CIHRT Exhibit P-0488 Page 1 28 2008/P-0488... · 2008-04-28 · Joyce Penney, Executive Assistant...

Minutes of Executive Management meeting held 10 January 2007 at 10:00 a.m. ConferenceRoom A- Corporate Office, St. John's.

Present:George Tilley, Chief Executive Officer - ChairpersonGeorge Butt, Vice PresidentBeverley Clarke, Chief Operating OfficerPat Coish-Snow, Chief Operating Officer (via conference call)Stephen Dodge, Vice PresidentLouise Jones, Chief Operating OfficerAlice Kennedy, Chief Operating OfficerFay Matthews, Chief Operating OfficerDr. Oscar Howell, Vice PresidentLouise Jones, Chief Operating OfficerPat Pilgrim, Chief Operating OfficerWayne Miller, Senior Director

Joyce Penney, Executive Assistant

Regrets:Susan Bonnell, Director Corporate Communications

George Tilley extended a Happy New Year to all.

1.

2.

2.1

Action

Penney

Pilgrim

Motion Time Frame

ASAP

CIHRT Exhibit P-0488 Page 1

2.2

3.

Executive Management10 January 2007

Action

Tilley

Miller

Butt

Pilgrim

Tilley

Motion

2

Time Frame

KIV

KIV

3.1 Resignation of Staff from Strategic Communications

Leona Barrington, Media Relations Officer has tendered herresignation effective the 26 January 2007. This is a tremendousloss for the organization. Leona Barrington was well respectedamong Executive, her peers and the media community. StephenDodge met with Leona Barrington and discussed her decisionhowever it appears that her decision is final. An exit interview will bescheduled. An active recruitment campaign is underway. A note ofcaution was given that the market is very thin and given thecompensation package available it will be a challenge to recruitsomeone into the position.

DodgeBonnell


3.2

3.3

3.4


Executive discussed briefly the issues associated with classificationand compensation as well as the extreme pressure and workloadwithin the Strategic Communications Department. There has beensignificant turnover in that department during the past year. StephenDodge to review the structure in conjunction with the Director, SusanBonnell.

Action

DodgeBonnell

Dodge

Dodge

Motion

Approved

3

Time Frame


Executive Management10 Januar 2007

3.20 ER/PR Testing to Resume January 15, 2007

The organization will resume ER/PR testing January 15, 2007.

Dr. Howell explained that the monitoring of one receptor will continueto be carried out via contract with Gamma-Dynacare MedicalLaboratories. The organization has renewed the contract withGamma-Dynacare $33,000.00 a month and the organization willutilize the saving in pathologists salaries (currently 6 vacancies) tooff-set the cost. However the question was raised that the SalariedPhysician Budget is a separate budget that cannot be utilized for thispurpose. George Butt to clarify operating funds vs. salariedphysician budget.

The organization has received another resignation from one of ourpathologists. Currently the organization is down 13 pathologists fromthe normal contingent of 19. The Workload Report commission bythe Department of Health and Community Services is expected to bereceived by the end of the month.

Dr. Howell noted that it is critical to get all pathologists on one sitewithin City. Renovations have been slow. Facilities Managementare involved.

Action

HowellButt

Motion

9

Time Frame

3.21

3.22

Clarke

ClarkeDodge



Action Motion

12

Time Frame

3.33

Miller

3.34 Confidence in the 5 stem/Qualit Culture

Concern for quality component of the organization was discussed atlength.

Wayne Miller to forward his concerns to the Diagnostic andLaboratory Directors with respect to his recent experience. Patients Millershould not assume that "no news means everything is ok". In fact, itis our understanding that patients who are seen for diagnosticprocedures are given reading material in this regard.

Executive agreed that the perception of confidence in the system isworthy of further reflection. The following points were raised:

" Staff perception of the organization - negative

" Community health - errors/complaints have increased (symptomof the pressure and workload).

" No active strategy to combat the negative media coverage forhealth care issues

" Leadership - Managers feel disengaged. The organization mustlook for ways and opportunities to engage this group. StephenDodge noted that Culture Strategy that was endorsed byExecutive recommended that the Senior Management groupcome together more frequently; however the engagement ofmanagers needs to develop further. Moving forward onimplementing components of the Culture Strategy (Retreat)should proceed.

" COO's should link closer with Director and Managers on aregular basis.

" Our Health Magazine - positive publication. Preliminarydiscussion is underway to use the Our Health Magazine templatefor new health program.

" Good news /interesting health related stories should bepromoted. Community Services monthly health promotion storieswere lost through integration. Bev Clarke advised that her

Dodge

coo's


3.35

3.36

4.1

4.2


portfolio met with Strategic Communications to highlight goodnews stories and try to restore the positive health promotioninitiatives.

" Good News Stories. Stephen Dodge to follow-up with SusanBonnell regarding "good news stores" (i.e. Leader in PACS,CIHI recognizing Eastern Health Portal as leaders in this area).

Action

DodgeBonnell

DodgeBonnell

Tilley

Dodge

Executive

Tilley

ButtCOO's

Motion

13

Time Frame

KIV


4.2.1

4.2.2

4.3

4.4


Action

Executive

Howell

Matthews

Miller

Howell

ClarkeHowell

Motion

14

Time Frame


4.5

5.

5.1

5.2

5.3

5.4


The organization will undergo an accreditation process September23 - 28,2007. This Accreditation Process is being lead by Qualityand Risk Management.

The need for education for Leadership/Partnership Team membersand proposed approach was not discussed. Deferred to the nextmeeting.

Stephen Dodge provided a verbal report of issues arising out the 5January 2007. The following points were noted:

" Telehealth Strategy - Government has approached NLCHI tolook at Info way funding to proceed with the Provincial Telehealthstrategy. Each Authority will have two (2) FTE's for each region(clinical and technical lead).

A Telehealth Working Group has been established internally. TheTerms of Reference are being finalized. The Telehealth plan willbe reviewed by 1M &C for approval to Executive.

Action Motion

15

Time Frame

Deferred24 Jan 2007


ApprovedMinutes of Executive Management meeting held 24 January 2007 at 10:00 a.m. Conference Room A- Corporate Office, S1. John's.

Present:George Tilley, Chief Executive Officer - ChairpersonGeorge Butt, Vice President (via conference call - Carbonear)Beverley Clarke, Chief Operating OfficerPat Coish-Snow, Chief Operating Officer (via conference call - Clarenville)Stephen Dodge, Vice PresidentLouise Jones, Chief Operating OfficerAlice Kennedy, Chief Operating OfficerFay Matthews, Chief Operating Officer (via conference call - Whitbourne)Dr. Oscar Howell, Vice President (via conference call- Health Sciences Centre)Louise Jones, Chief Operating OfficerPat Pilgrim, Chief Operating OfficerWayne Miller, Senior Director


Regrets:Susan Bonnell, Director Corporate Communications


ApprovedExecutive Management24 Januar 2007

system 18 months and the staff retained as volumes have steadilyincreased. Social workers are concerned about liability issues,particularly in this climate and are cognizant of the fact that the Actalso specifics that assessments must be conducted with 24 hours.There are other positions that are needed to support the work ofthe Social Workers i.e. social work assistants. Stephen Dodgenoted that there is a Committee that met 3 January 2007 activitylooking at job descriptions that were previously approved for SocialWork Assistants and there were a number of action items arisingout of this meeting. Executive was supportive of movingforward with a call for applications for social work assistantsand social workers at the same time.

3.7 VP Medical and Diagnostic Services - Dr. Oscar Howell

" Cancer Care Physician - continuing to work through issues.

" Pathologist - Dr. Howell confirmed that the Salaried PhysicianBudget cannot be utilized to off-set the cost for the contract withGamma-Dynacare; consequently the organization will incur adeficit in the Laboratory budget this year. The WorkloadReport commissioned by the Department of Health andCommunity Services is expected in the near future.

Action Motion

Agreement

8

Time Frame

3.8 VP

HowellPilgrim

HowellMatthews



4.4

4.5

The organization will undergo an accreditation process September23 - 28,2007. This Accreditation Process is being lead by Qualityand Risk Management. The need for education forLeadership/Partnership Team members and proposed approachwas discussed and it was agreed to invite Carla Williams to thenext meeting of Executive.

Action

ClarkeHowell

Miller

Miller

Motion

13

Time Frame



5.4

Approved minutes of 1 December 2006 were included in theExecutive Package. Minutes from the 5 January 2007 meeting notyet approved.

" Disaster Recovery/Business Continuance/ Protection ofInformation. This issue was raised at the Finance Committeeof the Board at their January Meeting. The ExecutiveLimitations - Protection of Assets EL 9 does not address thisconcern. However, Stephen Dodge in collaboration withGeorge Butt will follow-up with the Finance Committee.Business Continuance is separate from asset protection.

" Accreditation_- As part of the Accreditation process theInformation Management Committee will be soliciting feedbackfrom key stakeholders.

