Open Board Minutes - Thunder Bay Regional Health Sciences Centre

Thunder Bay Regional Health Sciences Centre
Board of Directors
Wednesday, May 2, 2012
Boardroom – 5:00 p.m.
Present:
Angèle Brunelle, Chair Andrée Robichaud* Gil Labine
Susan Fraser Jay Storeshaw Grant Walsh
Dr. Rhonda Crocker Ellacott* Karen McDaid (Audio) Sharon Cole Paterson
Steve Henderson Nadine Doucette Dr. George Derbyshire*
ACTION
By Invitation – Senior Management Team:
Dr. Michael Wood Michael Power Lori Marshall
Cathy Covino Scott Potts Tracie Smith
Bruce Sutton
Rod Morrison
By Invitation:
Carol Anne Aikman Rec Sec. Renée Laakso Mary Ann Mountain
Nick Persichino
Josh Liswood
Dr. William Hettenhausen (for President, Professional Staff Assoc.)
Regrets – Board Members:
Dr. Roger Strasser, Sandra Cornell,
Dr. Suzanne Allain*
Regrets – Administration:
Dr. Gordon Porter, Janet Sillman
1. CALL TO ORDER - The Chair called the meeting to order at 5:06 p.m.
Presentation – Credentialing of Professional Staff – Josh Liswood, Miller Thomson, LLP
Mr. Josh Liswood from the law firm of Miller Thomson, LLP, provided a presentation on
the Credentialing of Professional Staff and Legal Issues. The following information was
highlighted:
‣ Public Hospitals Act (s. 36) – Empowers Board to appoint and re-appoint physicians.
‣ Reg. 965 (s. 4) – Board shall pass by-laws that provide criteria for appointment & reappointment
of medical staff & procedures for appointing Chief of Staff & Dept. Chiefs.
‣ Medical Advisory Committee (s. 35) – Every Board establishes a Medical Advisory
Committee which makes recommendations re: appointment and re-appointments.
‣ Sources of Directors’ Responsibilities – Common law governing corporations; Ontario
Corporations Act; Public Hospitals Act; and the By-Laws of the hospital.
Dr. Wood joined the meeting 5:20
‣ Comprehensive Credentialing Policy – Board policy must address responsibilities
related to New Applications; Criteria for appointment; Alteration of privileges; Ongoing
review of quality of care by privileged physicians. The policy is approved by the Board
and delegated to the Medical Advisory Committee.
‣ Appointment Disputes (Foundation for Review) – Competency and quality of care;
Resource availability; Collegiality/Disruptive behavior.
‣ Appointment Disputes – Directors are tribunal members.
‣ Remediation – Require comprehensive complaints process.
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* Denotes Non-Voting Member

Dr. Crocker Ellacott was excused from the meeting – 6:00 pm.
Presentation – Performance Management Cycle – Lori Marshall
Ms. Marshall, Executive VP Strategy, Performance & Aboriginal Health, provided an
overview of the TBRHSC Annual Planning & Performance Management Cycle. A one-page
summary was distributed for review.
2. APPROVAL OF AGENDA
Moved by: Susan Fraser
Seconded by: Gil Labine
Motion
“That the Agenda be approved as circulated.”
CARRIED
2.1 Conflict of Interest – None.
2.2 Chair’s Remarks –
The Chair noted the following upcoming events:
‣ Volunteer Recognition dinner – May 3 rd , 6:00 pm, Victoria Inn
‣ Long Service Awards Celebration – June 13 th , 7:00 pm, Victoria Inn
‣ LHIN Governance-to-Governance Sessions – Attendees required for Fort Frances
Being the last Board meeting Michael Power would be attending before resigning, he was
acknowledged for his phenomenal leadership of the Regional Cancer Care Program over
the last 16 years and his key role in the development of the Thunder Bay Regional Research
Institute.
3. APPROVAL OF PREVIOUS MINUTES
3.1 Board of Directors - April 4, 2012
Moved by:
Seconded by:
Sharon Cole Paterson
Grant Walsh
Motion
“That the minutes of the Board of Directors meeting held April 4, 2012 in the Boardroom, be
approved as presented.”
CARRIED
4. REPORTS FROM OTHER BOARD MEETINGS
The following reports were circulated for information.
4.1 Lakehead University Report – n/a
4.2 TBRHS Foundation Report
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4.3 Volunteer Association Report
4.4 Medical Staff Association – President’s Report – n/a
4.5 Northern Ontario School of Medicine – Dean’s Report - Dr. Roger Strasser
4.6 Thunder Bay Regional Research Institute
5.0 Report from the President and CEO
The President reported on the following:
‣ April 12 th – MOH/LHIN Patient-Based Funding Engagement Session in Sudbury
‣ April 24 th - LHIN Governance-to-Governance session held in Thunder Bay
‣ Update on Strategic Plan will be presented at the Annual General Meeting
6.0 Chief of Staff Report – Dr. George Derbyshire
‣ The By-Law revisions were approved by Medical Advisory Committee and will be
reviewed by the Governance/By-Laws Committee.
‣ Consent Form – Reviewing confidentiality issues
‣ Long Service Celebration – Physicians are also being recognized at this event
7.0 Chief Nursing Executive
8.0 Reports from Senior Management
8.1 Senior Management Team Report
Corporate and Diagnostic Services:
‣ Financial Position - end of March 31, 2012 – deficit of $3.5M compared to $2.3M last year
‣ 2012/13 Operating Budget – LHIN provided 0.2% as indicative planning number. The
hospital is required to submit Operating Budget by May 29 th using this planning
assumption.
‣ Northwestern Ontario Supply Chain Management Collaborative launched April 18 th
‣ Diagnostics – MRI/CT Utilization Project – Sponsored by UHN
‣ Energy Performance Contract – Johnson Control Inc. completed energy efficiency study
Patient Care, Health Professions, CNE:
‣ Medication Reconciliation – Critical Care Services
‣ ED Pay for Results (P4R) Program
‣ P.A.R.T.Y. Program – Prevent Alcohol & Risk Relation Trauma in Youth
Strategy, Performance & Aboriginal Health:
‣ Program and Service Plan approval; Finalizing a new Corporate Balanced Scorecard
‣ Annual Report will be presented jointly with TBRRI
‣ Patient & Family Centred Care – Plans to look at formal consulting program
‣ IT/IS – Working with Bell Canada to implement patient/visitor internet access
‣ eHealth Ontario approved expansion to the Physician Office Integration Service
‣ eHealth Summit – In conjunction with the LHIN the Northwest Health Alliance is
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May 2, 2012

