LENNOX AND ADDINGTON COUNTY GENERAL HOSPITAL

Transcription

1 A meeting of the Board of Directors of the Lennox and Addington County General Hospital was held in the at 6:30 p.m. on. PRESENT: Board: Peggy Rice (Chair) Tony Brazda Elaine Stillwell Robert Paul Cathie Vick Chris Seeley Judge Geoff Griffin Deb Lowry Ric Bresee Dr. Mamdouh Andrawis Norm Clark Dr. Kim Morrison Bob Clancey Wayne Coveyduck Tracy Kent-Hillis REGRETS: Allan MacGregor Michelle Smith Staff in Nancy Manion Gert Switzer Shari Sampson Attendance: Angela McCullough (Recorder) 1. Call to Order/Opening Remarks The meeting was called to order at 6:30 p.m. by Peggy Rice. Peggy solicited feedback from the members of the Board that attended the Board Retreat. All Board members that were in attendance at the retreat provided positive feedback. 2. Approval of the Agenda Motion 1 Motion: The Board of Directors hereby approves the agenda of June 3, Moved by: Robert Paul Seconded by: Deb Lowry Page 1 of 15

2 3. Conflict of Interest The Chair inquired if any member of the Board wished to declare a conflict of interest based on items identified in the Agenda. There were no identified conflicts of interest. 4. Minutes of Previous Meeting The minutes of June 3, 2014 were reviewed and no changes were noted. Motion 2 Motion: The Board of Directors hereby approves the minutes of the previous meeting dated June 3, Moved by: Robert Paul Seconded by: Deb Lowry 5. Minutes of the Special Meeting of the Board The minutes of the Special Meeting of the Board held on June 10, 2014 were reviewed and no changes were noted. Motion 3 Motion: The Board of Directors hereby approves the minutes of the Special Meeting of the Board dated June 10, Moved by: Deb Lowry Seconded by: Norm Clark 6. Business Arising There was no business arising from the minutes. 7. Reports 7.1 Quality Committee Elaine Stillwell highlighted the following from the Quality Committee meetings held on June 17, 2014 and September 16, The committee reviewed the Balanced Scorecard for Q4 of 2013/14. A copy of the Balanced Scorecard was provided in the Board package. Elaine advised that while our ER volumes were below target for year-to-date 2013/14, Q1 of 2014/15 has reflected an increase in volume. Page 2 of 15

3 The committee reviewed utilization data for Q4 2014/14. Due to the size of the Board package this month, copies of the utilization data that was reviewed by the Quality Committee was not provided in the Board package; however, copies of the data reports will be provided in next month s Board package. The committee reviewed the requirements of the Accessibility Act and what LACGH has done to meet the targets. There are no outstanding barriers and all our targets have been met. Accessibility Review will be added to the Quality Committee s work plan. Elaine also advised that the Hospital won the Inter-Hospital Health Challenge for the second year in a row. 7.2 Ethics Committee Elaine Stillwell highlighted the following from the Ethics Committee meeting held on September 10, The committee conducted a thorough review of their Terms of Reference and recommended a change to reflect that this committee shall meet quarterly or at the call of the Chair. The Ethics Committee has recommended that their Terms of Reference be approved by the Board. The Board reviewed the Terms of Reference and no additional changes were noted. Motion 4 Rationale: Each committee of the Board is required to review their Terms of Reference on an annual basis to ensure that it reflects the current practice of the committee and/or changes in legislation. Motion: The Board of Directors hereby approves the Ethics Committee Terms of Reference as recommended by the Ethics Committee. Moved by: Judge Geoff Griffin Seconded by: Tony Brazda The committee also discussed changes to the Ethical Framework and Ethics Concern Form. The committee will continue to work on these items and will bring them to the Board upon their completion. Page 3 of 15