Action

Miller

Dodge

coo'sMiller

Dodge

Motion

14

Time Frame

5.5


Minutes of Executive Management meeting held 7 February 2007 at 10:00 a.m. Conference Room A- Administrative Office, S1. John's.

Present:George Tilley, Chief Executive Officer - ChairpersonGeorge Butt, Vice President (via conference call - Carbonear)Pat Coish-Snow, Chief Operating OfficerStephen Dodge, Vice PresidentLouise Jones, Chief Operating OfficerAlice Kennedy, Chief Operating OfficerFay Matthews, Chief Operating OfficerDr. Oscar Howell, Vice PresidentLouise Jones, Chief Operating OfficerPat Pilgrim, Chief Operating OfficerWayne Miller, Senior Director

Susan Bonnell, Director Corporate CommunicationsJoyce Penney, Executive Assistant

Regrets:Beverley Clarke, Chief Operating Officer

WelcomeA warm welcome was extended to Carla Williams, Accreditation Manager and Lisa Browne, PlanningSpecialists. Lisa Browne will be assisting Executive with the completion of the Leadership &Partnership (L&P) components for Accreditation.

With respect to the interim accreditation for the Peninsulas and the Cancer Care Program that wassubsequent cancellation, Carla Williams advised that the review has been completed. It is anticipatedthat the review will go to the CCHSA Internal Review Committee next week and we can expect a reporton the findings by the end of February.

Executive received a detailed presentation and a demonstration on the organizational portal.

The following points were highlighted during the presentation:

" 10 surveyors will be visiting for the 2007 Accreditation Survey. Bio's will be shared with Executivewhen received. There will be 6 Client Care and Core Team and 4 Lab Surveyors. The schedulewill be circulated when finalized.

" Laboratory Services will participate on a voluntary basis. The outcome of the findings will not affectthe outcome of the accreditation.

" Diagnostic Imaging will continue to be rolled into the Care Team. Mammography is accreditedthrough their professional body.

" 4 Regional Core Teams (Leadership & Partnership, Human Resources, Environment andInformation Management) and 16 Core Teams have been established.

" Focus groups will be established - Regional Focus Groups (3) will be fully integrated.


Executive Management7 February 2007

" There are 140 recommendations from the legacy organizations that have been separated intoresponsible Teams. There are 28 recommendations for L & P.

2

" A communications strategy has been developed. Regional generic education sessions for staff willcommence March thru May.

" All data will be entered and submitted by 15 May 2007, thus providing time for final review byExecutive and preparation time for submission to CCHSA by July 1,2007.

" ROP's (Required Organizational Practices) are new and a mandatory component of Accreditation,effective 2006. There are five (5) specific safety areas - Culture, Communication, Medication Use,Worklife/Workforce and Infection Control. Two (2) ROP's specific to L & P (Culture andCommunications) were highlighted. The ROP ratings different from the Team ratings. Theorganization will receive one organizational-wide rating for each ROP. Teams will provide specificresponses relevant to each ROP, in addition, the organization must have a specific ROP's evidencebinder to demonstrate organizational-wide compliance. To assist with the development andimplementation, members of the Quality and Risk Management Department have been assignedspecific ROP's Leads. Executive briefly discussed the ROP -"Medication Use - MedReconciliation" and the implications from a human resource and sustainability perspective. Theorganization has established a working group to develop the specific Med Reconciliation.

" Portal Demonstration. Executive received a brief tutorial on the CCHSA portal. All documentationwill be done electronically. Lisa Browne agreed to follow-up with the Executive in terms of inputtingthe appropriate data. Target date of 28 February was established for the review and feedback.

Executive agreed that a separate meeting will be scheduled for final review and rating of theLeadership and Partnership Standards. Target date early April.

George Tilley will reflect on how to apprise the Board of their role in the Accreditation process.

1.

2.

2.1

Action

Penney

MillerJones

Motion Time Frame


Executive Management7 Februar 2007

3.6

" Pathologist - Dr. Fontaine has agreed to stay on until June2007. The Department of Health and Community ServicesWorkload Report is complete. With respect to remuneration,we understand that a package has gone forward to Treasury

Action

Howell

Howell

Howell

DodgeHowell

Howell

Motion

6

Time Frame



Board. Similar complaints have been received with the lengthof time for reports for pathology. This issue is being addressed.

Action Motion

7

Time Frame

3.7

3.8

3.9

3.10


Minutes of Executive Management meeting held 21 February 2007 at 10:00 a.m. ConferenceRoom A - Administrative Office, St. John's.

Present:George Tilley, Chief Executive Officer - Chairperson (partial)George Butt, Vice President (via conference call - Carbonear)Beverley Clarke, Chief Operating Officer (partial)Pat Coish-Snow, Chief Operating Officer (via conference call- Clarenville)Stephen Dodge, Vice PresidentLouise Jones, Chief Operating OfficerAlice Kennedy, Chief Operating OfficerFay Matthews, Chief Operating OfficerDr. Oscar Howell, Vice PresidentLouise Jones, Chief Operating OfficerWayne Miller, Senior Director


Regrets:Pat Pilgrim, Chief Operating Officer

George Tilley was delayed at a previously scheduled meeting. Stephen Dodge assumed the Chair.

1.

2.

2.1

Action

Penney

Dodge

Motion TimeFrame



5

3.5

3.6

3.7

" Pharmacy - The pharmacy shortage is still beingexperienced in the Clarenville and Burin parts of theregion. Pat Coish-Snow and Oscar to discuss further.S1. John's should have a full compliment of Pharmacistsby July 2007. By April 1,2007 Clinical Pharmacy in ICUand committee structures including P& T Committee willresume. A decision has been made to advertise

Action

Executive

Matthews

HowellCoish-Snow

Motion TimeFrame



" Oncology - The issue of compensation for oncologyphysicians is still active. Physicians continue to dialoguewith the Department of Health and Community Servicesin this regard. The primary concern is the thresholdpercentage for administrative vs. clinical compensation.

Action

PilgrimHowell

Howell

Motion

6

TimeFrame

KIV

Butt Agreement


Minutes of Executive Team meeting held March 7, 2007 at 10:00 a.m. Conference Room A-Administrative Office, St. John's.

Present:

George Tilley, Chief Executive Officer - ChairpersonGeorge Butt, Vice President (via conference call - Carbonear)Beverley Clarke, Chief Operating OfficerPat Coish-Snow, Chief Operating Officer (via conference call - Clarenville)Stephen Dodge, Vice PresidentLouise Jones, Chief Operating OfficerAlice Kennedy, Chief Operating OfficerFay Matthews, Chief Operating OfficerWayne Miller, Senior DirectorPat Pilgrim, Chief Operating Officer

Mary Haynes, Executive Assistant

Regrets:

Dr. Oscar Howell, Vice PresidentSusan Bonnell, Director Corporate CommunicationsJoyce Penney, Executive Assistant

1.

2.

2.1

Action

Penney

Motion TimeFrame


Executive TeamMarch 7, 2007 5

2.4

2.5

3.

3.1

The terms of reference were drafted based on feedback onthe ethics structure from the COOs. Membership includes aCOO as Executive lead, chairs of existing ethics committeesand representatives from areas without existing committees.Ethics education, a plan and policy will be developed and willbe regional in nature.

Following discussion, the terms of reference were approvedwith the recommendation to change the reporting structure tothe Re ional Qualit Council.

Action

DodgeMiller

Jones

Dodge

Motion

Approved

TimeFrame

March21/07


Minutes of Executive Management meeting held 21 March 2007 at 10:00 a.m. Conference RoomA - Administrative Office, S1. John's.

Present:

George Tilley, Chief Executive Officer - ChairpersonGeorge Butt, Vice President (via conference call)Beverley Clarke, Chief Operating OfficerPat Coish-Snow, Chief Operating OfficerStephen Dodge, Vice PresidentDr. Oscar Howell, Vice PresidentLouise Jones, Chief Operating OfficerAlice Kennedy, Chief Operating OfficerFay Matthews, Chief Operating OfficerWayne Miller, Senior DirectorPat Pilgrim, Chief Operating Officer


Regrets:

1.

2.

2.1

Action Motion TimeFrame


Executive Management21 March 2007

2.5 Media Relations Specialists - Recruitment

Recruitment for a Media Relations Specialists for StrategicCommunications has been suspended. Unfortunately, therewas only one suitable candidate and that individual decidedto accept another offer. In the interim, Susan Bonnell willassume this responsibility.

On a related note, Strategic Communications has contractedBristol Communications to develop the Crisis CommunicationStrategy for the organization. At a future date a resourceperson from Bristol will be invited to present to Executive.

Action

Bonnell

Motion

4

TimeFrame

KIV

3.

3.1


Minutes of Executive Management meeting held 18 April 2007 at 11: 15 a.m. Conference Room A -Administrative Office, St. John's.

