Accreditation Report

Transcription

1 Hamilton Niagara Haldimand Brant Community Care Access Centre Hamilton, ON On-site survey dates: February 22, February 26, 2016 Report issued: March 10, 2016 Accredited by ISQua

2 About the Hamilton Niagara Haldimand Brant Community Care Access Centre (referred to in this report as the organization ) is participating in Accreditation Canada's Qmentum accreditation program. As part of this ongoing process of quality improvement, an on-site survey was conducted in February Information from the on-site survey as well as other data obtained from the organization were used to produce this. Accreditation results are based on information provided by the organization. Accreditation Canada relies on the accuracy of this information to plan and conduct the on-site survey and produce the. Confidentiality This report is confidential and is provided by Accreditation Canada to the organization only. Accreditation Canada does not release the report to any other parties. In the interests of transparency and accountability, Accreditation Canada encourages the organization to disseminate its to staff, board members, clients, the community, and other stakeholders. Any alteration of this compromises the integrity of the accreditation process and is strictly prohibited. Accreditation Canada, 2016

3 A Message from Accreditation Canada's President and CEO On behalf of Accreditation Canada's board and staff, I extend my sincerest congratulations to your board, your leadership team, and everyone at your organization on your participation in the Qmentum accreditation program. Qmentum is designed to integrate with your quality improvement program. By using Qmentum to support and enable your quality improvement activities, its full value is realized. This includes your accreditation decision, the final results from your recent on-site survey, and the instrument data that your organization has submitted. Please use the information in this report and in your online Quality Performance Roadmap to guide your quality improvement activities. Your Accreditation Specialist is available if you have questions or need guidance. Thank you for your leadership and for demonstrating your ongoing commitment to quality by integrating accreditation into your improvement program. We welcome your feedback about how we can continue to strengthen the program to ensure it remains relevant to you and your services. We look forward to our continued partnership. Sincerely, Leslee Thompson President and Chief Executive Officer A Message from Accreditation Canada's President and CEO

4 Table of Contents 1.0 Executive Summary Accreditation Decision About the On-site Survey Overview by Quality Dimensions Overview by Standards Overview by Required Organizational Practices Summary of Surveyor Team Observations Detailed On-site Survey Results Priority Process Results for System-wide Standards Priority Process: Governance Priority Process: Planning and Service Design Priority Process: Resource Management Priority Process: Human Capital Priority Process: Integrated Quality Management Priority Process: Principle-based Care and Decision Making Priority Process: Communication Priority Process: Physical Environment Priority Process: Emergency Preparedness Priority Process: Patient Flow Priority Process: Medical Devices and Equipment Service Excellence Standards Results Standards Set: Case Management - Direct Service Provision Standards Set: Infection Prevention and Control Standards for Community-Based Organizations - Direct Service Provision Standards Set: Medication Management Standards for Community-Based Organizations - Direct Service Provision Instrument Results Governance Functioning Tool (2016) Canadian Patient Safety Culture Survey Tool: Community Based Version Worklife Pulse Organization's Commentary 37 Appendix A Qmentum 38 Appendix B Priority Processes 39 Table of Contents i

5 Section 1 Executive Summary Hamilton Niagara Haldimand Brant Community Care Access Centre (referred to in this report as the organization ) is participating in Accreditation Canada's Qmentum accreditation program. Accreditation Canada is an independent, not-for-profit organization that sets standards for quality and safety in health care and accredits health organizations in Canada and around the world. As part of the Qmentum accreditation program, the organization has undergone a rigorous evaluation process. Following a comprehensive self-assessment, external peer surveyors conducted an on-site survey during which they assessed this organization's leadership, governance, clinical programs and services against Accreditation Canada requirements for quality and safety. These requirements include national standards of excellence; required safety practices to reduce potential harm; and questionnaires to assess the work environment, patient safety culture, governance functioning and client experience. Results from all of these components are included in this report and were considered in the accreditation decision. This report shows the results to date and is provided to guide the organization as it continues to incorporate the principles of accreditation and quality improvement into its programs, policies, and practices. The organization is commended on its commitment to using accreditation to improve the quality and safety of the services it offers to its clients and its community. 1.1 Accreditation Decision Hamilton Niagara Haldimand Brant Community Care Access Centre's accreditation decision is: Accredited with Exemplary Standing The organization has attained the highest level of performance, achieving excellence in meeting the requirements of the accreditation program. Executive Summary 1