4 7.3 Finance Committee Deb Lowry provided the following highlights from the Finance Committee meeting held on June 24, Board, CEO and Senior Management Expenses The Finance Committee reviewed the Board, CEO and Management expenses which totalled a credit for $ Deb Lowry advised that the credit was the result of a cancelled hotel room. The Finance Committee recommends to the Board that the following expenses be approved. Motion 5 Rationale: The Broader Public Sector Accountability Act requires that the expenses of the Board, CEO and Senior Management be reviewed and/or approved by the Board. Motion: The Board of Directors hereby approves the following expenses which totalled a credit for $81.26 as recommended by the Finance Committee: May 2014 Name Meals Hospitality Accommodations Vehicle Rental/Own used Mileage Incidentals (Parking, tolls, etc.) Fares TOTAL Wayne Coveyduck -$ $ Nancy Manion $18.32 $68.53 $86.85 Shari Sampson $37.02 $36.07 $12.63 $85.72 Gert Switzer $18.57 $26.59 $1.81 $46.97 TOTALS $ $ $ $ $81.26 Moved by: Norm Clark Seconded by: Chris Seeley Combined April and May Financial Statements The Finance Committee reviewed the April and May Financial Statements and has recommended to the Board that they be approved. Motion 6 Motion: The Board of Directors hereby approves the April and May Financial Statements as recommended by the Finance Committee. Moved by: Judge Geoff Griffin Seconded by: Elaine Stillwell Page 4 of 15

5 7.3.3 May Cheque List The Finance Committee reviewed the May 2014 Cheque List which totalled $1,935, and no concerns were noted by the Finance Committee or the Board. Motion 7 Motion: The Board of Directors hereby approves the May 2014 Cheque List which totalled $1,935, as recommended by the Finance Committee. Moved by: Judge Geoff Griffin Seconded by: Elaine Stillwell H-SAA Schedules The Finance Committee reviewed the H-SAA Schedules that are to be appended to the H-SAA Amending Agreement and forwarded to the SE LHIN. The committee requested that the SE LHIN be advised that there will be a variance between the budget and actual for the Financial Performance Targets. The H-SAA Schedules were recommended to the Board with this provision. Motion 8 Rationale: In order to meet legislative requirements, the SE LHIN has requested that the H-SAA Schedules be approved appended to the H-SAA Amending Agreement. Motion: The Board of Directors hereby approves the H-SAA Schedules with the understanding that there will be a variance between the budget and actual for the Financial Performance Targets as recommended by the Finance Committee. Moved by: Tony Brazda Seconded by: Elaine Stillwell Insurance Policies The Finance Committee reviewed the cost implications of the renewal of the Hospital insurance policies and has recommended them to the Board for approval. Motion 9 Rationale: The Hospital insurance policies are reviewed and/or approved by the Finance Committee and the Board of Directors on an annual basis. Motion: The Board of Directors hereby approves the renewal of the Hospital insurance policies as recommended by the Finance Committee. Moved by: Deb Lowry Seconded by: Elaine Stillwell Page 5 of 15

6 7.3.5 Capital Equipment Requests The Finance Committee reviewed a request for the allocation of $13, towards the purchase of a blood pressure monitor for the Clinic (Added Cost $815.00) and two (2) stretchers for the Emergency Department (Cost $12,500.00) and has recommended to the Board that this allocation be approved. Motion 10 Motion: The Board of Directors hereby approves the allocation of $13, towards the purchase of the following equipment as recommended by the Finance Committee: Blood Pressure Monitor for the Clinic (Added Cost $815.00) Two (2) stretchers for the Emergency Department (Cost $12,500.00) Moved by: Robert Paul Seconded by: Chris Seeley Deb Lowry provided the following highlights from the Finance Committee meeting held on September 30, Board, CEO and Senior Management Expenses The Finance Committee reviewed the Board, CEO and Management expenses which totalled $ The Finance Committee recommended to the Board that the following expenses be approved. Motion 11 Rationale: The Broader Public Sector Accountability Act requires that the expenses of the Board, CEO and Senior Management be reviewed and/or approved by the Board. Motion: The Board of Directors hereby approves the following expenses which totalled $87.18 as recommended by the Finance Committee: August 2014 Name Meals Hospitality Accommodations Vehicle Rental/Own used Mileage Incidentals (Parking, tolls, etc.) Fares TOTAL Wayne Coveyduck $41.19 $45.99 $87.18 TOTALS $41.19 $45.99 $87.18 Moved by: Tony Brazda Seconded by: Deb Lowry Page 6 of 15

