HSN Public Package | Governance | Committee

Innover et servir de modèle d’excellence en matière de soins aux patientes et aux patients.

Leading and innovating for excellence in patient care

Board of Directors Conseil d'administration

Public and Media Package Séance publique

Tuesday, January 10, 2012 at 5:30 PM mardi le 10 janvier 2012 à 17h30

Northeast Cancer Centre Board Room, 4th Floor Ramsey Lake Health Centre, Health Sciences North Sudbury, Ontario

Our Vision
Leading and innovating for excellence in patient care.

Our Mission
As a regional hospital serving the residents of the City of Greater Sudbury and northeastern Ontario, we: Deliver high quality patient- and family-centered care, in both official languages; Provide reliable and timely access to care; Support the development of employees, medical staff, volunteers and students; Participate in research and the development and application of evidence-based practices; and Respond to changing needs and advocate for resources and services that promote health and wellness in the communities we serve.

We Value
Compassionate care Our employees, medical staff, volunteers and students and their quality of work life Respect for diversity Team work, collaboration and partnerships Learning, research and professional development Wise use of our resources Accountability within an integrated regional system A safe environment for our patients and all who work at Health Sciences North Open, honest and ethical communication and decision-making

Notre vision
Innover et servir de modèle d’excellence en matière de soins aux patientes et aux patients.

Notre mission
En tant qu’hôpital régional desservant les citoyennes et les citoyens de la Ville du Grand Sudbury et du Nord-Est de l’Ontario : Nous offrons des soins de première qualité centrés sur le patient et la famille, dans les deux langues officielles; Nous fournissons un accès fiable et opportun aux soins; Nous favorisons le perfectionnement des employés, du personnel médical, des bénévoles, des étudiantes et des étudiants; Nous participons à la recherche, au développement et à l’application de pratiques fondées sur des données probantes; Nous répondons aux besoins changeants et défendons les ressources et services qui font la promotion de la santé et du mieux-être dans les communautés que nous servons.

Nous valorisons
Des soins prodigués avec compassion; Nos employés, notre personnel médical, nos bénévoles, nos étudiants, de même que leur qualité de vie professionnelle; Le respect de la diversité; Le travail d’équipe, la collaboration et les partenariats; L’apprentissage, la recherche et le perfectionnement professionnel; Une sage utilisation des ressources; La responsabilité au sein d’un réseau régional intégré; Un environnement sûr pour nos patientes, nos patients et tous ceux qui travaillent à l’Horizon Santé-Nord; Une communication et une prise de décision ouvertes, honnêtes et éthiques.

HSN Board of Directors Open Session Meetings
Welcome
The Board of Directors is committed to being open and transparent to its shareholders by conducting its business in public through open board meetings. This is an opportunity for the Board of Directors to keep the public abreast of what is happening in their health care system. The meetings also create and promote an understanding of the role of Health Sciences North/Horizon Santé-Nord in the community and to emphasize the responsibilities of the Board and its decisionmaking process. The public is welcome to attend these meetings. Protocol for attending the HSN Board meetings: • • • • • • Members of the public and media are asked to be seated along the sides of the room. Cameras (with no audio) are permitted in the meeting. Tape recorders are prohibited during Board meetings. Members of the public and media are not permitted to ask questions or interrupt proceedings during the meeting. Members of the public and media will be excused from closed (in-camera) sessions. Members of the public and media will receive an agenda for open sessions, minutes from previous board meeting, presentation handouts, reports from the Chair and CEO, and committee reports. If media wishes to interview the HSN Board of Directors regarding matters related to the Hospital or to health care, the CEO and the Board Chair shall act as the HSN Board of Directors’ exclusive media spokesperson, unless otherwise delegated. Meeting Schedule
Meetings begin at 5:30 PM: September 13, 2011 October 11, 2011 November 8, 2011 December 13, 2011 January 10, 2012 February 14, 2012 March 13, 2012 April 10, 2012 May 8, 2012 June 12, 2012

