TBRHSC Board of Directors Open Meeting Wednesday, November

TBRHSC Board of Directors
Open Meeting
Wednesday, November 4, 2015 – 5:00 pm Boardroom, Level 3, TBRHSC
980 Oliver Road, Thunder Bay
AGENDA
Vision: Healthy Together
Mission: We will deliver a quality patient experience in an academic health care environment that is responsive to the
needs of the population of Northwestern Ontario
Values: Patients ARE First (Accountability, Respect and Excellence)
#
Time
(X)
Presenter
Item & Purpose (Y)
Expected
Outcome (Z)
CONSENT AGENDA
6.2
6.3
6.4
6.5
6.6
6.7
7.0
7.1
7.2
N. Doucette
N. Doucette
N. Doucette
N. Doucette
Quorum (8 members total required, 6 being voting)
Conflict of Interest
Approval of the Agenda
Chair’s Remarks*
Information
5.0
5.1
5.2
5.3
6.0
6.1
1
1
1
1
Discussion
CALL TO ORDER
PATIENT STORY – Dr. Andrew Turner
Education
Recommendation
/Decision/Action
1.0
2.0
3.1
3.2
3.3
3.4
4.0
4.1
X
X
PRESENTATIONS/UPDATES
10
Dr. M. Henderson
A. Skillen
Occupancy Update*
Board of Directors: Approval of Minutes –October 7, 2015*
Report Volunteer Association Board*
Report Thunder Bay Regional Research Institute*
X
X
X
X
X
X
REPORTS AND DISCUSSION
10
Senior
Report from Senior Management*
Management
5
Dr. McCready
Report from the Interim President and CEO
2
G. Craig
Report from the TBRHS Foundation*
2
Dr. Thibert
Report from the Professional Staff Association
2
Dr. A. Turner
Report from the Acting Chief of Staff*
2
Dr. R. Crocker
Report from the Chief Nursing Executive*
Ellacott
2
Dr. P. MoodyReport from the Northern Ontario School of Medicine (NOSM)
Corbett
BUSINESS/COMMITTEE MATTERS
2
G. Walsh
Resource Planning Committee – October 20, 2015
7.1.1 Board Attestation: Wages and Source Deductions for Fiscal
Q2 2015-2016*
2
D. Mannisto
Quality Committee Meeting – October 20, 2015*
7.2.1 Research Quality Oversight Program*
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Page 1 of 2
#
Time
(X)
Presenter
Item & Purpose (Y)
Expected
Outcome (Z)
Information
Discussion
Education
Recommendation
/Decision/Action
8.0
8.1
8.2
9.0
10.0
11.0
FOR INFORMATION
Board Comprehensive Work Plan*
Webcast Statistics*
X
X
X
BOARD MEMBER COMMENTS
DATE OF NEXT MEETING – December 2, 2015 @ 6:00 p.m.
ADJOURNMENT
X
Ethical Framework
TBRHSC is committed to ensuring decisions and practices are ethically responsible and align with our mission/vision/values.
All leaders should consider decisions from an ethics perspective including their implications on patients, staff and the
community.
The following questions should be considered for each decision.
1.
Does the course of action put ‘Patients First’ by responding respectfully to needs & values of our patients, families, and
communities?
2.
Does the course of action demonstrate ‘Accountability’ by advancing a quality patient experience that is socially and
fiscally accountable?
3.
Does the course of action demonstrate ‘Respect’ by honouring the uniqueness of each individual and his/her culture?
4.
Does the course of action demonstrate ‘Excellence’ by fostering an environment of innovation and learning to advance a
quality patient experience?
For more detailed questions to use on difficult decisions, please refer to TBRHSC’s Framework for Ethical Decision Making
http://intranet.tbrhsc.net/Site_Published/i5/render.aspx?DocumentRender.IdType=5&DocumentRender.Id=110784
Page 2 of 2
BOARD OF DIRECTORS (Open)
November 4, 2015 – DRAFT
Agenda
Item
Committee or Report
Motion or Recommendation
Approved or
Accepted by:
3.3
Agenda – November 4, 2015
“That the Agenda be approved as circulated.”
Moved by:
Seconded by:
5.0
Consent Agenda
“That the Board of Directors:
5.1 Approves the Board of Directors Minutes of October 7, 2015,
5.2 Receives the Volunteer Association Board Report
5.3 Receives the TBRRI Report dated November, 2015,
Moved by:
Seconded by:
as presented.”
6.0
Reports and Discussion
“That the Board of Directors:
6.1Accepts the Report from Senior Management,
6.2 Accepts the Report from the Interim President and CEO,
6.3 Accepts the Report from the TBRHS Foundation,
6.4 Accepts the Report from the Professional Staff Association,
6.5 Accepts the Report from the Acting Chief of Staff,
6.6 Accepts the Report from the Chief Nursing Executive,
6.7 Receives the Report from the NOSM,
Moved by:
Seconded by:
dated November, 2015 as presented.”
7.1.1
7.2.1
Board Attestation: Wages and
Source Deductions Q2 2015/16
“That the Board of Directors accepts the Q2 2015-2016 Board Wages and
Source Deduction Attestation, as presented.”
Moved by:
Seconded by:
Research Quality Oversight
Program
“That upon recommendation from the Quality Committee, the Board of
Directors approves the Research Quality Oversight Program Governance
Framework, as presented.”
Moved by:
Seconded by:
1 of 1
Report from Nadine Doucette
Chair, Board of Directors
November 4, 2015
October is Breast Cancer Awareness month and TBRHSC’s participation began with the
23rd annual Tbaytel Luncheon of Hope. The event is an annual highlight of the Thunder
Bay Regional Health Sciences Foundation and this year was no exception. It featured two
inspirational speakers, Florence Strang and Susan Gonzalez, who emphasized the
importance of attitude in dealing with the challenges, fear and uncertainty that accompany a
diagnosis of breast cancer. The speakers were an integral part of this year’s luncheon, but,
as usual, the community and the attitude they bring to the event makes it. From all
accounts, this year was no exception. Whether it’s dancing in the aisles during the Bling
Blitz to the hearty laughs sometimes mixed with tears during the presentations, the
community again rose to make this not only an important fundraiser for the Northern
Cancer Fund but also a unique and memorable event for our guests. This is a wonderful
example of the essential work the Foundation does for our hospital.
Our Prevention and Screening Services team used Breast Cancer Awareness month to
encourage women between the ages of 50 and 74 to get regular mammograms and
highlighted the Screening Coach that brings this service to rural communities in
Northwestern Ontario.
October features a further highlight on the events calendar, the annual Balmoral Park Acura
Save a Heart Ball. This year’s event was particularly exciting given the news last June that
we will be moving ahead with a full cardiovascular surgical program at TBRHSC.
Acute Mental Health is one of the five strategic directions of our five-year plan and on
October 6th staff, patients and partners at TBRHSC recognized Mental Illness Awareness
Week by walking together to help raise awareness and reduce stigma surrounding mental
health and addictions.
The CEO Search Committee and search firm Promeus Inc. continue their work to find a
President and CEO. We have adjusted the timeline slightly for that work and initial
interviews are scheduled in November.
