Board of Directors Meeting

Open Session

Tuesday October 30, 2018

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 - October 30, 2018

b) Approval of Minutes - September 25, 2018

Governance Committee Report - Page 11

Terms of Reference - Governance - Page 12

c) Governance Committee Report

d) IT Joint Advisory Committee Report

e) President and CEO Report

COS Report - Page 19

f) Chief of Staff Report

18-10-30 Agenda - Page 5

18-09-25 Minutes - DRAFT - Page 9

2018-2019 Committee Work Plan - Page 15

IT Joint Advisory Committee Report - Page 16

CEO Report - Page 17

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

5 min 5. Quality Committee Report 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

18-10-30 Summary of Motions - Page 4

MAC Highlights - October 2018 - Page 20

18-10-30 OPEN BOD Package18-10-30 OPEN BOD Package

AGENDAAGENDA

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Quality Committee Report - Page 21

6. Next Meeting - November 27, 2018 Information D. Mills

7. Meeting Adjournment Decision D. Mills

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BOARD OF DIRECTORS OCTOBER 30, 2018

SUMMARY OF RECOMMENDED MOTIONS OPEN SESSION: Agenda and Consent

a) Approval of Agenda – October 30, 2018 b) Approval of Minutes – September 25, 2018 c) Governance Committee Report

Terms of Reference It is recommended that the Governance Committee Terms of Reference be forwarded to the Board for approval as presented.

d) IT Joint Advisory Committee Report e) President and CEO Report f) 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 October 30, 2018 6:00 p.m.

Boardroom, Level 2

AGENDA ITEM LEAD ACTION TIME PAGE

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 – Oct 30, 2018

b) Approval of Minutes – Sept 25, 2018

c) Governance Committee Report d) IT Joint Advisory Committee

Report e) President and CEO Report f) Chief of Staff Report

D. Mills

Decision 1 min

5. Quality Committee Report D. Mills Decision 5 min

6. Next Meeting: November 27, 2018 D. Mills Information

7. 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

Jan 29

Feb 26

Mar 26

Apr 30

May 28

June 25

AGM

Dale Mills - Chair P

Eileen Bain P

Christine Bevan-Stewart P

Terry Campbell P

Jennifer Caspers P

Brian Cowan P

Edward Fraser P

David Forestell P

Steven Hoey – President MSA P

Rena Hubers P

Janet Kaufman P

David Kennedy P

Sara Sayyed P

Edward Sehl P

Matt Stanley P

Marianne Walker P

Kathy Wilkie – Vice Chair P

GUESTS:

Ian Phillips – VP MSA R

Suzanne Bone P

Rod Carroll R

Gavin Webb R

Amanda Babensee - Recorder R

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MINUTES – OPEN MEETING - DRAFT Board of Directors

Tuesday September 25, 2018 Boardroom, Level 2

Present: D. Mills – Chair, E. Bain, C. Bevan-Stewart, T. Campbell, J. Caspers, B.

Cowan, F. Edward, D. Forestell, S. Hoey, R. Hubers, J. Kaufman, D. Kennedy, T. Sehl, M. Stanley, M. Walker, K. Wilkie and L. Orosz - Recorder

Regrets: Guests: S. Bone, C. Cowden

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. D. Mills acknowledged the hard work and service of former Board Member R. Carter. It was noted that a letter of recognition and thanks was sent to R. Carter.

a) Summary of Motions

4. PHYSICIAN CREDENTIALING AND THE ROLE OF THE BOARD Dr J. Caspers presented to the Board an overview of the physician credentialing process. The following points were highlighted:

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The distinction between the credentialing and privileging process: Credentialing is an annual process of obtaining, verifying, and

assessing qualifications. It is a legal requirement. Privileging is a process which comes afterward; whereby authorization

for a specific scope and content for patient care services occurs. The Board’s role in credentialing and privileging:

The Credentials Committee (MAC Sub-Committee) reviews a physician application and reports to MAC, who then considers the application and makes a recommendation to the Board.

A discussion occurred regarding physician compensation, and third party reviews of the credentialing system.

J. Caspers noted that GGH is currently in the process of transitioning to a web-based credentialing system.

5. APPROVAL OF THE AGENDA AND CONSENT AGENDA

a) Approval of Agenda – September 25, 2018 b) Approval of Minutes – June 26, 2018 c) Governance Committee Report d) Administration and Facilities Committee Report e) President and CEO Report f) Chief of Staff Report

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

6. NEXT MEETING

The next meeting will be held October 30, 2018 7. ADJOURNMENT It was MOVED by D. Kennedy 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

OCTOBER 30, 2018 The Committee met on Tuesday October 16, 2018 FOR ACTION Terms of Reference The Committee reviewed the proposed changes to the terms of reference in detail. An overview of the mandate, membership and meeting schedule was provided for the new committee members as well as the responsibilities of the committee. It is recommended that the Governance Committee Terms of Reference be forwarded to the Board for approval as presented. FOR INFORMATION Committee Work Plan 2018-2019 The Committee reviewed the work plan in detail. The 2018-2019 work plan is enclosed for information. Ted Sehl Chair

