MIDDLESEX HOSPITAL ALLIANCE
BOARD OF DIRECTORS MEETING
Wednesday, February 27, 2013
SMGH BOARDROOM
1730 hours
Present:
C. Waters (chair)
K. Williams
J. Aristone
R. Coe
F. Ellett
I. Haan
B. Montgomery
C. Osborne
D. Peddie
Ex-Officio:
J. Dreyer
P. Ferner
N. Naylor
P. Long
N. Maltby
Regrets:
D. Butler
N. MacLean
G
Guests:
T. Deruiter
L. McGill
D. Taves
C. Swan, Recorder
1.
PRESENTATIONS
Breast Assessment Program – Trish Deruiter, Director Diagnostic Services and Dr. Don Taves,
Radiologist
What is a Breast Assessment Program (BAP)?
 An Ontario Breast Screening Program (OBSP) is an initiative to improve access to care and surgical
treatment for women facing breast abnormalities.
 A model of care with funding assistance provided by Cancer Care Ontario (CCO) and accountability
reported to OBSP.
 The program is coordinated by a multidisciplinary team of breast health experts facilitated by a
primary contact (Breast Health Navigator).
What are the benefits?
 Improved customer service.
 Improved access to care.
 Improved quality of service.
Current State
 Solid team with breast focused expertise in place.
 SMGH has been a screening site since 2001 and shares some highly skilled technical
staff/radiologists/pathologists with London and maintains an excellent working relationship. In many
cases, we use the same equipment.
Financial Outlook

Operating costs are increased but offset by increase in CCO funding and revenue opportunity (OHIP
technical fees).
 Foundation is currently conducting a feasibility study to ascertain the need and interest to fund and
sustain the program. In the past, the Foundation has been responsible mainly for equipment. This
initiative encompasses sustaining a program which aligns with the MHA Strategic Plan.
Dr. Don Taves, a radiologist who provides service at SMGH provided an overview of the pathway and tests
that a patient with an abnormal mammogram would follow, explaining what equipment is used and the
benefits of each. This program would allow patients to have tests closer to home in a shorter timeframe,
which is a win-win for both the patients and the care givers. Quality indicators to measure success in breast
care are measured through OBSP. Dr. Taves is also associated with the Department of Radiology at SJHC
and SWOMEN and is the Cancer Imaging Program Lead for the SW LHIN.
MHA Board of Directors Meeting February 27, 2013
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Dr. Taves was questioned about a recent study which claims that breast screening does not help to save
lives. Dr. Taves is not in agreement with this statement as the program helps with early detection which
does save lives.
The Board Chair thanked Trish Deruiter and Dr. Taves for a very informative and educational presentation.
Accreditation 2013 – Laurie McGill, Accreditation Coordinator
Qmentum – What is it?
 Accreditation program introduced in 2008, MHA participated in 2010 survey.
 Features are updated with new standards, Quality Performance Roadmap, customized survey plan,
revised self-assessment and on-site survey process, performance measures and new accreditation
report.
 MHA on-site visit is scheduled for October 7-11, 2013.
 Accreditation 2013 Qmentum standards make it easy for health care organizations to embed
accreditation and quality improvement into daily activities. Standards are prioritized – Required
Organizational Practices (ROP’s) - and focus on safety and quality. During the accreditation survey, it
is mandatory to meet 32 ROP’s.
Governance Standards – 5 Key Functions
 Develop mission, vision and values
 Collect and use knowledge and information
 Develop the organization
 Build relationships with stakeholders
 Demonstrate accountability
Governance has no ROP’s but high priority criteria related to safety, ethics, risk management and quality
improvement. Two new standards around Ethics have been added for Governance.
Next Steps
Board members are asked to complete two Surveys online by March 15 - Governance Functioning Tool
and Self Assessment Questionnaire. The Quality Performance Roadmap will be generated from the
responses to the self-assessment survey. Responses to standards will be rated with red, yellow or green
flags. The responses will be reviewed by the Governance Committee in April.
The Board Chair thanked the Accreditation Coordinator for guiding the board through the process for the
2013 Accreditation review.
2.
3.
MOTION
BG: 37/12
CALL TO ORDER
The Chair called the meeting to order at 1845 hours.
APPROVAL OF AGENDA
A motion was made and seconded BE IT RESOLVED THAT:
The agenda be accepted as presented.
Carried
4.
DECLARATION OF INTEREST
The Chair stated that each board member must declare a conflict of interest at the appropriate time on any
item within the agenda that a member may have a vested interest.
5.
OPENING REMARKS
The Board Chair welcomed everyone to the meeting and provided the following updates:
 MPP Breakfast February 22
P. Long, Interim CEO and the Board Chair attended the MPP breakfast sponsored by the Strathroy
Chamber of Commerce. The MPP spoke about the PC party position on several topics. The Interim
CEO posed a question about funding and financial decisions made based on assumptions prior to
funding announcements. The MPP acknowledged the challenge however responded like the
opposition should!