It will come as no surprise to anyone that we continue to face challenges with overcapacity
and gridlock. We are in regular contact with our system partners to find ways to
accommodate the growing numbers of ALC patients as we begin the transfer to the new
Hogarth Riverview Manor long term care home. We know full well that this puts extra
strain on our staff in an environment that is already challenging. I want to reiterate again
how appreciative we are of the excellent staff we have here at TBRHSC and the high
quality of work and continued commitment to Patient and Family Centred Care provided
under these often trying circumstances. That appreciation is equally deserving for our
hundreds of volunteers who provide irreplaceable help in performing our duties.
980 Oliver Road
Thunder Bay, ON
P7B 6V4
Thank you all.
We are Healthy Together.
Phone:
684-6007
Website:
www.tbrhsc.net
Nadine Doucette, Chair
Board of Directors
TBRHSC Bed Management Update:
September, October 2015
TBRHSC Board Meeting (Open Session) Presentation
Wednesday, November 4, 2015
Aaron Skillen
Program Director, Chronic Disease and Medicine Service, TBRHSC
Regional Director North West, Ontario Renal Network
1
Presentation Outline
1.
TBRHSC Beds for Admitted Patients
2.
September, October 2015 Admitted Patient Bed Use
3.
September, October 2015 Patient Flow Summary
4.
Patient Flow Strategy
a)
Physician Length of Stay Working Group
2
TBRHSC Beds for Admitted Patients
•
395 Funded
36 Not Funded
375 Beds
•
10 Medical Short Stay Unit beds (3TM) *temporary funding
•
8 Overflow beds (Surgical Day Care) *temporary funding
•
2 PCI recovery beds (IP Unit 2C, 290) *temporary funding
•
12 Treatment room beds
•
14 Patient lounges
•
10 Emergency Department
•
431 Maximum admitted patient beds
3
Admitted Patient Bed Use
(September, October 2015)
•
No additional inpatients in:
•
4 PCI recovery beds (2C, 290)
•
4 Surgical Day Care beds
•
4 Post-Anaesthesia Care Unit beds
•
4 Pediatric Outpatient beds
•
“Prior Day” Surgical Cancellations = 0
•
“Same Day” Surgical Cancellations = 2
•
PCI Cancellations = 0
4
2015-16 Patient Flow Summary
Indicator (Daily Ave.)
YE 14-15
September
October
(1-29)
YTD 15-16
ED Visits
288.2
301.0
302.0
294.6
ED Admits
30.2
32.3
31.8
31.1
10.5%
10.7%
10.5%
10.6%
Total Admits
52.5
57.2
54.7
54.0
Total Discharges
52.4
56.9
54.2
54.2
ALOS (excl. ALC)
5.85
Admitted Pt. Census
416
410
405
405
ALC Patients
61.4
57.9
63.1
57.2
Gridlock Days
28.0
23
20
19.3
ED Admit Rate
5.66
5
Patient Flow Strategy
•
2015-16 Quality Improvement Plan
•
•
Average Length of Stay (excluding ALC)
TBRHSC Strategic Plan 2020 – Comprehensive Clinical Care
•
Goal 3: Enhance access to clinical services supported by patient flow
efficiencies.
•
Objective 1: Internal patient flow efficiencies
• Patient Flow Strategy Steering Committee
• Physician LOS working group
6
Questions?
7
Thunder Bay Regional Health Sciences Centre
Board of Directors
Wednesday, October 7, 2015
Boardroom – 5:00 p.m.
Present:
Nadine Doucette, (Chair)
Dr. Bill McCready*
Dr. Penny Moody-Corbett
Dr. Rhonda Crocker Ellacott*
Gerry Munt
Dr. Mark Thibert*
Anita Jean
Doug Shanks
Dick Mannisto
Gary Whitney
Dr. Syed Zaki Ahmed* (Dr. Turner)
By Invitation – Senior Management:
Peter Myllymaa
Glenn Craig
Anne-Marie Heron
Dawn Bubar
Dr. Mark Henderson
Dr. Stewart Kennedy
Rod Morrison
By Invitation:
Angela Kutok Rec. Sec.
Tracie Smith (C. Pothier)
Jessica Nehrebecky
Hilary McIver (C. Covino)
Regrets Board of Directors:
John Friday
Georjann Morriseau
Grant Walsh
Dr. Andrew Turner*
Regrets Administration:
Cathy Covino
1.0
Chisholm Pothier
CALL TO ORDER – The Chair called the meeting to order at 5:00 p.m.
The Chair welcomed the Board members, Senior Management, guests and web audience.
Dr. Rhonda Crocker Ellacott, Executive Vice President, Patient Services and Chief Nursing
Executive (CNE), invited Board members and Senior Management to sign the Patient and
Family Centred Care (PFCC) board as a way to re-affirm and reinvigorate their
commitment to PFCC over the next five years of the Strategic Plan.
2.0
PATIENT STORY – Rod Morrison
Mr. Rod Morrison, Executive Vice President, Health Human Resources, Planning, and
Strategy, shared a video called ” Hands Only CPR” created by the British Heart
Foundation which conveyed the message that simple CPR can be learned by any one.
3.1
Quorum – Quorum was attained.
3.2
Conflict of Interest - None
Board of Directors Meeting – Open – October 7, 2015
* Denotes Non-Voting Member
Page 1 of 7
3.3
Approval of the Agenda
Moved by:
Seconded by:
Anita Jean
Dick Mannisto
Motion
“That the Agenda be approved, as circulated.”
CARRIED
3.4
Chair’s Remarks – for information
4.0
PRESENTATIONS
4.1
Environmental Compliance and Fire Safety Update
Mr. Peter Myllymaa, Executive Vice President, Corporate Services and Operations
provided an update on Environmental Compliance and Fire Safety Compliance.
The following was highlighted:
 Thunder Bay Regional Health Sciences Centre has no outstanding orders under the
Fire Code (as overseen by the Fire Department) or the Environment Protection Act
(as overseen by the Minister of Environment) and is not aware of any
non-compliance to the requirements of these legislations.
 A minimum staffing drill will take place on October 22, 2015 and fire inspection
will take place in October 15, 2015.
 The Ministry of Environment (MOE) has approved the TBRHSC submission for
environmental compliance in regard to the noise and air emissions from 1040 Oliver
Road as well as noise and air emissions from cyclotron-radiopharmacy.
 The Cyclotron has been approved for commissioning and Fire Plan sub-plans are
complete.
 The Ethylene Oxide sterilization equipment in the Supply Processing and
Distribution (SPD) department has not been in use since 2014 and poses no risks
while it is being decommissioned.
 The Co-Generation facility construction timelines are on target.
 TBRHSC submitted an update to the Ministry of Energy (MOE) which outlines the
TBRHSC energy reduction program under the Green Energy Act 2009. The next
update to the MOE is due on July 1, 2016.
5.0
CONSENT AGENDA
Moved by:
Seconded by:
Doug Shanks
Gerry Munt
Motion
“That the Board of Directors:
5.1 Approves the Board of Directors Minutes of September 9, 2015,
Board of Directors Meeting – Open – October 7, 2015
* Denotes Non-Voting Member
Page 2 of 7
5.2 Receives the Volunteer Association Board Report
5.3 Receives the TBRRI Report dated October, 2015,
5.4 Receives the Quality Committee Minutes of September 15, 2015,
as presented.”