Present:George Tilley, Chief Executive Officer - ChairpersonGeorge Butt, Vice PresidentPat Coish-Snow, Chief Operating Officer (via conference call)Stephen Dodge, Vice PresidentLouise Jones, Chief Operating OfficerAlice Kennedy, Chief Operating Officer (partial arrived at 11 :45)Fay Matthews, Chief Operating OfficerWayne Miller, Senior DirectorJoyce Penney, Executive Assistant

Regrets:Susan Bonnell, Director Corporate CommunicationsBeverley Clarke, Chief Operating OfficerDr. Oscar Howell, Vice PresidentPat Pilgrim, Chief Operating Officer

10:00 am - 11: 15 pm - Executive continued review of the Leadership and Partnership Standards forAccreditation.

The regular business agenda convened at 11: 15 am

1.

2.

2.1

2.1.1.

Action

Penney

Miller

Motion Time Frame


2.1.5

2.1.6.

Executive Management18 April 2007

Executive reviewed the critical path for the 2008 - 2011 Strategic Plan. A BoardStrategic Planning Retreat is scheduled for September 14 -15,2007. Followingthat process the Strategic Planning Committee will review the draft plan andpresent to the Board for final review in December 2007. The Strategic Plan will besubmitted to the Department of Health and Community Services in January 2008.

Action

Dodge

Motion

Approved

4

Time Frame

2.2

2.2.1

Louise Jones and Wayne Miller to discuss further the process and time schedule to Jonesconduct focus groups with staff. Miller


Minutes of Executive Management meeting held 2 May 2007 at 10:00 a. m. Conference Room A -Administrative Office, St. John's.

Present:Beverley Clarke, Chief Operating Officer - ChairPat Coish-Snow, Chief Operating OfficerStephen Dodge, Vice PresidentDr. Oscar Howell, Vice PresidentLouise Jones, Chief Operating OfficerAlice Kennedy, Chief Operating OfficerPat Pilgrim, Chief Operating OfficerWayne Miller, Senior Director


Regrets:George Butt, Vice PresidentGeorge Tilley, Chief Executive OfficerFay Matthews, Chief Operating Officer

Executive continued with the Accreditation - Leadership and Partnership Standards review.

Regular business meeting called to order at 12:15 pm. Bev Clarke assumed the chair in theabsence of George Tilley.

1.

2.

2.1

2.1.1.

2.1.2

Action

Penney

Miller

Motion Time Frame


2.1.3

Executive Management2 May 2007

Action

Miller

Motion

3

Time Frame

2.1.4 HIROC - Risk Management Self Assessment

Executive reviewed the management module response details of theHIROC - Risk Management Self Assessment and raised concernswith some of the ratings. The VP's and COO's are to forward theirfeedback to Wayne Miller by Monday 7 May 2007. Following thisprocess, Louise Jones, Pat Pilgrim, Pat Coish-Snow, Bev Clarke andWayne Miller will carry out a final review. The document will againbe tabled at Executive. A response to HIROC is due by the end ofMay.

MillerJonesPilgrimCoish-SnowClarke

16 May 07

2.1.5

2.1.6.

ButtMiller

Pilgrim

Miller



3.3

3.4

3.5 Bristol Crisis Communication Session - 30 May 2007

The Bristol Crisis Communication session is scheduled for 30 May2007 in Clarenville. The session is scheduled for 4 - 5 hours. It wassuggested that a development/education session for ExecutiveAssistants be held simultaneously with this event. As details arefinalized they will be communicated. Regrets have been noted forFay Matthews and Alice Kennedy.

Action

BonnellKennedy

Motion

6

Time Frame

3.6


Minutes of Executive Management meeting held 16 May 2007 at 10:00 a.m. Conference Room A- Administrative Office, St. John's.

Present:

George Tilley, Chief Executive OfficerGeorge Butt, Vice PresidentBeverley Clarke, Chief Operating Officer - ChairPat Coish-Snow, Chief Operating Officer - via conference callStephen Dodge, Vice PresidentDr. Oscar Howell, Vice PresidentLouise Jones, Chief Operating OfficerAlice Kennedy, Chief Operating OfficerFay Matthews, Chief Operating OfficerPat Pilgrim, Chief Operating Officer - via conference callJoyce Penney, Executive Assistant

Regrets:Susan Bonnell, Director Corporate CommunicationsWayne Miller, Senior Director

10:00 am - 11 :15 pm



o Improved CD surveillance-flu update and technologyo Workload and cost comparisons across the region and standardization of

program and policyo Strengthen linkages with Government Service Centreo Develop research capacity

George Tilley thanked Bev Clarke and Ann Manning for the detailed and informative presentation.

1:00 pm - Ann Manning was excused from the meeting

2

1.

2.

2.1

2.1.1. HIROC Self Assessment - Management and OrientationModule WM

The COO's and VP's reviewed the HIROC Self AssessmentManagement module and made adjustments to the responses.Where the organization has responded "no", an explanation will begiven to demonstrate what the organization has in place. PatPilgrim in conjunction with Glenys Walsh will ensure consistencyacross the region and conduct a final review of the full corporateassessment prior rolling up the organizational wide document forfinal sign off (George Tilley/Pat Pilgrim) prior to forwarding toHIROC by the prescribed deadline of May 30,2007.

HIROC is requesting that all programs and departments completean Orientation Module from the perspective of their owndepartment/service. This component has not yet been completedfrom the Executive Team perspective. Stephen Dodge and TraceyTizzard Drover are meeting on May 23, 2007 to complete thedocument on behalf of Executive.

Action

Penney

Pilgrim

Dodge

ButtPilgrim

Motion Time Frame


2.1.4

2.1.5

2.1.6.

2.2


Action Motion

5

Time Frame

2.2.1 Estrogen/Progesterone Testing

There has been significant media attention related to the ER/PRreceptor testing. On 15 May 2007, George Tilley, Dr. Howell andHeather Predham briefed the Minister on the issue.

Calls from patients will be directed to the Quality Department. PatPilgrim will mobilize a team and put a process in place.

The organization will discuss further, outside this forum itscommunication strategy. Strategic Communications will begin topull together the key messages in preparation for a potential PressConference on the issue.


Minutes of Executive Management meeting held 30 May 2007 at 10:00 a.m. Conference Room A- Administrative Office, St. John's.

Present:

George Tilley, Chief Executive OfficerGeorge Butt, Vice President - via conference callBeverley Clarke, Chief Operating Officer - ChairPat Coish-Snow, Chief Operating Officer - via conference callStephen Dodge, Vice PresidentDr. Oscar Howell, Vice PresidentLouise Jones, Chief Operating OfficerFay Matthews, Chief Operating OfficerPat Pilgrim, Chief Operating OfficerWayne Miller, Senior Director

Joyce Penney, Executive AssistantSusan Bonnell, Director Strategic Communications

Regrets:Alice Kennedy, Chief Operating Officer

1.

2.

2.1

2.1.1.

Executive reflected on the events of the past week and discussed briefly,public confidence in the health system. The Board held a special meetingon 23 May 2007 and they are sensitive to the tremendous media pressurethe organization is currently experiencing and is also concerned that theconfidence in the system is being eroded as a result of themisrepresentation of the facts. Strategic Communications and externalcommunication specialists will begin to explore other communicationstrategies to ensure the correct messages are communicated to the public.

George Tilley provided a brief synopsis of the recent events surroundingthe ER/PR issue.

Action Motion Time Frame

Penney



2


• The CEO held a Press Conference on the ERIPR issue of Friday18 May 2007. A media statement and Q&A's were provided tothe media.

• Meeting with MHA's - On May 22 &23, 2007 and recognizing thecomplexity of the issue, the Minister of Health and CommunityServices offered an opportunity to the Provincial MHA's to attenda presentation by Eastern Health.

• Judicial Inquiry - On 22 May 2007 Government announced thatin order to maintain confidence in estrogen and progesteronereceptor (ER/PR) breast cancer testing system at Eastern Health,the province will undertake a Judicial Commission of Inquiry.The Judicial Commission of Inquiry will be established by theProvincial Cabinet under Section 3of the Public Inquiries Act.Cabinet will appoint a commissioner, set the terms of reference forthe inquiry and authorize an appropriate budget. Once thecommissioner's report is completed, it will be submitted to theMinister of Health and Community Services and will be releasedpublicly.

Stephen Dodge will consult with Donna Strong to initiate a Dodgeprocess of determining appropriate legal council to represent theorganization on this matter.

• Class Action Suit - On Monday 28 May 2007 the Judgerendered a decision to proceed with the PRIER Class ActionSuite.

• The CEO wrote a letter to the Editor of the Global Mailchallenging the article printed in relation to ER/PR. The full letterdid not get published. This is another example of themisrepresentation of the message. The Board Chair has agreedto bring the full letter and the articles to CHA at their meetings inJune.

• Canadian Cancer Society - Pat Pilgrim will be meeting with PilgrimPeter Dawe, Executive Director Canadian Cancer Society.

