SOUTH HURON HOSPITAL ASSOCIATION
MINUTES OF BOARD OF GOVERNORS MEETING
Thursday, June 24, 2010
Ernie Miatello Debra Hunt Rae Ann Ladouceur
Elizabeth Bell Tom Hayter Rob Morley
Jeff Keller Marion Snow Bill Brintnell
Dr. Ming Lam Christina Godbolt Wayne Deluca
Faye Reichert (Recording Secretary)
Regrets: Justin O’Rourke
Invited: Darlene Borland
Ernie Miatello called the meeting to order at 2010 hours.
1. Conflict of Interest – Declaration (Ernie Miatello)
No conflicts declared.
2. Election of Officers for the Ensuing Year 2010/2011 (Deb Hunt)
Currently there were two (2) elected vacancies on the Board for the up and coming year.
Christina Godbolt (2 year term) and Rae Ann Ladouceur (1 year term) have accepted
nomination for membership. Prior to the September Board meeting, Christina and Rae
Ann will be invited to join with Deb, Ernie and some of the members for an orientation
day and tour of the hospital.
Moved by: Bill Brintnell
Seconded by: Marion Snow
Motion: To elect Christina Godbolt for a two (2) year term and Rae Ann
Ladouceur for a one (1) year term, to the Board of Directors of South
Huron Hospital Association. Carried
Deb Hunt recommended the following slate of officers for the year 2010/2011:
Chair Ernie Miatello
Vice Chair Jeff Keller
Treasurer Tom Hayter
Secretary Debra Hunt
Moved by: Deb Hunt
Seconded by: Rob Morley
Motion: To approve the nomination of the above-captioned officers for the year
2010/2011 as presented. Carried
3. Additions/Changes to Agenda
No additions/changes to open session.
4. Minutes of May 27, 2010 Meeting
The minutes of the May 27, 2010 meeting had been provided previously for review.
Moved by: Elizabeth Bell
Seconded by: Bill Brintnell
Motion: To approve the minutes of the May 27, 2010 Board meeting as
5. Business Arising
6. Chair Report and Correspondence (Ernie Miatello)
6.1 Letters of Resignation
Ernie read a from Deb Hunt, President, Chief Executive Officer, Chief Nursing
Executive advising of her resignation, effective October 20, 2010. The timing
allows Deb to participate through the SHHA Accreditation and the planning
stages of the Strategic Plan process for 2010 to 2013.
As well, a letter was received from Dr. Ming Lam, advising she will not be
renewing for another term as Chief of Staff, effective September 30, 2010, at
which time her agreement expires. Dr. Lam has served as Chief of Staff and
represented the medical staff at Board meetings since 2006. This position will be
filled by September 30th.
6.2 Accreditation – “Quest for Quality”
The questions and answers for 4th and 5th quest provided for information. The
quests are a great learning tool in preparation for accreditation. Previous quests
and answers will be provided to Rae Ann and Christina.
6.3 Board Peer/Self-Assessment and Committee Assessments
Members asked to complete their Board and committee assessments and return to
Faye during the summer months, prior to September. Results will be compiled
and reported at a fall Board meeting.
7. C.E.O. Report (Deb Hunt)
7.1 Board BBQ
Members are reminded of the date for the Board BBQ – Wednesday, July 14th,
11:30 until 1:30. This event provides an opportunity to meet and mingle with the
staff as well as help to set out the “goodies” and allow time to enjoy lunch with
all. Faye has the schedule of times, if able to help, please let her know your plans.
The employee service awards for the December 2009 to June 30, 2010 will be
presented by the Board (approximately 12:45).
7.2 Amendments to Regulation 965 – Public Hospitals Act – Hospital Board
Composition (OHA Bulletin - Bill 46 Update – June 8th provided for information)
Recent Amendment/Implications –
Effective January 1, 2011, the Chief of Staff, if a Board Member, will no
longer have voting privileges on a Board of Directors and consequently on
respective Board Committees.
Consideration and further discussion should be given to replacing the
Chief of Staff position with a voting member on the Board and respective
committees. As a result of the up and coming changes, Board members
have an opportunity to revisit the current Board composition and size.
Also, the SHHA By-laws will be required to be revised. The OHA has
provided a template for By-Laws.
