Strategic and Operational Plan Quarterly Report #2 January 15, 2015

Transcription

1 Strategic and Operational Plan Quarterly Report #2 January 15, 2015

2 Table of Contents Executive Summary... 3 Introduction... 4 Priorities... 4 Improving Access to Care Across All Sectors... 4 Improving Quality and Safety Promoting Healthy Living Engaging Staff and Physicians...23 Balancing the Budget Other Enabling Priorities Summary

3 Executive Summary This report provides the January 15, 2015 update on progress in implementing the Fraser Health Strategic and Operational Plan ( Plan ) confirmed in June This progress report is delivered quarterly to the Fraser Health Board of Directors and the Ministry of Health in fulfillment of the requirement set out in Ministerial Order #282. The Plan identified 10 priority actions for quality and sustainable service delivery including: (1) Capacity for care across all sectors; (2) Quality and safety; (3) Public health measures; (4) Accountability; (5) Staff and physicians; (6) Patient centeredness; (7) Governance; (8) Operational organization and management; (9) Lower Mainland collaboration; (10) Budget accountability. Progress on these priority actions is measured using quantitative performance indicators published monthly on the Fraser Health web site under the heading of Our Health Care Report Cards. Progress is also measured using qualitative indicators from the past quarter which are identified in this report along with plans for the coming quarter. Progress highlights include the following: Improving access to care across all sectors continues to be a challenge. The following indicators are 10% or more off target: the number of long-stay patients in hospitals; the number of patient days classified as ALC ; the number of patients awaiting inpatient bed placements; and the number of patients in Emergency admitted to an inpatient bed within 10 hours. Vigorous implementation of strategies to improve these processes continues and is outlined in this report. Progress on improving quality and safety with targets met or exceeded in seven of eight key indicators has been made. In particular, progress continues on preventing infections, falls and nursing-sensitive adverse events. Public Health measures are well aligned with targets. Accountability processes have been put in place with particular emphasis on public reporting of performance indicators. Work continues on engaging staff and physicians, with targets met or exceeded in five of six measures. Work continues on pursuing a culture of patient centeredness. Board Governance practices are being strengthened. Progress has been made in strengthening operational organization and management structures and processes. Lower Mainland collaboration continues to be improved. Work continues to ensure optimized service delivery within a balanced budget. At the end of Period 9 (December 4, 2014), FH reported a year-to-date surplus; a balanced year-end position is projected. 3

4 Introduction Information presented in this report is driven by the 10 priorities identified in the Plan for Fraser Health (June 2014) and organized to be consistent with Our Health Care Report Card (November 2014 edition). For each of the performance measures, this report identifies the performance level relative to the target performance level and then highlights progress in recent initiatives, along with initiatives that are expected during the next quarter. Additional measures are included in some sections as they were identified in the Review and are important to the overall improvement efforts. The performance measures presented in this report are based on the most up-to-date information available. While Period 9 (December 4, 2014) fiscal measures have closed because of the holiday period, some measures could not be calculated in time for this report. Therefore, the latest analyzed measures at the time of report preparation are included. Priorities Improving Access to Care Across All Sectors Capacity to support growth and aging of the Fraser Health population will be increased by developing efficiencies throughout the acute and community sectors and increasing investment in primary and community care 1. Optimized use of non-hospital resources will liberate resources to be used elsewhere and help ensure clients, patients and residents receive the right care, in the right place, at the right time. It is important to note there is no one strategy to improve a specific measure of access to care; rather, multiple best practices, in combination, improve the patient journey and Fraser Health s indicator performance. 1 Primary care includes a variety of community-based clinics such as Diabetes, Respiratory, Cardiac, Aboriginal Health, and Mental Health and Substance Use, and may have the services of a nurse practitioner and/or family physician and members of an interdisciplinary team. Primary care also includes the 10 Divisions of Family Practice. Community care includes Home Health, End of Life, Mental Health and Substance Use (MHSU), Residential and Assisted Living, and Acquired Brain Injury care, clinics and services. 4