Conseil d’administration de l’HSN Réunions
Bienvenue
Le Conseil d’administration entend être ouvert et transparent envers ses actionnaires en dirigeant ses affaires en public grâce aux réunions publiques du Conseil. C’est une occasion pour le Conseil d'administration de tenir le public au courant de ce qui se passe dans le système de soins de santé. De plus, les réunions créent et favorisent une compréhension du rôle d’Horizon Santé-Nord (HSN) dans la communauté et mettent en relief les responsabilités du Conseil et son processus décisionnel. Le public est invité à participer à ces réunions. Voici le protocole pour participer aux réunions du Conseil d’Horizon Santé-Nord : • • • • • • On demande au public et aux médias de s'asseoir autour de la salle. Les caméras (sans audio) sont permises durant les réunions. Les magnétophones sont interdits durant les réunions du Conseil. Le public et les médias n'ont pas le droit de poser des questions ou d’interrompre le déroulement de la réunion. Le public et les médias ne peuvent assister aux réunions à huis clos. Le public et les médias recevront un ordre du jour des réunions, le procès-verbal de la réunion précédente du Conseil, les documents de présentation, les rapports du président et du présidentdirecteur général ainsi que les rapports des comités. Si les médias désirent interviewer les membres du Conseil d’administration d’HSN sur des questions liées à l’établissement ou aux soins de santé, sauf indication contraire, seuls le président-directeur général et le président du Conseil en sont les porte-parole. Calendrier des réunions
Les réunions commencent à 17 h 30 : 13 septembre 2011 11 octobre 2011 8 novembre 2011 13 décembre 2011 10 janvier 2012 14 février 2012 13 mars 2012 10 avril 2012 8 mai 2012 12 juin 2012

HSN BOARD OF DIRECTORS OPEN SESSION AGENDA Date: Time: Place: Tuesday, January 10, 2012 5:30 PM Northeast Cancer Centre Boardroom, Level 4

Item

Topic

1.0

Call to order • Declaration of Conflict of Interest Board Education 2.1 Capital Redevelopment Approval of Minutes 3.1 Minutes of December 13, 2011

M. McCann

2.0

J. Pilon

3.0

M. McCann 4.0 Ensure Program Quality and Effectiveness 4.1 Accreditation – Sustainable Governance Standards J. Pilon 5.0 Items for Information 7.1 Report of the Chair 7.2 Report of the CEO 7.3 Report of the Chief of Staff 7.4 Report of the President of the Medical Staff Other Business Adjournment

6.0 7.0

Capital Redevelopment Plans
January 2012

What is a Capital Redevelopment Plan
The plan provides a comprehensive strategy for the long‐term  redevelopment of Health Sciences North (HSN). It identifies appropriate facilities for areas defined in the Master Program  with a focus on the priority programs within HSN’s mission, vision and  strategic plan. It provides a framework for converting the requirements set out in the Master Program into physical reality over a twenty year time‐span. The purpose of this long term approach is to ensure that the next phase of  development does not cause waste of capital dollars or impede later  development phases.

Key Drivers for Our Plan
Our Academic Mission  The shift to Ambulatory Based Care  The development of a Paediatric Centre of Excellence  Improving access to general rehabilitative care, an under‐resourced program in  the Northeast Ontario Consolidation of our mental health programs from the Kirkwood site Space shortfalls resulting from scope and service changes as the new hospital  was being designed

Capital Redevelopment Plans

Parking Structure

Parking Structure

Parking Structure
750 Parking Spaces Located in the South Parking Lot Planning a link to the Hospital at Level 2 An own funds capital project funded through parking  revenues RFP issued in December

Pediatric Centre of Excellence

Pediatric Centre of Excellence (PCE)
The Centre will provide for health care needs that are currently unmet, under‐met or for which children and their families need to  go outside the region.  The PCE will offer a significant co‐location of pediatric services  that provides a major enhancement to our learners opportunities  and provides increased ability to establish new programs aimed  exclusively at the child and youth of North eastern Ontario We will offer a full continuum of ambulatory, day surgical and  medical service, specialized pediatric clinics and children’s  medical and mental health programming, crisis and eating  disorder beds. Initial phase will develop the ambulatory component.

