MEDICAL AFFAIRS AT COVENANT HEALTH LOCATION & FUNCTION Medical Affairs is the administrative arm that supports the Portfolio of the Vice-President, Medicine and Chief Medical Officer of Covenant Health. Dr. Owen Heisler, Vice-President Medicine & Chief Medical Officer of Medical Affairs, and Joanne Cowie, Corporate Director, Medical Affairs & IPC are responsible for the strategic direction of the administrative objectives of the portfolio, including budget, human resources, and staff leadership and development. Medical Affairs provides a number of services to support the relationship of Covenant Health to the privileged professional medical staff (physicians, dentists chiropracters and podiatrist) and manage all aspects of healthcare administration. Our Medical Affairs Department provides support services for all of our credentialed professional staff, and provides day-to-day support to our physician leadership team. The Vice-President and Chief Medical Officer is responsible for the Medical Staff role within Covenant Health, and similarly members of the Covenant Health Medical Leadership Structure are responsible for components of this. Some of the core responsibilities of the office include the following: i. Medical Leadership & Development ii. iii. iv. Medical Recruitment & Workforce Planning Appointments & Privileges Medical Education v. Administrative Coordination & Support to Medical Leadership vi. vii. viii. ix. Orientation Practitioner Dispute Resolution and Discipline Remuneration Medical Staff Wellness and Engagement Strategic Influence Medical Affairs staff stay up to date regarding Covenant Health and AHS strategic 1 Printed July 15, 2018
initiatives that impact the practice of medicine and/or medical training within Covenant Health and play a facilitative role in ensuring that the impacts of change on the medical staff are efficiently communicated, understood and considered. Medical Affairs also ensures that medical leaders and physicians are represented in strategic initiatives and communicated with as appropriate. Corporate Medical Affairs Location Main Floor of the Grey Nuns Hospital, Executive Administration 1100 Youville Drive West Edmonton AB T6L 5X8 Email: medicalaffairs@covenanthealth.ca Phone: 780.735.7185 Fax: 780.735.9921 Hours Monday to Friday, 8:00 a.m. to 4:30 p.m. MEDICAL STAFF BYLAWS & RULES The Medical Staff Bylaws define the relationship between Covenant Health and Covenant Health practitioners (those physicians, dentists, oral and maxillofacial surgeons and podiatrists with a Covenant Health appointment). The rules outline in detail the terms and conditions on which Covenant Health may grant practitioners clinical privileges; the responsibility of the medical staff to Covenant Health for the quality and safety of all professional services provided by practitioners to patients and to Covenant Health; the responsibilities of the medical staff and Covenant Health to each other for the organization and conduct of the medical staff, and in particular, the processes relating to medical staff appointments and delineation of clinical privileges; and the administrative structures for the governance of practitioners working in Covenant Health facilities. Covenant Health Medical Staff Bylaws Covenant Health Medical Staff Rules MEDICAL STAFF APPOINTMENTS AND CLINICAL PRIVILEGES Upon appointment to Covenant Health medical staff, individual practitioners are expected to comply with the Covenant Health Medical Staff Bylaws and Rules and such approved 2 Printed July 15, 2018
amendments as may from time to time be made, and with applicable Covenant Health Policies, the Covenant Health Health Ethics Guide, and the Professional Code of Conduct of the relevant college, and/or the respective code of ethics of the relevant profession. Practitioners are also expected to comply with all obligations contained in contracts for service between a member of the Medical Staff and Covenant Health. In keeping with Covenant Health s focus on creating a respectful workplace, all practitioners are expected to demonstrate respect, accountability, transparency and engagement in their interactions with Covenant Health staff, colleagues and patients. In addition, practitioners are expected to participate in quality improvement programs and other mechanisms to maintain and enhance clinical practice standards and professionalism. For detailed information on appointments and the granting of