5 ALOS / ELOS Ratio Avg LOS (Days) Average Length of Stay (ALOS) and ALOS compared to Expected Length of Stay (ALOS:ELOS) Avg LOS Annual Performance Vs Target / / /2014 Apr-Nov Actual Target ALOS: ELOS Ratio Annual Performance Trend Vs Target Actual Target Average Length of Stay (ALOS) was 8.2 days this period, unchanged compared to the previous period. Year to date ALOS is 8.3 days, higher than the three-year target of 7.8 days. The numerator for ALOS has two components acute days and ALC days. Continued focus on reducing both components is required. Many ALC patients have complex clinical, social and housing needs. Every hospital has a customized ALOS target, reflecting the different range of services offered at each site. For example, some hospitals have surgical patients or maternity patients who have low ALOS and other hospitals have patients in rehabilitation who are expected to have longer hospital stays. Adjustments have been made to site-based targets to better reflect differences in the service mix at the hospital level. An ALOS that is higher than the expected length of stay (ELOS) may reflect delays in the timely transition of patients from the hospital to home or residential care. Simply stated, more discharges need to be done on a more timely basis. This measure informs quality improvements in both the acute and community settings. Strategies initiated in the previous quarter to increase structure, accountability and focus on daily hospital operations are being maintained and enhanced. Site-based administrative and medical leaders are working with Hospital Operations Management Committees (HOMC) to monitor site performance against targets and to act on initiatives and process changes aimed at ensuring timely and appropriate discharges. 5

6 % ALC Days Number of Patients Number of Patients In order to increase the adoption of best practices, three high-priority clinical protocols (48/6, Catheter Associated Urinary Tract Infection (CAUTI) and Mobility) are being audited and actions are underway to ensure each protocol is fully implemented for all patients. All sites have shown an increase in compliance between the first and second audits, and strategies are underway to achieve full compliance by January. These protocols will improve quality of care while decreasing length of hospital stay. Progress has been made on physician-led initiatives to increase the use of an estimated date of discharge (EDD). Development of a toolkit to support care team application of an estimated date of discharge has been completed and is available for use. A phased roll-out and education plan for 12 hospitals is underway. Individual Hospital Operations and Management Committees (HOMC) action plans include: compliance with three priority clinical care protocols; initiatives to support the use of best practices in patient flow; and tools, education and audits to support the use of estimated date of discharge. Community investments described under the next measure will contribute to improved ALOS and ALOS: ELOS. Service and process redesign initiatives in the primary and community sector are underway to decrease transition times between care and to transition patients to the appropriate service as quickly as possible. Long Stay Patients Staying Over 30 Days and Alternate Level of Care (ALC) Patient Days in Acute Care Beds Long Stay Patients Annual Performance Trend Vs Target / /2014 Apr-Nov 2014 Actual Target Long Stay Patients By Hospital - Apr-Nov Actual ALC Annual Performance Trend Vs Target 40% 30% 20% 13.7% 12.8% 14.1% 10% 0% 2012/ /2014 Apr-Aug 2014 Actual Target 6