7 7.3.7 Benefit Renewal The Finance Committee reviewed a recommendation from the Hospital with respect to a change in benefits for the hospital staff. Manulife, our current benefit provider, had proposed significant increases in the LTD and Group Life rates so the Hospital sought comparisons from the market. Desjardin offered a significant savings over the renewal proposal with our overall renewal increase dropping to 3.8%. Desjardin has also guaranteed the rate to The Board reviewed the cost summary provided in the Board package and no concerns were noted. Motion 12 Rationale: After receiving a proposal from our current benefit provider that proposed significant increases in LTD and Group Life, the Hospital sought comparisons from the market and were able to obtain a proposal that dropped the overall renewal increase. The Hospital recommended the change in benefit carrier for LTD and Group Life. Motion: The Board of Directors hereby approves the changes in the benefits renewal as recommended by the Finance Committee. Moved by: Elaine Stillwell Seconded by: Deb Lowry Continuing Education Interest-Free Loan Program The Finance Committee reviewed a proposal for the establishment of a Continuing Education Interest-Free Loan Program. This program is to assist employees who are pursuing continuing educational opportunities in fields that will add value and be directly relevant to the services offered at the Hospital. It also provides the hospital with the opportunity to move to a knowledge organization. Employees must apply to the program and be approved based on the eligibility and section criteria outlined in the program. Motion 13 Rationale: The Hospital recognizes the value of continuing education for our employees. We endeavour to foster an environment in which our staff can grow professionally and contribute towards service excellence. In support of these goals and a strong belief that staff strives to continuously improve our programs and services, the Hospital has established a Continuing Education Interest-Free Loan Program. Motion: The Board of Directors hereby approves the Continuing Education Interest- Free Loan Program as recommended by the Finance Committee. Moved by: Robert Paul Seconded by: Judge Geoff Griffin Page 7 of 15

8 7.3.9 June and July Board, CEO and Senior Management Expenses, Financial Statements and Cheque Lists The Finance Committee did not meet during July and August; however, the expenses, financial statements and cheque lists were circulated via to the committee members for approval. No concerns were expressed from the Finance Committee so they have recommended them to the Board for approval. Motion 14 Motion: The Board of Directors hereby approves the following as recommended by the Finance Committee: June Board, CEO and Senior Management Expenses totaling $ June Financial Statements June Cheque List totaling $2,294, July Board, CEO and Senior Management Expenses totaling $27.95 July Financial Statements July Cheque List totaling $2,349, Moved by: Tony Brazda Seconded by: Elaine Stillwell August 2014 Financial Statements and Cheque List The Finance Committee reviewed the August 2014 Financial Statements and Cheque List and no concerns were noted. The Finance Committee has recommended that they be approved by the Board. Motion 15 Motion: The Board of Directors hereby approves the August 2014 Financial Statements and Cheque List which totalled $2,554, as recommended by the Finance Committee. Moved by: Elaine Stillwell Seconded by: Deb Lowry Page 8 of 15

