OPEN MINUTES
QUALITY AND PATIENT CARE COMMITTEE

March 23, 2016 at 12:00pm

Library ~ Charles Street Site

Membership:
Linda Hansen (Chair)
David Bessant
Sherri Fournier-Hudson
William Spencer
Jennifer Eastwood
Community Member(s):
Cheryl Cook
Ahmad Khadra
Wendy Bergeron / Ex-Officio, Voting Members:
Neil Bhatt
Ex-Officio, Non-Voting Members:
Dr. David Goldstein
Cathy Cassidy-Gifford
Tony Weeks
Tyler Milton
Staff Support
Kristi Carter / Guests:
Regrets:
Steve Smith
Recording Secretary:
Laurie Ouellette
NO. / DISCUSSION
1.0 / Call to Order
The Chair called the meeting to order at 12:00 pm.
2.0 / Dr. Goldstein Patient Safety Presentation “Organizational Culture and Professionalism”
K. Carter – complaint.
J. Gerritsen walked the members through the 360 project room for the ED Project. 8 initiatives have been identified by the ED Project Team. The members were given the opportunity to highlight the initiatives they felt were most impactful to patients.
3.0 / Move to In-Camera
MOTION: It was moved by S. Hudson/W. Spencer THAT the Quality and Patient Care Committee move to In-Camera at 12:35 pm. This motion was put to a vote and APPROVED.
4.0 / Approval of Agenda
MOTION: It was moved by D. Bessant /N. Bhatt THAT the Quality and Patient Care Committee approve the agenda as presented. This motion was put to a vote and APPROVED.
5.0 / Declaration of Conflict of Interest
The Chair called for conflicts of interest to be declared. There were none.
6.0 / Business Arising from Previous Meeting(s)
6.1 / Update on Ethics Patient and Family Centered Care
Dr. Thomas presented on physician assistant dying at the last Ethics Committee. A task force has been assembled to review and collect all data.
Item 6.1 will be added as a standing item with the Ethics Committee Update. As we move forward with the Emergency Department Project we will review how to be more family centered.
6.2 / Surgical Assist, Neonatal Resuscitation Protocol, Pediatric Care
-Alternate funding for pediatrics
The Chief of Staff reviewed the history of surgical assistants. The program is running at good capacity.
NRP-The Chief of staff reviewed the history of the NRP. We currently have two pediatricians. The program is being reviewed to look at all options of providing this service.
Pediatric Program-there is a pediatrician coming to BGH in the near future.
6.3 / Accreditation Update
The additional evidence required for submission to Accreditation Canada due March 31 has been drafted and will be edited/reviewed and submitted.
The antimicrobial stewardship program was the most complex item and we have since contracted the services of Dr. Zoutman to assist in the implementation of the program.
6.4 / ACU Plan-deferred.
6.5 / Update on Stroke Initiative
Nothing to add.
7.0 / New Business
7.1 / New NRCC Contract with OHA for Patient Experience Survey
There is a new contract for processing the patient experience surveys. It requires signature by BGH in order to participate. The company will offer different modes of delivery such as letter, telephone, postcard or email link and benchmarking. The rating system will be slightly different than previous.
7.2 / Physician Assisted Death Taskforce
The task force is formed and work has commenced.
8.0 / Executive Reports
8.1 / President & CEO
The CEO gave an update on Health Care Tomorrow (HCT). It is a partnership of seven hospitals. All hospitals in the LHIN work together, vote and feedback goes to the LHIN. The LHIN must approve any integrations.
Quality Improvement staff were encouraged to submit a paper to the annual Quality Congress regarding our LEAN journey. The paper will be presented at the Annual Quality Congress.
We submitted an application for the human spirit award for one of BGH charge nurses. Unfortunately we did not make it through the second step. We may look at establishing our own human spirit award to recognize the staff that go well above and beyond.
Redevelopment
This project is moving along. It is a timely process. We have submitted 3.1 for approval. There has not been a response yet but we were able to proceed with submitting 3.2. This appears favorable. There is always a risk however with these projects you don’t receive a certificate to move forward.
8.2 / VP & Chief Nursing Officer
We have a new Mental Health manager. K. Rees.
There is a new pharmacist and this will enable our pharmacists to be out on the units more.
We are trialing CPOE for medications. The team is going to Providence Care to review modelling etc.
We received permission for ten additional joints to be completed by the end of March.
Our ACU is expanding their systemic treatment services.
We are working at having huddle boards a daily occurrence.
8.2.1 / Ethics Committee Report
The Ethics and Research Committee report was included above.
8.3 / Chief of Staff –Nothing to Report.
The credentialing tool was rolled out yesterday for OB/GYN.
We are recruiting for hospitalists and pediatrician.
There has been discussion on increasing medical learners in our institution.
BGH is participating in a study on patient readmissions. This is an exciting opportunity.
9.0 / Standing Items
9.1 / QIP 2016/17 Quarterly Update
9.2 / Quality Stats/Quality Review
The quality stats were attached to the package and reviewed. The falls are trending upwards. The results are given to the managers and directors for their follow up and review.
There was discussion on falls risk and what triggers classifying who is at risk.
9.3 / Sentinel Events Update
Included in the package.
9.4 / Pharmacy Update
Discussed in VP CNO report.
9.5 / Clinical Review Follow Up
Deferred.
9.6 / Hospitalist Update
We are working with a physician recruiter to increase our hospitalists. We need a 1.5 increase.
10.0 / Information Items-None
11.0 / Date of Next Meeting
The date of the next meeting is April 27 2016.
12.0 / Adjournment
MOTION: It was moved by S. Hudson/N. Bhatt THAT the Quality and Patient Care Committee adjourn the meeting at 4:00 pm. This motion was put to a vote and APPROVED.

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