7 The year to date (August 2014) ALC rate was 14.1%, above the three-year 10 % target. The number of long stay patients (>30 days LOS) at 529 is above the fiscal year-end target of 455. By definition, patients classified as ALC no longer require acute care. They include elderly patients waiting for placement in residential care and patients affected by mental illness, substance use and acquired brain injury that need specialized housing. Still, others may require complex home care and some with complex family and social issues take additional time to match their care needs to housing and social supports. Some of these resources are not available in sufficient quantity. In addition to patients classified as ALC who no longer require acute care, many long stay patients are not considered ALC and require extended hospital stays to receive complex or specialized care that is not available in the community. Both these measures identify possible inappropriate use of acute care resources and delays moving patients to more ideal care environments. To achieve or exceed targets here, investments need to focus on (1) strengthening the primary and community sectors appropriately by shifting resources from acute to the community and by building efficiencies throughout the community sector, (2) promote the development of the General Practitioner for Me (GP4ME) initiatives that support longitudinal primary care, (3) enhance approaches and services in chronic disease management and (4) support vulnerable populations living in the community. Strategies implemented in the previous quarter are being sustained. These include opening additional residential care capacity (24 beds in Mission and converting 12 beds to complex care in Surrey) and increasing home health capacity by identifying efficiencies in service delivery. The process to manage complex and long stay patients is being improved by increasing organizational focus on this patient population and by clarifying policies that impact these patients. In addition, escalation protocols are being put in place, as are tools and education to support staff to improve management of these patients. Many sites have prioritized decreasing ALC and long stay patients in their HOMC action plans. All strategies identified in reducing the ALOS and ALOS: ELOS also apply to these measures. A regional strategy to further improve the monitoring and early identification and management of complex and long stay patients will be put in place along with targeted redesign of residential and housing settings in the community and investments in residential care. 7

8 Decrease Readmission Rates According to the most recent information available (2013/14 Quarter 3, abstracted data reported to CIHI), the readmission rate of 10.6% remains above the 10% three-year target. Fraser Health has completed a detailed analysis of the top three patient populations who tend to be readmitted Information from the analyses will be used to target and strengthen patient management strategies. The strategies identified in the previous quarterly report are being actively pursued. These include community-based actions to support chronic disease management (chronic obstructive pulmonary disease [COPD], heart failure and diabetes); strategies in the Emergency Department to prevent admissions; and strengthened hospital discharge planning to prevent patient readmission. Fraser Health s focus on chronic disease management has resulted in improvements to the hospital discharge process and changes to the Home Health surveillance nurse role to provide better support to patients transitioning back to home and community. A pilot is underway in Abbotsford in which discharged chronic disease patients receive coaching on self-management from a surveillance nurse to improve their health and decrease readmissions. Positions in the Emergency Department to support diversion to community services and avoid admissions are being reviewed to reduce duplication and improve coverage and effectiveness. Some communities have begun a root cause analysis to better understand what drives admission and readmission rates by population, disease and hospital. The insights from the analyses and the information gained from the recent Advisory Board workshop on Preventing Readmissions will be utilized to revise their improvement strategies. The remaining communities will undertake root cause analyses to better understand the drivers of hospital admission and readmissions and align their improvement strategies. Information gained from new initiatives regarding COPD care and readmission prevention will further inform patient and family teaching strategies. 8

9 Admissions per 100,000 People Aged <75 Decrease Admission Rates for Selected Conditions and Patient Populations 400 Admissions per 100,000 population (<75 yrs) for Ambulatory Care Sensitive Conditions (Aged <75 yrs) / / / / /2013 Apr-Dec Actual Target 2013 Ambulatory care sensitive conditions are chronic diseases which when treated effectively in community settings should not, in most cases, advance to hospitalizations. Hospitalizations related to these conditions are often referred to as avoidable hospitalizations and are considered an indirect measure of access to primary health care, care in the community and the ability of the health care system to manage chronic conditions. The admission rate for this population (Age < 75) in the third quarter of 2013/2014 was 252 per 100,000 residents, not yet achieving the three-year target of 234. The admission rate for this population (Age 75) for the third quarter of 2013/2014 was 3,154 per 100,000 residents, not yet achieving the target of 3,048. 9