6 1.2 About the On-site Survey On-site survey dates: February 22, 2016 to February 26, 2016 Locations The following locations were assessed during the on-site survey. All sites and services offered by the organization are deemed accredited. 1 Hamilton Niagara Haldimand Brant Community Care Access Centre, Brant Branch 2 Hamilton Niagara Haldimand Brant Community Care Access Centre, Burlington Branch 3 Hamilton Niagara Haldimand Brant Community Care Access Centre, Haldimand-Norfolk Branch 4 Hamilton Niagara Haldimand Brant Community Care Access Centre, Hamilton Branch 5 Hamilton Niagara Haldimand Brant Community Care Access Centre, Niagara Branch Standards The following sets of standards were used to assess the organization's programs and services during the on-site survey. System-Wide Standards 1 Leadership Population-specific Standards 2 Medication Management Standards for Community-Based Organizations Service Excellence Standards Governance - Service Excellence Standards Infection Prevention and Control Standards for Community-Based Organizations - Service Excellence Standards Case Management - Service Excellence Standards Instruments The organization administered: Governance Functioning Tool Canadian Patient Safety Culture Survey Tool: Community Based Version Worklife Pulse Executive Summary 2

7 1.3 Overview by Quality Dimensions Accreditation Canada defines quality in health care using eight dimensions that represent key service elements. Each criterion in the standards is associated with a quality dimension. This table shows the number of criteria related to each dimension that were rated as met, unmet, or not applicable. Quality Dimension Met Unmet N/A Total Population Focus (Work with my community to anticipate and meet our needs) Accessibility (Give me timely and equitable services) Safety (Keep me safe) Worklife (Take care of those who take care of me) Client-centred Services (Partner with me and my family in our care) Continuity of Services (Coordinate my care across the continuum) Appropriateness (Do the right thing to achieve the best results) Efficiency (Make the best use of resources) Total Executive Summary 3

8 1.4 Overview by Standards The Qmentum standards identify policies and practices that contribute to high quality, safe, and effectively managed care. Each standard has associated criteria that are used to measure the organization's compliance with the standard. System-wide standards address quality and safety at the organizational level in areas such as governance and leadership. Population-specific and service excellence standards address specific populations, sectors, and services. The standards used to assess an organization's programs are based on the type of services it provides. This table shows the sets of standards used to evaluate the organization's programs and services, and the number and percentage of criteria that were rated met, unmet, or not applicable during the on-site survey. Accreditation decisions are based on compliance with standards. Percent compliance is calculated to the decimal and not rounded. High Priority Criteria * Other Criteria Total Criteria (High Priority + Other) Standards Set Met Unmet N/A # (%) # (%) # Met Unmet N/A # (%) # (%) # Met Unmet N/A # (%) # (%) # Leadership 49 (100.0%) 0 (0.0%) 0 95 (100.0%) 0 (0.0%) (100.0%) 0 (0.0%) 1 Medication Management Standards for Community-Based Organizations 23 (100.0%) 0 (0.0%) (100.0%) 0 (0.0%) (100.0%) 0 (0.0%) 31 Governance 45 (100.0%) 0 (0.0%) 5 35 (97.2%) 1 (2.8%) 0 80 (98.8%) 1 (1.2%) 5 Infection Prevention and Control Standards for Community-Based Organizations 15 (100.0%) 0 (0.0%) (100.0%) 0 (0.0%) 8 53 (100.0%) 0 (0.0%) 20 Case Management 46 (100.0%) 0 (0.0%) 0 80 (100.0%) 0 (0.0%) (100.0%) 0 (0.0%) 0 Total 178 (100.0%) 0 (0.0%) (99.6%) 1 (0.4%) (99.8%) 1 (0.2%) 57 * Does not includes ROP (Required Organizational Practices) Executive Summary 4

9 1.5 Overview by Required Organizational Practices A Required Organizational Practice (ROP) is an essential practice that an organization must have in place to enhance client safety and minimize risk. Each ROP has associated tests for compliance, categorized as major and minor. All tests for compliance must be met for the ROP as a whole to be rated as met. This table shows the ratings of the applicable ROPs. Required Organizational Practice Overall rating Test for Compliance Rating Major Met Minor Met Patient Safety Goal Area: Safety Culture Accountability for quality (Governance) Patient safety incident disclosure (Leadership) Patient safety incident management (Leadership) Patient safety quarterly reports (Leadership) Patient safety-related prospective analysis (Leadership) Met 4 of 4 2 of 2 Met 4 of 4 2 of 2 Met 6 of 6 1 of 1 Met 1 of 1 2 of 2 Met 1 of 1 1 of 1 Patient Safety Goal Area: Communication Information transfer at care transitions (Case Management) Medication reconciliation as a strategic priority (Leadership) Medication reconciliation at care transitions (Case Management) The Do Not Use list of abbreviations (Medication Management Standards for Community-Based Organizations) Met 4 of 4 1 of 1 Met 4 of 4 2 of 2 Met 4 of 4 1 of 1 Met 4 of 4 3 of 3 Executive Summary 5