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1

GUELPH GENERAL HOSPITAL GOVERNANCE COMMITTEE

Terms of Reference Mandate The Committee supports the Board in developing and maintaining good governance processes, specifically as related to governance best-practice, By-law review, Board recruitment, Board education and the evaluation of the Board, the CEO and the COS. The Committee conveys its findings and recommendations to the Board of Directors for consideration and, where required, resolution by the Board. Membership The Committee shall consist of: (1) The Board Chair

(2) The Chief Executive Officer

(3) The President or Vice President of the Medical Staff Association (for a two-year

term) (4) A minimum of three (3) members of the Board of Directors, one (1) of whom

shall be the Chair of the Committee. Responsibilities and Functions

(1) Board effectiveness – Review the evaluation tools and report to the Board as per

the Board Policy.

(2) Board succession planning – Maintain a current skills matrix that will be used to assist with the recruitment of new Directors

(3) Board Retreat planning - Recommend the agenda, speakers and venue for the annual Board Retreat.

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2

(4) Evaluations – Oversee the evaluation of the Board, the Chief Executive Officer and Chief of Staff and inform or make recommendations to the Board including revaluation of compensation.

(5) Board Policies – Board policies shall be reviewed for initial approval or three-year review recommendations to the Board for their final approval.

(6) Board orientation and ongoing education – Oversee the board orientation program and develop an annual Board education plan.

(7) Strategic Planning – Initiate the strategic planning process or annual review of strategic goals and objectives.

(8) Ensure that the hospital leadership has sound processes in place to identify, assess and manage risk;

(9) Ensure that there are appropriate plans in place to mitigate leadership/external relations/reputational and regulatory risks.

Meetings

(1) The Committee shall meet no less than 4 times per year.

(2) The Chair of the Committee may call a special meeting of the Committee as deemed necessary.

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GOVERNANCE COMMITTEE WORK PLAN 2018-2019

POLI

CY

CM

TE

SEPT

OC

T

NO

V

JAN

FEB

MA

R

APR

MA

Y

JUN

E

Planning and Strategy Terms of Reference and Work Plan Review and Approval G X Board Retreat – Hold in Dec – Planning in Sept & event in December G X X Review Strategic Plan Strategic Initiatives for 2018-2019 G X Review Strategic Plan Scorecard G X Recommend Board Education Plan G X Recommend CEO Performance Goals and Objectives 2018/19 Recommend COS Performance Goals and Objectives 2018/19

G X

Communication Plan Update G X Generative Governance Discussion X Performance Evaluation CEO and COS Performance Goals and Objectives – 2018-2019 – Status Update 1-009 G X X CEO/COS Evaluations

- Determine appropriate evaluation methodology (March) - Approval of evaluation participants (April) - Online Evaluation Links sent out to Participants (if 360 degree selected) April) - Results shared with Governance Committee – (June) - Review results with CEO/COS – (June before the Board meeting) - Results shared with Board – (June)

- N/A

G X

X

CEO and COS Succession Plan Report - X Review Board GCE Board Self-Assessment and Current Governance Practices and Policies Checklist – Annually –Board Chair evaluation (Send out Survey in April – Survey available from April 1 to June 1)

1-020 G X X

Review Results from GCE Board Self-Assessment and Submit Recommendations to the Board 1-020 G X Executive Compensation 1-009 X Board Succession Planning & Recruitment Survey all Board members as to re-election, board committee membership and committee chair or board officer preferences

- Directors to complete self-assessment for individual’s skills as director (Skills Matrix – Include Article in Folder)

- Recommend a list of required competencies/characteristics that would be an asset to the Board for the upcoming year and future

- Review Board compositions, anticipated vacancies Begin recruitment process if required (Nominating Committee)

1-017 G X

Compliance Reporting and Polices Policies and Procedures – Review and Update as Required (Every 3 Years) G 1-002

1-006 1-008

1-015 1-017 1-018

1-023 1-024 1-025

1-027 11-150 11-251

Risk Register Updates 1-029 G X By-Law Renewal Page 15 of 21

REPORT OF THE IT JOINT ADVISORY COMMITTEE BOARD OF DIRECTORS OPEN MEETING

OCTOBER 30, 2018 The Committee met on Monday October 22, 2018 FOR INFORMATION Terms of Reference The Committee reviewed the Terms of Reference in detail and several changes were suggested. It was agreed that the Terms of Reference will need to be updated to reflect the new WHIN Agreement. The Committee also agreed that a Work Plan was required. The Terms of References will be updated and brought to the Board for approval at the next meeting. Dale Mills Chair

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REPORT OF THE PRESIDENT AND CEO BOARD OF DIRECTORS OPEN MEETING

October 30, 2018

Provide the safest and highest quality care Falls Prevention Project About four years ago, we developed and implemented a plan that resulted in a significant reduction in patient harm related to falls. Our team, along with members of the Patient and Family Advisory Committee, PFAC, are working

on a plan to continue to enhance our falls protocols. The addition of the PFAC members brings the patient’s perspective in how to reduce falls.

