board of directors meeting open session tuesday february 26, … · 2019. 5. 7. · board of...

Board of Directors Meeting

Open Session

Tuesday February 26, 2019

Boardroom, Level 2 Administration

115 Delhi Street

Guelph, ON, N1E 4J4

Dinner available in the Boardroom starting at 5:30 p.m.

MISSION: To provide the highest quality care and experience for patientsand their families

a) Summary of Motions

1 min 3. Chair Remarks Information D. Mills

a) Approval of Agenda - February 26, 2019

b) Approval of Minutes - January 29, 2019

19-02-12 Governance Committee Report - Page11

1-015 Consent Agenda Policy - Feb 2019 - Page12

c) Governance Committee Report

19-02-26 CEO Report - Page 17

Certificate of Compliance - May to June 2018 -0

Certificate of Compliance - July to Sept 2018 -Page 21

d) President and CEO Report

19-02-26 Agenda - Page 5

19-01-29 Minutes - DRAFT - Page 9

1-017 Director Recruitment Process - Feb 2019 -Page 14

Certificate of Compliance - Oct to Dec 2018 -Page 22

1 min 4. Approval of Agenda and Consent Agenda Decision D. Mills

1 min 1. Welcome and Call to Order Information D. Mills

1 min 2. Declaration of Conflict of Interest Information D. Mills

19-02-26 Summary of Motions - Page 4

19-02-26 OPEN BOD Package19-02-26 OPEN BOD Package

AGENDAAGENDA

Page 2 of 24

19-02-04 COS Report - Page 23

e) Chief of Staff Report

MAC Highlights - Feb 2019 - Page 24

1 min 5. Next Meeting - March 26, 2019 Information D. Mills

1 min 6. Meeting Adjournment Decision D. Mills

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BOARD OF DIRECTORS FEBRUARY 26, 2019

SUMMARY OF RECOMMENDED MOTIONS OPEN SESSION: Agenda and Consent

a) Approval of Agenda – February 26, 2019, 2019 b) Approval of Minutes – January 29, 2019 c) Governance Committee Report d) President and CEO Report e) Chief of Staff Report

It is recommended that the Board of Directors approve the Agenda and Consent Agenda as presented. Open Session Adjournment

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AGENDA – OPEN MEETING Board of Directors

Tuesday February 26, 2019 6:00 p.m.

Boardroom, Level 2

AGENDA ITEM LEAD ACTION TIME

1. Welcome and Call to Order D. Mills 1 min

2. Declaration of Conflict of Interest D. Mills Information 1 min

3. Chair’s Remarks

a) Summary of Motions

D. Mills Information 1 min

4. Approval of Agenda and Consent Agenda: a) Approval of Agenda – February 29,

2019 b) Approval of Minutes – January 29,

2019 c) Governance Committee Report d) President and CEO Report e) Chief of Staff Report

D. Mills

Decision 1 min

5. Next Meeting:

March 26, 2019

D. Mills Information

6. Meeting Adjournment D. Mills Decision

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GUELPH GENERAL HOSPITAL - BOARD OF DIRECTORS COMMITTEE MEMBERSHIP 2018-2019

Administration & Facilities Committee David Kennedy - Chair Dr. Steven Hoey* Rod Carroll – Resource Cheryl Cowden – Resource Fraser Edward David Forestell VP Patient Services Dale Mills Marianne Walker Glen Weppler – Community Member Gavin Webb – Resource Mark Zonneveld – Community Member

Audit Committee David Kennedy - Chair Christine Bevan-Stewart David Forestell Cheryl Cowden – Resource Dale Mills Brad Riley – Community Member Marianne Walker (non-voting) Gavin Webb - Resource

Nominating Committee Dale Mills– Chair Brian Cowan Marianne Walker Kathy Wilkie

Governance Committee Ted Sehl - Chair Rena Hubers Brian Cowan Janet Kaufman Dr. Ian Phillips* Dale Mills Marianne Walker

Quality Committee Kathy Wilkie – Chair Christine Bevan-Stewart Jennifer Caspers Jodi Coleman – Community Member Terry Campbell VP Patient Services Dale Mills Sarah Sayyed Melissa Skinner Matt Stanley Marianne Walker Karen Suk-Patrick Lise Betteridge – Community Member

IT Advisory Committee Dale Mills – Chair Jennifer Caspers Dan Coghan (North Wellington) Fraser Edward VP Patient Services Dale Maw – Resource Brian McMahon – (North Wellington) Community Member Stephanie Pearsall (Groves) Anca Preda – Community Member Stephen Street – Ex-Officio Paul Smith – (Groves) Community Member Gilles Madore – (Groves) Community Member Marianne Walker – Ex-Officio Gavin Webb