10 Required Organizational Practice Overall rating Test for Compliance Rating Major Met Minor Met Patient Safety Goal Area: Medication Use High-alert medications (Medication Management Standards for Community-Based Organizations) Met 5 of 5 3 of 3 Patient Safety Goal Area: Worklife/Workforce Client Flow (Leadership) Patient safety plan (Leadership) Patient safety: education and training (Leadership) Workplace violence prevention (Leadership) Met 7 of 7 1 of 1 Met 2 of 2 2 of 2 Met 1 of 1 0 of 0 Met 5 of 5 3 of 3 Patient Safety Goal Area: Infection Control Hand-hygiene compliance (Infection Prevention and Control Standards for Community-Based Organizations) Hand-hygiene education and training (Infection Prevention and Control Standards for Community-Based Organizations) Reprocessing (Infection Prevention and Control Standards for Community-Based Organizations) Met 1 of 1 2 of 2 Met 1 of 1 0 of 0 Met 1 of 1 1 of 1 Patient Safety Goal Area: Risk Assessment Home safety risk assessment (Case Management) Met 3 of 3 2 of 2 Executive Summary 6

11 1.6 Summary of Surveyor Team Observations The surveyor team made the following observations about the organization's overall strengths, opportunities for improvement, and challenges. The organization, Hamilton Niagara Haldimand Brant Community Care Access Centre (HNHB CCAC) is commended on preparing for and participating in the Accreditation Canada Qmentum program. The commentary below from teams and surveyors is qualitative and quantitative. The documentation provided by the organization was reviewed and validated through observations, document review, and conversations. The board of directors at the HNHB CCAC is fully engaged in the evolution of the organization s strategic framework and in quality monitoring. Key areas of focus include client experience, customer service, client safety, and employee engagement. A key strategy has always been to engage the client and family in a way that puts the needs of clients first and gives them control of their own health. With the latest standards of Accreditation Canada s Qmentum accreditation program, this organization is already in the forefront of health care agencies that are embarking on the journey to create a culture of client and family caring. The quarterly reporting process includes an environmental scan, quality report, and board corporate scorecard. Communication cascades effectively from the board of directors to the senior leadership team. The passion and commitment in the organization is seen from the board to the Chief Executive Officer (CEO) to the leadership team and front-line staff. The board reports they have a solid commitment to advance the transformation proposed in the 'Patients First' proposal." A Quality and Safety Committee of the board is in place, and annual quality improvement plans are developed and posted. The organization is commended for the client/patient and caregiver experience evaluation survey that has been in place for seven years. It is administered by a third party, allowing for provincial comparisons. The board prides itself, as do the community partners, on the board's transparency. Board meetings are open to the public and meeting times, agendas, and minutes are posted on the CCAC website. Board/executive expenses are posted quarterly, as are documents that support accountability including the Local Health Integration Network (LHIN) accountability agreement and compliance certificates, the Annual Report, and the CEO compensation framework. In times of fiscal restraint and in view of the recently released Auditor General s report, this transparency is a strength. As in all aspects of home care, the fiscal environment and sustainability are a real challenge, as are higher expectations regarding the availability of publicly funded home and community care. The organization has the challenge of addressing pressures on unpaid/family caregivers. The HNHB CCAC is mandated to meet the needs of an aging population and the increased number of patients with chronic and complex health conditions who need home care. The organization sees opportunity in continuing to evolve its partnerships with patients, families, and providers. They also feel there is an opportunity to use the 'Patients First' proposal as a platform to bring about greater alignment and service integration within the LHIN, to govern and manage the delivery of home and community care. A strong history of innovative partnerships focused on improving care for patients and families is in place at the HNHB CCAC. The organization reports a high rate of patient and caregiver satisfaction with regard to referrals to community supports and services. HNHB CCAC is proud of its significant research partnerships with universities including McMaster University, the University of Waterloo, and Brock University, to test and develop innovative Executive Summary 7