Mental Health/Post Acute Tower
Mental Health Beds increased according to population impact ‐ 72 beds for adult  psychiatry beds Bringing together those currently in the main hospital site and the  inpatient beds at the Kirkwood site (former NEMHC program) Continuation of Primary Mental Health consultation on main campus Establishes a partial hospitalization program as a transition step to  outpatient or from outpatient to inpatient

Mental Health/Post Acute Tower

Post Acute Care HSN’s current Specialized Rehabilitation Program will be expanded to  include General Rehabilitation.  The current General Rehabilitation bed‐to‐population ratio for the  northeast is the lowest in the province and is contributing to back‐ups in  the acute beds as those patients needing post‐acute short term  rehabilitation services can be difficult to transfer into the existing Rehabilitation beds. 

Research Tower
The Research Institute will an Independent not for profit Research  enterprise. A building with an initial phase of 50,000 square feet that can be  expanded to 100,000 square feet Anticipates staffing of 12 senior scientists and 80 technical and  scientific staff Will become an internationally recognized health research center in the translation of early medical technologies  Project to increase external funding to 20 million dollars per year  by 2020 Expected to increase research output by 2020 to 5 times from  levels seen in 2011

Ambulatory Care Centre
Ongoing development of ambulatory care as the preferred approach to  service delivery wherever possible;  Initiatives include:  •Significant enhancement to Medical Day Care capacity,  •An integrated Eye Suite,  •Enhanced capability and capacity for procedures on a day basis •Clinical Decision Unit •Geriatric Day Hospital •Asthma •Anticoagulation •COPD •Congestive Heart Failure

Next Steps
1. Review and Approval of Strategic Options and Business  Case by Building , Facilities and Long Range Planning  Committee – January 2012

2. Review Business Case with LHIN – February 2012

3. Submit Business Case to MOHLTC – April 2012

HSN BOARD MEETING MINUTES December 13, 2011 5:30 PM RCP 4th Floor Board Room Open Session Voting Members Present: Boyles, Russ (Chair) Bald, Roberta Byck, Peter Everest, Nicole Fildes, Deborah McCann, Mike Voting Members Excused: Burgess, Mark Prudhomme, Rachel Non-Voting Members Present: Bourdon, Dr. Chris Roy, Dr. Denis Non-Voting Members Excused: Prpic, Dr. Jason Staff: Pilon, Joe Petersen, Ben Hartman, Mark Antoine, Sharon

Petrovic, Stephen Pitblado, Roger Marsh, Dr. David Spencer, Jean-Marc Toffanello, Paul

Sawyer, Patrice

Zalan, Dr. Peter

McNeil, David Lapointe, Viviane Watson, Rhonda

Recorder: 1.0

CALL TO ORDER R. Boyles welcomed everyone and called the meeting to order at 5:34 p.m. APPROVAL OF AGENDA The agenda was accepted as circulated with no conflicts of interest being declared.

2.0

BOARD EDUCATION 2.1 Northeast Community Care Access Centre North East Community Care Access Centre CEO Richard Joly, Board of Directors Chair Ron Farrell and past chair Tom Trainor were welcomed to the meeting. They presented an overview of the NECCAC governance model - vision, mission, values and strategic direction; highlighted some of the NECCAC projects undertaken and the future of home care.

Board of Directors Meeting (OPEN) December 13 2011

2

R. Joly reported that the Home First and Integrated Discharge Planning programs have been successful. A 20% increase in demand for homecare over the last 16 months is presenting a significant challenge to sustaining these strategies. NECCAC is looking at different ways of delivering care in the community within available resources. Telehome Care was introduced as a pilot project this week. A new client care population based model has been developed. In the last 12 months NECCAC has seen 1000 less clients from the well category and 1000 more clients in the complex category. Programming will be adjusted to match the population need. R. Boyles thanked R. Joly, R. Farrell and T. Trainor for an informative presentation. He added that HSN understands their resource issues and looks forward to working together on future initiatives. 3.0 APPROVAL OF MINUTES R. Boyles asked the Board to approve the minutes from the November 8, 2011 open session meeting. MOTION: R. Pitblado / D. Fildes THAT the minutes of the Board of Directors open session meeting held on November 8, 2011 be adopted as circulated. CARRIED 4.0 ENSURE PROGRAM QUALITY AND EFFECTIVENESS Quality Committee 4.1 Report from the Quality Committee The report from the Quality Committee was received for information. N. Everest highlighted items on the report. The Quality Committee spent a considerable amount of time discussing the quality framework, indicators and the reporting matrix. Short-term and longterm solutions to simplify the quality scorecard and increase its effectiveness to Quality Committees and programs were reviewed. The new reporting format will be implemented in January. The quality scorecard and monitoring report for period ending November 2011 were reviewed. ED wait times continue to be highlighted as a concern. MRI and CT Scan have identified process and workflow improvements that translate to a 20% increase in efficiency. The hospital submitted a system improvement plan to the LHIN in January 2011. The LHIN has requested the resubmission of an updated plan. Health Quality Ontario (HQO) published the new Quality Improvement Plan Guidance document. One new dimension “Integrated” has been added to