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BOARD OF DIRECTORS MEETING ATTENDANCE

2018-2019

Sept 25

Oct 30

Nov 27

Dec 10 Retreat/Mtg

Jan 29

Feb 26

Mar 26

Apr 30

May 28

June 25

AGM

Dale Mills - Chair P P P P P

Eileen Bain P P P P P

Christine Bevan-Stewart P P R R R

Terry Campbell P P P P P

Jennifer Caspers P P P P P

Brian Cowan P R P P P

Edward Fraser P P P P P

David Forestell P P P P P

Steven Hoey – President MSA

P R P R P

Rena Hubers P R P P P

Janet Kaufman P R P P P

David Kennedy P P P P P

Sara Sayyed P P P P P

Edward Sehl P P P P P

Matt Stanley P P P P R

Marianne Walker P P P P P

Kathy Wilkie – Vice Chair P P P P P

GUESTS:

Ian Phillips – VP MSA R R P P P

Suzanne Bone P P P P P

Rod Carroll R R R P R

Gavin Webb R P P P P

Amanda Babensee - R P P P P

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Recorder

BOARD OF DIRECTORS

OPEN SESSION MOTION SUMMARY 2018-2019

MEETING DATE MOTION ACTION

REQUIRED/UPDATE

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MINUTES – OPEN MEETING - DRAFT Board of Directors

Tuesday January 29, 2019 Boardroom, Level 2

Present: D. Mills – Chair, E. Bain, T. Campbell, J. Caspers, B. Cowan, F. Edward, D.

Forestell, S. Hoey, R. Hubers, J. Kaufman, D. Kennedy, T. Sehl, M. Walker, K. Wilkie and A. Babensee - Recorder

Regrets: C. Bevan-Stewart, M. Stanley, S. Sayyed Guests: S. Bone, I. Phillips, G. Webb

1. CALL TO ORDER

The meeting was called to order at 6:00 p.m. 2. DECLARATION OF CONFLICT OF INTEREST

No conflicts of interest were declared.

3. CHAIRS REMARKS

D. Mills referenced the Summary of Motions included in the package. a) Summary of Motions

4. TOUR – INFORMATION TECHNOLOGY AND STROKE PROGRAM The members were introduced to D. Maw, Director of Information Technology who led the members on a tour of the Department. E. Bain, VP Patient Services led the members on a tour of the Stroke Program.

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5. APPROVAL OF THE AGENDA AND CONSENT AGENDA

a) Approval of Agenda – January 29, 2019 b) Approval of Minutes – November 27, 2018 c) President and CEO Report d) Chief of Staff Report

It was MOVED by D. Kennedy, SECONDED by B. Cowan that the Agenda and Consent Agenda as presented. CARRIED.

6. NEXT MEETING

The next meeting is scheduled for February 26, 2019

7. ADJOURNMENT It was MOVED by T. Sehl to adjourn the meeting at 6:45 p.m. ______________________________ ________________________________ Chair – D. Mills Secretary – M. Walker

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REPORT OF THE GOVERNANCE COMMITTEE BOARD OF DIRECTORS OPEN MEETING

FEBRUARY 26, 2019 The committee met on Tuesday February 12, 2019 FOR ACTION Policies and Procedures The Committee reviewed the following Policy

a) 1-015 Consent Agenda Policy

It is recommended that the Board of Directors approve the Consent Agenda Policy as presented.

b) 1-017 Director Recruitment Process

It is recommended that the Board of Directors approve the Director Recruitment Process as presented.

Ted Sehl Chair

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BOARD OF DIRECTORS POLICY: Consent Agenda Policy

Number: 1-015

Page 1 of 2

Disclaimer: Any PRINTED version of this document is only accurate up to the date of printing. Always refer to the Policies and Procedures Intranet site for the most current versions of documents in effect.

Policy Statement To ensure the efficiency and effectiveness of Board Meetings. To provide an efficient process for approval of regular or routine issues that come before the Board, or matters where no debate is anticipated. Policy Content of Agenda The agenda for Board meetings will distinguish between the following types of matters:

Decision Discussion: and Information Only decision items will require a motion, seconder and a vote.

Items requiring a decision that are expected to require no discussion or debate may, at the Chair’s discretion, be placed on the agenda under the heading “Consent Agenda”.

