Continuing Care Audits Working Group (CC-AWG) Terms of Reference

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1 Audits Working Group (CC-AWG) Terms of Reference Purpose: Accountability The Audits Working Group (CC-AWG) will review the current state of all AHS and AH auditing and assurance functions for continuing care including roles, responsibilities, gaps, duplications. This working group will provide recommendations on the role and responsibilities of AH and AHS audit responsibilities / functions and make recommendations for improvement and streamlining of auditing and assurance functions while at the same time increasing Albertan s confidence in the continuing care system. This Working Group will report recommendations and activities to: Quality (CCQ) who reports to Alberta Health Services Quality and Safety (QSEC). o The CCQ will accept or refine the recommendations to inform operational policy as per the mandate of the committee. Quality in (QuICCC) who reports to the Deputy Minister of Health. o The QuICCC will accept or refine the recommendations for measures to inform strategic and directional policy as per the mandate of the committee. Scope/Mandate: The Working Group shall: Review and prepare an analysis of the current state of auditing and quality assurance functions, including: o Health Service Standards and Continuing Care Accommodation Standards; o Accreditation and other quality monitoring and assurance functions; o Key definitions of auditing and quality assurance terms; o Current roles, responsibilities, duplication and areas of gaps. Develop a vision for the future state of auditing and quality assurance in Alberta s System including defining key principles. Version 11 Updated: November 24, 2014

2 Quality Audits Working Group - 2 Make prioritized recommendations for improvement to the current auditing and quality assurance functions to achieve the future state vision. The working group will ensure that recommendations for improvement are aligned with and support the implementation of the Quality Management Framework (CCQMF) and recommendations for improvement issued by the Health Quality Council of Alberta (HQCA) and the Office of the Auditor General (OAG). Commitment to significantly streamlining of the auditing and assurance functions to reduce burden on the system and increasing Albertan s confidence in the System. Relationships: The CC-AWG will maintain close linkages to the other CCQ working groups such as the, Quality Indicator Working Group (CC-QIWG). To inform, consult, support and streamline effort of the mandates of these two working groups to reduce any potential duplication or misalignment. This working group will maintain linkages and alignment with the AHS Quality Management Framework; Health Service Standards; Accommodation Standards; relevant Accreditation Standards recognized by approved accreditation bodies; HQCA Review of Quality Assurance in Continuing Care Health Services in Alberta Report (April 30, 2014), and; Office of the Auditor General Follow up Audit on Seniors Care in Long Term Care Facilities Report (October 2014). Guiding principles: The working group will be guided by the following principles: A shared focus on improving Alberta Health Services (AHS) and Alberta Health (AH) quality assurance functions for continuing care; Clear roles and responsibilities that are understood by all parties; Open and transparent processes between working group members and stakeholders; Collaborative, coordinated and efficient audit and quality assurance processes; A shared focus on continuous quality improvement. Development of recommendations that are actionable and outcomes that are achievable and measurable. Commitment to public transparency and accountability; Commitment to streamlining of the auditing and assurance functions as increasing Albertan s confidence in the Continuing Care System. 2

3 Quality Audits Working Group - 3 Governance Responsibilities: The CC-AWG mandate has a target completion date within 6 months from start date of working group. A report from the Working Group shall be provided to the QuICCC and the CCQ at every meeting during this time period. Meeting Frequency: Co-Chairs: Monthly or at the call of the CC-AWG co-chairs. The CC-AWG is co-chaired by the AHS Chief Audit, IA ERM and the AH Director, Standards, Compliance and Licensing. Members Responsibilities: The CC-AWG is comprised of members recruited from the CCQ and QuICC committees and Audit experts from AH and AHS. Share the perspective/opinions of their respective area. Attend and participate in all meetings regardless of the recommendations under consideration. Provide a consistent delegate name. Administrative Support: CSAMH will provide administrative support to prepare agendas, brief minutes and action items. Minutes will be circulated to the working group membership and the CC-AWG co-chairs. Membership: Name Co-Chairs Ronda White Cheryl Whitten Members Vacant Beth Robb Carol Anderson Role Co-chair CC-AWG Chief Audit, Internal Audit and Enterprise Risk Management, AHS Co-chair CC-AWG Director, Standards, Compliance and Licensing Branch, Health System Accountability and Performance Division, AH Patient / Family / Resident Representative Manager, Internal Audit, Internal Audit Services & Enterprise Risk Management, AHS Director,, Edmonton Zone, Urban Zone Operations Rep, AHS 3