Board of Directors Meeting (OPEN) December 13 2011 the Quality Improvement Plan. D. Barnard presented the proposed approach for the development of the 2012-2013 Quality Improvement Plan. The committee received an update on accreditation. The self assessments and Governance Functioning tool will be administered to the Board of Directors in January 2012. An education plan covering key elements of information Quality Committee members need to know or be aware of to help them make more informed decisions is being developed. Education content suitable for the full Board will be brought forward to the Governance and Nominating Committee for consideration. 5.0 ENSURE FINANCIAL VIABILITY Finance Committee 5.1 Report from the Finance Committee The report from the Finance Committee was received for information. J. M. Spencer noted that the Finance Committee received presentations on the 35 Centennial Drive Parking Lot and the Expense Reporting Tool on the public website.

3

6.0

ENSURE BOARD EFFECTIVENESS Governance & Nominating Committee 6.1 Report from the Governance & Nominating Committee The Governance and Nominating Committee Report was received for information. M. McCann highlighted that the report includes recommendations for the Board to approve the updating of Board Policies to reflect the new name of HSN, the work plans of the Executive, Quality and Finance Committees, revisions to Board Policies II-4 and II-6 and the postponement of the Board Plenary Session to early spring. The report also highlights that P. Toffanello and Dr. Roy will be making a presentation to the Timmins and District Board of Directors in the New Year. MOTION #1: P. Byck / R. Bald CONFIRMATION OF MOTION Please Note this motion was approved by the Board of Directors via email on November 24, 2011 THAT the Governance and Nominating Committee recommends the Board of Directors approve the appointment of Vince Pollesel to the position of community member on the Finance Committee.

Board of Directors Meeting (OPEN) December 13 2011 MOTION #2: P. Toffanello / Dr. D. Marsh WHEREAS the HRSRH is now operating as Health Sciences North / Horizon Santé-Nord;

4

THAT upon the recommendation of the Governance and Nominating Committee the Board of Directors approve the updating of all Board of Directors Policies with the organization’s new name of “Health Sciences North / Horizon Santé-Nord”. AND THAT the Board of Directors approve the revised policies as presented. MOTION #3: D. Fildes / N. Everest THAT upon the recommendation of the Governance and Nominating Committee the Board of Directors accepts the 2011/2012 Executive Committee Work Plan. MOTION#4: D. Fildes / R. Pitblado THAT upon the recommendation of the Governance and Nominating Committee the Board of Directors accept the 2011/12 Quality Committee Work Plan. MOTION #5: P. Byck / R. Bald THAT upon the recommendation of the Governance and Nominating Committee the Board of Directors accept the 2011/12 Finance Committee Work Plan. MOTION#6: P. Toffanello / J. M. Spencer THAT upon the recommendation of the Governance and Nominating Committee the Board of Directors accept the changes to the Board of Directors Policies II-4 and II-6 to reflect the new quarterly meeting format of the Executive Committee. MOTION #7: D. Fildes / N. Everest THAT upon the recommendation of the Governance and Nominating Committee the Board of Directors approve moving the date of the 2012 Board Plenary Session to early spring. Building, Facilities & Long Range Planning Committee 6.2 Report from the Building, Facilities and Long Range Planning Committee The report from the Building, Facilities and Long Range Planning Committee were received for information. R. Bald highlighted that the committee received an update on the multi-level parking structure and Centennial Drive Parking lot; they discussed the HSN strategic planning process and endorsed the membership of the Strategic Planning Steering Committee; and finalized their committee work plan.