9 Capital Equipment Requests The Finance Committee reviewed a request for the allocation of $35, towards the purchase of the following and has recommended to the Board that it be approved: Refrigerator for the Convalescent Care Unit (Cost $2,065.00) Meat Slicer for the Dietary Department (Cost $4,460.00) Dietary Refrigeration Project (Cost $17,000.00) Air Pal Mattress for the Emergency Department (Cost $1,765.00) Glidescope for the Emergency Department (Cost $5,145.00) Stretchers for the Emergency Department (Added Cost $140.47) PACS Server for the Radiology Department (Added Cost $733.74) Additional doors on the Security System (Added Cost ($3,973.71) Motion 16 Motion: The Board of Directors hereby approves the allocation of $35, towards the purchase of the following equipment as recommended by the Finance Committee: Refrigerator for the Convalescent Care Unit (Cost $2,065.00) Meat Slicer for the Dietary Department (Cost $4,460.00) Dietary Refrigeration Project (Cost $17,000.00) Air Pal Mattress for the Emergency Department (Cost $1,765.00) Glidescope for the Emergency Department (Cost $5,145.00) Stretchers for the Emergency Department (Added Cost $140.47) PACS Server for the Radiology Department (Added Cost $733.74) Additional doors on the Security System (Added Cost ($3,973.71) Moved by: Judge Geoff Griffin Seconded by: Tony Brazda 7.4 Executive Committee Peggy Rice advised that as the Board did not meet during July and August, the Executive Committee was required to meet to address an important item that required the Board s immediate attention. The Executive Committee met on July 2 to review and ratify the ONA Local Agreement. It was ratified on a motion by Deb Lowry and seconded by Allan MacGregor. The SE LHIN, CEO s, Board Chairs and Board Vice Chairs met to talk about the communication of the sustainability project. The Executive Committee participated in the Great Waterway Classic Pro-Am Golf Tournament. The Executive Committee met in September to talk about the possibility of supporting KGH in their campaign to purchase and install a second MRI machine. With that in mind, it has been proposed that a fundraising event could be organized in our community to help support KGH s efforts. The Board recognizes that the communication of this endeavour is the key to its success. We need to ensure that it Page 9 of 15

10 is reiterated to our community, physicians, staff and volunteers that KGH provides services that our patients require and that cannot be accessed in our community. The Board had a robust discussion on the possible negative outcomes that this could have to the Foundation s fundraising efforts but agreed that we should financially support the KGH MRI campaign. Motion 17 Rationale: To strengthen our relationship with our community partners and assist in providing our community with greater access to an MRI, the Board of Directors discussed possible fundraising efforts for the KGH MRI campaign. Motion: The Board of Directors hereby agrees to financially support the MRI campaign at KGH. Moved by: Judge Geoff Griffin Seconded by: Norm Clark It was recommended by the Board that a gala be held at the LACGH Westdale Complex and the proceeds from the event will be donated to the KGH MRI campaign. Robert Paul advised that the Foundation Board is in support of this endeavour and he has agreed to present the idea to the Volunteer Services, Physicians and staff. It was identified that a slogan such as Helping others, helping us might be used in the advertisement of the event. Motion 18 Rationale: The Board of Directors recognizes the importance to our community in KGH obtaining a second MRI and has agreed to donate the proceeds from a gala event to support their campaign. Motion: The Board of Directors hereby agrees that the proceeds from a gala event will go to support the Imaging Campaign at KGH in partnership with the Foundation, Physicians and Volunteer Services. Moved by: Norm Clark Seconded by: Ric Bresee Page 10 of 15

11 7.5 Governance Committee Judge Geoff Griffin provided the following highlights from the Governance Committee meeting held on September 3, The Governance Committee conducted a review of the by-laws and position description for the Board Chair to ensure consistency in the term of the Board Chair. The Committee noted that a by-law amendment would be required to Article 10.1 to reflect the maximum term of the Board Chair as five (5) consecutive years. Motion 19 Rationale: To ensure consistency with our Corporate By-Laws and position description with respect to the term of the Board Chair position, an amendment to the By-Laws will be required. Motion: The Board of Directors hereby approves that Article 10.1 of the Corporate By- Laws be amended to reflect the following as recommended by the Governance Committee. Moved by: Tony Brazda Seconded by: Deb Lowry The Governance Committee conducted a review of their work plan, the Statement of Roles and Responsibilities of the Board, the Position Descriptions for the Officers of the Board, the Position Description for Board Members and the Board Accountability Statement. The only change noted was to the Board Accountability Statement in which the Committee is recommending to the Board that the two accountabilities to the Members of the Hospital Corporation be combined. Motion 20 Rationale: As part of the Governance Committee s work plan, they reviewed the Statement of Roles and Responsibilities of the Board, the Position Descriptions for the Officers of the Board and for Board Members as well as the Board Accountability Statement. Motion: The Board of Directors hereby approves the 2014/15 Governance Work Plan, the Statement of Roles and Responsibilities of the Board, the Position Description for the Officers of the Board and Board Members and the revised Board Accountability Statement as recommended by the Governance Committee. Moved by: Deb Lowry Seconded by: Norm Clark Page 11 of 15