CARRIED
6.0
REPORTS AND DISCUSSION
6.1
Report from Senior Management
The following information was highlighted from the report:
 The 6th annual Caring and Sharing Together Exhibition was held during the week
of September 28 to October 2, 2015.
 TBRHSC is presenting PFCC best practices at Canada’s Virtual Forum on Patient
Safety and Quality Improvement Conference in Edmonton on October 30, 2015.
 Dr. Rhonda Crocker Ellacott will be a presenter and panelist at the Health Quality
Transformation 2015 Conference on October 14, 2015.
 Ambulance offload times (AOT) have been provincially monitored since April
2010, with the current provincial average at 40.5 minutes (90th percentile).
 The North West Local Health Integration Network (NW-LHIN) has reported the
lowest ambulance offload time of eight minutes (90th percentile), and TBRHSC
Emergency Department leads the way with an ambulance offload time of six
minutes (90th percentile).
 As of September 15, 2015 all targeted regional hospitals are live with Regional
Critical Care Response (RCCR) Program.
 A paper titled “An e-Health Initiative Providing Equity as a Dimension of Quality
of Care” was submitted for consideration to Health Quality Ontario
Transformation 2015 and was selected as “TOP 5” presenter for rapid fire oral
presentation.
 The financial position of TBRHSC as at August 31, 2015 is a $2.3 million deficit
compared to a budgeted deficit of $2.4 million and prior year deficit of $3.7 million.
 Budget process planning and consultations for the 2016-2017 budget cycle has
begun.
 TBRHSC was a finalist in a national awards program focusing on Human
Resources Strategy.
 Influenza season will be upon the community shortly. TBRHSC has already had
one confirmed case if influenza in the hospital.
 The Communications Department held a media event highlighting the Combined
Heat and Power (CHP) co-generation plant.
 An Aboriginal patient satisfaction survey will be implemented to identify areas for
improvement and to measure the impact of the Aboriginal Health Strategic
Direction.
 The Help Desk receives over 30,000 calls annually largely attributed to password
issues. As such, a Request for Proposal (RFP) for a self serve password resets will
Board of Directors Meeting – Open – October 7, 2015
* Denotes Non-Voting Member
Page 3 of 7




be underway.
Finalization of a revised Research (Admin 13) policy and a new joint Intellectual
Property policy is nearing completion.
Staff are working with a medical device company, XLV Diagnostics Inc., to
ascertain the feasibility of opening a clinical trial in Thunder Bay to test their new
digital mammography technology.
Presentations were held on Choosing Wisely which is a campaign to help
physicians and patients engage in conversations about unnecessary tests,
treatments, and procedures.
It is anticipated to have six psychiatrists on staff, with four in place by January
2016.
6.2 Report from the Interim President and CEO
The Interim President and CEO reported the following activities:
 TBRHS Foundation hosted a major donor breakfast reception on September 22,
2015.
 TBRHSC participated in a community walk around the Hospital grounds as a part
of the Northern Ontario School of Medicine (NOSM) 10th anniversary activities.
 A Senior Research Fellow from Australia, Dr. Matthew McCrail, visited TBRHSC to
discuss collaborations with NOSM.
 The Interim President and CEO met with the Medical Officer of Health regarding
reporting of infectious diseases.
 The Interim President and CEO attended a Canadian Academic Hospitals of
Ontario (CAHO) meeting in Toronto where discussions were held with the
Minister of Health regarding funding for hospitals.
 The Strategic Plan process continues with the development of indicators.
 A fundraising event encouraging philanthropy among medical staff was held in
September.
 Administrative and Medical Staff leaders participated in a webinar on disruptive
physician behavior.
 The Interim President and CEO presented at regional grand rounds regarding
PFCC, and attended an event with Patient Family Advisors (PFA), Volunteers, and
Staff.
 The Thunder Bay Regional Research Institute (TBRRI) strategic planning retreat is
planned for October 23, 2015.
6.3 Report from the Thunder Bay Regional Health Sciences (TBRHS) Foundation
The President and CEO of the TBRHS Foundation highlighted the following:
 On Tuesday September 22, 2015 the TBRHS Foundation launched their 'Missing
Piece' Campaign which is intended to highlight that without donors and
donations the TBRHSC would be missing vital pieces of equipment.
 The 22nd annual Tbaytel Luncheon of Hope will be held October 9, 2015.
 The Balmoral Park Acura Save a Heart Ball will be held on October 17, 2015 at
Board of Directors Meeting – Open – October 7, 2015
* Denotes Non-Voting Member
Page 4 of 7

the Victoria Inn. This gala event celebrates TBRHSC’s successes in cardiac care.
The Volunteer Association and Health Sciences Foundation have partnered
again this year to offer the Family CARE Grants.
6.4 Report from the Professional Staff Association - none
6.5 Report from the Acting Chief of Staff
The Acting Chief of Staff highlighted the following:
 The new Chief of Pathology, Dr. David Welbourne was welcomed.
 A Chief of Psychiatry recruitment is underway.
 The Length of Stay (LOS) data is being presented at all the section meetings.
 The Physician Quality improvement initiative project is ongoing.
6.6 Report from the Chief Nursing Executive
The Chief Nursing Executive highlighted the following:
 TBRHSC is hosting a Best Practice Champions Workshop on October 15 and 16,
2015 in order to maintain the deliverable of having 15% of the nursing staff trained
as Best Practice Champions.
 The Nursing Task Force has completed online voting to establish a color for the
standard nursing uniform resulting in a majority of votes cast for the blue uniform
top, together with a black pant. Next steps include the completion of an RFP to
identify a supplier for the top and the updating of the TBRHSC dress code policy.
 TBRHSC continues to work with our educational partners to support current and
future Registered Nurse (RN) graduates in the successful completion of the
National Council Licensure Examination (NCLEX) RN test.
6.7
Report from the Northern Ontario School of Medicine
The following was highlighted:







NOSM publicly launched its new 2015-2020 Strategic Plan, created in collaboration
with people and communities of Northern Ontario.
NOSM officially opened its 10th anniversary celebration by engaging communities
across Northern Ontario to “Be Active with NOSM.”
NOSM’s Francophone Affairs Unit is hosting the School’s 5th Francophone
Symposium at Laurentian University in Sudbury.
TVO’s upcoming The Doctor Can See You Now, is a documentary which examines
Northern Ontario health-care issues, and provides insight into how the NOSM is
addressing the chronic shortage of physicians in our region.
A Board of Directors meeting was held on September 23, 2015. Four new Board
members were appointed.
The Aboriginal Affairs Unit of NOSM held a historic Elder's gathering on the
traditional lands of Fort William First Nation.
Ray Hunt has been appointed as NOSM’s Chief Administrative Officer (CAO) and
Board of Directors Meeting – Open – October 7, 2015
* Denotes Non-Voting Member
Page 5 of 7


will start in this role on November 2, 2015.
NOSM and the NOSM Faculty Union announced the ratification of their fourth
collective agreement, covering full-time faculty, professional librarians, and
professional staff at the School.
NOSM’s Northern Ontario Dietetic Internship Program (NODIP) has received full
accreditation status from the Dietitians of Canada (DC) until 2022.