clinical privileges, medical staff responsibilities, periodic reviews, etc., please refer to our Covenant Health Medical Staff Bylaws and Rules and Appointment Privileging Overview. MEDICAL LEADERSHIP OF CLINICAL PROGRAMS List of medical directors, facility chiefs & section leads (Click here to download pdf version) Medical Directors Edmonton Acute Care Grey Nuns Hospital Dr. Greg Hrynchyshyn Misericordia Hospital Dr. Robert Black Villa Caritas Dr. Candace Walker Medical Directors Continuing Care Edmonton General (Edmonton) Dr. Srinivasa Manchikanti St. Joseph's Auxiliary (Edmonton) Dr. Robert Bradstock Youville Home (St. Albert) Dr. Darryl LaBuick St Michaels (Lethbridge) Dr. Joel Weaver St Joseph's Home for Aged (Medicine Dr. Anthony Jeraj Hat) 3 Printed July 15, 2018
Medical Directors Covenant Care Dulcina Hospice (Calgary ) Dr. Rajeev Sharma Foyer Lacome (St. Albert) Dr. Ben Macedo Associate Chief Medical Officer Rural All Rural Sites listed below Dr. Guy Lamoureux Medical Directors Rural Banff Mineral Springs (Banff) Dr. Matthew McIsaac Bonnyville Health Centre (Bonnyville) Dr. Travis Webster St. Mary's Hospital (Camrose) Dr. Guy Lamoureux (Interim) Our Lady of Rosary (Castor) Dr. Dr. David Hanton Killam Health Centre (Killam) Dr. Dr. Ahmed Meer Mary Immaculate Hospital (Mundare) Dr. Guy Lamoureux (Interim) St Mary's Health Centre (Trochu) Dr. Anish Chari St. Joseph's General Hospital (Vegreville) Dr. Guy Lamoureux (Interim) Facility Chiefs Grey Nuns Hospital Anesthesia Dr. Matthew Simmonds Cardiac Sciences Dr. Sanjay Sharma 4 Printed July 15, 2018
Child Health Dr. Michael Bowman Diagnostic Imaging Dr. Jordan English Emergency Dr. Patrick San Agustin Familly Medicine Dr. Irene Colliton Geriatrics Dr. Lotje Wasilenko Intensive Care Unit Dr. Dominic Carney Laboratory Dr. Maruf Saddik Medicine Dr. Amanda Brisebois Pallitative Care Dr. Robin Fainsinger Mental Health (Psychiatry) Dr. Jan Banasch Surgery Dr. Cliff Sample Women's Health Dr. Tom Corbett Facility Chiefs Misericordia Hospital Anesthesia Dr. Dorothy Hardy Cardiac Sciences Dr. Sayra Khandekar (interim) Child Health Dr. Shariff Shaik Diagnostic Imaging Dr. Malcolm Scott Emergency Dr. Korwin Cromwell Familly Medicine Dr. Grant Sawisky Geriatrics Dr. Marjan Abbasi 5 Printed July 15, 2018
Intensive Care Unit Dr. Ella Rokosh Laboratory Dr. Gregory Charrois Medicine Dr. Ben Sugars Mental Health (Psychiatry) Dr. Rick Gurke Surgery Dr. Gary Gray Women's Health Dr. Gail Black ACUTE CARE COVERAGE Our Medical Affairs office is responsible for providing support to various clinical services and sites to ensure adequate, effective medical coverage is available to patients at Covenant Health acute care facilities. Support is provided by using a variety of acute care coverage providers such as licensed physicians working as clinical associates, international medical graduates working as clinical or surgical assistants, and residents providing service outside of their academic responsibilities working as physician extenders. See Acute Care Coverage section of Medical Staff Portal. If you are a physician and interested in opportunities as acute care coverage provider, you may call 780.735.2209 or email medicalaffairs@covenanthealth.ca. For AHS acute care coverage information, please call 780.735.0794 or visit AHS Insite. CODE OF CONDUCT Our Covenant Health Medical Staff Code of Conduct and Commitment to Ethical Integrity outlines the values, principles and standards of conduct that guide our actions and interactions. Our Covenant Health s Commitment to Ethical Integrity is our code of conduct it sets the standard and reinforces that as a member of the Covenant Health team, we are each accountable to uphold standards of behaviour and create the ethical culture by which our organization will be widely known. It is based on both rights and responsibilities. It protects and guides equally all of those who are part of, or work within, our health 6 Printed July 15, 2018