• Message to Staff - A message to all staff from the CEO will becirculated. Executive is fully aware that the events of the pastseveral days are playing heavy on the staff, particularly the

Howellpathologists and lab technicians. Anxiety has been heightenedsince the announcement of the Inquiry. Dr. Howell agreed to



follow-up with the Director of Laboratory and staff in this regard.Action

3

Motion Time Frame

2.1.2 Update on Burin Radiolo

HowellCoish-Snow

Pilgrim

KIV


2.1.3

2.1.4

2.1.5

2.1.6


• Disclosure Policy - Executive discussed briefly the disclosurepolicy. There may be a need to develop (2) two separate policies- i) disclosure when there is a mass impact that requiresdisclosure to public (systemic errors) and another policy for ii)disclosure to the individual patients/clients. The Canadian PatientSafety Institute (CPSI) is currently drafting guidelines related toDisclosure.

Action

Miller

Howell

4

Motion Time Frame

13 June 07



Action

2.1.7 Changes at Senior Executive (Deputy Minister) Department of Healthand Communit Services

The Premier announced today 30 May 2007 changes within the seniorexecutive ranks of the Public Services. Effective immediately Mr. JohnAbbott has been released of his duties. Mr. Robert Thompson has beenappointed to Secretary to Cabinet for Health Issues, Secretary to theCommission of Inquiry and Acting Deputy Minister of Health andCommunity Services.

2.1.8 Recove Strate ies - Buildin Confidence back in the S stem

Executive discussed briefly options for a recovery strategy to buildconfidence back in the system, not only from the public perspective butalso the management and staff. It was agreed that it would be beneficial Tilleyto bring Directors together as a group at some future date. However forthe immediate a message from the CEO will be sent to all staff.

5

Motion Time Frame

2.1.9

Miller



3.

3.1 HIROC - Self Assessment

Action

8

Motion Time Frame

HIROC has granted an extension to 29 June 2007 for the submission of Pilgrimthe self-assessment. Work is in progress and nearing completed. PatPilgrim is taking the lead to finalize the document.

4.

4.1

4.2

4.2.1

4.3

June 07

13 June 079:00 am

Sept 2007


1.

1.1

ApprovedMinutes of Executive Management meeting held June 13,2007, at 10:00 a.m. Conference RoomA- Administrative Office, St. John's.

Present:

George Tilley, Chief Executive OfficerGeorge Butt, Vice PresidentBeverley Clarke, Chief Operating OfficerPat Coish-Snow, Chief Operating Officer - via conference callStephen Dodge, Vice PresidentDr. Oscar Howell, Vice PresidentLouise Jones, Chief Operating OfficerFay Matthews, Chief Operating OfficerWayne Miller, Senior Director

Attending:

Susan Bonnell, Director Strategic CommunicationsMary Haynes, Executive Assistant

Regrets:

Alice Kennedy, Chief Operating OfficerPat Pilgrim, Chief Operating Officer

rge Tilley, George Butt,ment Funding from Dr.


Haynes

Miller


ApprovedExecutive ManagementJune 13, 2007

1.3 Update on ERIPR Receptor Issue (GT)

• Judicial Inquiry - The appointment of a Commissioner and theterms of reference are expected to be announced this week.

Action

3

Motion Time Frame

•

• Board - the Board has had two in camera sessions

• Minister and Deputy Minister - The CEO met with the Ministerand Deputy Minister on June 11,2007. Questions were raised onhow events were tracked by our organization, and the Departmentoffered the support of the Newfoundland and Labrador Centre forHealth Information on the development of tracking mechanisms.Software tracking is available commercially, and Mr. Dodge andMr. Miller agreed to follow up with Information Management andTechnology to investigate options.

DodgeMiller

•

•

• HIROC - HIROC has expressed concern regarding publicdisclosure and the potential impact on insurability, increasingclass action suits, and premium increases.

1.4 Update on Burin Radiolo

• The process of contacting all patients involved in the review of thediagnostic imaging reports of a radiologist in the Burin area hasbegun. Ms. Coish-Snow indicated that there are 13 people in acall pool making approximately 400 calls to patients today, and theDoHCS has requested an update on the status of the process.The volume of work is considerable, and the Senior Managementgroup will be contacted to provide whatever support they candurin the rocess.

• Dr. Howell indicated that the Diagnostic Imaging Program hasaccepted the need for a regional focus and an internal auditprocess.



•

•

1.5 Communication with Senior Mana ement and Clinical Chiefs

There was a general discussion on the ripple effect of the extensive mediacoverage of both the ER/PR and Burin radiologist issues on the moraleand confidence of Directors and Clinical Chiefs and the potential negativeimpact on accountability and decision-making within the organization. It iscritical that senior managers understand the issues and the approachtaken by Executive Team.

It was agreed that a meeting will be scheduled of Executive Team,Directors and Clinical Chiefs to discuss these key issues.

1.6 CEO Meetin with Minister and De ut Minister

The CEO is scheduled to meet with the Deputy Minister of Health andCommunity Services, Board Chairs and CEOs on June 14, 2007, andrequested input on key messages:

• Education to distinguish between errors versus variation inmedical treatment

• Move to ajust culture• Potential negative impact on leadership, accountability and

decision making as a result of intense media interest• HIROC's concern with full disclosure and the impact on insurability• Implications for recruitment in an atmosphere of blame• Difference between patient disclosure and public disclosure• Need for highly skilled human resources to accompany major

capital equipment investments in rural areas

Action

Miller

Dodge

Dodge

Haynes

4

Motion Time Frame


2.

2.1

2.2

2.3


• Location of services• Increase in potential liability issues as a result of politicization

Action

Dodge

Clarke

Jones

5

Motion Time Frame


ApprovedMinutes of Executive Management meeting held 28 June 2007 at 10:00 a.m. Conference RoomA- Administrative Office, St. John's.

Present:

George Tilley, Chief Executive OfficerGeorge Butt, Vice PresidentBeverley Clarke, Chief Operating OfficerPat Coish-Snow, Chief Operating Officer - via conference callDr. Oscar Howell, Vice PresidentLouise Jones, Chief Operating OfficerAlice Kennedy, Chief Operating OfficerPat Pilgrim, Chief Operating OfficerFay Matthews, Chief Operating Officer


Regrets:Stephen Dodge, Vice PresidentWayne Miller, Senior DirectorSusan Bonnell, Director Strategic Communications

1.

1.1

1.2 Update on ER/PR Receptor Issue (GT)

• Judicial Inquiry - On June 14, 2007 the Premier appointedJustice Margaret Cameron to oversee the Judicial Inquiry into thehormone receptor testing and the work will begin on July 3, 2007.The Terms of Reference will be released in the coming weeks.Justice Cameron is expected to delivery a final report by 30 July2008.

Action

Haynes

Miller

Motion TimeFrame

11 July 07

•Tilley


Executive ManagementJune 28, 2007

4

Action

Clarke

ClarkeMiller

Motion TimeFrame

Miller

2.4 Accreditation - FMEA rocess

Item deferred to Regional Quality Council. Pat Pilgrim to follow-up withthe Director of Quality and Risk Management. However, Executive gave Pilgrimgeneral support to the recommendations as outlined in the briefing note.Cost analysis to be identified and brought back to Executive for approval.

2.2

2.2.1

2.2.2

Miller


2.2.3

2.2.4

Executive ManagementJune 28, 2007

There will be some reorganization within Executive that will see PatPilgrim taking the lead to have a more dedicated focus on the qualitysafety. Consequently there will be changes within that portfolio that haveyet to be determined.

Pat Pilgrim will also be the lead person within the organization for theCommission of Inquiry on hormone receptor testing.

Action

TilleyDodge

Clarke

Motion

5

TimeFrame


ApprovedMeeting of Executive Management held 9 July 2007 at 2:00 pm Conference Room A-Administrative Office, St. John's.

Present:Louise Jones, Interim President and CEO

George Butt, Vice PresidentBeverley Clarke, Chief Operating OfficerStephen Dodge, Vice PresidentPat Coish-Snow, Chief Operating OfficerDr. Oscar Howell, Vice PresidentAlice Kennedy, Chief Operating OfficerFay Matthews, Chief Operating Officer - via conference callPat Pilgrim, Chief Operating OfficerWayne Miller - Senior Director


-as interim President and CEO chaired the meetin .

1. Business

Board Chair discussion with Minister of Health and Community Services

Louise Jones advised that the Joan Dawe, Board Chair contacted the Minister requesting ameeting. She provided him with a brief overview of Executive's concerns regarding theorganizations relationship and the lack of partnership with Government.

Media Coverage - CEO's resignation

Joan Dawe agreed to do media coverage in response to the announcement of the CEO'sresignation. The message will be support for the organization and that the details of the CEO'sresignation are between the CEO and the Board.


Executive Management9July 2007 @2:00 pm

3

1.9 Judicial Inquiry ER/PR

Louise Jones to meet with Pat Pilgrim, Oscar Howell and Donna Strong, Internal Solicitor tocommence planning and processes for the Judicial Inquiry. A formal meeting will then beheld with Dan Simmons.

