Fraser Health Authority Medical Advisory Committee (HAMAC) Minutes of Meeting 2012 January 11 Central City Cedar/Dogwood Rooms

Transcription

1 Fraser Health Authority Medical Advisory Committee (HAMAC) Minutes of Meeting 2012 January 11 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 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 SL Dr. Jean Lauzon RDH Surgery JL Dr. Steve Ligertwood RDH Hospitalists SL 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 Dr. Mike Newton Dr. Luay Dindo Medical Staffs presidents Council rep ADMIN SUPPORT Shirley Hoffman Recording Secretary sh Peter Owen Director, Medical Affairs PO JZ MN LD GUESTS none 1

2 1.0 CALL TO ORDER Dr. Doris called the meeting to order at 1730 hours. 1.1 Introduction of Guests no guests Approval of Agenda : That the agenda of the HAMAC meeting of January 11, 2012 be accepted as circulated. 1.3 Approval of Minutes : That the minutes of the HAMAC meeting of 2011 December 14 be accepted as circulated. 1.4 Chair Remarks A review of HAMAC s terms of reference will be on the agenda for next month following a preliminary review by the Executive Committee. (Documentation will be pre-circulated). Included in this discussion will be the continuing relevance of the HAMAC mission statement as notated on the Header of the Minutes each month. This is a holdover from the previous (pre-program Management) HAMAC. 2.0 PRESENTATIONS 2.1 Quality Performance Committee Structure JK presented a slide show and spoke to pre-circulated information. He emphasized that Quality is an all encompassing theme in all aspects of medical care. QPC (Quality Performance Committee) structures as mandated by the Board outlining the relationships and reporting structures between the Program Quality Performance Committees, the Regional Department, Divisional or Local Quality Performance Committees, HAMAC and the FH Board s QPC. This document is intended as a framework for PMDs and RDHs to ensure they have the appropriate structures and reporting systems in place. JK reviewed the Responsibilities of the PMD for Quality Improvement and Patient Safety, the QPC Structure including the Board Quality Performance Committee, FH Quality Performance Committee, and the Program Quality Performance Committee. He continued to review the Regional Department Medical Quality Committee, Local Surgical Quality Committee (example) - these TORs have now been ratified at the December Board meeting. Dr. Kornder s presentation is posted on the HAMAC SharePoint site. 2.2 Standard Quality Agenda JK presented a proposed standardized agenda template for medical staff committee meetings on the premise that standardization (where appropriate) of all processes and procedures enhances quality care. 3 That the circulated Agenda template be used for all medical staff committees. 3.0 Business Arising 3.1 Allied Health Professionals TW noted there is no consistency across the province in dealing with permits for allied health professionals. He will bring this discussion back when there is something to report. PENDING 3.2 Flu Vaccine Supply Issues to GP Offices DJ raised issues of supply of the flu vaccine to GP offices. Discussion points included: Pharmacists 2

3 Training (are they properly trained?) who intervenes if there are medical issues after administration of the vaccine (response: they are trained and should be at least to the level of a nurse immunizer who runs clinics without a doctor present). Compensation of pharmacists they are paid a fee equivalent to that of dispensing other products PV recognizes there are concerns with the availability of the vaccine to physicians. BC CDC concerns about the wastage of vaccine in previous years has reduced access to more vaccine. It is difficult with a short time program to have exactly the right number of doses in every surgery. Some wastage is inevitable 325,000 BC FH residents were immunized this flu season which is an increase of 20%. The Public Health goal is to double the volume of immunizations over the next two to three years. 3.3 Anesthesia Issues JR noted the earlier reported threat of service withdrawal by anesthetists may be coming to resolution. Funding is still in negotiations. 3.4 Interdepartmental Planning Conflicts Discussion continued from last meeting. Communication among department heads at a local level is key to resolving issues and to highlight any planned changes to determine and mitigate impact on other Departments. These discussions should take place at the MHCC level and if issues cannot be resolved, they could be escalated to PMDs or, depending on the nature of the concern, RDHs who could bring forward to HAMAC table. 4.0 MEDICAL STAFF CREDENTIALING A Recommendations for Board Approval 1. Applications for Appointments and Privileges Recommended 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 circulated. 5. Applications for Change of Category, Site and /or Privileges Addition: Thomas Michael Curry, EM, Active, DH add CGH 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. 8. Leadership Appointments Added: Dr. Grant McCormack, HDL, Critical Care, SMH Dr. Willem De Klerk, HDL, FP, MMH 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 Deleted: 4 JS, Cardiology, FP, RCH 19 TG, Hospitalist was a duplicate That it be recommended the Board ratify the temporary appointments with temporary 3

