HEADWATERS HEALTH CARE CENTRE BOARD OF DIRECTORS September 27, 2011

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HEADWATERS HEALTH CARE CENTRE BOARD OF DIRECTORS September 27, 2011 Present: Regrets: Peter Harris, Chair Dr. Ken Derksen Steve Desrocher Rob Hamilton Ron Hay Angella Hughes Elizabeth Hull John Innes Terry Irwin Bonnie Ledson Dr. Dan Mallin Ursula Manuel Frans Richter Bill Roy Liz Ruegg Joan Waechter Bill Waite Louise Kindree, John Christie In Attendance: Joan Burdette, Ann Cain, Donna Hyatt, Bruce Irwin, Cindy Sabo, Jason Spalding, Dr. Mick Jain, and representatives from Midwives of Headwater Hills 1. CALL TO ORDER The meeting was called to order at 6:05 p.m. 2. DECLARATION OF CONFLICT OF INTEREST No conflict of interest was declared. 3. EDUCATION 3.1 OHA Conference on Effective Governance for Quality and Patient Safety Members were provided with the opportunity to view a short video that was presented at the above noted OHA conference. This video highlighted the lessons learned and changes to health care practices in the United Kingdom following the untimely death of the narrator s spouse. 4. ADDITIONS TO THE AGENDA Dr. Dan Mallin requested the opportunity to provide a report on behalf of the General Medical Staff. Dr. Mick Jain was introduced to the Board of Directors. Dr. Jain commenced his role as Chief of Diagnostic Imaging on September 12, 2011.

Board of Directors Page 2 5. APPROVAL OF MINUTES It was moved by Bonnie Ledson, seconded by Rob Hamilton, [11-35] that the minutes of the regular meeting held prior to the Annual General Meeting on June 21, 2011 be approved, as presented. It was moved by Steve Desrocher, seconded by Ron Hay, [11-36] that the minutes of the special meeting held June 21, 2011 following the Annual General Meeting be approved, as presented. 6. BUSINESS ARISING No business arising was brought forth. 7. REPORTS 7.1 Quality Patient Story A positive story focusing on the hospital s telemedicine program was shared with the Board of Directors. Highlights of the Quality Committee meeting of September 14, 2011 were reviewed. It was moved by Bill Roy, seconded by Elizabeth Hull, [11-37] that the Quality Committee Terms of Reference be approved, as presented. It was moved by Bonnie Ledson, seconded by Steve Desrocher, [11-38] that the Quality Committee report be accepted, as presented. 7.2 Finance The minutes of the Finance Committee meeting held September 19, 2011 were discussed. It was moved by Bill Roy, seconded by Steve Desrocher, [11-39] that the Finance Committee Terms of Reference be approved, as amended. It was moved by Bill Roy, seconded by Rob Hamilton, [11-40] that the Financial Operating Statements for the period ending August 31, 2011, depicting a surplus of $184,565 for a year-to-date surplus of $759,098, be approved.

Board of Directors Page 3 It was moved by Bill Roy, seconded by Angella Hughes, [11-41] that the 2011-2012 Operating Budget (HAPS) be approved for submission to the Central West Local Health Integration Network. It was moved by Bill Roy, seconded by Elizabeth Hull, [11-42] that the Finance Committee report be accepted, as presented. 7.3 Governance Highlights of the September 20, 2011 Governance Committee meeting were provided. It was moved by Rob Hamilton, seconded by Bill Roy, [11-43] that the Governance Committee Terms of Reference be approved, as amended. It was moved by Bill Roy, seconded by Bonnie Ledson, [11-44] that the Public and In-Camera Meeting board policy be approved, as presented. It was moved by Rob Hamilton, seconded by Elizabeth Hull, [11-45] that the Governance Committee report be accepted, as presented. 7.4 Chief of Staff Credentials Upon the recommendation of the Credentials Committee and the Medical Advisory Committee, several applications for medical staff privileges were presented for consideration. No outstanding issues or cause for concern were found by either committee. It was moved by Dr. Ken Derksen, seconded by Bonnie Ledson, [11-46] that the application of Dr. Tripti Papneja for Courtesy Staff Privileges in the Department of Medicine; that the application of Dr. Stephanie Maggisano for Locum Tenens Staff Privileges in the Department of Family Practice; that the application of Dr. Lopita Banerjee for Courtesy Staff Privileges in the Department of Obstetrics; and that the application of Dr. Dan Mozeg for Locum Tenens Staff Privileges in the Department of Diagnostic Imaging, with privileges as delineated until June 30, 2012 be approved. Action: It was requested that, in future, along with the credentialing process insert already included in the Board package, a credentialing checklist be provided as well as a form of due diligence.