7.3 Bill 46 (OHA Bulletin Bill 46, the Excellent Care for All Act provided for
The above noted Bill was introduced on May 3, 2010 and affects every aspect of a
hospital’s quality agenda. Not all requirements have been given a time-line at this
Once proclaimed, Bill 46 will require hospitals to:
Develop and post annual quality improvement plans
Establish quality committees that report to the hospital Board on quality-
related issues, including quality improvement initiatives and policies, and
oversee the preparation of the annual quality improvement plans
Link executive compensation to achievement of quality plan performance
Implement a patient and employee satisfaction surveys
Implement a patient complaints process
Prepare a patient declaration of values
One of the amendments to Regulation 965 of the Public Hospitals Act which has
already be enacted involves significant changes to hospital practices –
Require critical incidents to be reported to the Medical Advisory Council and
the hospital administrator and require that a system be established for the
analysis of critical incidents and development of action plans to avoid or
reduce the risk of recurrence, effective July 1, 2010.
SHHA has already started to revise policies and job descriptions to comply with
7.4 Hospital-Physician Relationship (OHA Bulletin and power point presentation –
Hospital-Physician Relationships – dated June 14th provided for information)
Two (2) teleconferences have already been held with participation from various
hospital Chiefs of Staff, Vice Presidents of Medical affairs, Hospital CEO’s and
Board Chairs. The topics discussed during the teleconferences included: Bill 46,
The Excellent Care For All Act and its associated regulations, and what they
mean for hospitals and physicians; the OHA’s Prototype Professional Staff B-
Laws and a number of other related items.
As further communications are received, members will be provided with the
Deb expressed thanks to all the Board members for their support over the past
years and has very much enjoyed her position at SHHA. Deb is looking forward
to retirement and wishes the Board “all the best”.
8.1 Medical Advisory Committee (“MAC”) (Dr. Ming Lam)
A meeting was held earlier this date with two (2) presentations –
Connie Harris, RN – Senior Clinical Specialist Wound care Framework
Project Lead. This is a SW-LHIN project and the goal of the project is to
develop and deliver an integrated, client-centered approach to evidence-based
would care that is measurable and sustainable. (standardize would care,
dressing, procedures, etc.)
Lisa Campbell provided an overview of the Medication Reconciliation system
and expressed the importance of such for patient safety. The medication
reconciliation is a formal process of obtaining a complete and accurate list of
patient’s current medications for use in writing admission, transfer and/or
discharge medication orders. During the process, discrepancies are identified
and resulting changes in orders documented. There will be a standard
form/format for the nursing staff and physicians to complete.
Re-Applications – April 1, 2010 to March 31, 2011
Moved by: Bill Brintnell
Seconded by: Tom Hayter
Motion: To accept the recommendation of the Medical Advisory
Committee for approval of the re-applications for active
privileges for Drs. Mark Nelham, Munsif Bhimani and Maureen
and courtesy privileges for Drs. Tania Wilson and Yasmin
and consulting privileges for Dr. Malcolm Carlson.
8.2 Board Risk, Utilization & Quality Committee (Bill Brintnell for Cindy Maxfield)
Bill distributed and reviewed the draft minutes of the June 16th meeting.
Following highlights noted –
Presentation by Lisa Campbell regarding the Automated Medication
System/FMEA – project has been successful in increasing patient safety as
well as cost saving.
Patient Satisfaction Results – reviewed first three quarters as final quarter
results not yet received. Members reminded all complaints, concerns
should be forwarded to either Deb Hunt, Cheryl Pfaff or Sandra Albrecht
for follow-up and resolution.
Work Plan will be revised to include:
1. Adherence to Legislative Changes
2. Education – Bed-side Ultra Sound
3. Falls Prevention Program
Amendments to Public Hospital Act – involve significant changes to
hospital practices. Effective July 1, 201 - Critical incident reporting now
required to be reported to the Medical Advisory Committee and hospital
administrator as well as establish a process to avoid and/or reduce risk of
recurrence. The following three (3) SHHA polices have been revised to
comply with the changes:
1. Occurrence Management System
2. Disclosure of Harm
3. Administrator On-Call
Motion by Bill Brintnell
Seconded by Elizabeth Bell
Motion to approve the recommendation of the Board Risk, Utilization
and Quality Committee to approve revised policy#23-005
Occurrence Management System, #23-002 Disclosure of Harm
and #15-025 Administrator-On-Call in order to comply with
OHA Bill 46, Regulation 965 effective July 1, 2010.
8.3 Executive & Resource Committee (Ernie Miatello)
No further meetings.
8.4 Governance & Planning Committee (Jeff Keller)
Minutes of May 27th meeting had been provided for information.
Discussion held on the process for filing position of CEO. The Governance &
Planning Committee will form a Search Committee to look at available options
for a replacement. Potential candidates will be interviewed and recommendation
made to the Board. Meetings over the summer months may be required in order to
have placement by late summer/early fall. Agnew Peckham, the firm working on
the SHHA strategic plan may be able to provide guidance, due to their experience
and knowledge of the health care system.