12 tools and inform new and evolving models of care. There is an infection prevention and control partnership with an academic hospital and direct links to the regional infection control network. Patients benefit from the shared resources for greater access to care and smooth transitions that are enabled by the co-location of staff including CCAC staff in hospitals and community support service agency staff in HNHB CCAC offices. The organization shares ethics leadership through the regional ethics network. HNHB CCAC has communication plans and processes to support the development and implementation of new programs with partners. Leadership is provided for regional programs and committees including the Community Leaders Council, co-chaired by the CEO with community leaders. Membership includes HNHB LHIN, long-term care and community support service agencies, family health teams, and others. The HNHB LHIN Quality Guidance Council is co-chaired by CEOs of the HNHB LHIN and HNHB CCAC, an indication of the belief the organization has in partnerships. Surveyors learned from service providers that the organization works collaboratively with them. As a result of the significant provincial focus on home and community care, the organization is experiencing varied expectations from its partners and the public, including provincial funding announcements with local variations. It is thought that 'Patients First' may create uncertainty regarding home and community care services for patients, families, and partners. There is a challenge in supporting clear and consistent communication. The organization sees opportunity in using the 'Patients First' planning phase as an opportunity to establish greater consistency regarding expectations for government-funded home and community care. The team reports that their organizational structure is aligned with a focus on optimizing the patient experience and providing consistent care and partnerships. The organization has improved its partnerships with primary care providers. One of the most notable strengths of this organization is its people, with their proven commitment and resiliency and ability to maintain a focus on quality patient care and continuous improvement. The organization is recognized for its ability to work with multiple stakeholders in different sectors to develop and implement initiatives to improve access to care and patient flow while being supportive of and sensitive to potentially different values and organizational mandates. The organization has ongoing affiliations with universities to pilot tools, participate in patient-focused research, and undertake advanced analytics. The DIVERT program came from this research partnership. The organization is commended for ensuring continuity of patient care during a nine-month labour disruption of contracted nursing services in Niagara and Norfolk, developing relationships with partners, and sharing timely and relevant patient information, such as the common electronic medical record for day-to-day care to support patients and families in a safe environment that best meets their needs. The organization is recognized for embedding evidence-based decision making into all patient-related activities, including initial and ongoing assessments and care planning. HNHB CCAC reports being challenged by the need to adjust to and manage limited resources to meet the needs of an aging population (and their families and caregivers) and the increasing number of individuals with complex care needs. As well, attracting and retaining staff with who have the expertise to meet changing needs, including developing fluency with supporting technology, is identified as a challenge. The organization sees the need to remain focused on positive patient experience, advance patient and family engagement, and partner with providers including primary care. Another area for improvement is to provide leadership for health system integration and sustainability of the home and community care sector. The organization reports there is an opportunity to promote and publish research with academia to disseminate best practices. Executive Summary 8

13 Section 2 Detailed On-site Survey Results This section provides the detailed results of the on-site survey. When reviewing these results, it is important to review the service excellence and the system-wide results together, as they are complementary. Results are presented in two ways: first by priority process and then by standards sets. Accreditation Canada defines priority processes as critical areas and systems that have a significant impact on the quality and safety of care and services. Priority processes provide a different perspective from that offered by the standards, organizing the results into themes that cut across departments, services, and teams. For instance, the patient flow priority process includes criteria from a number of sets of standards that address various aspects of patient flow, from preventing infections to providing timely diagnostic or surgical services. This provides a comprehensive picture of how patients move through the organization and how services are delivered to them, regardless of the department they are in or the specific services they receive. During the on-site survey, surveyors rate compliance with the criteria, provide a rationale for their rating, and comment on each priority process. Priority process comments are shown in this report. The rationale for unmet criteria can be found in the organization's online Quality Performance Roadmap. See Appendix B for a list of priority processes. INTERPRETING THE TABLES IN THIS SECTION: The tables show all unmet criteria from each set of standards, identify high priority criteria (which include ROPs), and list surveyor comments related to each priority process. High priority criteria and ROP tests for compliance are identified by the following symbols: High priority criterion ROP MAJOR MINOR Required Organizational Practice Major ROP Test for Compliance Minor ROP Test for Compliance Detailed On-site Survey Results 9

14 2.1 Priority Process Results for System-wide Standards The results in this section are presented first by priority process and then by standards set. Some priority processes in this section also apply to the service excellence standards. Results of unmet criteria that also relate to services should be shared with the relevant team Priority Process: Governance Meeting the demands for excellence in governance practice. Unmet Criteria High Priority Criteria Standards Set: Governance 2.3 The governing body includes clients as members, where possible. Surveyor comments on the priority process(es) Hamilton Niagara Haldimand Brant Community Care Access Centre (HNHB CCAC) is one of fourteen Community Care Access Centres in Ontario. It is reported by the leadership team to be among the largest across many dimensions, including with regard to budget and service provision. It is the result of a merge of five CCACs in As is the mandate of CCACs, HNHB CCAC provides system navigation, care coordination for community, and facilitates placement in long-term care homes. The comments below are based on the high-quality, comprehensive documents provided to the surveyors, and on conversations with HNHB CCAC board members, community partners, and a wide range of staff members. Conversations were held with the board of directors as a group. Covering a wide and challenging environment that is both rural and urban, the organization is justified in the pride it takes in not only the quantity of services delivered but also in the leadership it provides to many initiatives from the Ontario Association of CCACs, its partnership with the LHIN, and the quality of its client- and family-focused services. A review of the Strategic Plan, developed in 2012, and reviewed annually since then, emerges from the statement common to all 14 CCACs and indicates the Board is up-to-date with its knowledge of strategic government policies and directions. The board is current with the developments and directions from the health ministry and the HNHB LHIN. This is evidence that the board recognizes the importance of remaining compliant with the direction and rules established in the province of the main funding sources. It is noteworthy that beyond compliance there is a strong working relationship between the HNHB CCAC and the HNHB LHIN. Numerous examples were provided of common goals established and achieved, a mutual sense of purpose, respect and trust for each organization, and an understanding and recognition by each that enhancing a client and family culture of caring underpins all strategic directions and goal achievement. This is a situation that bodes well for a potential future merger of these two entities. Detailed On-site Survey Results 10