sponsoring a full day discussion on eHealth in NW Ontario
‣ Patient Safety – Focus on improvements in Medication/IV incidents
‣ Infection Prevention – Hand Hygiene compliance rates remain a challenge
Chronic Disease Prevention & Management:
‣ Diagnostic Assessment Program EPS receives Challenge Incentive Award
‣ National Oncology Nursing Day celebrated April 3 rd
‣ Cardiac Rehab adds Eighth Regional Satellite Program in Geraldton
‣ NWO Stroke Network Update
‣ TBRHSC & SJCG working toward Single Point of Entry for Community Mental Health
Services
Human Resources
‣ Dyad & SMT Leadership Training – scheduled for May 28 th and all day May 29 th
‣ Staff Safety Reporting – Number of reported incidents are up from last year - More
hazards are being reported, not only actual incidents.
‣ Volunteer Appreciation Dinner May 3 rd – ‘Celebrating their Passion, Action & Impact’
Medical & Academic Affairs:
‣ All graduating Clinical Clerks matched successfully to a residency program for this year
‣ New class of Clinical Clerks on site (final year of Medical School) starting May 14 th
‣ New Practice & Education system is being developed
‣ Hospitalist Program is moving to Chronic Disease Prevention & Management
Research:
‣ TBRRI developing a new Strategic Plan – to be presented to the Boards in the fall
‣ New Scientists – Jane Lawrence, Ph.D. and Samuel Pichardo, Ph.D.
‣ Research Grant of $1.6 M over six years awarded to Dr. Alla Reznik and team
‣ Dr. Mitchell Albert & team awarded NSERC Discovery Grant of $200K over 5 years
‣ Our scientists published in 21 peer-reviewed publications this year
Moved by:
Seconded by:
Steve Henderson
Gil Labine
Motion
“That the following Reports dated May 2012 be accepted as presented:
- the Report from the President & CEO
- the Chief of Staff
- the Report from the Chief Nursing Executive, and
- Report from Senior Management”.
CARRIED
9. MINUTES AND RECOMMENDATIONS FROM COMMITTEES
9.1 Resource Planning Committee – April 24, 2012 – Mr. Scott Potts
Mr. Potts, Executive VP, Corporate & Diagnostic Services, provided a brief summary of the
financial update provided to the Resource Planning Committee. The year finished with
revenue of $295M and expenses of approximately $297M. Very high occupancy levels have
contributed to the deficit position.
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10. BOARD MEMBER COMMENTS
11. BUSINESS ARISING
11.1 Corporate Membership List
Moved by:
Seconded by:
Steve Henderson
Nadine Doucette
Motion
“That the Board of Directors accepts the applications for membership to the Corporation
received for the period February 1 st to April 20, 2012, as per the attached listing.”
CARRIED
12. NEW BUSINESS – n/a
13. DATE OF NEXT MEETING – June 6, 2012 – 5:00 p.m.
14. ADJOURNMENT – The meeting adjourned at 6:26 p.m.
____________________________
Chair
___________________________
Board Secretary
_____________________________
Recording Secretary
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