Board of Directors Meeting (OPEN) December 13 2011 7.0 ITEMS FOR INFORMATION 7.1 Report of the Board Chair The Report of the Board Chair was received for information. 7.2 Report of the CEO The CEO Report was received for information. Dr. D. Roy noted that his participation in the Healthcare Reform Symposium and World Executive Forum on Healthcare allowed him to realize that we are not alone in experiencing difficult health transformation. 7.3 7.4 Report of the COS None. Report of the President of the Medical Staff Dr. Zalan emphasized that it will be crucial to implement lean management processes and maximize our resources in these difficult economic times.

5

8.0

OTHER BUSINESS None.

9.0

ADJOURNMENT There being no further business to discuss, the meeting was adjourned at 628 p.m. /Dr. D. Marsh

R. Boyles, Chair

Standards for Sustainable Governance
January 2012

Accreditation Canada
Accreditation Canada is a not-for-profit, independent organization that provides health organizations with an external peer review to assess the quality of their services based on standards of excellence.

Accreditation standards assess governance, risk management, leadership, infection prevention and control, and medication management, as well as services in over 30 sectors.

Accreditation Canada’s Sustainable Governance Standards are based on current research and best practice in the field, and reflect a focus on accountability for ensuring quality of care.

Standards for Sustainable Governance
Accreditation Canada's Standards for Sustainable Governance are built on five key functions of governance: 1. Developing the mission, vision and values; 2. Collecting and using knowledge and information; 3. Developing the organization; 4. Building relationships with stakeholders; and 5. Demonstrating accountability. Much of the Board’s governance responsibilities are met through its committees: • Executive Committee (EC) • Governance and Nominating Committee (GNC) • Quality Committee (QC) • Finance Committee (FC), Audit Committee (AC) • Building, Facility and Long Range Planning Committee (BFLRC)

Developing a Clear Direction
The governing body develops the organization’s mission. (BFLRC) The governing body leads a strategic planning process to define the organization’s vision, and sets the strategic plan, goals, and objectives. (BFLRC) The governing body defines values for the organization that are used to guide decision-making and for determining how services are delivered. (BFLRC)

Building Knowledge Through Information
The governing body uses strategic information to make decisions. The governing body reviews information from a variety of internal and external sources. The governing body uses the information to make informed decisions and guide the organization’s long-term direction. (BFRLC, QC, FC) The governing body allocates resources and delegates authority to collect and analyze the information it requires to carry out its responsibilities. (QC, FC) The organization maintains records of the governing body’s activities and decisions that are easy to access and meet legal requirements. (GNC)

Functioning as an Effective Governing Body
The governing body addresses changes in its membership. (GNC)

The governing body operates according to its roles and responsibilities. (GNC)

The governing body regularly evaluates its own performance. (GNC)

The governing body regularly assesses its own team functioning using the Governance Functioning Tool. (GNC)

Supporting the Organization to Achieve its Mandate
The governing body recruits, selects, and evaluates the Chief Executive Officer . (EC and Board) The governing body works effectively with the CEO, senior management, and clinical leadership to achieve the strategic goals and objectives and improve the organization’s performance. ( All Board Committees) The governing body approves the allocation of resources. (FC)

Maintaining Positive Relationships with Stakeholders
The governing body strengthens relationships with stakeholders and the community. (Board as a whole) The governing body works with the CEO to identify stakeholders and gather information about their characteristics. The governing body works with the CEO to establish a communication plan. The communication plan includes strategies to communicate key messages to different groups and the community. The governing body, with the CEO, promotes the organization and demonstrates the value of its services to stakeholders and the community.

Being Accountable and Achieving Sustainable Results
The governing body regularly monitors and evaluates the organization’s performance. (QC, FC) The governing body has an effective system of financial planning and control. (FC, AC) The governing body demonstrates accountability to its stakeholders. (Board as a whole) The governing body works with the CEO to reduce risks to the organization and promote ongoing quality improvement. (QC, FC) The governing body fosters and supports a culture of safety throughout the organization. (QC,FC)

Board Self Assessment
Accreditation Canada requires the Board to do a self assessment using two tools: 1. Sustainable Governance Questionnaire – this is directed at assessing your performance in meeting the standards outlined by Accreditation Canada.
Website, Organization Code and Password: will be communicated to Directors via email

The portal will be open from January 10 – 24 for board members to complete the on-line survey.