Moved by:
Seconded by:
Doug Shanks
Dick Mannisto
Motion
“That the Board of Directors:
6.1Accepts the Report from Senior Management,
6.2 Accepts the Report from the President and CEO,
6.3 Accepts the Report from the TBRHS Foundation,
6.4 Accepts the Report from the Professional Staff Association,
6.5 Accepts the Report from the Chief of Staff,
6.6 Accepts the Report from the Chief Nursing Executive,
6.7 Receives the Report from the NOSM,
Dated October, 2015 as presented.”
CARRIED
7.0
BUSINESS/COMMITTEE MATTERS
7.1
Resource Planning Committee – September 15, 2015
7.1.1
Board attestation: Wages and Source Deductions Q1 2015-16
The Board Wages and Source Deduction Attestation was presented to the Board of
Directors.
Moved by:
Seconded by:
Gerry Munt
GaryWhitney
Motion
“That the Board of Directors accepts the Q1 2015-2016 Board Wages and Source Deduction
Attestation, as presented.”
CARRIED
7.2
Corporate Membership
The updated 2015-2016 Corporate Membership list was received by the Board of Directors.
Moved by:
Seconded by:
Doug Shanks
Anita Jean
Board of Directors Meeting – Open – October 7, 2015
* Denotes Non-Voting Member
Motion
Page 6 of 7
“That the Board of Directors accepts the applications for membership to the Corporation
received for the period June 26 to September 28, 2015, as per the attached listing.”
CARRIED
7.3
Board Work Plan
The updated 2015-2016 TBRHSC Board Workplan was received by the Board of Directors.
Moved by:
Seconded by:
Motion
Gerry Munt
Dick Mannisto
“That the Board of Directors approves the Board Work Plan for 2015-2016, as presented.”
CARRIED
8.0
FOR INFORMATION
8.1
Board Comprehensive Work Plan – for information
8.2
Webcast Statistics – for information
9.0
BOARD MEMBER COMMENTS
10.0
DATE OF NEXT MEETING – November 4, 2015
11.0 ADJOURNMENT
There being no further business, the meeting adjourned at 5:47 p.m.
___________________________
Chair
___________________________
Board Secretary
_____________________________
Recording Secretary
Board of Directors Meeting – Open – October 7, 2015
* Denotes Non-Voting Member
Page 7 of 7
VOLUNTEER ASSOCIATION TO
THUNDER BAY REGIONAL HEALTH SCIENCES CENTRE
BOARD REPORT
Presented at the November 4, 2015 Board meeting
Our monthly board meeting was held on October 21, 2015.
The Vice President and Secretary of the board attended the Hospital Auxiliaries and
Associations of Ontario (HAAO) teleconference. Its purpose is to dialogue and share
information about the respective hospital Auxiliaries/Associations in the Superior
North District. At that conference, it was decided that all would meet in April in Fort
Francis.
Confirmation has been received that a committee to determine the recipients of the
Family Care grants has been selected. That process begins in late October.
Amendments to the guidelines for job descriptions for the members of the Volunteer
Board are ongoing. As well, the Board is developing a package to give to potential new
Board members. The application has been designed and accepted by the Board. As well,
an application has been placed on the hospital website for Board members.
Advertisements have been designed and posted for an Assistant Manager and part time
staff for Seasons. Our goal is to have a person in place for the Christmas season.
The Board invited the bookkeeper to this month’s meeting to educate all directors on
the financial standing of the Association.
“SUPPORTING PATIENT FAMILY CARE”
Respectfully submitted,
Margaret Power
Vice President, Volunteer Association
Thunder Bay Regional Research Institute Report
for TBRHSC Board – November, 2015
Submitted by: Dr. Bill McCready, Interim CEO – TBRRI and Interim President & CEO
– TBRHSC – October 28, 2015
Clinical Research Services Update
The Clinical Research Services Department is excited to welcome two new staff. On
October 19th Gordhan Jethoo joined the team as the department’s new Manager.
Gordhan has over nine years experience conducting Phase II-IV Clinical Trials. In
addition his skills fostering collaborative relationships with Research Ethics Boards
and his thorough knowledge of clinical trial regulations and guidelines will be a
valuable asset to the Clinical Research Services Department.
In addition, Daniel Horne will be joining the department as the Clinical Research
Services Compliance Coordinator on November 2nd. Daniel has a strong
background in compliance and has lead over 110 inspections for Health Canada’s
medical devices inspection program and completed over 240 compliance
verifications. In this role, Daniel will be responsible for ensuring the submission and
maintenance of ethics and regulatory documents for the department.
TBRRI New Strategic Plan Development
The development of the Research Institute’s 2020 Strategic Plan is well underway
and got a significant boost during the recent TBRRI Annual Retreat. On October 23rd
40 individuals representing the Board of Directors, Scientists, senior management
and members of the Strategic Plan Steering Committee met to identify a new
Mission, Vision, Values and Strategic Directions around which the new plan will be
formed. To kick off the day, the group heard from Dr. Vasanthi Srinivasan about “The
Shifting Research Landscape in Canada with a Spotlight on Patient Oriented
Research” and Dr. Tom Chau of Holland Bloorview Kids Rehabilitation Hospital
regarding “Families as Partners in Research”. The Foundation’s own Athena Kreiner
shared her personal patient story which inspired the group and stressed the
importance of research to help solve medical
mysteries. The TBRRI Strategic Plan Steering
Committee will take the findings from the retreat
and start planning a number of engagement
sessions to be held early in the New Year.
Cyclotron Update
Commissioning of the Cyclotron is nearing
completion. A training program has been
established for all staff who will be working in
the facility. The training is designed in
accordance with Canadian Nuclear Safety
Commission license requirements and covers
safety and operations. A procedure is in place
for designating staff as Nuclear Energy Workers
(NEWs). Market research is being conducted
by staff to help guide the timing of product
development. A public information session
will be held on November 11th at TBRHSC.
Facilitating Research Knowledge Transfer
On October 26th Dr. Mitch Albert and
associates Dr. Francis Hane, Marcus Couch and
Tao Li gave a presentation on “New advances in
hyperpolarized and inert gas MR lung imaging
and 129Xe biosensor MR”. MRI is a non-invasive
imaging modality for monitoring disease
progression and hyperpolarized agents can
improve the sensitivity of MRI for diagnosis and
treatment of disease by up to 100,000 times.
Unfortunately this technique uses gases and
polarizers that are very expensive. Imaging
using inert fluorinated gases is a technique that
has the potential to overcome this challenge.
Studies are showing that there is huge potential
and a wide range of applications for HP gas MRI
and inert fluorinated gas MRI in the diagnosis
and treatment of human diseases.
On September 25th, Dr. Chris Phenix made a presentation
to the Prostate Cancer Canada Network. Dr. Phenix spoke
about his research with probes and radiotracers and how
isotopes produced by our cyclotron can be used at TBRHSC
for imaging studies using Positron Emission Tomography.
Research is Making a Difference
An app is being developed right here in Thunder Bay that will help stroke patients.
Shayna Parker was recently awarded a $50,000 grant from the Ontario Brain
Institute to help develop a stroke recovery application that she is creating. Shayna
is working with TBRRI Scientist Dr. Jane Lawrence Dewar and is building this “brain
based training game designed for people who have had a stroke and lost some of the
function in their hands”. The app is meant to help individuals regain control over
motor functions in their hand.
