ATTACHMENT S - Councils Boards and Committees MCM 00-64.pdf

DEPARTMENT OF VETERAN AFFAIRS

VETERANS HEALTH ADMINISTRATION

VISN 19

COUNCILS, BOARDS AND COMMITTEES

I. PURPOSE: To standardize local governance, governing procedures, and the language used when referring to the governance structure and the elements within it, to ensure alignment and focus on VHA priorities. The intent is to establish a collaborative and participative structure that develops the identity of the organization; fosters collaboration and sharing of best practices; improves consistency and coordination among stakeholders; improves facility-level understanding of VISN priorities, information systems and funding mechanisms, and includes facility representative from all services in strategic planning and quality, safety, value, organizational health and operational oversight. The contents of this MCM applies to all organizational elements of EOVAHCS and associated community-based outpatient clinics.

II. POLICY: It is the policy of the EOVAHCS to:

a. Utilize councils, boards, and committees in an organized structure to promote effective governance, leadership, communication and oversight of the health care system’s operations. Information and data provided to executive leadership through the councils, boards and committees enhances understanding and decision making. The council structure is a key component of the health system’s efforts in support of high reliability organizational principles.

b. Incorporate the Communication Flow outlined in EOVAHCS’s current committee communication flowchart. (See Appendix A)

III. DEFINITIONS:

a. Boards: Are formally chartered and oversee the governance and leadership direction of the EOVAHCS.

b. Councils: Are formally chartered and oversee and govern their specially designated or selected, respective areas of responsibility.

c. Committees: Are formally chartered and monitor and oversee operations for specific areas of concern or programs. Committees are required to meet regularly, create an agenda for each meeting, and keep an official record of the meeting (minutes).

EASTERN OKLAHOMA VA HEALTH CARE SYSTEM MUSKOGEE, OKLAHOMA

MEDICAL CENTER MEMORANDUM 00-64 NOVEMBER 29, 2019

EOVAHCS Councils, Boards and Committees 11-29-19 Medical Center Memorandum 00-64

d. Sub-committees or work groups: Are a sub-group of a formally charted committee that are created to meet an ongoing need of the parent committee. Sub-committees/work groups do not keep formal minutes, but one or two members should be designated as responsible to keep notes and report the group’s actions to the committee.

e. Charter: Charters shall include membership with designation of chair and voting members; purpose of the committee; responsibilities of members; performance improvement activities; meeting frequency and organizational link. Charters will be reviewed/updated every three years.

f. Quorum: A quorum for all EOVAHCS councils, boards and committees is defined as fifty-one percent of voting members, unless clearly and specifically stated otherwise in the charter.

g. Ad Hoc Members are non-voting members.

h. Recorders: The person responsible for the completion of the agenda, minutes, and filing of final, approved minutes. The recorder is also responsible for posting the committee minutes to the EOVAHCS share point and storage of a hard copy of the minutes. Minutes are to be completed in a timely manner to facilitate signature by the Chair and the appropriate Quadrad member or designee, within 14 working days of the meeting. Signed, hard copies of the minutes are to be kept for a minimum of 3 years (per Record Control Schedule 10-1).

III. RESPONSIBILITIES

a. General Attendee Requirements.

(1) Confidentiality: It is the expectation that group deliberations are private, allowing for open and honest discussion of issues. However, the final outcomes, concerns and action items resulting from these discussions will be cataloged in the minutes.

(2) Consensus: Meeting participants should work by reaching a common understanding of the issue, dealing with the options, choosing one, and supporting the decision.

(3) Respect: All attendees must exhibit professional behavior and courtesy to others. The Chairperson maintains the ability to ask an individual to leave if their behavior becomes disruptive or disrespectful.

b. Chairperson.

EOVAHCS Councils, Boards and Committees 11-29-19

(1) Keep the group on task and in line with the purpose, objectives and responsibilities outlined in the charter;

(2) Set a yearly calendar of meeting times and activities so the goals and objectives are reached;

(3) Set agendas, run efficient meetings and help follow up on action items;

(4) Represent the group in discussions with the respective governing/chartering group and;

(5) Monitor participation.

c. Co-Chair:

(1) Assist the chairperson in ensuring goals and objectives of the charter are being met, reviewed and updated;

(2) Ensure follow up and review of all action items;

(3) Monitor all outcome measures;

(4) Ensure minutes get completed timely, posted and shared; and

(5) Serve as the chairperson’s backup.

d. Secretary (Minute Taker)/Administrative Support:

(1) Record the minutes, disseminate the minutes, publish the minutes in a timely manner;

(2) Assure attractive and conforming formatting, timely sharing and posting of agendas and minutes;

(3) Ensure all agendas are filled out thoroughly – including all open action items from previous meetings and;

(4) Assist with correspondence and communication updates.

e. Members:

(1) Actively participate in regular conference calls. Members must participate in and be present for 85% of all meetings, which includes active participation and being prepared for each meeting. Voting members may provide a proxy. If a member will not be able to participate on a n on-going basis, they have the responsibility to inform the chairperson to allow a replacement to be voted upon and selected;

EOVAHCS Councils, Boards and Committees 11-29-19

(2) Volunteer periodically to follow-up on action items or projects. The success of the group depends on the contributions of all its members;

(3) Share best practices from their facility;

(4) Presenters will distribute copies of their handouts to all group members via Outlook mail at least two days prior to the meeting. The group’s secretary will make sure these attachments become part of the minutes.

f. Supervisors and QUAD Members:

(1) Allow members time away from their job responsibilities, when necessary, to perform group business;

(2) During at least on staff meeting a year, supervisors will meet with their Service/unit to discuss how facility interests are being represented throughout the

IV. PROCEDURES:

a. Chairs/Co-Chairs are responsible for ensuring that requirements for governance, leadership and operations are being met in their respective areas of responsibility. This includes:

(1) Ensuring communications with other councils, committees, relevant sub-committees within their reporting structure.

b. Agenda: An agenda will be prepared by the chair and/or recorder and distributed to members at least five days prior to the meeting if possible. The agenda should include the meeting name, date, time and location; review and approval of minutes of the previous meeting; announcements and informational items; and items related to committee oversight.

c. Attendance: Membership on councils, committees, sub-committees and other groups is a responsibility that members must take seriously. Regular attendance is expected. Membership attendance will be tracked as Present, Excused (notice was given to the Chair prior to the meeting), or Absent (no notice provided). It is the expectation, for all voting members, that a representative is sent in one’s absence.

d. Minutes: The standardized format reflected in Appendix B of this memorandum shall be used in preparing minutes of all committee meetings.

(1) Discussion: Includes pertinent dialogue, including the plan (what is being measured) of the performance improvement activity being discussed. Conclusions:

Summarize the measurement and assessment of findings, including trends of the performance activity being discussed. Systematic, aggregated, and analyzed data must

EOVAHCS Councils, Boards and Committees 11-29-19 be clearly reflected in the minutes. If improvement is noted, this must be clearly reflected in the minutes.

(2) Recommendations: Include the committee’s proposed actions that will reflect improvement resulting from the process change/action plan. Include what has been done, what is planned to ensure that improvement occurs or is sustained. Actions: Determine how recommendations will be addressed. The phrase “Continue to monitor” should be used judiciously and prudently. Action items will have a due date and will be carried forward in the minutes until such a time that a completion date can be entered into the minutes. Completion dates must be viewed and acted upon as a committee deadline.

(3) Status/Target Date: Must have date completed and/or target date for completion. If no further action is required, item is Closed. Informational is used if items are only for discussion or announcement purposes and no action is required by the committee. Open items will be carried forward with a due date and should appear in the “old business”.

(4) Unnecessary information will not be included in the minutes. This includes such information as direct quotes (unless requested, or if remarks of the guest speaker).

Content of embedded items should have content evaluated by the Chair prior to attachment.

(5) Minutes will be reviewed each time a new agenda is prepared to ensure that all recommendations and pending items are either addressed or closed. The evaluation of actions is addressed when indicated. There should be no pending issues left in any set of monthly minutes for more than two consecutive meetings.

V. REFERENCES:

a. Department of Veterans Affairs Records Control Schedule 10-1 dated May 2016.

VI. FOLLOW-UP RESPONSIBILITY: Quality, Safety & Value Service is responsible for the contents of this MCM.

VII. RECISSION: Medical Center Memorandum 00-64, Councils, Boards and Committees, dated September 30, 2016

/s/

MARK E. MORGAN, MHA, FACHE

Medical Center Director

Attachments: Appendix A – Committee Flow Chart Pen & Ink dated 2-4-20 inserted Appendix B – Committee Minute Template Dist: C

EOVAHCS Councils, Boards and Committees Appendix A

COMMITTEE FLOW CHART

Committee Flow

Dec PDF.pdf

EOVAHCS Councils, Boards and Committees Appendix B

NAME OF COMMITTEE MEETING CONVENED:

ADJOURNED:

DATE: Attendance for FY:

Membership/

Position

Staff Name Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep

Guest/ Presenters

Recorder

Legend: P=Present, E=Excused, A=Absent, O=Meeting Cancelled, R=Representative from Service

Topic Discussion/ Conclusions Recommendations/ Actions Status/ Date Responsibility

I. Review of Minutes

II. Announcements

III. Old Business Discussion & Conclusions Recommendation & Action Status & Date

IV. New Business Discussion & Conclusions Recommendation & Action Status & Date

V. Standings Reports Discussion & Conclusions Recommendation & Action Status & Date

VI. Next Meeting

Original Signed Minutes are located in

APPROVED: _________ DISAPPROVED: ______ COMMENTS:

Signature (Chair of Committee) Date

Signature (Quadrad Member) Date