10 The strategies that apply to reducing ALOS, ALOS: ELOS and Readmissions apply to Ambulatory Care Sensitive Conditions as well. In particular, community-based chronic disease management programs and services thatare population specific (e.g. South Asian Health Centre in Surrey) offer culturally responsive services to promote self-management of chronic diseases. Findings from the root cause analysis (described above) will be used to identify the areas of greatest opportunity to support individuals and their families to maintain their own health and prevent worsening of chronic diseases in their community through formal (e.g., GPs, Fraser Health) and informal (e.g., Canadian Diabetes Association) services. This will further inform Fraser Health s approach to a community-based system of health. Emergency Patients Admitted to Hospital (an Inpatient Bed) Within 10 hours Year to date, 39% of patients requiring admission from the Emergency Department were admitted to an inpatient bed within 10 hours. This rate falls well below the fiscal year target of 55%. Improving this measure requires network-wide, community and hospital-specific strategies to improve access and flow into an inpatient bed. Actions described for other measures of Access to Care will contribute to improvements in this measure as well as in patient outcomes and patient experience. Emergency Department ( ED ) congestion is influenced by a number of factors the number of patients presenting for care; efficiency of patient assessment and treatment; efficient movement of admitted patients from the ED to inpatient wards; and inpatient length of stay. Strategies to improve these measures help to reduce Emergency Department congestion. Access managers at each site have the authority to improve performance and lead local changes to support more timely transfer of patients from Emergency Departments to inpatient units. Current processes at each hospital have been mapped and improvements identified. Data entry of patient transfer times has been standardized. These efforts are being regionally shared and coordinated to accelerate change, share success and identify regional actions that will support further improvements. Non-emergency IV therapy reassessment (currently in the ED) is being analysed at Abbotsford Regional Hospital to determine how best to avoid an ED visit for follow-up. The analysis reviews the effects on 10

11 patient flow and experience, and features a cost-benefit study on the impact of diverting these visits from the Emergency Department to other locations. The Emergency team is developing individual care plans for approximately 518 patients who are frequent users of the Emergency Department (> 20 visits/year) and who are often admitted. Approximately 60 care plans have been developed. The care plan is electronic and available to all hospitals. These patients generally have serious issues involving complex health and mental health and substance abuse issues, housing, and social and financial needs. Emergency staff are to complete the implementation of a standard discharge checklist for all vulnerable patients prior to discharge. A staff survey to identify issues, barriers and strategies to ensure compliance and improve care and discharge was also completed this quarter. Executive directors have developed winter congestion plans for each program and hospital to proactively plan for seasonal variation and staffing. Detailed analysis demonstrates that while seasonal volume increases do occur, it is variation in the availability of staff, physicians and acute and community services that create holiday-period hospital congestion. Appropriate staffing and less variation in patient flow will improve this measure as well as Emergency Department congestion during the coming months. Efforts are ongoing to finalize and implement changes at each hospital to move patients from Emergency within 60 minutes of an inpatient bed assignment. Work continues to strengthen care processes that lead to improvements in patient experience and increased efficiencies in delivery of IV antibiotic therapy and reassessments at Abbotsford Regional Hospital. Through this work, opportunities to consider redirection of IV therapy reassessments from Emergency to the Outpatient Antibiotic Therapy (OPAT) clinic and other locations will evolve. Suture removal is another service sometimes provided in Emergency. An analysis of frequency and volumes will be undertaken to assess the impact of this practice on Emergency Department congestion. Work continues to develop prototypes for triage practices at Royal Columbian and Surrey Memorial Hospitals to decrease congestion. The real- time patient survey at Surrey Memorial, Peace Arch and Delta hospitals continues. Early results are being reviewed and findings will be used to support care and service improvements. The next site for survey implementation is Abbotsford Regional Hospital. Admitted Patients Awaiting Inpatient Bed Placement (including Emergency Admits) 11