Developed by: Governance Committee

Review or Revision by: Governance Committee

Approval Date: Initial: February 26, 2013 Revised: January 26, 2016 February 26, 2019

Review or Revision Date: Every Three Years

Approved by: Board of Directors

Signature(s)

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of 2

When items are placed under the heading “Consent Agenda” the following must occur:

1. A motion must be made to approve and/or reject. 2. The motion to approve the agenda must be worded “motion to approve the agenda and consent agenda”.

Materials and motions proposed to be dealt with under the consent agenda portion of the agenda shall be clearly identified as falling under the consent agenda in the meeting packages. Board members should review the consent agenda items prior to the meeting on the expectation that no discussion will take place during the Board meeting. Approval of Agenda The agenda will be approved by the Board at the beginning of each meeting.

Members of the Board may request that matters be added, deleted or that the order of items be moved and the Chair shall make a decision on each such request. Any such decision may be subject to challenge and reversed by the Board.

Items may be moved out of the consent agenda section at the request of

any member of the Board prior to approval of the agenda. No motion or vote of the Board is required with respect to a request to move an item out of the consent agenda.

When a member of the Board requests that an item be moved out of the

consent agenda section, items will be addressed following the consent agenda or as appropriate.

When any item(s) in a committee report is requested to be moved, those

item(s) shall be moved out of the consent agenda and the rest of the items in the report shall remain in the consent agenda.

Approval of the agenda and consent agenda by the Board constitutes

approval of each of the items listed under the consent agenda portion of the meeting.

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BOARD OF DIRECTORS POLICY: Director Recruitment

Number: 1-017

Developed by: Governance Committee

Review or Revision by: Governance Committee

Approval Date: Initial: June 2012 November 24, 2015 February 26, 2019

Review or Revision Date: Every Three Years

Approved by: Board of Directors

Signature(s):

Disclaimer: Any PRINTED version of this document is only accurate up to the date of printing. Always refer to the Policies and Procedures Intranet site for the most current versions of documents in effect. Policy Statement The Board must ensure that the Directors possess the skills, experience, diversity and attributes that are necessary for effective Board governance and performance. Policy The Governance Committee will recommend to the Board the skills and attributes which need to be considered when choosing a candidate to fill a Board vacancy or to address an unmet skill required on the Board. The terms of reference of the Nominating Committee provide that the Committee shall present nominees to the Board for election as Directors. Directors will be elected based on a demonstrated record of possessing the specific qualifications and competencies necessary for effective governance. Process Governance Committee Responsibilities The Governance Committee will:

In February of each year start the recruiting process.

1) Survey all current Directors as to their intentions with respect to re-election to the Board, membership on Board committees and serving as a

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Number: 1-017

committee chair or Board Officer.

2) Recommend a list of competencies or characteristics that would be

an asset to the Board in the next year and future years, given its strategic priorities and needs of the Hospital.

3) Request that all current Directors complete a self- assessment of their

competencies/skills as a Director.

4) Review the Board’s current composition and anticipated vacancies and identify particular competencies to look for in new Directors.

5) Begin the recruitment process that will include:

inviting non-Director members of committees to apply for vacant

Director positions if they possess competencies being considered; encouraging Directors to recommend candidates possessing the

competencies for consideration by the Nominating Committee; and advertising the vacancies in local media and Guelph General

Hospital’s website. Nominating Committee Responsibilities The Nominating Committee will:

1) Accept formal applications from interested individuals to fill vacant Director positions.

2) Review prospective Board candidates against the Board skills profile and develop a short list of candidates for interview.

3) Interview short listed candidates to assess the prospect’s interest and qualifications against the Board’s needed competencies.

4) Select candidates for election as Directors. The final selection of the nominees rests with the Nominating Committee.

5) Provide the Members with information about the recommended candidates.

6) At a meeting of the Members, nominate the persons for election as Directors. The committee may, at its discretion, present the nominees together as a slate.

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Number: 1-017

Filling Interim Vacancies 1) The Nominating Committee will recommend nominees for vacancies that arise to fill an unexpired term. Appointment will be approved by the Board until an election is held at the next annual meeting.

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REPORT OF THE PRESIDENT AND CEO BOARD OF DIRECTORS OPEN MEETING

February 26, 2019

Provide the safest and highest quality care Medication Safety Working with our Wellington hospital partners, to work improve medication safety, we are on target with meeting our milestones, and Patient Keeper implementation. We have highly engaged staff and physicians that are

contributing to the implementaion and oversight of the project.