12 7.6 Foundation Robert Paul advised of the following: On Thursday, October 9, 2014 there will be a donor tea. The Tim Horton s Smile Cookie Campaign raised $5,700 in one week. Earlier today, the Royal Canadian Legion donated $2,500 towards the purchase of medical equipment. A little over $10,000 was raised from the Great Waterway Classic Pro-Am Golf Tournament. 7.7 Volunteers Cathie Vick advised that $8,000 was raised on Tag Day and that the Annual Thanksgiving Tea and Bake Sale will be held on Friday, October 10, 2014 in the. 7.8 Medical Advisory Committee Dr. Kim Morrison welcomed Dr. Mamdouh (Andrew) Andrawis to the Board as the incoming President of Medical Staff. She advised the Board that the credentialing process will be streamlined and changes will be made as a result of the information provided at this years Board Retreat. Dr. Morrison also advised the Board that Dr. Carl Lee will be taking on the Role as the Credentials Committee Chair from Dr. Paul Kenny who has held the position since At the June 19, 2014 meeting of the Medical Advisory Committee, the Committee reviewed several applications for reappointment to the LACGH Medical Staff and has recommended them to the Board for approval. Motion 21 Rationale: Pursuant to the Medical Staff By-Laws, the MAC is required to review and make recommendations to the Board of Directors on reappointments to the Medical Staff. Motion: The Board of Directors hereby approves the reappointment of the following to the LACGH Medical Staff as recommended by the Medical Advisory Committee: Dr. Ransri Perera Active Staff (Emergency) Dr. Matthew Martin Active Staff (Emergency) Dr. Kimberley Morrison Active Staff (Family Practice) Dr. Basia Farnell Active Staff (Emergency) Moved by: Robert Paul Seconded by: Chris Seeley Page 12 of 15

13 At the October 2, 2014 meeting of the Medical Advisory Committee, the Committee discussed a recommendation that Medical Residents should be included in our Remote Access Policy. The Committee agreed with this recommendation and is recommending to the Board that the revised policy be approved. Motion 22 Rationale: Revisions to Board policies requires the review and/or approval of the Board of Directors prior to implementation. Motion: The Board of Directors hereby approves the revised Remote Access Policy #PR4-100 as recommended by the Medical Advisory Committee. Moved by: Robert Paul Seconded by: Judge Geoff Griffin The committee also reviewed several appointment and reappointment applications to the LACGH Medical Staff and has recommended to the Board that they be approved. Pursuant to the Medical Staff By-Laws, applications for Associate staff privileges require that the physician be supervised by a physician from their department for the first year on our Medical Staff. Dr. Kalyanram Hota will be supervised by Dr. Carl Lee and Dr. Mykola Khokhotva will be supervised by Dr. Ven Hota. Motion 23 Rationale: Pursuant to the Medical Staff By-Laws, the MAC is required to review and make recommendations to the Board of Directors on appointments to the Medical Staff. Motion: The Board of Directors hereby approves the appointment of the following to the LACGH Medical Staff as recommended by the Medical Advisory Committee: Dr. Allison Chow Courtesy Staff with Admitting Privileges (Emergency) Dr. Sara-Anne Arul Courtesy Staff with Admitting Privileges (Family Practice) Dr. Kalyanram Hota Associate Staff (Family Practice) Dr. Doug Barton Courtesy Staff with Admitting Privileges (Emergency) Dr. Filip Gilic Courtesy Staff with Admitting Privileges (Emergency) Dr. Keith Gregoire Consulting Staff (Paediatrics) Dr. Mykola Khokhotva Associate Staff (General Surgery) Moved by: Deb Lowry Seconded by: Elaine Stillwell Page 13 of 15