15 This board, with several new directors and a new chairperson, has been very successful in developing and implementing a governance model that allows it to comply with all tenets of Accreditation Canada s requirements for good governance. Members are well informed of their roles and fiduciary responsibilities. The structural arrangement of the board (a governance policy model is used) and a review of the minutes of board meetings and various committees validates that the energy, wisdom, and commitment of the directors has enabled the board to live their mission, vision, and values as well as strongly adhere to their strategic directions. A review of board minutes and conversations with the chair and board members indicate the commitment, dedication, and expertise this board demonstrates in taking care of the clients and families as well as those who care for them. The governance model of the board, the structural arrangement, and the document review that included the Quality Report strongly indicate the board has a practical vision that has been implemented through hard work and a focus on living the mission. Currently, efforts to enhance the role of clients and families in planning their care and providing direction and support to HNHB CCAC indicates strong support for the mandate of establishing a caring culture and a recognition of the value of this approach. The board advised that there is an annual review of strategic directions and standing committees, including a Quality and Safety Committee. There is a regional approach to board recruitment and composition and the board is commended for the competency that exists among board members. The Nominating Committee strives to focus on skills, geographical representation, and cultural diversity when recruiting new members. Orientation is in place for new members. The board is very much aware of the accreditation process, familiar with the governance standards, and recognizes, as the CEO reported, that the accreditation process is a comprehensive quality improvement strategy that applies a fine lens to all board processes and activities. Detailed On-site Survey Results 11

16 2.1.2 Priority Process: Planning and Service Design Developing and implementing infrastructure, programs, and services to meet the needs of the populations and communities served. The organization has met all criteria for this priority process. Surveyor comments on the priority process(es) The comments below are derived from the materials and documents provided by the board and conversations with membership from various leadership teams of the HNHB CCAC. Prior to meeting the leadership group dedicated to planning and service design, the policies and protocols that govern this function were reviewed. These indicate that this HNHB CCAC is very much focused on planning and has a very rigorous approach to it. The Strategic Plan is a formal, written document that defines the long-term direction of the organization as a whole. As with the other 13 CCACs the vision and mission of the organization provide the foundation upon which the Strategic Plan is developed. The plan identifies strategic themes and overarching focus areas, strategic initiatives, goals, and objectives with time frames and specific outcomes and measurements. It is the task of the strategic planning group to identify broad strategic themes, define objectives with accompanying indicators for measurement and outcomes, and develop a format for the balanced scorecard which will be used for performance assessment and reporting. The Strategic Plan is aligned with the organization's mandate. It identifies expectations of the LHIN as well as the Ministry of Health and Long-Term Care s (MOHLTC) priorities. The team reported that organizational planning and priorities are aligned with MOHLTC and LHIN strategic directions, the provincial CCAC vision and mission, and the multi-sector service accountability agreements and community annual planning submissions. The team reported that program priorities are driven by strategic and operational plans. Evaluation and measurement are at the core of all programs. When asked, the team advised that the frameworks provide tools for monitoring achievement toward meeting goals and objectives. The team reported that input to planning involves multiple stakeholders including the LHIN, primary care, service providers, and partners. The planning process is communicated to stakeholders and shared regularly with staff and leadership. Communication is structured around Wildly Important Goals, strategic objectives, and the corporate work plan. The planning team is commended for its constant monitoring. They shared that a structured review process that includes weekly huddles and executive roll-up to monitor progress on goals is in place, as is a corporate work plan. The organization uses multiple data sources to make decisions and plan services that meet the needs of clients and families and comply with the organizational mandate. It gathers and analyzes multiple metrics to monitor patient flow, and leverages data including RAI (Resident Assessment Instrument) to understand population health needs. The team is commended for their dedicated effort to strengthen program evaluation models and resources, leverage partnerships for better understanding of patient and community needs, and share data with partners to support decision making. Detailed On-site Survey Results 12