system. It is at the heart of the Covenant Health Bylaws and Rules, principles, directives, policies, procedures, protocols, standards, codes of practice and any other applicable guidelines, regulations and directives that set out how we conduct ourselves as physicians. Our promise to ethical integrity is grounded in the Health Ethics Guide. The guide is published by the Catholic Health Alliance of Canada and is approved by the Canadian Council of Catholic Bishops. It is our primary resource for ethical discernment and decision making. Individual members of the medical staff shall demonstrate their accountability and compliance with Covenant Health Bylaws, Covenant Health Policies, the Health Ethics Guide published by the Catholic Health Alliance of Canada, the relevant Professional Code of Conduct, and the respective code of ethics of the relevant profession. CPSA Code of Conduct The CPSA Code of Conduct clarifies the college s expectations for Alberta s physicians in all stages of their careers, in all facets of medicine, and in all methods of care delivery. The Code is consistent with the Canadian Medical Association s Code of Ethics and complements the CPSA s Standards of Practice. Alberta physicians are expected to know and abide by these rules. The CPSA Code of Conduct is the product of collaboration between the college and other key groups and a comprehensive consultation incorporating feedback received from physicians. Ethics at Covenant Health For more information, including steps in the decision-making process, key principles, and definitions, see our brochure Ethics at Covenant Health. Hard copies of this brochure are available by request through the Medical Affairs office. Helpful Links Ethics Services (COV) Code of Conduct (Medical Staff Portal) CPSA Code of Conduct (PDF) Alberta Health Services Code of Conduct (PDF) 7 Printed July 15, 2018
Canadian Medical Association Code of Ethics CONCERNS - PROFESSIONAL & PATIENT Healthcare Professional Concerns Most concerns are effectively dealt with at the first point of contact. If resolution is not achieved please escalate to your medical leader. If the issue still cannot be resolved you can bring your concern to your leader s superior. If the concern continues to persist, the next step would be to submit a written formal concern to your facility chief, site medical director or to the Chief Medical Officer, or designate. Concern From Patient Involving Patient Care All patient concerns regarding care by a physician are routed through Covenant Health Patient Relations and forwarded to Medical Affairs for review. A Triggered Initial Assessment [TIA] Part A as per MSB Section 6.3 (an investigation and initial assessment of a concern) may be initiated. (All information will be kept strictly confidential and will not be disclosed to anyone outside of the process unless agreed to, in writing, by all parties or required by law to ensure public and/or patient safety). A letter and a copy of the concern is sent to the affected practitioner for information. If further investigation is decided, TIA-Part B (Triggered Review) will be started and a letter and a copy of the concern is sent to the affected practitioner to provide written response to reviewer and a copy to the Associate Vice President (AVP) or designate, who then reviews responses and provides written assessment and any further actions needed. For detailed information regarding concerns see Staff Bylaws Concern Process Concerns Guide CURTAILMENT OF PRIVILEGES FOR INCOMPLETE CHARTS Practitioners and Covenant Health share the responsibility to create and maintain an accurate health record of the care provided to every patient in Covenant Health facilities. 8 Printed July 15, 2018
In accordance with the AHS and Covenant Health Medical Staff Rules (Section 4.21.4), a shared AHS/Covenant Health process was initiated in 2012 for the Curtailment of Clinical Privileges for Incomplete Health Records. According to the Rules, if at any time a Practitioner accumulates ten or more Patient health records that have been incomplete for more than 28 days after they have been provided to the Practitioner for completion, or any single Patient health record has remained incomplete for more than 90 days after it has been provided to the Practitioner for completion, the Practitioner is eligible for curtailment of clinical privileges. For detailed information please refer to Medical Staff Portal web page "Curtailment of Privileges for Incomplete Charts." PHYSICIAN WELLNESS Health & Wellness Physicians are important role models for their patients and peers, which makes their own personal health an influential factor in health promotion and disease prevention. Physicians are characterized, in all of their interactions with patients, colleagues and support staff, by values of stewardship, integrity, collaboration, respect, compassion and social justice. The medical profession is demanding. Often