1.10

1.11

The meeting adjourned at 3:25 pm. Executive agreed to meet on again 11 July 2007 as previouslyscheduled.


Meeting of Executive Management held 11 July 2007 at 11 :00 a.m. Conference Room A-Administrative Office.

1.

2.

2.1

2.2

Present:Louise Jones, Interim President and CEOGeorge Butt, Vice PresidentBeverley Clarke, Chief Operating OfficerStephen Dodge, Vice PresidentPat Coish-Snow, Chief Operating Officer (via conference call)Dr. Oscar Howell, Vice PresidentAlice Kennedy, Chief Operating OfficerWayne Miller - Senior DirectorPat Pilgrim, Chief Operating Office (partial)


RegretsSusan Bonnell, Director Strategic CommunicationsFay Matthews, Chief Operating Officer

Action

Penney

Motion TimeFrame

25 July 07


2.3 Burin Radiolo U date

Action

Jones

Motion

2

TimeFrame

2.4

A press scrum vs a press release was held at 10:00 am this morning withLouise Jones addressing the media.

Louise Jones along with Board Chair prepared a generic press releaseon the Burin Radiology issues. A significant part of yesterday wasoccupied with debating with the Department of Health and CommunitServices and the Minister of Health the content of the press releaseThey insisted on using numbers however concrete numbers areavailable. The media is focusing on the number and ato the recent events.

The Ministers' press secretary indicated he wo Id be aam to day to discuss Eastern Health press rep tativefrom Eastern Health's Strategic Communi rtment will be inattendance.

Executive went on to state that therlearned from this process, iprocesses etc. Wayne Micreating a database to validFundamentally wethat is tagged witreviewed. Resou·process and


Executive Management11 Jul 2007

3


2.5 ERIPR Judicial In ui

Miller

Dodge

als no longere upcoming

hat if it is an issuerincipal of providing legal

articulated and drafted.rong to investigate. If a currentevelop a policy consistent with the

Louise Jonesmeet'info·

Executive discussed the issue of legal couemployees of Eastern Health, particularCommission of Inquiry. Stephen Darising out of normal emploservices applied. PolicyStephen Dodge to requestepolicy exists, revie the policyprinciples discuss

2.6


2.7

2.8

3.1

3.1.1

Executive Management11 July 2007

d Privacy Commission Re ERIPR

ulated correspondence from the Office of thePrivacy Commissioner dated 3 July 2007 with respect to

the reques or review under the Access to Information and Protection ofPrivacy Act, in particular, the request from Mark Quinn for informationrelated to PRIER.

The Privacy Commissioner's office DOES NOT agree with the position ofEastern Health in this regard and stands by the comments andconclusions that such information should be provided.

Action

Miller

Miller

DodgeJones

Motion

4

TimeFrame


3.1.2

3.1.3

3.1.4


Executive discussed the pros and cons recommended NOT re releasethe information as it feels strongly that it is president setting and theinformation is part of the health information.

Pat Pilgrim will follow-up with Dan Boone to communicate Executive'sposition.

Action

Pilgrim

KennedyCoish-Snow

Executive

KennedyJones

PenneyELTCA

Motion

Supportive

5

TimeFrame


3.1.5

3.1.6

3.1.7

3.1.8

3.1.9


Action

Dodge

Clarke

Pilgrim

Motion

6

TimeFrame

25 July 07


3.2.1 Executive Meetin with Board of Trustees

TimeFrame

Deferred to25 July

2007

7

Motion

Jones

Action

y Lack of partnershiy Capital Equipmeny Judicial Inquiry PRJy Burin Ra ' logy Issuey Relations Advocate's Office

,i~~~~~~~>\_

On a related note, Louise Jones advised tDeputy Minister Robert Thompson on ThuExecutive is requested for forward to LouiAmong the issue that will be raised are'··

Board Chair offered the Executive to meeting with the Board to voicetheir concerns directly to the Board. Executive declined the offer.Direction for Louise Jones from Executive collectively, is to cant'past practice and the CEO will be the conduit with the B d..Jones will express these concerns to the Board Cha'Executive.

4.1

3.2

3.1.10

3.2.2

4.


Meeting of Executive Management held 25 July 2007 at 10:00 a.m. Conference Room A-Administrative Office.

Present:Louise Jones, Interim President and CEOBeverley Clarke, Chief Operating OfficerPat Coish-Snow, Chief Operating Officer (via conference call)Dr. Oscar Howell, Vice PresidentAlice Kennedy, Chief Operating OfficerFay Matthews, Chief Operating OfficerWayne Miller - Senior DirectorPat Pilgrim, Chief Operating Officer

Joyce Penney, Executive AssistantSusan Bonnell, Director Strategic Communications

RegretsGeorge Butt, Vice PresidentStephen Dodge, Vice President

1.

2.

2.1

y Request from ATIPPAn ATIPP request has been received requesting all information, e-mails,etc. on the Burin Radiolo issue since Januar 2007. The parameters

Motion TimeFrame

Accepted



Action

2.2 Commission of Inqui - ERIPR

Pat Pilgrim provided an update on the progress the activities related tothe Commission of Inquiry.

y A Coordinating Group has been established with key players withinEastern Health and including legal counsel, Dan Simmons. TheGroup will meet on a regular basis. Terms of Reference are beingrefined.

y The organization has been having regular daily interaction with DanSimmons. Meetings with key players/individuals have commenced.Legal Council has toured the Laboratory. A presentation by Dr.Howell, similar to the presentation to the MHA's on ERiPR will be Howellscheduled as part of educating our legal counsel.

y Eastern Health Counsel, Dan Simmons, Counsel for the Departmentof Health and Community Services, Mr. Pitchard and Counsel for theCommission, Sandra Chaytor and Bernard Coffey will meet regularly(every Friday) for coordination of information and establish strictparameters regarding information sharing as it relates to theCommission of Inquiry, the Class Action Suite and the Task Forceon Adverse Health Care Events, lead by Robert Thompson.

y The Department of Health and Community Services Task Force onAdverse Health Care Events terms of reference have not yetdefined. It is our understanding that the Task Force will addressvarious adverse health care events including ER/PR, RadiologyReview Burin, Turner Report, etc.

Motion

3

TimeFrame


2.3


y Debbie Gregory has been seconded to the Task Force on AdverseHealth Care Events. Wayne Miller to confirm.

y With respect to the Commission of Inquiry, Judge Cameron's Officehas seconded IT person within Government to work with her office.The individual has been in contact with 1M &T to learn about theMeditech system.

y The sharing of documentation from the "Peer Reviews" has comeunder much debate. The new Judicial Inquiry Act is very broad andcould be interpreted to give the Commissioner authority to accessthe peer review documents. Pat Pilgrim advised that Dan Simmonswill provide the organization with a legal opinion in this regard.

y NLCHI has been requested to develop data information for theDeputy Minister of Health based on three pointed questions for theperiod 1997 and 1998 1) who where the patients affected 2) howmany results changed and 3) where they notified.

y 1M &T are in the process of security all electronic files as of 25 July2007. Messages have been circulated to the system with respect tothe release of information and to ensure that all information, prior toits release must be vetted through the office of Pat Pilgrim.

Action

Miller

Pilgrim

Motion

4

TimeFrame


2.7

Louise Jones provided an update on her meeting with Deputy MinisterRobert Thompson as follows:

y There was discussion on the "rules of engagement" and anunderstanding of each others roles and the need to keep theMinister informed. However there must be processesestablished whereby information is requested through theExecutive level within the organization and directed back throughthe Department of Health and Community Services.

Louise Jones went on to explain that the day-to-daycommunication of the organization is carried out between theCEO with Deputy Minister and the Board Chair links directly withthe Minister. The organization must also strengthen its ourcommunication processes by ensuring that aVice President orChief Operating Officer signs off on document that is forwardedto the Department of Health and Community Services. A formalpolicy will be developed n this regard and will need to bereinforced at the Director level.

y There was brief discussion on the Transparency andAccountability Act and the Minister's accountability to the publicfor the health system, with a recognition that sometime there iswill be cross over.

y Brief discussion on the Health Authorities Act and their requestfor feedback

y Brief discussion re Task Force on Adverse Health Events andsharing of information.

Action

JonesDodge

KIVforBoard

PilgrimJones

Motion

6

TimeFrame


2.8

2.9

2.10

3

3.1


Louise Jones and Susan Bonnell will discuss further the initial proposalfrom Bristol and request that they review and revise in light of the recentevents experienced through the organization with a focus on recoverystrategy.

Action

PilgrimCOO'sJones

JonesBonnell

Motion

7

TimeFrame

Sept



Executive briefly discussed the need to bring stability and confidence inthe system. Part of the strategy will include:

y Senior ManagemenUClinical Chiefs meeting - target Septembery Louise Jones Interim PresidenUCEO to meet face to face with

Directors throughout the regiony Executive Team to continue to meet regularly with Directorsy Executive to develop a strategy of key messages

A more focused discussion on a recovery strategy will take place at theExecutive Retreat Day to be scheduled for September.