Board Self Assessment
Accreditation Canada requires the Board to do a self assessment using two tools: 2. Governance Functioning Tool – this assessment is directed at assessing the performance of the Board processes and structures.
Website, Organization Code and Password: will be communicated to Directors via email

The portal will be open from January 10 – 24 for board members to complete the on-line survey.

Board Self Assessment
Your responses to the survey will create an electronic roadmap identifying opportunities for the Board to improve its performance, processes and structures.

REPORT OF THE CHAIR JANUARY 2012 OPEN SESSION REPORT

New Year Greetings 2011 proved to be a year of great challenges, opportunities and accomplishments at HSN. In the past twelve months we both honoured our past and charted a new course for our future. We launched new innovative programs, increased our research activities, saw groundbreaking surgical procedures performed, and recruited record numbers of health care providers, all while providing vital front-line care to our patients. This year will see us continue to expand the range of services we provide. We will increase our research and teaching activities, and make further strides in our goal to provide effective, efficient and timely care in a manner that is transparent and accountable to all of our stakeholders. I look forward to many more successes at HSN this year, thanks to the quality of our people and the strength and support of our community.

REPORT OF THE CEO JANUARY 2012 OPEN SESSION REPORT HSN Employees Honoured by Greater Sudbury Police Service Congratulations to HSN nurses Jill Riva-Patey and Debbie Casera who were honoured for their community service at this year’s Greater Sudbury Police Services Board Annual Awards Banquet. They both received Police Assistance Awards for their roles in helping victims of two separate vehicle collisions this past year. Jill Riva-Patey is a Registered Nurse who is the Manager of CQI, Risk Management and Special Projects in the Mental Health and Addictions Program at HSN. She has been an employee at HSN for 20 years. Debbie Casera is a Registered Nurse and the Clinical Leader of the Functional Assessment and Outcome Unit at the Sudbury Outpatient Centre of HSN. She has worked at HSN for 32 years. We’re very honoured to have Ms. Riva-Patey and Ms. Casera as part of the HSN family. HAVEN Program Celebrates 20th anniversary this month This month, the HAVEN Program is celebrating its 20th anniversary. HAVEN (HIV/AIDS Extended Network) provides clinical care, counselling, and social support to people with HIV/AIDS. Since HAVEN started in 1992, it has helped over 800 patients with HIV/AIDS. Congratulations to the multidisciplinary team at HAVEN, and we look forward to its ongoing success. Good Catch Recognition Program The Good Catch Recognition Program is a pilot project running from December 1st, 2011 to February 29th, 2012. The program aims to encourage the reporting of “Good Catches” throughout the organization allowing us to create a culture of learning and continuous improvement. A Good Catch is defined as an event or situation that could have resulted in an accident, injury, illness or damage to a patient, client, visitor, staff or physician. To date, the program is already beginning to show results. In the month of December, there were more good catches reported than in any previous month. These good catches have provided us the opportunity to put corrective actions in place to prevent any harm to patients and staff. KICX For Kids Campaign In 2011, HSN launched a five-year campaign with radio station KICX 91.7 FM to raise $250,000 for our Family and Child Program and Pediatric Centre of Excellence. The first goal of the KICX For Kids campaign is to raise funds to purchase three new ventilators in our Neo-natal Intensive Care Unit. The KICX For Kids campaign enjoyed a successful holiday season, with such promotions as an all-day on-air auction and fund-raising giftwrapping booth at the New Sudbury Centre. Staff Food Drive Through the efforts of many willing staff members who volunteered their time to make this time of year a little brighter for their colleagues, the HSN family was able to collect, package and deliver over 400 food boxes to confidentially identified staff members in need. I would like to thank our staff and physicians for their continued generosity and to the many other programs and services who held their own food and toy drives to help their patients and clients in need.

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