MINUTES Client Services, Quality & Safety Committee (CSQS) Held September 8, 2015 Champlain CCAC Head Office

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1 Head Office 4200 Labelle Street Suite 100 Ottawa ON K1J 1J8 Siège social 4200, rue Labelle Bureau 100 Ottawa ON K1J 1J8 Tel/Tél : Fax/Téléc : BOARD COMMITTEE MEMBERS (CSQS): REGRETS (CSQS): BOARD COMMITTEE MEMBERS (FINANCE): FINANCE REGRETS STAFF PRESENT (CSQS): FINANCE STAFF PRESENT FOR JOINT PORTION OF MEETING: MINUTES Client Services, Quality & Safety Committee (CSQS) Held September 8, 2015 Champlain CCAC Head Office Sherryl Smith Andrée Durieux-Smith Abebe Engdasaw Melody Isinger Maria Barrados Denise Alcock Robert D Aoust Michel Parent Marc Sougavinski Catherine Butler Paula Greco Ashley Haugh Brian Lawless Ellen Odai Glenda Owens Deryl Rasquinha Jamie Stevens Sara Bisson Acting Chair Chair Ex-officio member RECORDER: Ashley Haugh Executive Assistant GUEST: Chief Executive Officer Vice-President, Clinical Care Senior Lead, Program Evaluation Executive Assistant Manager, Service Provider Programs Manager, Client Relations Director, Care Coordination Vice-President, Performance and Strategy Director, Business Intelligence & Planning Corporate Controller 1.0 Declaration of Conflict of Interest There were no declarations of conflict Minutes Champlain CCAC Client Services, Quality and Safety Committee September 8, 2015 Champlain Community Care Access Centre Centre d accès aux soins communautaires de Champlain

2 2 2.0 Approval of Agenda for September 8, 2015 It was moved by Andrée Durieux-Smith, seconded by Abebe Engdasaw and agreed to approve the agenda for September 8, 2015 as amended. CARRIED 3.0 Approval of Minutes The minutes of the June 8, 2015 meeting were approved by consent. 4.0 Business Arising As a follow-up to the June 2015 CSQS meeting, more details on the acuity of patients in Long-Term Care will be provided at the October CSQS meeting. 5.0 Quality Reports It was moved by Andrée Durieux-Smith, seconded by Sherryl Smith and agreed to move in-camera CARRIED 5.1 Adverse Events There are no adverse events to report. 5.2 Quality Improvement Plan (QIP) Status Update The Committee received an update on the first quarter results of the QIP. QIP activities are divided into the following areas and recent and new activities in each area were discussed: Safety o Work continues to reduce the percentage of long stay patients who record a fall. CCAC Care Coordinators are continually working with patients on fall prevention. The CCAC has also partnered with Ottawa Public Health on e-training related to falls prevention. Initial implementation of the e-training will take place in September and expand in January All SPOs will be taking the online training. Access o Work continues internally and with partners to decrease the number of days from a patient being referred to CCAC to when services begin (referral to first service). This includes reviewing staffing levels at CCAC intake; working with Service Provider Organizations (SPOs) to pick up referrals on a quicker cycle, reinforce first visit date requirements on referrals, etc. Effectiveness o Work continues to reduce the number of CCAC patients who are making unplanned, less urgent visits to the Emergency Department or readmission to the hospital within 30 days of discharge from hospital. At The Ottawa Hospital (TOH) staff is working on data

3 sharing to evaluate when CCAC clients are making ED visits. Integrated discharge planning is being piloted at TOH in fall Since March 2015, Renfrew Paramedics are providing check-ups on patients to reduce unplanned visits to the ED and data will be available later in 2015 to evaluate the program. o CCAC Care Coordinators have increased the number of assessments conducted per month, increasing touch points with patients. Client-Centred o Work continues to increase the overall experience results measured by the Client and Caregiver Experience Evaluation. Automated provider reports is a new initiative to improve communications between the CCAC and SPOs Events Report - Quarterly Status The Committee reviewed the Q1 Events Reporting: The top five reported events in the Champlain Events Learning System (CELS) were: o Quality of Services Provided by Champlain CCAC, SPO and HealthCare Team (Subcategories: professionalism; responsiveness; time management; cleanliness) o Client Fall (Subcategories: Witnessed without injury; Witnessed - with injury; Not witnessed) Staff is reviewing subdividing the not witnessed to without injury and with injury o Improper procedure or intervention as per College standards or established practice o Abuse/Threat/Harassment/ Injury to Staff o Not Reportable Events Improvement activities are being developed and/or implemented for each area. 5.4 Complaints and Compliments Report - Quarterly Status The Committee discussed the Events and Complaints report: Complaints about Service Provider Organization (SPO) staff are shared with the SPO. Complements regarding SPO staff are also shared with the SPO. When a pattern in the complaints regarding care, missed visits, etc. is found it will be investigated and will be addressed with the SPO immediately, at the quarterly meeting or through a Quality Improvement Notification. 6.0 Special Needs Strategy Update The Committee received an update on the Integrated Rehab portion of the Special Needs Strategy: In Ontario, 34 local planning tables were identified by the MOHLTC to review services, including 5 in Champlain. CCAC staff sit at all tables..

