OPEN MINUTES
QUALITY AND PATIENT CARE COMMITTEE

October 28, 2015 at 12:00pm

Library ~ Charles Street Site

Membership:
Linda Hansen (Chair)
Trea Tuck (Vice-Chair)
William Spencer
Steve Smith
Suzanne Thorson
David Bessant
J. Easton
Community Member(s):
Cheryl Cook
Ahmad Khadra (in at 12:30)
Marilies Rettig (in at 12:27) / Ex-Officio, Voting Members:
Neil Bhatt
Ex-Officio, Non-Voting Members:
Dr. David Goldstein
Kristi Carter
Cathy Cassidy-Gifford
Tony Weeks / Guests:
P. Summers
Regrets:
Wendy Bergeron
Sherri Fournier-Hudson
Recording Secretary:
L. Ouellette

NO. / DISCUSSION
1.0 / Call to Order
The Chair called the meeting to order at 12:03 pm.
2.0 / Presentation-Patient Safety Education Module
The complaint for this month was reviewed prior to the education module. It dealt with communication which was also the theme of Dr. Goldstein’s presentation.
Dr. Goldstein presented our second module of the Patient Safety Education Course. This month the theme was communication. There was a video clip, discussion and questions to assist membership engagement.
3.0 / Move to In-Camera
MOTION: It was moved by D. Bessant/N. Bhatt THAT the Quality and Patient Care Committee move to In-Camera at 12:30 p.m. This motion was put to a vote and APPROVED.
The Committee moved out of in-camera at 12:36 p.m.
4.0 / Approval of Agenda
MOTION: It was moved by J. Easton/W. Spencer THAT the Quality and Patient Care Committee approve the Open 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 Education Patient Centered Care
This was sent to SLT and was deferred until after accreditation and it will require going through a procurement practice which includes three quotes.
6.2 / Update on Clinical Review
This was completed in camera.
6.3 / Update LLG Integrated Stroke Planning Workgroup
This was completed in camera.
6.4 / Update on Trillium Gift of Life
There was a meeting in house a few weeks ago. There was data reviewed and shared by TGLN. BGH is a recent TGLN designate. We are on board and our involvement will be progressive. The Chief of Staff has had discussion with the Medical Director of TGLN regarding BGH’s level of involvement.
6.5 / Surgical Assist, Neonatal Resuscitation Protocol, Pediatric Care
There have been a number of discussions. There is a change in distribution of on call money to assist in surgical assist coverage. This issue is still being worked on.
NRP coverage is coordinated by the pediatricians and OB/GYN physicians. The availability of the pediatricians will be given three months in advance moving forward.
7.0 / New Business
7.1 / ACU Plan
There was an update on the plan for ACU. We are currently looking at rebranding the clinic from its current streams of procedures and consults. We would like to see expansion of services such as dermatology, colposcopy, chemo etc.
There will be a nursing director and a medical director to assist in the running of the clinic. The Chief of Staff will be the medical director in the interim.
Quality metrics and wait times are some of the data currently being reviewed.
7.2 / Clinical Informatics
As we move toward clinical changes, electronic MAR, CPOE etc. a clinical informatics person could bridge the gap between QuadraMed and our resources. We are looking at recruitment.
7.3 / Cancer Care
The Chief of Staff is co-chairing the committee with B. Carter. Cancer Care will assist up with approach, policies, guidelines etc. in our cancer care. They will assist us in doing a market value assessment.
9.0 / Executive Reports
9.1 / President & CEO
The last Board Report had the latest HealthCare Tomorrow update. This will be sent to non-board members.
9.2 / VP & Chief Nursing Officer
The report was attached.
MAC felt that an algorithm would be of value in regards to the surge policy. That will be completed and sent on to MAC.
SELHIN is working on patient flow and there is a subcommittee that has been meeting and planning over the last few months. Policies will be implemented that are consistent across the LHIN with some minor tweaking for individual hospitals. There will be a refresh to the home first program.
9.2.1 / Ethics Committee Report
There was a patient care issue and a small group was brought together for the first level of discussion.
There is an ethicist coming to speak next month at the Ethics Committee.
There currently is a bioethicist who sits on the committee and he and the VP CNO will have some future discussions on the committee and its direction.
9.3 / Chief of Staff
All Chiefs and medical colleagues will have encrypted BGH emails in the future.
We are moving towards having patient safety program modules for physicians in the future, hopefully starting in November.
10.0 / Standing Items
10.1 / QIP 2014/15 Quarterly Update-deferred
10.2 / Quality Stats/Quality Review
These were sent in the package and a question time was provided. It was reinforced that the stats are incidents that occurred or nearly occurred. They are not deaths.
There was discussion on falls as they are trending upward. Is the increase better reporting? What are some possible solutions?
An audit of the falls would be necessary for a comprehensive evaluation.
10.3 / Quality Review/ Sentinel Events Update
This was attached to the package.
10.4 / Accreditation Update
Accreditation is moving along nicely. Staff are sharing and the accreditors have observed incredible talent here at BGH.
We are on track with some items and could improve on others.
The 1 East renovation was wonderful however it was not able to fix some of the storage and infection control issues. Our infection control rates are positive despite this.
The preliminary results will be released on Friday.
10.5 / Pharmacy Update
We are reinitiating the ADD, CPOE and eMAR projects next week. The physicians have provided assistance with purchasing sterile products in reference to our sterile hood not being up to date therefore we can’t mix certain medications onsite.
We are working on the formulary and it can be uploaded to Quadramed and simultaneously with the ADD machines.
T. Weeks left at 1:35.
10.6 / Hospitalist Update
Demand on our hospitalists will likely increase over the flu and Christmas season. We need approximately 2-3 more hospitalists to fill our complement. We have been advertising, reaching out to universities and other contacts. We have met with the family physicians to discuss assistance with coverage until our complement is met.
There was discussion on timely med rec and discharge summaries and the beneficial edischarge tool used by some hospitals.
10.7 / ED Working Group Update
We are working on a strategy to do a large change to the ED which will not be solely structural in nature. There was a recent meeting with the physicians and staff to discuss ideas and it was met with positive uptake.
10.8 / Compliment/Complaint Review
This month is a complaint and it was read and discussed during the patient safety module.
11.0 / Information Items-there were none.
12.0 / Date of Next Meeting
The date of the next meeting is November 25th, 2015.
13.0 / Adjournment
MOTION: It was moved by W. Spencer/C. Cook THAT the Quality and Patient Care Committee adjourn the meeting at 2:09pm. This motion was put to a vote and APPROVED.

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