17 Information on the numerous programs that are in place and the rationale for establishing these programs was provided. Commendable for their innovativeness are the e-health initiatives that include Enhanced Respite Palliative Care and efforts to improve chronic disease management through an e-clinic, providing caregiver support through respite and care coordinator training. HNHB CCAC is commended for its attention and compliance with the Qmentum standards that encourage organizations to use a client- and family-centred care (CFCC) approach to care delivery. Compliant with this approach is the efforts in place at HNHB CCAC to embark on CFCC are the Patient Advocate role that is now implemented. A patient and family engagement framework and enhancements to patient engagement opportunities are in place. There are plans to further develop a patient advisor program. The team is commended for their efforts to expand their system navigation role through My Health GPS and the HNHB CCAC prides itself, and rightly so, on the efforts to develop and sustain community partnerships. The team was pleased to report that the LHIN Patient Flow Steering Committee is a key partner. As well, HNHB CCAC plays a leadership role in the LHIN Palliative Council. Examples of efforts made to engage in community partnerships include the expansion of the Partnering for Change model as well as support for the implementation of the Ontario Special Needs Strategy, community capacity building, and the Community Support Service Collaborative. The team is aware of the need to use a change management planning approach to future changes in the planning and service design function. Detailed On-site Survey Results 13

18 2.1.3 Priority Process: Resource Management Monitoring, administering, and integrating activities related to the allocation and use of resources. The organization has met all criteria for this priority process. Surveyor comments on the priority process(es) The organization states that it is a defined Health Service Provider, with funding determined by health system funding reform. Financial planning is conducted annually and articulated in the CEO-approved budget policy and procedures. The organization has a well-defined indicator monitoring system for financial accountability. Indicators that range from daily spend rate to variance analysis of contracted-out patient care. HNHB CCAC follows the Health-Based Allocation Model (HBAM) for alignment. This methodology is used to align service levels with provincial averages. All staff have received education on the new funding formula over the past two years. The organization has also provided education on this funding formula and the impact on its budget as part of the orientation for new staff. Information on HBAM funding is provided to care coordinators and managers through their dashboards, and shared with all staff through weekly huddles. The organization is commended on their education on budget and funding formulas to all staff. HNHB CCAC is commended on maintaining one of the lowest percentages of administration costs in the province. This is also seen as one of their challenges for the future. HNHB CCAC uses an internally developed Resource Allocation Model (RAM) as a budget allocation and monitoring tool for all staff from directors to front-line staff. This information is refreshed overnight and is reviewed daily by frontline staff. The daily spend rate is reviewed by executive and management levels. Teams that are not included in HBAM are able to review costs on their dashboards. Nursing Care Centre utilization is also reviewed. One of their future challenges is to increase utilization of these centres. The organization is commended for its financial accountability and the education provided to all staff to help them understand funding and spending limitations. They have empowered their staff and staff have a feeling of ownership and actively look for ways to reduce spending without compromising client- and family-centred care. The team explained the shift to move clients receiving care through CCAC-contracted service providers to community support service providers as a way of being fiscally responsive to funding challenges. The team is encouraged to continue consultation with the clients and families, focusing on the client- and family-centred care philosophy, before these changes occur. Future challenges to maintain financial stability are prioritizing patient needs by identifying the most complex patients and costs associated with their needs, HBAM alignment, reviewing administration costs and efficiencies, and looking at the possibility of alternative care settings. Detailed On-site Survey Results 14

19 2.1.4 Priority Process: Human Capital Developing the human resource capacity to deliver safe, high quality services. The organization has met all criteria for this priority process. Surveyor comments on the priority process(es) A review of this priority process included dialogue with the leadership team and key staff members responsible for human resources and organizational development. The organization is well managed from a human capital perspective. It employs over 958 employees of whom 836 are unionized. There are 708 full-time, 159 part-time, and 91 PTB/casual/relief staff. The team explained the value for the organization derived from the PULSE (People Understanding and Linking Staff Engagement) Committee, co-chaired by the CEO and the vice president of human resources and organizational development. In 2016, the organization was recognized as one of the top employers in the Hamilton Niagara area. In addition, the Quality Healthcare Workplace Bronze Award 2016 is another indication of how this organization knows how to care for the people they employ. While the team reported that there have been human resource challenges in the past year, including a work stoppage by care coordination staff of nine of the ten CCACs in which staff are represented by the Ontario Nurses Association (ONA), they were pleased to report that HNHB CCAC was not one of them. The team was excited to report their involvement in a cultural revitalization project, described as Our Quest to Dramatically Improve the Patient Experience. When asked to further explain this project, the team reported that the project was about "dramatically improving the patient experience. The team indicated: we must have the right people, doing the right thing, the right way, all at once, at the right time and place. We must be able to prove it and sustain it and because we are part of a system, we are obligated to share our knowledge, resources and outcomes with others." Challenges that were identified and addressed during the past year were: decentralized scheduling across all branches, the need for a manager-led interview process, developing an appropriate attendance program, formalizing a coverage process for planned and unplanned absences, managing workload, and recruiting for a high number of vacancies across the organization. The organization addressed the problems by centralizing scheduling into human resources and organizational development, developing and implementing a recruitment-driven and behaviour-based interview process, implementing an attendance awareness program that decreased unplanned absences, and introducing a float model concept. The team is commended for completing these projects in a short period of time and in a manner that did not ostracize staff, many of whom are union employees. Personnel files (all in electronic format) were reviewed and seen as compliant with good human resource practice for file management. The comprehensive Human Resources and Organizational Development Annual Plan (2015/2016) was reviewed. It is aligned with the vision, mission, and strategic goals of the HNHB CCAC. The organization s efforts to assist employees to identify their learning needs and avail themselves of the opportunities and resources to meet those needs is admirable. Detailed On-site Survey Results 15