Action

Jones

Motion

8

TimeFrame

8Aug 07

3.6

HowellJones


Minutes of Executive Management meeting held August 22, 2007, at 10:30 a.m. ConferenceRoom A - Administrative Office, St. John's.

Present:

Louise Jones, Interim President and Chief Executive OfficerNorma Baker, Interim Chief Operating OfficerGeorge Butt, Vice PresidentBeverley Clarke, Chief Operating OfficerStephen Dodge, Vice PresidentDr. Oscar Howell, Vice PresidentFay Matthews, Chief Operating OfficerWayne Miller, Senior DirectorPat Pilgrim, Chief Operating Officer

Attending:

Susan Bonnell, Director Strategic CommunicationsMary Haynes, Executive Assistant

Regrets:

Pat Coish-Snow, Chief Operating OfficerAlice Kennedy, Chief Operating OfficerWayne Miller, Senior DirectorJoyce Penney, Executive Assistant

Ms. Jones welcomed Ms. Baker to the meeting and thanked her for assuming the position ofInterim Chief Operating Officer.

1.

2.


Penney


Executive ManagementAugust 22, 2007

3.2.

3.3.

3.4.

3.5.

3.6. Board of Trustees' Meeting - September 14,2007 (LJ)

The agenda for the September meeting will focus mainly on updates tothe Burin Radiology Review, ER/PR issues, CCHSA Accreditation,financial status, etc.

In light of the current atmosphere in the organization, the Board islooking for advice on how to move the organization forward. This issuewill be discussed at the upcoming Executive Team Retreat as well as theBoard's role in achieving this.

The deadline for submission of the annual performance report to theMinister is August 30, 2007. In light of this and the fact that the Boardmeeting does not occur until September 14, 2007, the draft report will besubmitted to the Board and Board Committee Chairs for review.

The need for additional training for Executive Team on the policygovernance model for Boards was noted, and members were asked toindicate their interest in receiving training. There was a generaldiscussion on policy governance, and the following issues were noted:

5


Howell


3.7.

3.8.


• policy governance - pure versus modified• establishment of committees• education for Trustees - need for a coach/consultant• education for Executive Team and Senior Managers• monitoring reports

The Board Policies will be circulated to Executive Team.

6


Haynes

DodgeBonnellHaynes


4.

4.1

4.2

4.2.1


Executive Team Retreat and Mana ement of Critical Issues

The Executive Team Retreat is scheduled for September 20,2007. Adraft agenda is being compiled, and consideration of issues fordiscussion and the preparation work required began:

• Prior to the retreat, Executive Team should review the followingdocuments:

o Information Management Plan - a presentation toExecutive Team will be scheduled prior to the retreat

o Management Development Plan/Leadership pieceo Crisis Communication (Recovery) Plano Cultural Strategy(Mr. Dodge will provide these documents to ExecutiveTeam)

• Benchmarks on administrative investment (Mr. Butt will provide)• the Board of Trustees has requested Executive Team's input to

identify what we need to be successful and move theorganization forward. Consideration is also required on theBoard's needs versus the needs of Executive Team.

• Future major human resource challenges• Facilitator - it was agreed to use a facilitator for the day, and

there was some discussion on the type of facilitator required.• It was suggested that a one-day retreat is not sufficient.

Executive Team agreed to forgo the Executive Team meetingscheduled for September 19 and expand the retreat to two days(Sept. 19 and 20)

9


Butt

Dodge

Butt


Minutes of Executive Management meeting held 19 September 2007 at 10:00 a.m. ConferenceRoom A- Administrative Office, St. John's.

Present:Louise Jones, Interim President and Chief Executive OfficerNorma Baker, Interim Chief Operating Officer (arrived at 11 :15 am)George Butt, Vice PresidentBeverley Clarke, Chief Operating OfficerPat Coish-Snow, Chief Operating Officer (via conference call)Dr. Oscar Howell, Vice PresidentAlice Kennedy, Chief Operating OfficerFay Matthews, Chief Operating OfficerWayne Miller, Senior DirectorPat Pilgrim, Chief Operating Officer

RegretsStephen Dodge, Vice President

Attending:Susan Bonnell, Director Strategic CommunicationsJoyce Penney, Executive Assistant

Presentation - Web Base Operational PlanningJane Mcdonald - Planning SpecialistSteve Greene - Programmer AnalysisGerard Gibbons, Project Leader

Meeting called to order at 10:10

Louise Jones welcomed Jane Mcdonald, Steve Greene and Gerard Gibbons to the Executive meeting.Executive received an initial presentation on the web based operational plan in the early spring. Thispresentation is intended to be a follow-up prior to the start of the pilot to launch the web base operationalplan. Copy of the presentation was circulated in the Executive package.

Wayne Miller offered Pat Coish-Snow an opportunity for a hands-on presentation, in light of the fact that shewas not able to attend the presentation in person.

The following points were highlighted in the presentation:

./ The web base operational plan pilot (one director from each portfolio) will be undertaken commencing 25October. Fay Matthews recommended that another director be selected to replace Cathie Barker Pinsentas she does not have secretarial support to assist with the pilot. It was suggested that Judy O'Keefe orGail Downing. Jane Mcdonald will follow-up in this regard.


Executive Management19 September 2007

Action

Deceased patientsThere are approximately 21 families of deceased patients that have notbeen contacted. There was a conscious decision to wait until theclinical significance component was completed prior to contactingfamilies of the deceased. However in light of the delay due to thecompensation issue for physicians. Adecision has to be made toreview the 21 files in question and how we will proceed.

Motion

4

TimeFrame

2.2.

y Request for Standing at the Commission of Inquiry commencedtoday 19 September 2007 - Phase I

y Data collection is ongoing as requests from the Commissioner.

JonesHowell

y The organization is seeking clarification on the right of the PilgrimDepartment of Health and Community Services to the detailedinformation being requested to prepare the Department for the COl.

y The Terms of Reference for the Task Force on Management ofAdverse Health Events have not yet been released. There is nolegislative power at this time that gives the Task Force or theDepartment the right to receive the information collected specificallyfor the COl.

2.3.

2.4. CEO Meetings with Managers - Regionally

The schedule has been circulated.



2.6. Accreditation Preparation Sept 23 - 28, 2007

Leadership and Partnership Presentation - Sunday 23 Sept 07The slide presentation for Leadership and Partnership has beenfinalized. Executive will attend the L& Ppresentation. Format of thepresentation will see the Board Chair present followed by the CEO andthen open discussion with the Accreditors

CEO Debriefing Sept 28,2007 @2:00 pmIt was agreed that not all Executive are required to attend the CEOdebriefing. Therefore, Bev Clarke and Dr. Howell will attend along withthe CEO and the Board.

Action

Executive

Motion

5

TimeFrame


3.


Public Debriefing Sept 29, 2007 @3:00 pmTrustees, Executive and Staff are all invited to the Public debriefingFriday 28 September 2007 at 3:00 pm at the auditorium HSC. Audioconference will be available throu hout the re ion in selected sites.

3.1.

3.2. Preparation for AGM - 24 October 2007

Executive reviewed the Action Plan for the Annual General Meetingscheduled for 24 October 2007 at 7:00 am.

Executive discussed the following as it relates to the AGM:

./ CEO presentation will be developed focusing on achievements.Louise Jones to discuss further with Susan Bonnell.

./ Executive suggested that a guest speaker be invited to speak onpatient safety/quality health care with a national perspective.Louise Jones agreed to approach Wendy Nicklin, CEO, CCHSA inthis regard. Failing that, Pat Pilgrim will review the speakers forHalifax 5- CPSI and determine if there are any potential guestspeakers that would have a presentation already developed onpatient safety/quality health care and would be available for EH'sAGM.

Action

JonesBonnell

JonesPilgrim

Motion

6

TimeFrame



7


./ Directors will be encouraged to have displays at the AGM related toquality and/or safety

./ Consideration will be given to launching the Community Grantsinitiative. Pat Coish-Snow to finalized the criteria and advise if this Coish-is feasible for the AGM. Snow

./ The Annual Report for the AGM will be the same as the onepresented to Government with some design changes and graphics.Strategic Communications will develop fly sheets for circulation at Bonnellthe AGM highlighting positive stories from various portfolios.

./ Financial Report will be included in the Annual Report

./ Formal invitations will be sent to stakeholders as per last year. TheCEO reviewed the listing and approved same. Mary Haynes will be Haynesrequested to take the lead to send electronic and formal invitations.

./ The Minister of Health and Community Services has confirmed hisattendance to bring greetings. A formal invitation will be sent.

./ The draft agenda will be modified once the details are finalized. Itwas recommended that the report from the Chair of the FinanceCommittee occur earlier in the agenda.

