. In addition, she highlighted areas of current developments and issues, which included the following: A review of how St. Joseph s will be measuring the four strategic plan metrics for There is question as to how St. Joseph s will continue to measure patient experience as the current tool utilized will be changing in April Mr. Butler provided information related to the current process/tool used for measuring patient satisfaction and shared details regarding the implementation of a new survey tool based on the OHA s review of requests for proposals. It is anticipated that the new tool will be different and will therefore create some difficulty in St. Joseph s ability to compare results year to year through Members were in agreement that the directional goal relevant to patient experience remain with the understanding that a new baseline will need to be established once the new tool is available; The Strategic Goal of being recognized for leadership in the three areas outlined in the Strategic Plan is challenging to define good metrics. Draft metrics were presented and there was a question regarding the H factor. H factor is standardized in its definition and application in the CAHO hospitals It is measured year over year by Lawson and Dr. Hill believes it is one component that will give information regarding external recognition; The Smoke-Free Ontario Act and the Electronic Cigarettes Act has been passed which will see no smoking, including electronic cigarettes on hospital grounds effective January 1, St. Joseph s has been smoke-free for a number of years now, but legislation will now apply to all hospitals in Ontario; Health Quality Ontario released its first report related to Quality in Primary Care. There is great variation by province and by economic status noted throughout the report. Dr. Kernaghan shared a few highlights from the report including that most Ontarians have a family doctor; The Ministry is looking at supply chain management to see what further efficiencies can be gained across the province and HMMS will participate in this initiative. Alberta Health Services will be going through some structural changes following the announcement of the resignation of Vickie Kaminski, President and CEO, which is to occur in the new year; Reference was made to the second quarter strategic indicator report which revealed many of the indicators moving in a positive direction. It was clarified that the increase related to fall with injury, from last quarter, is as a result of falls occurring on the veteran dementia unit. Dr. Kernaghan concluded by reminding members of the Christmas service scheduled in the St. Joseph s Hospital Chapel at noon on December 22 nd. P a g e 2

3 2.3 St. Joseph s Health Care Foundation [P. Mastorakos] The Season of Celebration launched on November 15 th marking its 26 th year. This year s campaign will focus on the addition of important patient care equipment, and will also focus on a specific project to redevelop the Palliative Care Unit at Parkwood Hospital. 2.4 Lawson Health Research Institute [H. Rundle] No issues or concerns were raised on the pre-circulated report. It was highlighted that Lawson is ranked eighth in the country according to the 2015 edition of Canada s Top 40 Research Hospitals List. The ranking looks at funds received from all sources, both internal and external, to support research at the organization. According to the report Lawson received just over $113.3 million in research income in However, in terms of research dollars as a percent of hospital s budget, Lawson ranked 5th. 2.5 London Health Sciences Centre [S. Elliott / M. Glendining] It was reported the current LHSC MAC Chair term comes to an end June 2016 and the process has been initiated related to succession planning. 3. Committee Minutes with Recommendations for Approval 3.1 Governance Nov 18/15 [M. Kellow] Ms. Kellow prefaced items 3.1a through c with the following statements: two iterations of the documents have been through Governance Committee; from the beginning of the process, Karen Stone, VP HR & Facilities, has been involved in drafting of the documents; this is only the beginning of work that is being undertaken by Governance Committee to create formalized role descriptions and selection process for various leader positions of the Board and Committees of the Board; feedback from the Society has been sought as facilitated through John Callaghan who is a member on the Governance Committee; and research comparisons have been conducted as to what peer facilities have in place for their volunteer board of directors, in addition to consulting the OHA's Guide to Good Governance. It was MOVED and SECONDED that the Board approve the Role Description for Chair, Board of Directors. TABLED. Related to the Chair, Board of Directors role description, question was raised whether it is the Chair s accountability for ensuring that Directors discharge their responsibilities or whether the Chair is accountable for the Board as a whole / process as a whole. Request was made for Governance to reconsider this statement. Furthermore, there was discussion around the Chair s role as an ex-officio and clarification requested as to whether ex-officio implies non-voting status. Request was made for Governance to clarify the language related to the two bullets that speak to ex-officio duties of the Chair of the Board. ACTION: Governance Committee to take into consideration the comments raised by the Board and amend the Chair, Board of Directors role description for future presentation to the Board. It was MOVED and SECONDED that the Board approve the Role Description for Director, Board of Directors. APPROVED. It was MOVED and SECONDED that the Board approve the Selection Process for Chair, Board of Directors guideline. TABLED. On the subject of selection process for Chair, Board of Directors, it was proposed that the document reads as if it were more a selection process for the Vice Chair, Board of Directors. It was requested the document should clearly specify whether it is an expectation and/or assumed that the Vice Chair will assume the role of Chair. P a g e 3