20 Workplace violence prevention is covered by a comprehensive strategy and the organization is in compliance with the Required Organizational Practice that is in place to monitor implementation and evaluation. Staff and leadership report that there is an Employee Assistance Program. The team is commended for providing a wellness program for all employees and providing resources for professional development. HNHB CCAC strives and dedicates resources to creating an environment that encourages staff to lead a healthy lifestyle and to have a positive and well-balanced work life. The team is commended for the attention paid to monitoring staff fatigue and supporting those who may need help. There was also evidence of flexibility to allow staff to organize their personal lives and family responsibilities, with flexible hours while remaining accountable and client and family focused while still enjoying a rewarding career. Supportive financial and physical resources (e.g., ergonomic assessments are in place to check seating requirements), ongoing education and orientation, mentoring, and an active Occupational Health and Safety Program are hallmarks of this well-managed division led by a dynamic and knowledgeable team. According to observations, documentation, and conversations with many levels of staff and the leadership human resources and organizational development team, the plan is well on the way to achieving what it is intended to do. HNHB CCAC is committed to honouring and encouraging individuals and teams who contribute through their efforts and actions to the provision of high-quality client services. Detailed On-site Survey Results 16

21 2.1.5 Priority Process: Integrated Quality Management Using a proactive, systematic, and ongoing process to manage and integrate quality and achieve organizational goals and objectives. The organization has met all criteria for this priority process. Surveyor comments on the priority process(es) The integrated quality management priority process reviews how the organization is using a proactive, systematic, and ongoing process to manage and integrate quality and achieve organizational goals. During the on-site survey, conversations were held with members of the leadership team and others who have a role in quality, risk management, and patient care. In addition, the on-site survey team engaged with front-line staff in the field as well as clients to discuss quality and risk and their roles in these areas. The team reports that the HNHB CCAC framework for quality, risk and patient safety is aligned with the organization s vision, mission, values and strategic directions. Quality and safety committees are in place for the board of directors and staff. On an annual basis HNHB reviews and releases a Quality Improvement Plan as mandated by the ministry, a Patient Safety Plan and a Risk Management Plan. Continual improvement is demonstrated through the implementation of an Enterprise Lean Six Sigma program that includes mandatory white belt training in all new employee orientation, ongoing green belt projects, and weekly organizational huddles supported by two certified Lean Six Sigma black belts. The team identified their accomplishments and provided a lively discussion of the numerous and commendable efforts to have clients and families involved in continuous quality improvement activities. New policies relevant to risk identification and avoidance were developed with client input. It is apparent through a document review and conversations with the quality leadership team that there is a philosophy of continual improvement embedded throughout the organization, including clients, families, service providers, and partners. The team is commended for the development of enhanced risk management guidelines and for inviting clients and service providers to participate in this initiative. A major quality improvement initiative is the achievement of a mandated five day maximum wait time for nursing services. The electronic dashboard now available enabled tracking of performance. The documents compiled to review integrated quality management and risk management indicate the organization has a comprehensive process in place to address the many facets of quality and risk as they apply to client safety. Aligning with the Strategic Plan, the quality, risk, and patient safety framework informs the Quality Improvement Plan and the Patient Safety Plan. A scorecard provides measures that align with Health Quality Ontario s quality dimensions. A key component of the quality framework is the Patient Safety Plan that identifies objectives related to patient safety, activities, indicators, and responsibilities. HNHB CCAC is a champion in the area of best practice development and has earned the designation of being a Registered Nurses Association of Ontario Spotlight Organization. Client safety is a major focus during orientation for new staff. Quality and safety updates are standing agenda items for all meetings including the Detailed On-site Survey Results 17