3.3. Capital Equipment - Planning for Presentation to Government(GB)

George Butt advised the content of the extensive review of capitalequipment needs for the organization as per the documents circulatedat the last Capital Equipment and Infrastructure Review Committee.

The Board at its September 14, 2007 meeting supported the motion toallow the Finance Committee to develop the presentation toGovernment in conjunction with administrative staff and physicians. Adate has yet to be determined.

George Butt will mobilize the Committee and key players to develop thepresentation for Government on capital equipment needs. It wasfurther agreed that this presentation should be received by the Board Buttprior to being presented to Government.



Action

Correspondence has been received from Government related to the2008 - 2008 capital budget. A response is requested by Friday 9November 2007.

Motion

8

TimeFrame

Jones

Donna Strong, senior solicitor, requested an update on the Commission Pilgrimof Inquiries. Updates to Donna Strong are appropriate and Pat Pilgrimwill provide.



3.11 Canadian Patient Safety Workshop Nov 20 - 21 - Winnipeg

Action Motion

11

TimeFrame

Every year CPSI hosts a workshop with patient perspective.The purpose of participation is to establish the patient perspectiveregarding communication and patient safety. Last year EH participatedas a Bronze sponsor. The organization has identified an individual whohad been misdiagnosed at the Cancer Centre. She has agreed toparticipate. Executive was supportive of a Bronze sponsorship($3,000) again this year. Pat Pilgrim will follow-up on the paper work Pilgrim Supportiveassociated with confirmation EH's representative at the workshop.

3.12

3.13

3.14

Executive agreed that this initiative and last year's experience shouldbe acknowledged at the AGM.

Bonnell

ExecutivePenney

Supportive


5.3

5.4


Action Motion

17

TimeFrame

5.5 Information Management Committee (SO)

Meeting September 7, 2007 (minutes not available). Minutes from April13, 2007 and 1 June 2007 circulated for information. No discussion.

5.6

5.7

t.t .... ' •• t ttt .. . t ...... .!..

Meeting held September 10, 2007 (minutes not availableOMinutes of May 14 and August 9, 2007 circulated for information.

Discussion

Executive discussed the process of some of the regional policyconsolidation. Executive is encouraged to go back to Directors toensure policies continue to move forward from a regional andconsistency perspective. Again it was emphasized that if there areissues that are a risk potential from a policy perspective then the issuesare to be brought forward to Tracy Tizzard-Drover to be addressedimmediately. It was clarified that the organization is continuing to workunder existing policies until the new policies are implemented. .

Wayne Miller agreed to provide an update to Executive at the nextmeeting on the areas of concern.

Executive

Miller

6. Deferred Items/KIV

Jones


Minutes of Executive Management meeting held 3 October 2007 at 10:00 a.m. ConferenceRoom A - Administrative Office, St. John's.

Present:Louise Jones, Interim President and Chief Executive OfficerGeorge Butt, Vice PresidentBeverley Clarke, Chief Operating OfficerPat Coish-Snow, Chief Operating Officer (via conference call exited meeting at 12:00noon)Stephen Dodge, Vice PresidentDr. Oscar Howell, Vice PresidentAlice Kennedy, Chief Operating OfficerFay Matthews, Chief Operating Officer (exited the meeting at 2: 15 pm)Pat Pilgrim, Chief Operating Officer


RegretsNorma Baker, Interim Chief Operating OfficerWayne Miller, Senior Director

Discussion· Executive Training for Research Application (EXTRA)Alice Kennedy, Chief Operating OfficerBetty Reid White, Director Integrated Health Services - Community (Rural Avalon)


3.

Executive Management3 October 2007

2.3.

2.4.

2.5.

3.1. Burin Radiology Update

1. Appeal by Physician - discussions are ongoing between thelawyers with respect to the appeal.

2. Review of the decease files - is still outstanding. There is animmediate need to move forward with respect to the 19deceased filed (which may not necessarily be associated to thisissue) however they must be reviewed. Demographics arebeing gathered, Dr. Justice Arthur is back next week and theorganization will wait until his return to address this issue.

Action

ClarkeCoish-Snow

Dodge

5

Motion

Supportive

Supportive

TimeFrame


3.2.

Executive Management3October 2007

Pat Pilgrim advised that Justice Cameron has made decisionsregarding "Standing" at the inquiry.

The Coordinating Committee for the Commission of Inquiry (COl) isseeking out ways to support staff through the process and preparationfor the Inquiry, which is anticipated to start the second week of January2008. There will be no cameras in the court room however there will beweb cast capability.

Disclosure proposal has been cleared with the Mount Sinai Lawyer inrelation to the concerns expressed by the external reviewer(technologist). The Commission of Inquiry will be advised of EasternHealth's position in this regard.

Action

Coish-Snow

BonnellJones

6

Motion

Supportive

TimeFrame


3.3.

3.4.

3.5.

3.6.


The Wall Street Journal has requested an interview on the ER/PRissue. Pat Pilgrim to follow with Strategic Communications.

Pat Pilgrim and Louise Jones to discuss outside this form the requestfor information re ER/PR from the Department of Health andCommunity Services

Action

PilgrimJones

Motion

7

TimeFrame



4.7. Patient Safety Survey Results

Circulated for information was a copy of the combined summary resultsof the Patient Safety Culture Survey Pilot Test Phase 1 (approximately647 respondents). Further analysis being conducted and will go forwardto the Regional Quality Council with a view to focusing on issues thatthe organization can move forward.

Action

Jones

10

Motion TimeFrame

4.

4.8.

4.9

4.1 Financial

12:45 pm . Sharon Lehr - joined the meeting to discuss the budgetprocess.

A response to the DoHCS on the operating budget is due Dept October



11


22 , however an extension has been granted for after the Boardmeeting 24 October 2007.Executive is meeting on Friday 19 Octoberand again on Monday 22 October for final approval of the budget priorto it being presented to the Finance Committee on 23 October 2007.Friday 12 October the Budget Analysis will be taking all "budget asks"to finalize into DoH&CS template. Monday 15 October an e-mail will besent to each Executive member with your portfolio "budget ask" inDepartment of Health template - briefing notes attached. Executive isasked to review and prioritize your individual portfolio initiatives.

Sharon Lehr noted that Executive can feel free to send back to her forediting if necessary for discussion at the October 19th Friday. Executivewill not see inflation and utilization increases in the budget. Theassumption is that DoHCS will address this from previous information.

Oscar away from October - 10 - 21 st. Sharon Lehr to coordinatedirectly with Dr. Howell

Sharon Lehr exited the meeting at 1:10pm

4.2 Board

4.2.1 Future Education Sessions - Board

• Pandemic Influenza Plan - date to be determined (WM)• Information Technologv - date to be determined (SO)• Public Health Networking - date to be determined (BC)• Capital Equipment Presentation for Government - October 24, 2007• Medical Staff Organization - date to be determined (OH)

4.2.1. Identification of items for October 24, 2007 Board &AGM

Louise Jones noted that it is preferred that issues for Board come toExecutive prior to the Board.

17 Oct./ Presentation for Capital Equipment to Minister - Draft will be 07

circulated to Executive and then made available to FinanceCommittee and on to the Board on October 24th . George Butt willendeavor to have a draft document for review by the CEO by Friday11 October 2007.



4.3

4.4

4.5 Accreditation

No discussion. Report is expected within 6weeks.

Action

Jones

12

Motion TimeFrame

4.6

4.6.1

Miller



13

4.6.2

4.6.3

4.6.4

5.

5.1

5.2

5.3

5.4

5.6



Meeting September 7, 2007 (minutes not available). October 5, 2007meeting cancelled. Next meeting 2 November 2007.

5.8


Minutes of Executive Management meeting held 31 October 2007 at 10:00 a.m. ConferenceRoom A- Administrative Office, St. John's.

Present:Louise Jones, Interim President and Chief Executive OfficerNorma Baker, Interim Chief Operating OfficerGeorge Butt, Vice PresidentBeverley Clarke, Chief Operating OfficerPat Coish-Snow, Chief Operating OfficerStephen Dodge, Vice PresidentDr. Oscar Howell, Vice PresidentAlice Kennedy, Chief Operating Officer (arrived at 11 :00 am)Fay Matthews, Chief Operating OfficerWayne Miller, Senior Director


RegretsPat Pilgrim, Chief Operating Officer

Presentation: - Health Care Security - A Strategic ApproachKeith Bowden - Director Infrastructure SupportGar Barnes - Mana er Securit


Executive Management31 October 2007Approved 14 Nov 07

2

•

•

• ry

Louise Jones exited the meeting at 10:35 am to prepare for media press release - Burin RadiologV

Dr. Howell assumed the chair.



Quality Assurance ProcessDr. Howell advised that the Radiologists (in St. John's as an initial start)will begin their own internal audit on a monthly basis. It is anticipated thatthis process will extend to the other areas of the region over time. Thisinterim QA process will involve reading each others reports andidentifying discrepancies. As was announced during the press releasethe organization is currently formalizing a Diagnostic Imaging QualityAssurance Program with peer audits.