4 Finally, Members queried whether the amendment statement is necessary as the Board would have authority to amend the document at any time. It was suggested that reference be made to other Board policies and similar language applied in regards to amendment entitlements. ACTION: Governance Committee to take into consideration the comments raised by the Board and amend the selection process for Chair, Board of Directors for future presentation to the Board. It was MOVED and SECONDED that the Board approve the 2015/16 Human Resource Committee Work Plan. It was MOVED and SECONDED that the Board approve the 2015/16 Quality Committee Work Plan. It was MOVED and SECONDED that the Board approve the 2015/16 Resource Planning & Audit Committee Work Plan. It was MOVED and SECONDED that the Board approve the revised 2015/16 Health Care Ethics Committee Work Plan. Ms. Kellow thanked all Committee Chairs for presenting their 2015/16 Work Plans to the Governance Committee and for the detail set forth in the plans. She concluded by reminding Members the work of the Nominating Committee will begin in the New Year and that if Members have a candidate in mind to bring their name and credentials forward. 3.2 Medical Advisory Nov 18/15 [S. Jarmain] It was MOVED and SECONDED that the Board approve the following as presented: - New Professional Staff Appointments - Professional Staff Appointment Changes - New Clinical Fellow Appointments Dr. Jarmain provided brief context related to the recommendation to create the Department of Medical Imaging. She stated that: The merging of the two departments on the hospital side would mirror what currently exists on the Schulich side; Numerous of discussions have be held between the hospitals, Schulich and the current Chiefs of each the Department of Nuclear Medicine and Department of Diagnostic Radiology; There is strong support from both Department Chiefs; Nuclear Medicine would move from being a department to a division under Medical Imaging, with a Division Chief; The MAC desires to support both departments equally as they transition into one and therefore is supportive of appointing the Chief of the Division of Nuclear Medicine as a member of the MAC for a specified duration throughout this transition. It was MOVED and SECONDED that the Board approve the merging of the Department of Diagnostic Radiology and the Department of Nuclear Medicine to create the Department of Medical Imaging, effective July 1, Dr. Jarmain reported that the MAC showed a great deal of engagement in its discussions related to the Royal College of Physicians and Surgeons of Canada and College of Family Physicians of Canada Membership for Professional Staff. This thoughtful dialogue demonstrated the MAC s willingness to dive into an issue and come to a consensus on where to set the bar for Professional Staff credentials at London s teaching hospitals. P a g e 4

5 3.3 Resource Planning and Audit Nov 17/15 [B. Beattie] Mr. Beattie drew Members attention to a statement under the Audit section of the Resource Planning & Audit Committee s (RPAC) 2015/16 Work Plan relating to a process for confidential reporting of possible improprieties which falls under to the duty of the Chair of RPAC. He wanted to ensure Members are aware of the process and to report that there have been no calls to the hotline during his term as Chair. It was MOVED and SECONDED that the Board approve the Internal Audit Charter and the Internal Audit Plan for It was MOVED and SECONDED that the Board approve the financial statements of St. Joseph s Health Care London for the period ended September 30, The regular meeting of the Board moved to an in-camera session for discussion of the next agenda item at 5:20 pm and resumed the regular meeting at 6:40 pm. It was MOVED and SECONDED that, subject to concurrent approval by the LHSC Board, the St. Joseph s Board approve the ESC Business Case and the PACS/DI-r Business Case, and directs the ITS Team to proceed to the Business Plan phase. 4. Updates from Committees with No Recommendations 4.1 Health Care Ethics Nov 3/15 [P. Kiteley] 4.2 Human Resources Oct 8/15 and Oct 23/15 [B. Smith] 4.3 Quality Nov 5/15 [D. Harris] 5. Other Business Arising 6. Adjournment It was MOVED and SECONDED that the meeting be adjourned at 6:45 pm. Philip J. Griffin, Chair Dr. Gillian Kernaghan, Secretary P a g e 5