Support our Exceptional Staff

Automated Staff Scheduling We are in the process of automating staff scheduling which will result in improving efficiencies and workload. The system includes standardization, automated payroll and shift call out via technology. Significant work is

required to implement this project and we are thankful for our talented teams.

Create a coordinated high quality system of care with our partners. Cardiac Care –Heart Failure and Cardiac Rehab We continue to make progress in improving patient readmission rates related to patients experiencing HF. In Q1 we achieved a rate of 17.2% and in Q2 15.4%. Our teams, working with the Guelph Family Health Team, are implementing strategies that help keep people healthy avoiding admission to

hospital.

Over the past several months, we have been working on developing a proposal for cardiac rehab within a Node, Hub and Spoke model for Guelph/Puslinch. St. Mary’s General Hospital being the Node, St. Joseph’s Health Centre the Hub and the Guelph YMCA the Spoke. We are in the final stages of the proposal development that will be submitted to the LHIN in March.

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Sustain our Financial Health Over Capacity We persistently experienced growth in inpatient activity once again over the past month. We continue to care for patients in unconventional spaces to accommodate the added volumes of unfunded beds. We are working with our WWLHIN Home and Community Care to ensure that our patients receive the most appropriate care as soon as possible.

PROVINCIAL UPDATE

Arbitration Board Releases Decision in Ontario Government & OMA Dispute According to the Ontario Hospital Association, last week a three-member board of arbitration, chaired by William Kaplan, released its decision in the negotiations for a new Physician Services Agreement between the Ontario Government and the Ontario Medical Association (OMA).

Highlights from the arbitration award include:

A new four-year physician services agreement, which is partially retroactive, running from April 1, 2017 to March 30, 2021;

No cap on how much doctors can be paid; The establishment of a “appropriateness working group” to eliminate or restrict

inappropriate or overused physician services.

The arbitration decision also eliminates most of the fee cuts imposed by the province in recent years, and awards physicians with increases of 0.75 per cent for 2017; 1.25 per cent for 2018; 1 per cent for 2019; and 1 per cent for 2020.

The release of this decision marks the completion of phase 1 of the arbitration process. Phase 2 will look at how the physicians’ services budget is to be divided up among different specialty groups, a process known as “relativity.”

City of Guelph Homelessness Task Force report - Media release

Guelph, Ont., February 20, 2019 – Mayor Cam Guthrie has released a report on the conclusions of the Task Force on Homelessness and Community Safety.

The Task Force, which Mayor Guthrie announced in his inaugural address, met twice in January and agreed on a list of five priorities that would have a positive impact on homelessness, substance use, and mental health issues in Guelph. The five priorities are:

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https://guelph.ca/wp-content/uploads/Mayors-Task-Force-Report.pdf

Develop permanent supportive housing to house 15 chronically homeless individuals with complex needs, with 24/7 staffing to support residents with addiction, mental health, or chronic health issues.

Re-open a supported recovery room, which would meet sleep and recovery needs for clients for up to 72 hours. It would be staffed by a registered nurse, addiction counsellor, and peer worker.

Fund the Welcoming Streets outreach worker who supports individuals and businesses in Guelph’s downtown by educating, empowering, and connecting them to services and supports.

Re-start an addiction court support worker program, which provides an addiction counsellor for people who are in bail court and connects them to services and supports.

Implement system and service improvements such as expanding service hours to evenings, weekends and holidays; including peer supports in service delivery; and involving end-users in the design of services.

Discussions are now underway to secure funding for the priorities. Full report found here: https://guelph.ca/wp-content/uploads/Mayors-Task-Force-Report.pdf FOR INFORMATION Certificate of Compliance The Certificate of Compliance for the period May 1, 2018 to June 30, 2018, July 1, 2018 to September 30, 2018 and October 1, 2018 to December 31, 2018 are attached. Marianne Walker President and CEO

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https://guelph.ca/wp-content/uploads/Mayors-Task-Force-Report.pdf

To: The Board of Directors, Guelph General Hospital Date: February 26, 2019 Reporting Period: May 1, 2018 to June 30, 2018 RE: CEO Certificate of Compliance I have reviewed, or caused to be reviewed, such files, books of account and records of the Hospital and have made, or caused to be made, such enquiries of the financial, accounting and other personnel of the Hospital as I have determined necessary for the purpose of this certificate. In my capacity as President and CEO of Guelph General Hospital, and for the reporting period identified, I hereby attest that to the best of my knowledge, and except as set our below:

1. Salaries and Benefits - The Hospital has met all of its obligations in respect of the payment of all employee salaries and wages, vacation pay, holiday pay, termination pay, severance pay and benefits. The hospital is in compliance with the provisions of the Public Sector Compensation restraint to Protect Public Services Act, 2010.