8.5 Public Relations Committee (Deb Hunt)
With Cindy Maxfield leaving the Board, this committee will require a new Chair
for the next term. The presentation to the Lambton Shores Council was held on
June 17th and very well received by a large group who attended that evening.
Lambton Shores is our second largest catchment. The next presentation is
scheduled for Lucan/Biddulph Municipality on July 5th. Bill Haskett has agreed to
participate in the presentation.
8.6 Auxiliary (Elizabeth Bell)
No further meetings held, the next meeting of the new term will be in September.
8.7 Audit Committee (Tom Hayter)
The “draft” minutes of the May 27, 2010 meeting were provided for information.
The year end draft financial statements were reviewed and accepted with no major
concerns recognized. The implementation of the computerized inventory has been
successful and maintains good control of the inventory carts. The motion was
passed to retain Vodden, Bender & Seebach for the 2010/2011 year. The
assessment forms were provided to members for completion and return.
Moved by: Tom Hayter
Seconded by: Wayne Deluca
Motion: To approve the committee reports as presented. Carried
9. Other Business (Darlene Borland)
9.1 Financial Statements
The financial statements for the period ended May 31, 2010 indicate a positive
position with a surplus from operations of $7,292 or 0.43% against targets of
$0.00 and 0.904. The balance sheet is strong with a current ratio of 1.71 against
the target range of 0.8 – 2.0.
To date, no firm funding announcement for 2010 – 2011, therefore, these
statements reflect estimates and a base with 0% increase. Once confirmation of
monies is received, the budget will be revised accordingly.
9.2 Compliance Statement
The statement of compliance indicated compliance of all statutory remittances for
payroll and sales taxes due and corporate tax and information returns filed in a
timely manner for the year ended March 31, 2010.
9.3 Capital Summary
For period ended May 31, 2010 provided for information. It was noted the
portable Ultra Sound Machine has been delivered and the new dishwasher has
9.4 Utilization Report
The May 31, 2010 report was reviewed, noting following highlights –
Total days of care increased to 569 as compared to 292 prior year
Total patient days decrease to 440 as compared to 468 prior year
(patients are requiring more care, due to respective illness)
Increase to 1.0727 from 0.8436
Expected Average Length of Stay
Increase to 7.9 as compared to 6.8 prior year
Emergency Room Visits
Slight decreased to 764 as compared to 774 prior year
Family Practice Clinic
Increase to 1,767 as compared to 1,199 prior year (partially due to
addition of physician and return from leave)
Decrease to 589 as compared to 781 prior year (partially due FPC
physicians accepting more patients)
Decrease to 238 as compared to 278 prior year (no loner have internal
medicine and ortho clinics)
Darlene noted the change in statistical collection methods – laboratory tests are
not included in current figures, nor in prior period figures for comparability.
The format and presentation of this report will change for the September Board
meeting to better reflect the targets SHHA has agreed to.
Moved by: Tom Hayter
Seconded by: Bill Brintnell
Motion: To approve the financial statements for the period of May 31,
2010, as presented. Carried
10. Other Business (Jeff Keller)
10.1 Foundation (update)
No further meetings held, the Annual General Meeting for the Foundation is
scheduled for Wednesday, June 30th.
11. New Business
11.1 Orientation for New Members
Over the summer months, new Board members will be provided with an
orientation binder. The CEO and some of the Board members will meet with the
new members for a tour of the hospital and orientation. All Board members are
welcome to attend as a “refresher” on policies, etc.
11.2 Board Retreat
In order to have the strategic plan completed for early October, the Board Retreat
will be held prior to October. After some discussion, members agreed upon
Tuesday, September 14th, from a 9:00 a.m. until 4:00. Jeff will contact the Town
Hall for availability of a room.
Following discussion, Board members were in agreement the retreat will be
attended by Board of Directors, CEO and the incoming CEO (pending contract)
Administrative Assistant and Agnew Peckham consultants.
11.3 Search Committee
After discussion, members were in agreement that a committee be formed to start
the process of locating a replacement for retiring CEO.
Moved by: Jeff Keller
Seconded by: Rob Morley
Motion: To set up a search committee, in conjunction with Agnew
Peckham; to consist of the Board Chair, Vice Chair and
incoming Chief of Staff to find suitable candidates for position of
12 Next Meeting
Members will be notified well in advance of the date of the next meeting (tentatively
13. Motion to adjourn to in-camera session 2150 hours, requesting recording secretary to
Moved by: Wayne Deluca
Seconded by: Elizabeth Bell
Motion: To adjourn to in-camera session. Carried
13. Motion to adjourn open session 2215 hours.
Moved by: Marion Snow
Seconded by: Bill Brintnell
Motion: To adjourn open session. Carried
Ernie Miatello, Debra Hunt,