Support our Exceptional Staff

Healthy Hospital Employee Survey – 2018 Pulse Check We started our Healthy Hospital Survey. We are extending the dates to complete the survey as our response rates are slowly increasing during such a busy time. At GGH we value feedback from staff and physicians which

allows us to assess organizational culture, staff engagement, and develop continuous improvement plans. Once we receive the results the team will determine the areas that they would like to improve.

Create a coordinated high quality system of care with our partners. Sub-Region Planning We continue to work with our partners to drive change in the system to improve the health of our community. One area that had complete support was the Safe Injection Site at the Community Health Centre. A joint letter was sent to the Minister of Health and Long Term Care supporting the need for

this valuable program along with addiction treatment programs.

Sustain our Financial Health

Managing Over Capacity at GGH We continue to experience significant increases in patient volumes. Admissions from our emergency department are up by 4% compared to the same time last year which was 6.1% higher than the first quarter of 2016/17. Patient days are up in medicine by 16% compared to last year and we are

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using 25 more beds than two years ago. Our occupancy in medicine and emergency department admits remain at 114%. We did receive one-time funding for two surge beds. Provincial Updates:

Premier’s Council: A Premier’s Council has been set up by the government led by Council Chair Dr. Rueben Devlin. The Council will recommend strategic priorities and actions to improve Ontario’s health outcomes and improve patient satisfaction, while improving system efficiency. Dr. Devlin indicated that the Premier’s Council will work closely with the Minister of Health and Long Term care to recommend a strategic long-term vision for health care in Ontario. The Council is also tasked with articulating critical issues and identified solutions, developing a capacity plan and long-term funding approach, and identifying measureable outcomes. To view the full announcement, please click here.

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REPORT OF THE CHIEF OF STAFF BOARD OF DIRECTORS OPEN MEETING

OCTOBER 30, 2018

FOR INFORMATION MAC Highlights The Medical Advisory Committee met on October 1, 2018. The MAC Highlights are attached for your information. J. Caspers Chief of Staff

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October

2018

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: Anesthesia –

Dr. Ayman Rofaeel

Professional Staff Recognition Letters of recognition to the Department of Emergency Medicine, Dr. Khaled Al-Shakman, Dr. Liliya Grebenyuk Budget Update We continue to forecast a deficit related to 12 unfunded beds including hallway beds, decline in revenue-generating Bariatric patient admissions and minimal revenue increases. The Guelph census area is one of seven Census Metropolitan Area in Canada to experience accelerated growth between 2011to 2016. During that time our population grew by 8.3% last year, Guelph was the 3rd highest growth area in the country and the highest in Ontario. That increase along with an aging population results in ever-increasing demands for our hospital. Patient Preferences for Resuscitation and Scope of Care A template has been developed and will be trialed in ICU and Step-Down for two months, then to be re-evaluated and taken to the Patient and Family Committee before a final product being released to the entire hospital. Strategic Objectives for MAC 2018-2019: Opioid Plan for GGH Letter sent to the Minister of Health regarding Safe Injection Site at the CHC; The Opioid Strategic Plan (April 2017) was adapted with minimal changes to be

circulated to all departments and integrated as a policy within Professional Staff Clinical Policies.

Construct an education module that all PS must complete on line and ?link to re-credentialing.

Consider a targeted education session with the CPSO and CMPA. An intranet site accessible from the GGH home page will be made available with

opioid resources. “My Chart” An initiative being propelled forward by the Ministry of Health that makes in-hospital patient records available for their review – labs, pathology, consults. Strongly supported by the MoH consultant, Rueben Devlin, and the implementation may be through portals such as Clinical Connect. Healthy Hospital Survey for Professional Staff Coming in October. Mandatory under the Excellent Care for All Act. Sub-Region Activity LHIN-wide Cardiac plan to be completed by 31 March 2019. Chiefs Annual Review Ongoing. Professional Staff Achievement Review (PAR) 2018-19 documents circulating; 1 already totally completed (DI). Professional Staff Scorecard Coming forward again in November.

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REPORT OF THE QUALITY COMMITTEE BOARD OF DIRECTORS OPEN MEETING

OCTOBER 30, 2018 The Committee met on Thursday October 11, 2018 FOR INFORMATION Departmental Presentation Template Review The Committee reviewed the Departmental Presentation Template in detail. The members provided the following suggestions:

Include Financial Health Strategies 3-5-year plan in regards to strategic goals – challenges in the future

Quality Scorecard Template Review The Committee reviewed and approved the proposed revised Quality Scorecard Template in detail. Dale Mills Interim Chair, Quality Committee

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