Canada's Top 40 Research Hospitals
Once again TBRHSC has been named one of Canada’s
Top 40 Research Hospitals! TBRHSC ranked 35th for 2014
which is two spots higher than the prior year. Re$search
Infosource Inc. publishes this list annually and this year
noted that research activity at Canada’s leading health
research organizations rose by a combined 5% in fiscal
2014 compared with a 1.1% increase in 2013. They also
reported that for 2014, Ontario was home to 59% of all
research activity compared with 26.4% in Quebec and
11.2% in British Columbia.
Senior Management Report
to the Board of Directors
Thunder Bay Regional Health Sciences Centre
November 4, 2015
Corporate Services and Operations
Financial Services
 The financial position of TBRHSC as at September 30, 2015 is a $2.5 million deficit
slightly better than budgeted and forecast to be in line with budget at year end.
 Key patient activity is in line with budget and less than prior year. Paid staffing hours
continue to be over budget.
 Actuals for sick time and overtime continue to track over budget.
 The 2016-2017 budget planning cycle has begun and includes benchmarking facilitated
by external consultants.
Informatics
 Planning for the Data Centre relocation continues, with funding proposals with external
partners being developed.
Capital Planning and Operations
 TBRHSC has no outstanding orders under the Fire Code (as overseen by the Fire
Department) or Environment Protection Act (as overseen by Ministry of Environment) and TBRHSC is not aware of any non-compliances in regards to the requirements of
these legislations.
 The cogeneration project is in progress and on track. The project goal is for start up by
calendar year-end.
Research
Clinical Research Services Department
 Gordhan Jethoo has started as the new Manager of this department.
 Daniel Horne will join Nov. 2nd as the Clinical Research Services Compliance
Coordinator.
980 Oliver Road
Thunder Bay,
ON
P7B 6V4
Phone:
684-6007
Website:
www.tbrhsc.net
TBRRI New Strategic Plan Development
 Following the conclusion of the recent annual retreat, the Board adopted a new Mission,
Vision and Values along with some draft Strategic Directions that will be the foundation
of the new 2020 Strategic Plan.
 The TBRRI 2020 Strategic Plan Steering Committee will be organizing engagement
sessions to further develop the plan early in the new year.
Canada’s Top 40 Research Hospitals
 TBRHSC has once again been named one of Canada’s Top 40 Research Hospitals.
Communications & Engagement, Aboriginal Affairs & Government Relations
Media Events
 Mental Illness Awareness Week Walk
Page 1 of 4
Publications
 Chronicle Journal x 25
Aboriginal Affairs
 Health Links training for Aboriginal Lead and Patient Navigators
 Investigating funding for Cultural Sensitivity “Walk a Mile”
 Patient Satisfaction Surveys implemented at Wequedong Lodge
 Aboriginal Advisory Committee engagement regarding volunteer recruitment
Communications & Engagement Projects
 Engagement Session provided for TBRRI Strategic Plan 2020
 Continuing collaboration regarding respect. campaign
 Patient waiting area screens moving forward, content being established
 Accessible Forms and Communication Supports pilot project underway
 Engagement support to Regional Cancer Program and Prevention & Screening Services
 Public tours process
 New website performance assessment; website content review
 TBRRI website review
 TBRHSC Pride Committee to be established
Project Supports
 Regional Cancer Program
 Patient Services
 Regional Stroke Network
 TBRRI
Health Human Resources, Planning, and Strategy
Human Resources,Organizational Development, and Library Services
 The Studer Group met with Executives as a first step in the leadership development
implementation.
 Walk the Talk Selection Committee met on October 30th to select the 2015 award
winners.
Labour Relations
 COPE interest arbitration was completed on October 19th. An award is expected within
60 days.
980 Oliver Road
Thunder Bay,
ON
P7B 6V4
Phone:
684-6007
Website:
www.tbrhsc.net
Strategy & Performance Management and Decision Support
 The 2020 Strategic Plan implementation will launch officially in December, following
the HCM benchmarking and budget process.
Occupational Health and Safety
 Annual Influenza clinics will begin October 26, 2015. Booked clinics, booths in cafeteria,
roaming cart and appointments in departments will occur again this year.
Volunteer Services
 Work continues to recruit Aboriginal volunteers, including the ACE (Aboriginal Career
Exposure) Program to give students from Dennis Franklin Cromarty an opportunity to
learn about TBRHSC, career and volunteering options.
Page 2 of 4
Medical & Academic Affairs
Medical Affairs
 Dr. Richard Bitar accepted the position of Cancer Care Ontario Medical Lead for
Regional Breast Imaging.
 Dr. Amit Patel, a Nephrologist, joined the Professional Staff on October 5, 2015.
 Site visits completed in October include 2 Interventional Radiologists, 2 Psychiatrists, 1
Urologist, 1 Hospitalist and 1 Gastroenterologist.
 We are actively recruiting in the areas of Cardiology, Dermatology, Endocrinology,
Gastroenterology, Hospitalist Medicine, Neurology, Psychiatry, Vascular Surgery, and
Rheumatology.
Academics and Interprofessional Education
 The Choosing Wisely Canada Campaign was introduced to Senior Administration and
Physician Leadership with agreement to implement at TBRHSC.
 Initial research on utilizing simulation for quality initiatives has started. Specifically,
investigating how simulation can be used for Root Cause Analysis after a critical event
is under way.
Pharmacy - Medication Reconciliation
 The MedRec Admission overall rate was 61.3% for the month of September 2015.
 Follow up MedRec Education is being planned for nursing and physicians.
Regional Pharmacy Program
 Pharmacy will be seconding a Pharmacist to work as the Clinical Lead for the Regional
Pharmacy Program until March 31, 2016 as per the initiative.
Patient Services and Chief Nursing Executive
Patient Flow & Overcapacity
 ED meets length of stay (LOS) targets for non-admitted high acuity patients = 6.6 hrs
(target 7 hrs) and low acuity patients = 3.4 hrs (target 4 hrs) for September
 In September, an average of 19 admitted patients waited 28 hours in ED until they were
transferred to an in-patient bed (target 25-27 hours) re: hospital overcapacity
 Several targeted patient flow strategies are underway to address overcapacity and
improve patient flow
 2 surgical cancellations occurred during the month of September as a result of
overcapacity and delays in patient flow
980 Oliver Road
Thunder Bay,
ON
P7B 6V4
Phone:
684-6007
Website:
www.tbrhsc.net
Quality Based Procedure & Wait Time Strategy Funding Allocations
 2015/16 surgical volumes have been confirmed; year-end projections suggest all
targets are within reach
Regional Diagnostic Service
 Beginning in October 2014, TBRHSC initiated a Regional Transfer Nurse Process to
enable Regional hospitals to transfer stable admitted patients for pre-booked diagnostic
tests, unescorted, into the care of a receiving Regional Transfer Nurse (RTN) in our
facility.
 When patients arrive, the RTN assumes care of the patient until the test is complete and
EMS transfer has occurred. Since the project began, only 48 patients have utilized this
service = < 4 pts/month or about 25% of patients being referred into TBRHSC.
Page 3 of 4


Starting November 2, as a strategy to improve utilization, patient criteria has been
expanded to include select stable isolated patients for urgent diagnostic procedures.