Board of Directors Page 4 The application of Dr. Mick Jain was introduced. Dr. Jain was a member of the medical staff for a number of years prior to 2009. Dr. Jain applied for and has accepted the position as Chief of Diagnostic Imaging at the hospital. A contract outlining defined responsibilities and accountabilities has been signed. Dr. Derksen noted that a process to formulate contracts for all departmental chiefs is underway. It was moved by Dr. Ken Derksen, seconded by Ron Hay, [11-47] that Dr. Mukesh Jain for Active Staff Privileges in the Department of Diagnostic Imaging with privileges as delineated for the period ending June 30, 2012 be approved, as circulated. [11-48] that Dr. Mukesh Jain be appointed Chief of Diagnostic Imaging as of September 12, 2011. The Medical Advisory Committee and the Senior Team are planning to recognize Dr. Louise Keevil s for her years of service as the Chief of Diagnostic Imaging. A recognition event is being planned for October. Dr. Avi Matzov has advised he will step down as the Chief of Anaesthesia after several years of dedicated leadership. Dr. Kenji Miyata has accepted the position. It was moved by Dr. Ken Derksen, seconded by Bill Roy, [11-49] that Dr. Kenji Miyata be appointed Chief of Anaesthesia as of October 1, 2011. Clinical Services Plan The 2011-2012 Clinical Services Plan was presented for review. It was moved by Dr. Ken Derksen, seconded by Bonnie Ledson, [11-50] that the 2011-2012 Clinical Services Plan be approved, as presented. General Medical Staff The professional staff bylaw template jointly developed by the OHA and OMA was released in early 2011. The template was reviewed by a sub-committee of Headwaters physicians. The group felt some minor changes were required and these revisions were forwarded to Josh Liswood at Miller Thomson LLP. Mr. Liswood met with the physician group on August 31 st and presented his revised professional staff bylaw document. Unfortunately, the work was not available until the day of the meeting which meant the group had little time to review it prior to the meeting. The group has since reviewed the document and requested that OMA counsel provide a legal opinion on Mr. Liswood s document due to the number of differences noted from the OHA OMA template. The OMA s position is expected soon and will be presented at an upcoming special meeting of the medical staff. ACTION: It was proposed the OMA s response be discussed by mid-october with a target for presentation to the Governance Committee and Board of Directors in November.

Board of Directors Page 5 7.5 Foundation The many successful fundraising events held over the summer months and methods for achieving sustainable funds over the next five years were discussed. 7.6 Auxiliary It was estimated that the Auxiliary raised over $60,000 at the Annual House Tour held September 17 th. 7.7 President and CEO Several meetings with individuals, services clubs and groups have allowed the CEO and Foundation staff members the opportunity to provide information on hospital services and achievements over the last year. A special meeting of the Medical Advisory Committee is scheduled for September 28 th. Senior Team members are meeting with representatives from Agnew Peckham on September 29 th to discuss the Master Plan Master Program refresh. The annual fall retreat is scheduled for Wednesday, October 12 th at Monora Park. The President and CEO attended several Health and Care Centre meetings over the course of the summer with respect to both Bolton and Shelburne. A specialist physician clinic has been established at Mel Lloyd Family Health Team in Shelburne with an expected start date in October. The President and CEO also took park in several meetings with respect to the future of the Shelburne facility that include the Mayor of Shelburne, Warden of Dufferin County, and local businessmen. The Deputy Minister of Health and Long Term Care held a Community Hospital CEO Consultation Session on September 26 th. The purpose of the meeting was to discuss current Best Practices that support High Quality Health Care System, and the key challenges to support improvement. It was an excellent opportunity to share our suggestions on what could improve the system. Wednesday, October 19 th is the date chosen for the first Breakfast with Liz affording the staff with an opportunity to meet with the CEO and discuss what is going well, what are the challenges and what staff would like to see changed. Every staff will have the opportunity to have lunch or breakfast with the CEO throughout the year. Jason Spalding, Director of Human Resources was introduced to the Board. Jason provided an update on ONA and OPSEU negotiations. The Freedom of Information and Protection of Privacy Act was briefly discussed. In an effort to be seen as proactive, the OHA is suggesting that hospitals post the executive salaries in January. The impact that the Broader Public Sector Accountability Act will have on the hospital s reporting mechanisms was reiterated. The expenses related to travel, accommodations, and meals for senior executives and board members are required to be publicly posted. A website portal specific to board members, which would allow members access to board and committee information packages on-line, was introduced. Action: Further investigation and discussion of a board specific website portal is required.

Board of Directors Page 6 As mentioned previously, extensive renovations and the installation of new equipment in the general x-ray room will take place over a six week time period beginning October 7 th. There may be some challenges in maintaining support to the emergency department while taking priority cases. Notices will be issued to physicians and community with respect to the renovations. Preliminary discussions seem to indicate that the renewal of the Ambulance Agreement between the County of Dufferin and Headwaters Health Care Centre are successfully progressing towards a five year renewal with two two-year options. 8. NEW BUSINESS 8.1 Consent Agenda The implementation of a consent agenda at future board meetings was introduced. Action: Members were requested to review the document and provide feedback at the October meeting. 9. FUTURE AGENDA ITEMS Members are requested to forward suggestions for future agenda items to the Board Chair or Chief Executive Officer. 10. REFERENCE INFORMATION Several references items were provided for information. 11. IN-CAMERA The Board of Directors moved in-camera at 8:50 p.m. 12. DATE OF NEXT MEETING The next regular meeting of the Board of Directors is scheduled for Tuesday, October 25, 2011. 13. ADJOURNMENT There being no further business the meeting was adjourned. Peter Harris, Board Chair Liz Ruegg, Secretary