22 board meeting. The team is commended for the education given to service providers and other community partners to promote client and family safety in service delivery. A failure mode effects analysis (FMEA) process has been used and from it improvement strategies have been implemented to promote the safe use of high-alert medications. The organization is commended for enhancing its disclosure process to include ongoing monitoring to determine client needs related to incident disclosure. The team and indeed the whole organization including the board are commended for the work that has been done as well as the ongoing work on quality improvement and risk management. Detailed On-site Survey Results 18

23 2.1.6 Priority Process: Principle-based Care and Decision Making Identifying and making decisions about ethical dilemmas and problems. The organization has met all criteria for this priority process. Surveyor comments on the priority process(es) HNHB CCAC has a very dynamic Ethics Committee. Committee members include management and front-line staff from all departments as well as an ethicist consultant. The committee has reviewed and revised the ethics framework and developed education for all levels of the organization including the board of directors. Since 2014, the organization has been a member of the LHIN regional ethics network. HNHB CCAC has the services of an ethics consultant who supports them through the process of principle-based decision making, education, and capacity building. The committee carried out a formal needs assessment to assess staff needs, and determined that staff wanted face-to-face learning on the ethics program. The committee also developed an enhanced education approach for staff by developing the resource centre on the intranet. Ethics education sessions for all staff are posted on the education calendar. Members of the Ethics Committee are also provided with educational opportunities to enhance their knowledge. The organization participates in research activities with other academic centres such as McMaster University. There is a policy and procedure that includes criteria for participation in research activities. These activities must align with the mission, vision, and values of the organization and show alignment with the community. It is the responsibility of the requesting organization to provide research ethics board approval. The Ethics Committee has completed all work identified in the 2015 work plan, and a new work plan has been developed for Challenges in this work plan include recruiting a client representative who will be an active contributor to the committee, and developing a plan to assist staff who may face challenges with physician-assisted dying. Detailed On-site Survey Results 19

24 2.1.7 Priority Process: Communication Communicating effectively at all levels of the organization and with external stakeholders. The organization has met all criteria for this priority process. Surveyor comments on the priority process(es) The HNHB CCAC Communication Plan was reviewed. The plan has all the essential components to guide, manage, and promote internal and external communication for staff, stakeholders, and clients and their families. Communication has been identified as a priority throughout the organization. To have meaningful communication within and outside the organization, it must be two way. The team had looked at communication within the organization with various levels of staff and the board of directors, and externally with clients and their families, service providers, ministry staff, and the general public. The team has completed many activities to enhance communication in the organization. They have developed the intranet which is a dynamic tool for staff who work at offices or remote locations. Monthly staff and leadership forums allow for two-way conversation. Themed newsletters help staff stay abreast of ongoing activities in the organization. Communication activities continue to be monitored to ensure they provide value to the organization. Client- and family-centred care has been and continues to be a priority. The organization continually reviews the website to ensure materials are current and meaningful to their clients and prospective clients. Client kits are produced electronically and in print form, and are appropriate to the clientele for whom they are intended. The organization has developed a program that identifies Heroes in the Home, a caregiver recognition program. Electronic health records continue to be refined. Communication between the organization and contracted service providers continues to be a focus for improvement initiatives. A Joint Service Provider Relations Advisory Committee work plan was developed to enhance communication. The ongoing focus for communications for the team is to advance client and family participation by developing a client and family advisor role. This will allow clients and their families to have a say in the development of home and community care programs and materials. The organization is commended on its forward thinking in developing social media platforms to promote awareness of home and community care and support the impending sector transition. Detailed On-site Survey Results 20

25 2.1.8 Priority Process: Physical Environment Providing appropriate and safe structures and facilities to achieve the organization s mission, vision, and goals. The organization has met all criteria for this priority process. Surveyor comments on the priority process(es) HNHB CCAC comprises five branch offices, eleven nursing care centres, and twenty-four CCAC offices in area hospitals. All locations are leased or have a space-sharing agreement. The team reported the offices are well maintained, temperature controlled, and well lit, and have well-designed work areas. Panic buttons have been installed in all reception areas. It is obvious the board and the leadership are concerned with the health and welfare of their approximately 950 staff. At each nursing care centre, site visits are completed annually. Check lists are completed and results are reported back to the Nursing Care Centre Committee. At all locations, fire drills are conducted twice a year. Monthly generator load testing is conducted at each branch. There is compliance for occupational health training which is mandatory for all managers. All staff must complete an online ergonomics training course annually. The organization has exceeded the requirements for the workplace health and safety act and meets all Accreditation Canada requirements. The organization has developed a policy and procedure to ensure the safety of their staff and contracted service providers who perform work in the community. Challenges for the future will be ensuring the leadership team maintains consultation and engagement with clients and families for changes or updates to any facilities as part of planning for future needs. The team is commended for their awareness that client homes are physical environments where they need to promote the safety and comfort of the clients and workers. Detailed On-site Survey Results 21