It is expected that with this expansion in patient criteria, volumes may increase to > 15
pts/month, or 75% of regional diagnostic transfers.
Patient Services and Cancer Care Ontario
Comprehensive Cardiovascular Surgical Program
 We continue to await funding approval from the Ministry of Health and Long-Term Care
for 2015/16 operating funds.
Psychiatry Services
 After many years of providing Psychiatric care at TBRHSC, our Chief, Dr. Lois
Hutchinson, will be retiring next month. The recruitment efforts to increase our
Psychiatrist complement continues and we are hopeful that we will begin to grow in
numbers by January 2016. This will then see the beginning of many strategic initiatives
that are related to Psychiatrist resource requirements including the development of a
Psychiatric Consultation Liaison service.
Quality and Risk Management
Ethics
 The Ethics Framework, developed in 2014 and located at the bottom of agendas, was
evaluated over the winter/spring and results were analyzed over the summer. A report
was produced and presented to Senior Management. Results indicated:
o The majority of respondents (88%) were aware of the framework. Those who used
the framework rated their experience positively.
o Overall those who used the framework rated their experience positively.
o The majority of respondents found the framework helpful and would choose to use
it on an ongoing basis to help guide decision-making.
o Opportunities for improvement include: increasing awareness of the more detailed
supporting document available online, as well as increasing familiarity and comfort
using the framework through manager training.
 Feedback was provided on the Pandemic Plan.
 The Bioethicist actively participated in the Strategic Direction workgroup on Seniors
Health over the summer. The delivery of ethical care that protects the autonomy, choice,
and diversity of senior patients, through their active involvement in the development of
care plans, as well as advance care planning, are objectives for which ethics will hold
primary responsibility over the coming five years.
Emergency Preparedness
980 Oliver Road
Thunder Bay,
ON
P7B 6V4

Phone:
684-6007

Website:
www.tbrhsc.net


The second annual Minimal Staffing Drill was conducted with the Thunder Bay Fire
Department on Oct. 22, 2015.
The entire facility was involved to a degree but this year’s units of focus were 3A and
3B.
The drill simulates a code red that develops into a code green, staff are evaluated on
their ability to move Patients out of danger in a timely manner.
Volunteers and staff participated and three Fire Department Officials were on site to
evaluate and time the exercise.
Page 4 of 4
Chief of Staff Report
to the
Board of Directors
Thunder Bay Regional Health Sciences Centre
November 2015
Chief of Staff
Physician Length of Stay Working Group
 A formal presentation and introduction to the data reports from Health Records has
now been completed at all relevant section meetings
 Two new reports are being developed to capture equivalent length of stay data for
psychiatry in-patients and physician related ready for discharge data being captured by
Medworxx
 The working group continues to strategize on ensuring physician groups have the right
information they need to work towards reducing lengths of stay
Thanksgiving Thank You
 A sincere thank you to Dr. Jehan Zaib from our Hospitalist program and her generous
donation of coffee and tea for all TBRHSC staff working Thanksgiving Monday morning
Choosing Wisely Canada
 Information on the Choosing Wisely Canada campaign was shared with members of the
MAC and the committee endorsed the adoption of the campaign at TBRHSC
 This is a campaign to help physicians and patients engage in conversations about
unnecessary tests, treatments, and procedures to help physicians and patients make
smart and effective choices to ensure high-quality care
Incomplete Records
 A new option through Meditech for a more efficient way of notifying Professional Staff
that they have records ready to be completed was endorsed at the September MAC
 This should help improve compliance with timelines for record completion by
Professional Staff
980 Oliver Road
Thunder Bay,
ON
P7B 6V4
Phone:
684-6007
Website:
www.tbrhsc.net
Page 1 of 1
Chief Nursing Executive
Report to the
Board of Directors
Thunder Bay Regional Health Sciences Centre
November 2015
Chief Nursing Executive – Open Report
Fall Prevention
 The falls rate/1,000 patient days are calculated utilizing the safety reporting tool. Although
the completion of a safety report is required with each patient fall, this does not always occur,
leading to a fluctuation in the reported falls rate. Over the past several years, the falls rate
has seen a low of 3.7/1,000 patient days to the current high of 6.03/1,000 falls.
 Recently, we have trialed a falls reduction strategy on 1 unit, with current spread to
additional in-patient units. The strategy emphasizes the need to complete safety reports and
accurately document falls, while better assessing for fall risk, and implementing falls
prevention tactics. As a result of our efforts, there has been a corresponding increase in the
number of falls reported, while the number of critical falls has dropped to zero.
 Q1 of 2015-16 has the highest number of falls/1,000 patient days, with a corresponding
decrease in critical falls for the same quarter.
Pressure Ulcer Prevention and Management
 On October 21 and 26, 2015, a pressure ulcer prevalence and incidence study was completed
on all adult in-patients (excluding AMH, Forensics and Maternal/Child nursing units).
 When compared to results from October 2014, both our prevalence and incidence have
decreased.
o 2014: Prevalence = 31%, Incidence = 18%
o 2015: Prevalence = 14%, Incidence = 4%
 Over the last year, there has been extensive staff education related to the identification of
risks related to pressure ulcer development, prevention and management techniques, as well
as the introduction of Wound Wednesday and Wound Rounds.
 Chart audits demonstrate that the compliance with documentation of the Braden Risk
Assessment Scale has improved from 5% a year ago to over 90% in previous months.
980 Oliver Road
Thunder Bay,
ON
P7B 6V4
Patient Family Centre Care
 TBRHSC received honorable mention for the Champion Awards by the Canadian Patient
Safety Institute (CPSI) Forum in two categories:
- Organizational – Patient Advisory Council
- Individual – Keith Taylor, PFA
Phone:
684-6007
Website:
www.tbrhsc.net
Page 1 of 1
Thunder Bay Regional Health Sciences Centre
Quality Committee of the Board
October 20, 2015
Administration Boardroom – 4:30 – 6:30 p.m.
Present:
Georgia Carr, Dr. Rhonda Crocker Ellacott, Anita Jean, Dick Mannisto,
Dr. William McCready, Georjann Morriseau, Gerry Munt, Dave Van Wagoner,
Gary Whitney
Regrets: Nadine Doucette
By Invitation: Cathy Covino, Senior Director, Quality and Risk Management,
Michael Del Nin, Manager, Decision Support,
Anne Marie Heron, Vice President Research and Acting Chief
Administrative Officer, TBRRI,
Hilary McIver, Manager, Infection Control and Risk Management,
Wendy Lange, Rec. Sec.
1.0
CALL TO ORDER – The Chair called the meeting to order at 4:33 p.m.
1.1
Quorum – Attained.
1.2
Conflict of Interest – None.
1.3
Approval of the Agenda
Moved by:
Seconded by:
Anita Jean
Dave Van Wagoner
“The agenda was approved, as circulated.”
Motion
CARRIED
2.0
PRESENTATIONS/REPORTS
2.1
Infection Prevention and Control Presentation
Ms. Hilary McIver, Manager, Infection Prevention and Control and Risk Management gave
the Infection Prevention and Control presentation.
The Infection Prevention and Control Committee ensures there is a current and quality
infection prevention and control program which improves patient care outcomes and
protects patients, staff, visitors, and the community from nosocomial infections.