2. Statutory Deductions - The Hospital has met all of its obligations in respect of the deduction, withholding and or remittance of funds under the Income Tax Act (Canada), the Income Tax Act (Ontario), the Employer Health Tax (Ontario), the Excise Tax Act (Canada), Workplace Safety and Insurance Act (Ontario), the Employment Insurance Act (Canada), the Canada Pension Plan Act (Canada), and the Retail Sales Tax Act (Ontario).

3. Financial Statements - The financial statements of the Hospital, as at the date of their preparation, were accurate and complete in all material aspects.

4. Insurance – All insurance policies remain in full force and effect. The Hospital is not in default with respect to any provisions contained in any insurance policy and has not failed to give any notice or present and claim under any insurance policy in a timely manner.

5. Compliance – The Hospital has conducted all business matters in compliance with:

a. All applicable laws of the Province of Ontario and Canada b. The terms of the H-SAA with the Waterloo Wellington LHIN

Marianne Walker, President and CEO

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To: The Board of Directors, Guelph General Hospital Date: February 26, 2019 Reporting Period: July 1, 2018 to September 30, 2018 RE: CEO Certificate of Compliance I have reviewed, or caused to be reviewed, such files, books of account and records of the Hospital and have made, or caused to be made, such enquiries of the financial, accounting and other personnel of the Hospital as I have determined necessary for the purpose of this certificate. In my capacity as President and CEO of Guelph General Hospital, and for the reporting period identified, I hereby attest that to the best of my knowledge, and except as set our below:








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To: The Board of Directors, Guelph General Hospital Date: February 26, 2019 Reporting Period: October 1, 2018 to December 31, 2018 RE: CEO Certificate of Compliance I have reviewed, or caused to be reviewed, such files, books of account and records of the Hospital and have made, or caused to be made, such enquiries of the financial, accounting and other personnel of the Hospital as I have determined necessary for the purpose of this certificate. In my capacity as President and CEO of Guelph General Hospital, and for the reporting period identified, I hereby attest that to the best of my knowledge, and except as set our below:








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REPORT OF THE CHIEF OF STAFF BOARD OF DIRECTORS OPEN MEETING

FEBRUARY 26, 2019

FOR INFORMATION MAC Highlights The Medical Advisory Committee met on February 4, 2019. The MAC Highlights are attached for your information. J. Caspers Chief of Staff

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February 2019

Chief of Staff Dr. Jennifer Caspers

President & CEO Marianne Walker

VP Patient Services and CNE Eileen Bain

President of the MSA Dr. Steve Hoey

Director Quality and Professional

Practice Melissa Skinner

Department Presentation on

Quality Indicators: Emergency

Department –

Dr. Ian Digby

Professional Staff Recognition: Letters of recognition: Drs. Arkilander and Wildenhain (ED) + DI support; Canadian Association of Gastroenterology Quality Endoscopy Recognition Award (IM/GS); Dr. Shecter (ED).

Gifts of Gratitude: Drs. Ganapathy (IM), Caspers (Paeds), Al-Qadhi (Anaestheia), Tremblay (HM).

New Bed Allocation and Crisis Bed Management: Hallway beds will be considered part of the bed allocation plan and will be used to keep the census of patients in ED waiting for admission at 0. Unconventional patient destinations are being monitored closely.

P4R Funding: Distribution of funds within the hospital reviewed.

Sub-Region Activity: LHIN-wide cardiac plan underway to be completed by 31 March, 2019.

Healthy Hospital Survey for Professional Staff Final count for Professional Staff = 67.2%, increased participation since 2016. Next steps: Each Chief will be briefed by the COS on the departmental results to share with their department.

Professional Staff Achievement Review (PAR): 68 of 99 (2018-19) completed to date – the reviewer shall make note of changes in privileges being asked for by members.

Non-responders have been identified and advised that their reapplication may be contingent on completion of their PAR.

Strategic Objectives for MAC 2018-2019: Opioid Plan for GGH:

Opioid Patient Handout introduced at MAC

Opioid Module on CMaRS reapplication system

Pain Management Centre at GRH’s Freeport Campus: Opening February 15th for the diagnosis and treatment of chronic pain.

Code Orange Protocol Review: Stage 1 – ED requires assistance Stage 2 – Hospital Wide Disaster (something is affecting the hospital’s ability to function)

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board of directors meeting open session tuesday february 26, … · 2019. 5. 7. · board of...

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