4 privileges in the report Temporary Appointments/Privileges for Ratification as amended. 4 That it be recommended the Board approve the report as noted above (4A and B). CARRIED C For Board Information Separations noted for information 4.2 Other 5 It was MOVED AND SECONDED That the meeting move in camera. (1915 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 8 That the in camera session be concluded (1920 hrs.) 7.0 MEDICAL STAFF FACILITIES ADVISORY COMMITTEE REPORT 7.1 Report 8.0 NEW BUSINESS 9.0 OTHER REPORTS 9.1 CEO no report AW reported on a discussion at MSFAC regarding the impact of program generated changes on other programs. Before a solution to a problem is implemented there needs to be clinical audit to define the problem, proper consultation, impact analysis of the proposed solution and communication. 9.2 VP Medicine no report 9.3 Chief Medical Health Officer PV provided his report earlier in the meeting. Pertussis - PV circulated a note which was circulated to all physicians advising of a pertussis outbreak in Hope with 30 confirmed cases. He advised that a major outbreak is over-due. No one is immune. The Board Chair and CEO have communicated with the Ministry about this and encouraged them to support the cost of boosters for all British 4

5 Columbia residents. Fraser Health is offering a pertussis booster (TdaP) to all Fraser Health employees at no charge; physicians are required to get a booster as part of recent changes to the rules in order to maintain credentials - a clinic schedule was circulated. PV highlighted the Infant Mortality Review Report prepared by BCCH of 2009 infant deaths in FH - Three key groups, of concern, he highlighted: 1. A group of sudden unexplained death in infancy previously called SIDS a program to advise on safe sleeping positions for babies is underway 2. Moms younger than 20 and over 35 years of age 3. Prematurity A suggestion was made to have these types of incidents reported through the Program Quality Committee to HAMAC. PV will provide this report to HAMAC members. sh 9.4 Medical Staffs Association Presidents Pursuant to an issue raised by SMH MSA President LD concerning the structure of a recent search and selection committee for the SMH HDL Pediatrics, discussion ensued on composition of Search and Selection Committees per the Medical Staff Rules. Clarification on responsibility for initiating search and selection committees for HDLs was reflected in the Rules changes recommended at the December HAMAC meeting. An RDH would automatically act as an HDL if an HDL position is vacant. There is no provision in the Rules for Interim HDLs. The HDL list on the Physicians Web Site is to be updated to reflect the SMH Ob/Gyn HDL position as vacant. PO AW and LD to have further discussion off-line. Access is restricted to the 5 th floor at Central City. PMDs should have this access. AW is working towards resolution in this regard. 9.5 Executive Medical Directors TW reported on: Physicians Health Program move under the auspices of the BCMA, new Board of Directors to be established He is working with the new Deputy Registrar at the College on return to work issues A number of PMI modules will be made available to medical staff through the spring and fall. RM reported: Physician administrator roles are covered under the HA s Liability Insurance. If any HAMAC members, as medical leaders, require legal advice concerning an administrative or Medical Staff matter, consult with Executive Medical Directors or VP Medicine prior to contacting a lawyer 9.6 Medical Director, Quality and Patient Safety no further report 9.0 ADJOURNMENT/NEXT MEETING The meeting adjourned at 1950 hours. The next regular meeting of HAMAC will be held on February 8, 2012 in the Dogwood and Cedar Rooms at Central City SUMMARY OF ACTION ITEMS TO THE BOARD TO THE BOARD (4) Credentials/Recommendations 5