Action

Miller

Coish-Snow

4

Motion TimeFrame



2.2. Judiciallnquiry ER/PR

In preparation for the Commission of Inquiry the Department of Healthand Community Services contracted NLCHI to build on the database ofclient who where ER/PR negative and to document in the databasewhether all patients have been notified. Discrepancies in the ER/PR datahave been identified. Both organizations are endeavoring to develop anaccurate list, however it is problematic. The validation process is ongoing

Deceased filesThe organization is starting to send the deceased data to Mount Sinai tobe re-read. The process is slower than anticipated. There is resistanceamong the oncologists with respect to meeting with the families of thedeceased. The Organization will be writing the families to advise that aretest will be done and offer an opportunity to meet to discussion. It hasyet to be determined who will be meeting with families that request tomeet.

On a related note Dr. Howell raised the issue of Unique PatientIdentifier. The Clinical chiefs have voiced concern that with the changingMCP # and the lack of a Unique Patient Identifier the organization is arisk.

5


Howell

Howell

Jones



Louise Jones rejoined the meeting at 11:45 am and assumed the Chair

2.3. Board Policies - schedule and accountability

Executive reviewed a copy of the draft schedule of board policies andassigned CEONP/COO responsibility including Executive Limitations,Governance Process, Board-Staff Relationship and Ends.

Wayne Miller elaborated on the process on which the EL's are broughtforward. It was recommended and accepted that all EL's must be tabledat Executive prior to being presented to sub-committees and to the Board.

Wayne Miller agreed to revised the draft monitoring schedule (by policy)and reporting accountability to include Board Sub-Committees (Finance,Planning and Safety and Quality Improvements), Executive and Boardresponsibilities and look at reporting schedule (annual or semi annual) forfurther discussion at the next meeting.

See Board 4.2.1 for details regarding Policy Governance Educationsession - Carol Gabanna.

Action

Baker

Howell

Howell

Miller

6

Motion TimeFrame

14 Nov07

2.4.



See 2.5 above

2.8.

2.9. Strategic Planning Retreat - Board - Nov 2- 3, 2007 Clarenville

As a follow-up to the previous meeting of Executive on 25 October 2007the following is a synopsis of the direction for the November 2- 3, 2007Board Planning Retreat

• The Minister of Health and Community Services agreed to attendto bring greetings at the Dinner on November 2,2007.

• The session will be facilitated by Transparency and AccountabilityOffice and the Department of Health and Community Services.

CEO Performance Objectives 2007 - 2008Louise Jones advised that the Board at their in-camera session during theOctober Board meeting agreed on the CEO Performance objectives for2007 - 2008. These are in keeping with some of the strategic directionoutlined for the board and will be discussed further at the Retreat.

3. New Business

Action

Pilgrim

Miller

8

Motion TimeFrame



Action

9

Motion TimeFrame

3.1.

3.2.

MillerJones

MillerDodge

Nov14/07

3.3. Feedback and outcome from CEO meetin s with Mana ers


3.4.


Louise Jones advised that the meetings throughout the region with themanagers proved to be worthwhile. In addition to the issues that hadalready been identified at the Executive Retreat, managers also raisedthe following:

• Complaints management process• Respect for managers and the management role• Communication - something that goes out specifically to

managers• Support for managers/mentor buddy system in times of crisis

Louise Jones agreed to communication to mangers by 1st . December2007 and deliver the following messages:

• a communication on what we can do immediately to helpmanagers

• Top priority top 23 budget requests for support systems• Commitment of support for funding to HR, IT, infrastructure• "Tools and resources" information from the Hewitt report

Discussion ensued regarding connecting with the manager. The followingwas suggested

• CEO visit once a year• Quarterly meetings Senior Management Group• Regular communicate from CEO• Mentor support network for managers

Action

Jones

Coish-Snow

10

Motion TimeFrame

KIV


3.5.

3.6.


Executive reviewed in detail at a previous meeting (19 September 2007) abriefing note detailing the legal services.

The organization is in the process of recruiting for the additional solicitor.Further discussion required with respect to the reporting structure for legalservices (Quality & Risk Management vs. VP People and InformationServices).

11


Kennedy

Nov14,

2007

3.7.

3.8.

3.9.

Executive

Coish-Snow KIV



3.13.

3.14. Changes at the Department of Health and Community Services

Effective Monday 29 November 2007, Mr. Robert Thompson has beenassigned full time at the Department of Health and Community Servicesresponsible for Task Force on Adverse Health Care event andpreparation of government for the Commission of Inquiry. Mr. Don Keatswill assume the role of Deputy Minister (A).

Action

14

Motion TimeFrame

3.15.

3.16.

3.17.

Coish-SnowMatthews

MillerJones

Dodge

Kennedy


4.

3.18.

3.19.

4.1.

4.2


15


4.2.1 Identification of items for next Board 12 Dec 2007

• Safety and Qualitv Improvements CommitteeExecutive reviewed the content of the draft EL 11 - 2.1 and 2.2and provided the following feedback.

2.1 Failure to ensure client confidentiality2.2 Failure to ensure clients are treated with culture and spiritualrespect.

Louise Jones to follow-up with Pat Pilgrim and sign off the reportfor the Safety and Quality Improvements Committee meeting on 2November 2007.



• Policv Governance Education Session - Carol Gabanna

The Board Chair has invited Carol Gabanna, Policy Governance to ameeting of the Board and Executive in December with the primarypurpose to provide education on "Ends" and outcomes. The sessionhas been confirmed for 12 December 2007 for Trustees andExecutive and a separate session on13 December 2007 foreducation session for Executive only.

Action

Miller

MillerMatthews

16

Motion TimeFrame

KIV14 Nov

07


4.2.2

4.3

4.4


Executive discussed engaging Carol Gabanna as a mentor in reportwriting. EL 1 is a good example for Carol Gabanna to providesupport in terms of writing reports. In advance of the December 13,2007 session, Executive will work on the interpretation components.

"Ends" is a larger component of Policy Governance that requiresconsideration about of work to be developed. Carol Gabanna will beconsulted to assist in this regard

Action

Executive

Miller

Dodge

Clarke

Howell

Clarke

Bonnell

17

Motion TimeFrame

4.5 Accreditation

Formal report from CCHSA pending.

4.6 External Linka es



18


4.6.1

4.6.2

4.6.3

4.6.4

Miller

Clarke

Matthews

KIV14 Nov

07

5. Report from Regional CEO's Meetings

Louise Jones provided a brief overview of the items discussed at theBoard NLHBA meeting held 12 October 2007 and the Regional CEO'smeeting held 11 October 2007


6.

6.1

6.2

6.3

6.4


• Negotiations - Dave Gale indicated that he wants to movenegotiation back inside TB. The Regional CEOs met with theDeputy Minister in this regard and discussed the implications forthe system at large. A message has also been sent to the Chairsof the RHAs. Outcome /decision yet to be determined. LouiseJones and Stephen Dodge to discuss further with the Board Chairregarding implications for Eastern Health.

• John Peddle has formally announced his resignation effectiveDecember, however he will stay until end of March 2008.

• The NLHBA Board has asked that NLHBA draft a document thatwill see Advocacy inside the Association with no fee implicationsfor the health authorities.

• Executive Staff Compensation - seeking a presentation to SocialPolicy

Action

JonesDodge

19

Motion TimeFrame



20


6.5


Meeting September 7,2007 (minutes not available). Meeting 5 October2007 cancelled. Next meeting scheduled for 2 November 2007.

6.7

6.8

7.

8.


Minutes of Executive Management meeting held 14 November 2007 at 10:00 a.m. ConferenceRoom A - Administrative Office, St. John's.

Present:Louise Jones, Interim President and Chief Executive OfficerNorma Baker, Interim Chief Operating OfficerGeorge Butt, Vice President (via conference call)Pat Coish-Snow, Chief Operating OfficerStephen Dodge, Vice PresidentDr. Oscar Howell, Vice PresidentAlice Kennedy, Chief Operating OfficerFay Matthews, Chief Operating OfficerPat Pilgrim, Chief Operating Officer


RegretsBeverley Clarke, Chief Operating OfficerWayne Miller, Senior Director

1.



Executive Management14 November 2007

2. Business Arisin

2.1. Judicial Inquiry ER/PR

Executive was provided an update at the Regional Quality Councilmeeting held 13 November 2007.

NLCHI Database re ERIPRA meeting will be held with key players to review the data in the NLCHIfile and produce a final report that will be utilized on a go forward basis.The organization prefers to validate the information rather than commenton the data haphazardly.

Action

2

Motion TimeFrame

2.2.

2.3.28 Nov

M

CIHRT Exhibit P-0488 Page 1 28 2008/P-0488... · 2008-04-28 · Joyce Penney, Executive Assistant...

Documents

Transcript of CIHRT Exhibit P-0488 Page 1 28 2008/P-0488... · 2008-04-28 · Joyce Penney, Executive Assistant...