14 Motion 24 Rationale: Pursuant to the Medical Staff By-Laws, the MAC is required to review and make recommendations to the Board of Directors on re-appointments to the Medical Staff. Motion: The Board of Directors hereby approves the reappointment of the following to the LACGH Medical Staff as recommended by the Medical Advisory Committee: Dr. Wendy Parulekar Consulting Staff (Oncology) Dr. David Good Consulting (Laboratory) Dr. Stephen Steele Consulting Staff (Urology) Dr. Craig Simpson Active (Emergency) Moved by: Norm Clark Seconded by: Chris Seeley 7.9 Chief Executive Officer s Report Wayne advised that he has received approval from SECHEF and KGH to proceed with a sleep clinic at our hospital. He also advised that Annette Stuart, our Respiratory Therapist, visited Campbellford Memorial Hospital to observe the set up of their sleep clinic. Based on what was seen, we need to ensure that the service is provided at and on a level we expect. To that end, we need to take the time to ensure we are comfortable with the total set up and arrangement. ParaMed Home Health Care has contacted Wayne requesting a follow-up clinic space at our Hospital. The individuals accessing this clinic will be funneled through the CCAC. Wayne has advised them that they will be required to pay rent for the clinic space which they have agreed to pay. A contract between our two organizations is in progress. They will be placed in one of the clinics room previously used for Ophthamology. Wayne met with the KGH Representatives regarding dialysis services in our community. There is potential for the Dialysis Program to be set up in the Westdale Complex. If the terms and conditions are favourable for the two parties, then we should proceed with making this happen. Motion 25 Motion: The Board of Directors hereby accepts the reports from the Quality Committee, Ethics Committee, Finance Committee, Executive Committee, Governance Committee, Hospital Foundation, Volunteer Services, Medical Advisory Committee and the CEO. Moved by: Chris Seeley Seconded by: Robert Paul Page 14 of 15

15 8. Other 8.1 Correspondence Received Up to September 25, 2014 Peggy Rice circulated a thank you note from Rick Walters. 9. New Business 9.1 Sustainability Deb Lowry advised that she and Wayne Coveyduck attended a Development of a Sustainable Integrated Model of Hospital Care Joint Governance Session on September 22, 2014 in Kingston. The objective of the session was to provide all governors with a formal introduction and consistent explanation regarding the Hospital Sustainability Project s objectives and direction; provide an overview of the key drivers of the project; and to engage all governors regarding their role in the project and to the sustainability of the hospital system in the SE LHIN. Deb advised the Board that the project overview starts on Page 196 of the Board package. The principles of the project are that all nine (9) SECHEF partners will have an equal opportunity to influence decisions. A video on the project has been developed and was shown at the Board meeting. At the session, everyone was given the opportunity to ask questions regarding sustainability. Subsequent to the questions, the LHIN undertook to develop answers and send them out to all attending participants. It has been recommended that this topic will be standing item on the Board agenda. 10. Next Meeting The next regular meeting of the Board has been moved to November 11, There will be a presentation from the Smoking Cessation Working Group starting at 6:00 p.m. The Board meeting will start at 6:30 p.m. 11. Adjournment The meeting was adjourned at 8:26 p.m. Motion 26 Motion: The Board of Directors hereby adjourns their meeting at 8:26 p.m. on October 7, Moved by: Deb Lowry Seconded by: Robert Paul Page 15 of 15