 Board Annual Evaluation Surveys
The Chair congratulated the Board on 100% participation in the survey. Results will be reviewed by
Governance at the March meeting.
 Board Software Survey
MHA Board of Directors Meeting February 27, 2013
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
6.
Thank you to all who completed the survey. Answers are quite diverse. The CIO will present the
results at an upcoming meeting together with recommendations. The target date to have an improved
application for the Board package is September 2013.
The Board Chair welcomed new Director Bill Montgomery to the Board. Members of the Board
introduced themselves and welcomed Bill to the Board.
STRATEGIC ISSUES
6.1 2013/14 MHA Quality Improvement Plan – D. Peddie and N. Maltby
Year in Review
 Big Dot Indicator Implementation
 Health Quality Council consultation at OHA Health Achieve – very complimentary about the
MHA Quality Improvement Plan
 Significant accomplishments have been achieved by both sites. The Q3 Scorecard was reviewed
for SMGH and FCHS. The following indicators which are below the targets were discussed:
 Patient Centred

Patient Satisfaction- overall care – both SMGH and FCHS are yellow – new metric
for 12/13 target of 93% - SMGH at 88.75%, FCHS at 89.32%
 Patient Satisfaction - would you recommend – FCHS ED satisfaction slightly below
provincial average but is improving. (Smaller number of patients contributes to the
outcome.)
 Integrated – Alternate Level of Care - percentage of ALC/total inpatient days
 FCHS is below the target but this is contributed to a flu outbreak at one of the long
term care facilities in the area closed to new admissions. Another factor is the slow
response time experienced for assessments by CCAC.
2013-14 Quality Improvement Plan
 The 2013-14 QIP includes the same indicators as the 2012-13 QIP as well as the addition of two
new mandatory indicators; rate of in-hospital mortality following major surgery and medication
reconciliation completion on admitted patients.
The Quality Committee reviewed the draft 2013-14 Quality Improvement Plan at its February meeting
and recommends that the Board of Directors accept the Plan as presented.
MOTION
BG: 38/12
A motion was made and seconded BE IT RESOLVED THAT:
The Board of Directors accepts the recommendation of the Quality Committee to approve the
2013/14 Quality Improvement Plan as presented.
Carried
6.2 MHA Professional Staff Rules and Regulations – Dr. P. Ferner, Chief of Staff
The Bylaws for the merged Professional Staff were passed in June 2012 and became effective January
1, 2013. In consultation with legal counsel, merged Rules and Regulations were developed for the
medical staff, which outlines operational matters such as attendance at meetings, performance reviews,
annual reappointment, etc. The Rules and Regulations is a “living document” and will be amended as
required to reflect current practice. Related policies have been updated. The only outstanding issue
with the amalgamation is the appointment of the Chief of Rural Medicine, which should be finalized in
the near future.
The Governance Committee reviewed the MHA Professional Staff Rules and Regulations and
recommends to the Board that the document be accepted as presented.
MOTION
BG: 39/12
A motion was made and seconded, BE IT RESOLVED THAT:
The Board of Directors accepts the recommendation of the Governance Committee to approve the
MHA Professional Staff Rules and Regulations as presented.
Carried
7.
BUSINESS ARISING
There was no business arising.
8.
CONSENT AGENDA
Items listed on the Consent Agenda were included with the Board package.
MHA Board of Directors Meeting February 27, 2013
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MOTION
BG: 40/12
A motion was made and seconded, BE IT RESOLVED THAT:
All Consent Agenda items, motions and recommendations be accepted as presented.
Carried
9.
COMMUNICATION/MESSAGES
There will be no release for the February board meeting. A release about the new orthopaedic surgeon, Dr.
Chris Chant, and the orthopaedic program is the next scheduled media release.
10.
CORRESPONDENCE AND ANNOUNCEMENTS
Packages were distributed to the Board members from the SMGH Foundation providing information on
upcoming events including the OHA Executive Golf Tournament scheduled for July 10, 2013.
11.
IN CAMERA SESSION AND REPORT
MOTION
BG: 41/12
A motion was made and seconded BE IT RESOLVED THAT:
The Board convenes to an in camera session to discuss Personnel Matters.
Carried
P. Long, N. Maltby, Dr. N. Naylor and C. Swan left the meeting.
MOTION
BG: 42/12
A motion was made and seconded, BE IT RESOLVED THAT:
The Board rise out of camera.
Carried
No report was submitted.
12.
ADJOURNMENT
The meeting adjourned at 2000 hours.
13.
INDEPENDENT DIRECTOR SESSION
There was no independent director session following the regular meeting.
Cheryl Waters
Board Chair
Paul Long
Interim CEO & Secretary
MHA Board of Directors Meeting February 27, 2013
Cathy Swan
Recording Secretary
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