Quality Committee of the Board – October 20, 2015
Page 1 of 6
The patient safety indicators include hand hygiene compliance, clostridium difficile
infection rates (CDI), methicinillin-resistant staphylococcus aureus rates (MRSA),
vancomycin-resistant enterococci rates (VRE), ventilator-associated pneumonia rates
(VAP), central line-associated primary blood stream infection rates (CLI), and surgical site
infection (SSI) prevention rates in hips and knee joint replacement surgeries. The data for
these indicators were reviewed.
Improvements include new directives for extended-spectrum beta lactamase (ESBL) and
clostridium difficile (C. Diff), VRE and MRSA research, Registered Nurse/Registered
Practical Nurse conversions, new software programs, patient letters to state their isolation
is discontinued, new equipment, auditing rooms upon discharge, and the surveillance of
catheter –associated urinary tract infections.
Infection Prevention and Control currently monitors the air with Maintenance and also
ensures the proper cleaning of filters takes place before and after any construction at the
hospital.
A suggestion was made to add to the next presentation a sense of impact scale, where the
hospital could be in the next three years, and how our Thunder Bay Regional Health
Sciences Centre (TBRHSC) compares provincially.
2.2
Research Quality Oversight Program Governance Framework
Ms. Cathy Covino, Senior Director, Quality and Risk Management gave the Research
Quality Oversight Program Governance Framework presentation along with Anne Marie
Heron, Vice President Research and Acting Chief Administrative Officer, Thunder Bay
Regional Research Institute (TBRRI).
A system level review of governance and research processes between TBRHSC, TBRRI,
and the Research Ethics Board (REB) was facilitated by Pierre Deschamps in May 2014.
Ten Recommendations were determined to address gaps in governance, communication,
roles, and responsibilities.
A plan was developed for a phased implementation of the recommendations including
Phase 1: Priority setting and REB Redesign, Phase 2: Developing a Research Quality
Oversight Framework, and Phase 3: Process, Policy, and Implementation by the
Operations Training Working Group.
There is a need for a quality structure and reporting mechanism for TBRRI and TBRHSC.
An engagement of ownership was needed with respect to certain policies and procedures
as well as a need for policy consistency between TBRHSC and TBRRI. There were an
absence of formal policies and clear lines of communication. A refinement of roles and
responsibilities was required.
Quality Committee of the Board – October 20, 2015
Page 2 of 6
The key recommendation was to develop a comprehensive governance framework to
guide and enhance high level research. The Governance Working Group conducted an
environmental scan by conducting a peer review of other academic health sciences centres
to determine best practices and gap analysis
The TBHSC/TBRRI Research Quality Governance Oversight Proposed Model was
reviewed. The REB reports to the TBRHSC Board of Directors through the Quality
Committee of the Board.
The authority for decisions made by the REB is delegated by the TBRHSC Board of
Directors. The REB is delegated the authority to review the ethical acceptability of research
on behalf of the institution and on behalf of any institution that has an official board of
record agreement with TBRHSC.
Changes have been made to the Quality Committee of the Board Terms of Reference to
include patient related research oversight and their Work Plan now includes an annual
Research Report.
The proposed model has been endorsed by the TBRRI Science and Research Committee
and Governance and Nominating Committees, the Research Quality Oversight Program
Steering Committee, Medical Advisory Committee, the TBRHSC Quality Committee of the
Board, and the TBRRI Board.
Next Steps include the development and/or revision of policies, procedures, and terms of
references to ensure communication flow, reporting and accountabilities and the
development of a training program for internal and external individuals performing
research at TBRHSC and TBRRI that involves human subjects.
Moved by:
Seconded by:
Anita Jean
Gerry Munt
“The Quality Committee of the Board recommends that the Board of Directors approve
the Research Quality Oversight Program Governance Framework, as presented.”
Motion
CARRIED
2.3
Enterprise Risk Management and Risk Management Presentation
Ms. Covino gave the Enterprise Risk Management and Risk Management presentation.
The top 5 risks and mitigation strategies identified by Senior Management are:
1. Mental Health Psychiatry Resources
The lack of adult and child psychiatrists and mental health patients waiting in
inappropriate locations due to overcapacity in Emergency Department. A review
has been completed.
Quality Committee of the Board – October 20, 2015
Page 3 of 6
2. Finances/Budget
TBRHSC is underfunded and capital is being eroded which is a financial risk of
TBRRI sustainability. A hospital improvement plan has been submitted and lobbying for
increased funding has begun.
3. Overcapacity
The demand for services exceeds current resources; therefore, there is continued
potential risk and stress on staff and patients. Patient flow strategies including
standardized admission and discharge process, UMS changes are taking place.
4. Primary Data Centre Back Up
The current location of the primary data centre is a risk as there is potential for
water damage. A business case for new data centre is being developed with a plan to
include this in the 2016-17 capital budget. Discussions are on-going with partners to
explore funding opportunities.
5. Research
There is a lack of mechanisms to deal with quality issues. A research enterprise
initiative has been developed and the quality research project is underway.
When developing action plans to mitigate these risks there is a need to consider budget
implications, time frames with realistic target dates, available resources and additional
resources required, the addressing of risks in the strategic plan, and a continued risk
management cycle.
2.4
Quality Improvement Plan Excerpt from Board Scorecard Presentation
Mr. Michael Del Nin, Manager, Decision Support gave the Quality Improvement Plan
Excerpt from the Board Scorecard presentation.
The 2015-16 first quarter indicators were carried forward from 2014-15 with minor
revisions. The 2020 Strategic Plan indicators and related targets are in development with
the Board and Senior Management and the updated 2015-16 Board Scorecard that reflects
2020 indicators are expected in the third quarter.
Indicator data that are improving or better than target are infection rates for central lines,
infection rates for ventilated associated pneumonia, hand hygiene before and after contact,
the surgical safety checklist, patient and family centred care action plans, patient
satisfaction in overall care received for in-patients and the Emergency Department, patient
satisfaction in all dimensions combined for in-patients and the Emergency Department,
number of full time nurses, occupancy for all and select, and strategic plan activities on
target.
Quality Committee of the Board – October 20, 2015
Page 4 of 6
Indicator data that are worse than target or regressing are infection rates for C-Difficile,
medication reconciliation on admission, gross margin, sick hours as percentage of worked
hours, overtime hours as a percentage of worked hours, Emergency Department length of
stay, performance appraisal compliance, number of faculty and staff actively involved in
research, year-over-year growth of external research funding, and patient accruals to
clinical trials.
TBRHSC has begun planning for the 2016-17 Quality Improvement Plan.
2.4
Compliments, Concerns, and Comments Report
Ms. Covino gave the Compliments, Concerns, and Comments Report.
The Ontario Hospital Association has rolled out a new Patient Relations Toolkit. Many of
the templates included in the toolkit came from TBRHSC. Quality and Risk Management is
currently working on a compliance comparison with the toolkit which includes an appeals
process for concerns.
3.0
CONSENT AGENDA
A request was made that the REB minutes note if there was a conflict of interest on an item
or mark “none” if there was no conflict of interest.
Moved by:
Seconded by:
Dave Van Wagoner
Georgia Carr
“That the Quality Committee of the Board:
3.1 Approves the Quality Committee of the Board Minutes of September 15, 2015, as
presented,
3.2 Received the Research Ethics Board Minutes of June 22, 2015,
as presented.”