physicians work long hours, with many patients and staff depending on them. The best interests of patients are served when physicians take time to meet their own needs and are continually aware of their own wellness. This means recognizing limits imposed by fatigue, stress or illness and taking care to ensure a healthy work-life balance. This is not always easy. Physicians set high expectations for themselves and may not immediately recognize either transient or longer term periods of incapacity. Recognition of transient incapacity is particularly difficult. Covenant Health recognizes the impact a medical career can have on a clinician s lifestyle and family. A Physician Wellness Committee is being created to address the physical, emotional and social needs of these very busy professionals. The purpose of Physician Wellness Committee will be to promote clinician well-being, prevent impairment from any cause and to assist clinicians who are impaired, or at risk of impairment, to return to the full, active, productive and satisfying practice of medicine, with no risk of patient harm. The Covenant Health Physician Wellness Committee will be available to offer confidential 9 Printed July 15, 2018
assistance when a clinician needs emotional or behavioural evaluation, support, guidance and referral. Find more information and resources regarding physician wellness, Please check back soon. PHYSICIAN ABSENCE NOTIFICATION PROCESS Notifying Medical Affairs As per section 4.16 of the Covenant Health Medical Staff Rules, Absence from a Covenant Health Site(s) of Clinical Activity, a Practitioner shall ensure requirements are met for coverage of all his/her responsibilities, and shall identify an alternative Practitioner to assume those responsibilities and to serve as Most Responsible Practitioner for his/her admitted Patients. The Practitioner providing coverage must have the appropriate Clinical Privileges. The Practitioner will document the identity of the covering Practitioner in the Patient s health record and shall inform the Patient, and/or his/her family and/or the Patient s Legal Representative. Leave of Absence Process Flowmap Key Messages The MS Rules are intended for medical staff to notify stakeholders if they are away from Clinical practice between 96 hrs and 45 days. Ifr you are working at multiple sites the 96 hr - 45 day rule does NOT apply when doing clinical work at another site. As per the MSR if you are taking vacation or on medical leave for greater than 96 hrs - 45 days you would complete the LOA form. 96 Hrs 10 Printed July 15, 2018
Coverage for patients during an absence of less than or up to 96 hours is provided through the on-call schedule of the service or group in which the practitioner participates, or by alternative prior arrangements. It is the physician s responsibility to make these arrangements and to ensure colleagues and healthcare team members are aware of the absence and coverage arrangements. > 96 Hrs 45 Days During an absence of greater than 96 hours, the provisions of section 4.15.2 of Medical Staff Rules for the formal transfer of responsibility must be fulfiled. In addition, notification of the absence and the identity of the covering practitioner will be provided to the relevant Covenant Health Facility medical director(s), who shall then forward this information to the Covenant Health Medical Affairs Office. Notification required to stakeholders as per Physician Absence Notification form or Medical Leadership Absence form. > 45 Days For an absence of greater than 45 consecutive days, a formal leave of absence is required and must be approved in advance by the Vice-President, Medicine, or designate, upon the recommendation of the Covenant Health clinical department facility chief and/or the Covenant Health facility medical director(s). For absences greater than 30 days please forward email request for approval to the Medical Affairs office at medicalaffairs@covenanthealth.ca. The For absences greater than 45 days forward email request for approval to the Medical Affairs office at medicalaffairs@covenanthealth.ca. recommendation and approval to grant a leave of absence will be based on consideration of the reason(s) for the request, the responsibilities of the practitioner, workforce needs and the Practitioner Workforce Plan, and any other relevant matters. Only in exceptional circumstances will the length of a leave of absence exceed one year. If approved, you will receive a formal letter signed by the Vice-President, Medicine, & Chief Medical Officer, Covenant Health granting your leave of absence. For specific notification information and forms please view Physician Absence Notification or Medical Leadership Absence Notification. ORGANIZATIONAL STRUCTURE 11 Printed July 15, 2018