4 4 The tables have a responsibility to build models and recommend the organizations that will deliver the service. The Champlain CCAC s goals at the tables are to ensure what is done is best for the children and that the best model of service delivery is established for this group of patients. It must be an improvement on existing models of care delivery. Focus is on children in publically funded schools receiving occupational therapy (OT), physiotherapy (PT) and speech language pathology (SLP). Depending on outcomes of each table, there will be impacts for the Champlain CCAC funding and staffing. Proposals are due in October to be implemented in September It was moved by Abebe Engdasaw, seconded by Sherryl Smith and agreed to move in-camera. CARRIED 7.0 Client and Caregiver Experience Survey (CCEE) The Committee reviewed the CCEE results: The CCEE is used by all 14 CCACs and, therefore, provides Champlain CCAC specific results as well as a comparison to the other CCACs. The survey is comprised of 47 Questions across 9 Key Performance Indicators (KPIs): o Overall Experience o Client Centred Care o Client Centred Care Appointments o Quality of Care o Building Relationships and Trust o Integrated Care and Support of Transitions o Willingness to Recommend o Expectations of Quality o Safety In Champlain, approximately 2,200 surveys are conducted. Surveys are conducted throughout the year. The KPIs related to overall experience, client- centred care, integrated care and support of transitions, and safety showed the greatest opportunities for improvement and are the focus of action planning. A work plan will be completed in Q3 with implementation beginning in January The work plan also involves the SPOs. It is also an Accreditation requirement to have a formal action plan for improvement associated with formal client feedback cycles. Results of the CCEE are shared with the Patient and Caregiver Council. 8.0 Accreditation Readiness Update The Committee received an update on accreditation preparation and readiness: The Champlain CCAC s onsite accreditation survey will take place

5 5 December 5-8, As a part of accreditation readiness, in spring 2015, board members and staff were asked to complete 7 different self-assessment surveys related to the standards applicable to the Champlain CCAC: o Governance o Leadership o Infection Prevention and Control o Medication Management o Case Management o Mental Health and Addictions o Home Care Overall, the results indicated that the organization is functioning well related to the applicable standards. However, there are some areas for improvement that have been identified by staff and the Board. An action plan for improvement has been completed with detailed timelines and accountabilities in each of the standard areas. For the Governance standards, the action plan was reviewed by the Board Accreditation Governance Team at its August meeting and details can be found in the draft Governance Committee minutes in the September Board package. Accreditation will also be a topic of discussion at the November 2015 Board retreat. The CSQS will receive quarterly updates on accreditation readiness and preparation. Joint Meeting with CSQS, Finance Committee, and Audit Committee 9.0 Scorecard Review and Discussion Performance Improvement Plan for Key Quality Indicators The Committees reviewed updates and highlights of the August 2015 (July 2015 data) scorecard: The Ministry of Health and Long-Term Care (MOHLTC) has set new province wide targets for three metrics that are in the process of being updated in the Champlain CCAC s Multi-Sector Service Accountability Agreement (MSAA) with the Champlain Local Health Integration Network (LHIN). The new targets have been updated on the scorecard and are currently all tracking red: o Action plans for improvements to service wait time in the community, and wait time for Personal Support Services (PSS) for complex patients include: Staffing levels at intake are being reviewed and augmented as necessary. Based on a new initial rapid assessment process, clients that need immediate service are placed on service and the full home assessment (RAI-HC) is completed after service has

6 begun. Based on the same rapid initial assessments process, patients who need only Community Support Services (CSS) are also referred immediately to CSS rather than waiting in the intake process. Ensuring the proper administrative hold is put on patients who have asked for a delay in the start of their services (e.g., relative is in town assisting, later discharge from hospital, etc.) will also improve the metrics. With action plans for improvement implemented, there should be a reduction in wait times by the end of Q3. o Alternate Levels of Care (ALC) targets have also been reduced. This is a joint indicator with hospitals. The Champlain CCAC assists to reduce ALC through supporting patients at home as early as possible after a hospital admission via Home First, Stay at Home, etc. Care plans for those released from the PSS and therapies wait list in spring and early summer 2015 were still being filled in August and have largely cleared in September. Year-to-date, the Champlain CCAC has a surplus of approximately $1.6M based on a planning target of a 1.5% base budget increase. In discussions with the Champlain LHIN and based on funding letters received to date, a 1% base budget increase is now expected and the budget will be recast to reflect the new funding levels. The Champlain CCAC is working to provide greater resources and support to caregivers. The Caregiver Exchange is a provincial website with resources for caregivers and is linked to the Healthline. The Champlain CCAC has contributed many resources and stories from our Patient and Caregiver Council to draw awareness to the website. Completed Performance Agreements for unionized staff is currently tracking red. With the launch of the new Care Model in February 2015 many staff joined new teams with new Managers, as a result the completion of Performance Agreements were delayed to allow Managers to work with new team members before completing performance agreements. 6 The scorecard is a standing item on the Board agenda and it will be reviewed with the Board at the September meeting. This will including discussing the action plan to improve the three new MSAA targets Service Provider Organization (SPO) Performance Management (Inspection Plan, Quality Improvement Notice (QIN) Status) The Committees received an update on SPO Performance Management: The Champlain CCAC partners with SPOs with the object of having a relationship which balances Performance Management, Strategic Engagement and Continuous Quality Improvement. The Champlain CCAC and SPOs have collaborated on strategic initiatives ACTION: SPO Performance Management updates will be presented to the joint committees quarterly.

7 such as neighbourhood care, increased clinic usage, etc. Staff meets with SPOs regularly as a group and individually to review current issues, areas of concern, opportunities for improvement, etc. The Champlain Events Learning System (CELS) provides early warning of issues in a region, by SPO, etc. and allows for early intervention. When necessary, Quality Improvement Notices (QINs) are issued to SPOs with specific action plans for improvement. There must be three quarters of continuous quality improvement for a QIN to be removed. Some CCAC services such as for Hips and Knees and Wound Care do have specific outcomes, pathways, etc. SPOs are expected to meet these standards and this is part of the ongoing quality monitoring. 7 The meeting was adjourned by consent. CONFIRMED: original signed by SHERRYL SMITH, ACTING CHAIR