4 Quality Audits Working Group - 4 Carolyn Dryden Director, Quality Outcomes, Community, Seniors, Addiction & Mental Health, AHS Carla Helder Prairie Mountain Health Advisory Council Member, Patient / Family / Resident Representative Cecilia Marion Senior Director of Operations, Youville Home and St. Joseph s Auxiliary Hospital, Covenant Health, LTC Operator Cindy Rota General Manager, White Horn Village on behalf of the Alberta Senior Citizens' Housing Association (ASCHA) Claire McCrank Director, Quality, Information Management, Projects and Evaluation (QIPE), AHS Iris Neumann Chief Officer, Capital Care, LTC Operator Rep Dr. James Silvius Medical Director, Seniors Health, Community, Seniors, Addiction & Mental Health, & Co-Chair for CCQ, AHS Judy Erickson Director, Standards, Compliance and Licensing Branch, Health System Accountability and Performance Division, AH Karin Fluet Director, Infection Prevention & Control, AHS Linda Tymchuk Director, Accreditation, Quality Healthcare Improvement, AHS Michel Thibaudeau Director, Internal Audit Services & Enterprise Risk Management, AHS Nora Yaghi Manager, Quality Improvement, Branch, Health Services Division, AH Robyn Maddox Director,, North Zone, Rural Zone Operations Rep, AHS Trudy Harbidge Program Advisor for CCQ & Senior Director, Community, Seniors, Addiction & Mental Health, AHS Tina Brown Administrative Support, Community, Seniors, Addiction & Mental Health, AHS Members are requested to send a consistent designate if unable to attend. Ad hoc members will be invited as needed. 4

5 Quality Audits Working Group - 5 Diagram A: Cascading Accountabilities Approval Date: November 27,

6 AB Government Leadership Teams p (other) CC Performance Measurement Framework WG to be established Legend Direct Reporting Working Relationships Working Relationships among multiple groups Quality Indicators Working Group Governance and Relationship Map Minister of Health HQCA Deputy Minister of Health Seniors Ministry Alberta Health Leadership Team Leadership Team Leadership Team AHS Leadership Team Collaborative Quality and Safety Strategic Clinical Network (SCN) Clinical Operations Exec. (COEC) Analytics Oversight Council (AOC) Leadership (AOC) Quality in (QuICCC) to be established tblihd AHS Quality (CCQ) Quality & Healthcare Improvement Measurement & Monitoring Advisory Seniors Health SCN Leadership Integrated Continuing Care Steering (ICCSC) Audits Working Group (WG) Quality Indicator Working Group Patient Experience Measurement & Reporting Steering Seniors Health SCN Data & Performance Measurement WG Seniors Health Dashboard WG CC Client / Family Experience WG TOR being revised Draft 3 Dec 3, 2014

7 Quality Indicator Working Group Governance and Relationship Map AHS The purpose of the Quality (CCQ) is to ensure quality and safe care is provided through coordinated and collaborative Quality (CCQ) AH Quality in (QuICCC) oversight to the monitoring, improvement and operational delivery of the quality services in Alberta. The committee will be accountable for ensuring all quality assurance and improvement structures, processes and outcomes related to safe care and service are necessary, sufficient and effective in achieving the CCQ mandate. The CCQ will provide a mechanism to share knowledge, learning, and build consensus in the development, implementation, maturing of the Quality Management Framework, inclusive of the Quality Governance Structure. The AH Quality in (QuiCCC) is in development. Quality Indicator Working Group Audits Working Group The Quality Indicator Working Group (CC QIWG) is accountable to the CCQ who reports to QSEC, and the QUICCC who reports to the Minister of Health. CC QIWG will provide expertise and advice to support the continuous improvement of measures for Quality Assurance (measures to monitor against indicators of quality care) and Quality Improvement (measures to show improvement in performance) within Alberta. The Continuing i Care Audits Working Group (CC AWG) is accountable to the CCQ who reports to QSEC, and the QUICCC who reports to the Minister of Health. CC AWG will review the current state of all AHS and AH auditing and assurance functions for continuing care including roles, responsibilities, gaps, duplications. This working group will provide recommendations on the role and responsibilities of AH and AHS functions and make recommendations for improvement and streamlining of auditing and assurance functions while at the same time increasing Albertan s confidence in the continuing care system. Collaborative The Collaborative is an advisory committee reporting to the Minister of Health s Forum, to provide a forum for collaboration and development of joint solutions to current and emerging issues in the System; and to help inform policy through recommendations to Alberta Health and Alberta Health Services. Patient Experience Measurement & Reporting Steering Seniors Health SCN Data & Performance Measurement WG Reporting to the Vice President, Quality and Chief Medical Officer, and the Vice President, Research, Innovation and Analytics, the Steering will lead the development of an AHS wide consolidated process for measuring, monitoring and learning from the patient s experience. The will coordinate patient feedback initiatives across AHS to ensure consistency and reduce overlap, primarily at the macro and meso level. Accountable to Quality & Healthcare Improvement Measurement & Monitoring Advisory. The purpose of this working group is to enable evidence based decision making, monitoring and evaluation within the SH SCN in collaboration with key stakeholders and provide recommendations on future sustainability, and continuous improvement regarding data collection and reporting. Seniors Health Dashboard WG Co chaired by provincial Community, Seniors, Addictions and Mental Health (CSAMH) and Data, Integration, Management and Reporting (DIMR). The Working Group will provide vision, leadership and direction to support the development of an Alberta Health Services Seniors Health Dashboard. This Seniors Health Dashboard will be part of the Alberta Health System Performance Measurement and Framework and will consist of key metrics for planning, measuring, and reporting health system performance and quality regarding Seniors Health clinical populations (e.g., palliative care and specialized geriatrics) and service areas (Home Living, Supportive Living, and Facility Living).

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