Click to view fullsize chart (PDF) MEDICAL AFFAIRS ADMINISTRATIVE CONTACTS Name Title Site Phone Fax Email Joanne Corporate MCH & 780.735.9144 780.735.9921 joanne.cowie@covenanthealth.ca Cowie Director, GNCH or 7124 or 9091 Medical Affairs & ICP Maureen Korzan Executive Associate & Team Lead Medical Affairs GNCH 780.735.7185 780.735.9921 maureen.korzan@covenanthealth.ca Darla Cote Executive Associate & Team Lead Medical Affairs MCH 780.735.2209 780.735.9091 darla.cote@covenanthealth.ca Breelyn Papillon Program Assistant (Casual) GNCH 780.735.9501 780.735.9921 breelyn.papillon@covenanthealth.ca Linette Physician GNCH 780.735.7561 780.735.9921 linette.morton- 12 Printed July 15, 2018
Morton- Banks Workforce Assistant (PWA 5) banks@covenanthealth.ca Jill Gordeyko Physician Workforce Assistant (PWA 1) GNCH 780.735.7606 780.735.9921 jill.gordeyko@covenanthealth.ca Meaghan Schram Physician Workforce Assistant (PWA 4) GNCH 780.735.7745 780.735.9921 meaghan.schram@covenanthealth.ca Cindy Heathcote Medical Education & Medical Staff Secretary GNCH 780.735.7434 780.735.9921 cindy.heathcote@covenanthealth.ca Christy MacKinnon Medical Education & Medical Staff Secretary MCH 780.735.2991 780.735.9091 christy.mackinnon@covenanthealth.ca Milly Secretary MCH 780.735.9050 780.735.9091 milly.abraham@covenanthealth.ca Abraham Lacey Simmonds Program Assistant MCH 780.735.9036 780.735.9091 lacey.simmonds@covenanthealth.ca Karen Administrative MCH 780.735.9994 780.735.9921 karen.anthony@covenanthealth.ca Anthony Assistant & or 9091 GNCH Karen Chilton Administrative Assistant GNH 780.735.9940 780.735.9591 karen.chilton@covenanthealth.ca Leslie Pelletier Physician Workforce Assistant (PWA 2) GNH 780.735.7331 780.735.9921 leslie.pelletier@covenanthealth.ca 13 Printed July 15, 2018
PWA ASSIGNMENTS FOR CLINICAL AREAS Edmonton Zone Facility Department Responsible Grey Nuns Misericordia Villa Caritas Youville Foyer Lacombe St Joseph Edmonton General Anesthesia Surgery Women s Health Jill Gordeyko Grey Nuns Misericordia Villa Caritas Youville Foyer Lacombe St Joseph Edmonton General Medicine Cardiac Sciences (CCU) Critical Care (ICU) Non-Appointed - All Areas ezone (Clinical Assistants, Physician Assistants, Surgical Assistants, Physician Extenders) Leslie Pelletier Grey Nuns Misericordia Villa Caritas Youville Foyer Lacombe St Joseph Edmonton General Addictions & Mental Health Family Medicine Geriatrics Palliative Care Meaghan Schram Grey Nuns Child Health Linette 14 Printed July 15, 2018
Misericordia Villa Caritas Youville Foyer Lacombe St Joseph Edmonton General Diagnostic Imaging Emergency Medicine Laboratory Medicine & Pathology Morton- Banks Calgary Zone Site Department Responsible Banff Dulcina (Calgary) All Areas Meaghan Schram Central Zone Site Department Responsible Camrose Castor Killam Mundare Trochu Vegreville All Areas Jill Gordeyko North Zone Site Department Responsible Bonnyville All Areas Linette Morton- Banks 15 Printed July 15, 2018
South Zone Site Department Responsible Lethbridge Medicine Hat All Areas Jill Gordeyko MEDICAL STAFF PORTAL/WEBSITE The Covenant Health Medical Staff Portal is a centralized source of information accessible to our medical staff anywhere (hospital, home or office) and gives us the ability to provide them with timely communication, relevant resources and immediate access to information they need. It offers a new environment of innovation, participation and engagement, better supporting our strategic initiatives. This website allows physicians access to corporate and clinical support services previously only available to them on the Covenant Health intranet - CompassionNet (behind the firewall). Check out some of the great features: Easily searchable Medical Staff Bylaws/Rules, Orientation manuals, etc. Find a Hospital Round or PMI course via the events calendar. Check out the latest news or alert. Submit a question to the Help line. This is a living website as such it constantly changes, updates and improves daily. Website Location Covenant Health Medical Staff Portal Want More Information? Contact Maureen Korzan 16 Printed July 15, 2018