OPEN MINUTES
QUALITY AND PATIENT CARE COMMITTEE
November 25, 2015 at 12:30pm
Library ~ Charles Street Site
Membership:
Linda Hansen (Chair)
Trea Tuck (Vice-Chair) teleconference
David Bessant
Marilies Rettig teleconference
Angela Rodgers
William Spencer
Steve Smith
Ex-Officio, Voting Members:
Neil Bhatt
Guests:
Ex-Officio, Non-Voting Members:
Dr. David Goldstein
Kristi Carter
Cathy Cassidy-Gifford
Tony Weeks
Regrets:
Cheryl Cook
Jennifer Eastwood
Sherri Fournier-Hudson
Recording Secretary:
Laurie Ouellette
ouela@bgh-on.ca
Community Member(s):
Ahmad Khadra
Wendy Bergeron
NO.
1.0
DISCUSSION
Call to Order
3.0
The Chair called the meeting to order at 12:04 pm.
Presentation on Patient Safety Module (Professionalism/Disclosure) by Dr. Goldstein
The compliment was read by K. Carter.
The meeting then proceeded with the professionalism/disclosure presentation/discussion. It was an
informative session with good feedback from the members. Discussion included the patient and physician
relationship, trust, professionalism and a culture of compassion with staff.
Move to In-Camera
4.0
MOTION: It was moved by W. Spencer/A. Rodgers THAT the Quality and Patient Care Committee move to InCamera at 12:45 pm. This motion was put to a vote and APPROVED.
Approval of Agenda
5.0
MOTION: It was moved by S. Smith/W. Spencer THAT the Quality and Patient Care Committee approve the
Open Agenda as presented. This motion was put to a vote and APPROVED.
Declaration of Conflict of Interest
2.0
6.0
6.1
6.2
6.3
6.4
The Chair called for conflicts of interest to be declared. There were none.
Business Arising from Previous Meeting(s)
Update on Ethics Patient Centered Care
There was discussion around this education. The educator sits on the Ethics Committee. We need to ensure
we have three quotes before proceeding with the education.
Discussion also included the changes occurring at BGH and if this was the best time to implement the
program.
This will go back to the SLT table for final decision.
M. Rettig left at 1:01 pm.
Update on LLG Integrated Stroke Planning Workgroup-this was included in camera.
Surgical Assist, Neonatal Resuscitation Protocol, Pediatric Care
We are looking at an alternate funding plan for pediatrics.
Accreditation Update
The final report has arrived and was distributed to leadership and the Board of Governors.
Of 2315 ROPs we had 85 unmet.
Our Mission: A progressive community partner delivering an outstanding health care experience,
guided by the people we serve, provided by people who care.
OPEN MINUTES
QUALITY AND PATIENT CARE COMMITTEE
November 25, 2015 at 12:30pm
Library ~ Charles Street Site
6.5
6.6
7.0
7.1
7.2
8.0
8.1
8.2
We had exemplary status last accreditation. Overall we performed better than last accreditation but the
process has changed. To get exemplary status now you must meet all tests of compliance at the time of
survey. There is no added time to complete them as before.
ACU Plan
The Chief of Staff is now the medical director of ACU. The two major functions of the department are
procedures and consults. We will ensure that the right support is given to the right area and more intense
nursing support to other areas of the clinic.
Clinical Informatics
Interviews are to be conducted next week.
New Business
HQO Report Quality in Primary Care
This was attached to the package. The data will be used for the QIP.
There was discussion on discharge summaries. We are working to acquire edischarge.
December Meeting Date
The next meeting date falls on Dec. 23rd. There was discussion and it was decided to have the meeting on the
16th of December at 12:30 pm. It will be a working meeting with focus on the QIP.
Executive Reports
President & CEO
Nothing to report.
VP & Chief Nursing Officer
The Chief of Staff and VP CNO is working with the LHIN on Christmas and surge. The plan includes
administration, physicians and clinical staff.
We are doing some fine tuning to our surge policy.
Cancer Care Ontario
There will be a meeting with CCO regarding the proposal of having chemo drugs premixed at KGH and
administered at BGH so our patients do not need to travel.
We are researching the possibility of having a holding area for patients who are discharged but are waiting
for transportation home and if volunteers could assist in this process.
There were recent meetings with area retirement homes and our patient flow staff. Discussion included
being proactive and enlisting CCAC assistance when appropriate verses calling for an ambulance for certain
issues.
8.2.1 Ethics Committee Report
Dr. Elford was a guest speaker by videoconference at the last Ethics Committee. This was an informative talk
on how Providence Care implemented their Ethics program.
They do not have an Ethics Committee but a program that involves staff with assistance by an ethicist. As
staff use the program they eventually require less assistance from the ethicist.
8.3
Chief of Staff
Nothing to report.
9.0
Standing Items
9.1
QIP 2014/15 Quarterly Update-deferred.
9.2
Quality Stats/Quality Review/
Our Mission: A progressive community partner delivering an outstanding health care experience,
guided by the people we serve, provided by people who care.
OPEN MINUTES
QUALITY AND PATIENT CARE COMMITTEE
November 25, 2015 at 12:30pm
Library ~ Charles Street Site
9.3
9.4
9.5
10.0
11.0
12.0
These were distributed prior to the meeting for review. We will provide for details on past historic events at
the next meeting.
Sentinel Events Update-attached to package.
Pharmacy Update
There has been an offer of a full time pharmacy manager.
Clinical Review
Human Resources is managing the hours of reduction.
The lifts for med surg are ordered.
We are examining bed criteria for Med/Surg.
Staff schedules are still being worked on.
The RPN for the Emergency Department training has occurred.
The Resource team will be pushed back a bit. This will allow staff some needed time off over the holidays.
Information Items-none
Date of Next Meeting
Adjournment
MOTION: It was moved by W. Spencer/A. Khadra THAT the Quality and Patient Care Committee adjourn the
meeting at 1:51 pm. This motion was put to a vote and APPROVED.
Our Mission: A progressive community partner delivering an outstanding health care experience,
guided by the people we serve, provided by people who care.