Motion
CARRIED
4.0
WORK PLAN - The Work Plan was discussed under item 5.2.
5.0
BUSINESS/COMMITTEE MATTERS – none.
5.1
Terms of Reference
The Terms of Reference revisions were reviewed.
The Vice President of Research at TBRHSC will be added to the membership of the
committee.
Quality Committee of the Board – October 20, 2015
Page 5 of 6
5.2
Work Plan
The Work Plan was reviewed.
Moved by:
Gerry Munt
Seconded by: Georgia Carr
Motion
“The Quality Committee of the Board recommends that the Governance Committee
approve the Quality Committee of the Board's Terms of Reference and Work Plan as
amended.”
CARRIED
6.0
FOR INFORMATION
6.1
Committee Meeting Evaluation – Committee members completed their meeting
evaluations.
7.0
BOARD MEMBER COMMENTS – none.
8.0
DATE OF NEXT MEETING – November 17, 2015
9.0
ADJOURNMENT - The meeting adjourned at 6:00 p.m.
Quality Committee of the Board – October 20, 2015
Page 6 of 6
Research Quality Oversight
Program
Anne-Marie Heron
Acting VP Research, TBRHSC/Acting CAO-TBRRI
Cathy Covino
Senior Director, Quality and Risk Management
Janet Northan
Senior Director, Strategic Partner Relations and Special Projects, TBRHSC/Director TBRRI
Quality Committee of the Board
October 20, 2015
1
Objective
• Present the TBRHSC/TBRRI Research
Quality Governance Oversight Framework
• Obtain TBRHSC Quality Committee of the
Board Endorsement
2
4 Accountabilities of Academic Health Sciences Centres
/ Research Hospitals in Ontario
Ontario’s research hospitals play a unique
and vital role in the province’s health care
system. In fact, they are traditionally
understood to play three roles: provide
Ontario residents with timely access to
advanced patient care services, train the
next generation of health care
professionals and conduct leading-edge
research. …..It is the integration of these
three roles that leads to a fourth
accountability to the system: acting as a
connector and partner with others in the
system, thereby building capacity for all.
CAHO Accountabilities for Research
Hospitals Report 2013
3
3
Background
 System level review of governance and research processes between
TBRHSC, TBRRI, and REB Board Members facilitated by Pierre
Deschamps in May 2014.
 Ten Recommendations were determined to address gaps in
governance, communication, roles, and responsibilities.
 Plan developed to implement recommendations (phased
implementation)
 Phase 1: Priority setting and Research Ethics Board (REB)
Redesign
 Phase 2: Developing a Research Quality Oversight Framework
 Phase 3: Process, Policy, and Implementation (Operations,
Training Working Group)
4
Consultant Report Gaps
 Need for a Quality Structure and reporting mechanism for TBRRI
and TBRHSC
 Engagement of Ownership needed with respect to certain policies and
procedures
 Need for Policy Consistency between TBRHSC and TBRRI
 Absence of Formal Policies
 Absence of Clear Lines of Communication
 Refinement of Roles and Responsibilites required
5
Key Recommendation
Comprehensive Governance Framework
6
6
Developing a Research
Quality Framework
 Governance Working Group convened to develop a
comprehensive research quality oversight framework
To guide and enhance high level research
 GAP analysis
 Environmental Scan
Peer Review of other academic health sciences
centres to determine best practice
7
7
TBRHSC/TBRRI Research Quality
Governance Oversight Proposed Model
8
Accountability Matrix
• Please refer to attachment
9
Endorsement
• TBRRI Science and Research Committee
• TBRRI Governance and Nominating
Committee
• RQOP Steering Committee
• MAC
• TBRHSC Quality Committee (supportive;
Approval of Vice President Research on
membership)
• TBRRI Board
10
Next Steps
Phase 3 – Process, Policy and Implementation
 Develop and/or revise policies, procedures, and terms of
reference to ensure proper communication flow, reporting
and accountabilities
 Develop Training Program – Internal and External
individuals performing research at TBRHSC and TBRRI
that involves human subjects
11
11
Phase 1
Recommendations
shared with
TBRHSC Board and
TBRRI Board
June 2014
Priority Setting
12
REB – Terms
of Reference
Sept 2014
TBRHSC
Quality
Program Integrate
Research
Timeline
Phase 2
Approval of
work plan
Oct 2014
Phase 3
Process Map
May 2015 June 2015
Comprehensive
Governance
Framework
Quality
Program
TBRRI
Sept 2015
Mirror Policies
and Processes
– TBRRI &
TBRRHSC
Nov 2015 Feb 2016
Comprehensive
Orientation
Program
TBRHSC &TBRRI
Recommendation
“That the TBRHSC Quality Committee recommends
that the Board of Directors approve the Research
Quality Governance Oversight Model as
presented.”
13
Questions?
14
14
THANK YOU!
15
Thunder Bay Regional Health Sciences Centre Board of Directors Comprehensive Work Plan
Updated: October 30, 2015
October
November
December
January
February
March
April
May
June
Activity
September
Accountability
Responsible
Body
#
As Needed
Legend:
BD: Board of Directors
EC: Executive Committee
Gov: Governance Committee
Nom: Governance/Nominating Committee
BL: Governance/By-Law Committee
Aud: Audit Committee
RP: Resource Planning Committee
Qual: Quality Committee
Colour Legend
Completed by target
In progress but not
completed by target
Not in progress, and not
x
x
x
x
x
x
x
x
x
Stakeholder Communication
Set up partnership meetings for the year
1 and Accountability
BD
x
2 Governance
Monthly education topics for the Board
BD
x
3 Oversight of Management
Participate in CEO evaluation via website
BD
x
4 Oversight of Management
5 Governance
BD
BD
x
6 Governance
Participate in COS evaluation via website
Approval of By-Laws
Approve Slate of Nominees to fill Board
vacancies
7 Oversight of Management
Approve CEO evaluation
BD
x
8 Oversight of Management
Approve COS evaluation
BD
x
BD
x
x
Comments
10 Legal Compliance
11 Legal Compliance
12 Quality Oversight
Approval of Committee terms of reference
and work plans
Environmental compliance and fire safety
update
Accessibility update
Critical Incidents Presentation
13 Oversight of Management
Physician recruitment plan update
BD
Performance Measurement
14 and Monitoring
Strategic plan update
BD
15 Quality Oversight
16 Quality Oversight
Research Ethics Board appointments
Research Ethics Board report
BD
BD
Scorecard update
TBRRI update
TBRHS Foundation update
Occupancy update
BD
BD
BD
BD
21 Oversight of Management
Evaluation of CEO
EC
x
22 Oversight of Management
Evaluation of COS
EC
x
9 Governance
17
18
19
20
Performance Measurement
and Monitoring
Governance
Governance
Governance
BD
June
May
April
March
February
January
December
November
October
September
Activity
As Needed
Accountability
Responsible
Body
#
Comments
x
BD
BD
BD
x
x
x
x
x
x
x
x
x
x
No new appointments this
year
x
x
x
x
x
x
x
x
x
x
**Note that the Committee work plans will be inserted into the comprehensive Board work plan once approved by the Board in December
x