12 % Cases % Cases At the end of Period 8, the year-to-date average for this measure was 193, short of the fiscal period target of 165. The numerator for this measure is the sum of two components - the average number of patients receiving care in a location not typically designed for inpatient care (hallways and other locations) and the average number of patients located in Emergency waiting for an inpatient bed. It is a combined measure reflecting the balance between supply and demand for inpatient beds. Focused efforts are underway at the larger sites to improve this measure. Implementation, monitoring and reinforcement of the above strategies continue. This measure reflects the combined result of multiple strategies and actions. Improving Quality and Safety The overarching goal is to improve safety and access across all sectors. The Canadian patient safety culture survey was tested at Ridge Meadows Hospital and will be used to establish a baseline measure of safety culture at the organizational, program, site and unit levels. Initiatives that support improvements in safety culture require the collaboration of multiple support departments (Professional Practice, Strategic Transformation, Organization Development and Quality Improvement Patient Safety) with operational and physician leadership. Initiatives to improve the safety culture include safety huddles, targeted walkabouts and supported audits. Percent of Hip Fracture Fixations Completed within 48 Hours 100.0% % Hip Fracture Fixations Within 48 Hrs AnnualPerformance Trend Vs Target 84.2% 91.0% 100.0% % Hip Fracture Fixations Within 48 Hrs By Hospital - Apr-Nov % 92.0% 90.0% 85.0% 87.0% 96.0% 92.0% 89.0% 75.0% 75.0% 50.0% 50.0% 25.0% 25.0% 0.0% 2013/2014 Apr-Nov 2014 Actual Target 0.0% ARH BH CGH LMH PAH RCH RMH SMH Actual Target By the end of November 2014, 91% of hip fractures were repaired within 48 hours. The fiscal period target of 90% is being met overall. Three hospitals have missed the 90% target: Langley Memorial (85%); Surrey Memorial (89%); and Peace Arch (87%). The results of this measure are analyzed each period with targeted strategies put in place at individual hospital sites. All patients admitted with hip fractures are closely monitored with a data collection tool to identify common themes and barriers to surgery. Dedicated time in operating rooms has been allocated for hip fracture patients. Ahip fracture escalation protocol to reduce and eliminate barriers to surgery has been 12

13 implemented. Increased awareness among all care providers of the need for specialized care and timely surgery to improve outcomes is helping ensure Fraser Health can continue to exceed this target. In addition, focused attention on pain management, enhanced nutrition and early and frequent mobility will ensure quality standards are met or exceeded. Reducing Nursing-Sensitive Adverse Events (NSAE) The year-to-date rate of nursing-sensitive adverse events (NSAE) was 40.4 as of the end of August With the observed trend moving in the right direction it is likely the annual target (43.1) at the organizational level will be achieved. NSAE performance targets are not being met at four hospitals: Burnaby (53.6); Ridge Meadows (49.2); Surrey Memorial (44.9); and Peace Arch (44.3). Performance is trending towards target at Ridge Meadows, Surrey Memorial and Burnaby. Specific actions for Burnaby Hospital include nursing staff education modules on CAUTI (Catheter Associated Urinary Tract Infections) and oral care, focus on clinical practice guidelines for CAUTI; daily huddles to discuss Foley catheter use; and support for patient mobilization through the use of patient-centred bedside whiteboards. Hospital Operations Management Committees are reinforcing support for, and expectations of, site operations and clinical directors for leading process changes, achieving improvements and reviewing results. Implemented actions include: mobile educational carts that visit nursing units for staff teaching huddles; the posting of unit results on quality boards; NSAE newsletters; checklists for reducing urinary tract infections and pneumonia; and chart reviews and audits to assist clinical teams in monitoring and improving practice. Site-based leaders are working with staff and physicians, especially on those units with the highest rates, to identify the underlying issues and challenges, take corrective action and improve quality of care. Dedicated physician strategies include increased use of protocols and improved documentation. Implementation, monitoring and reinforcement of the above strategies continue. This measure reflects the combined result of multiple strategies and actions. 13

14 Facility-Associated Clostridium difficile Infection (CDI) Incidence Year-to-date incidence rate of clostridium difficile infection (CDI) was 3.6 at the end of November 2014 which continues to be on track to meet the target (6.0) for this key measure at an organizational level. Annual targets are not being met at two hospitals: Eagle Ridge (6.6) and Mission Memorial (6.3). These are smaller sites that have fewer patient days in the denominator. Random statistical fluctuations may contribute to higher CDI incidence rates at these sites. An infection prevention and control practitioner is now serving Eagle Ridge Hospital, which should contribute to further reduction in the CDI rate. Intensified cleaning of Emergency Departments was begun in December 2014, in anticipation of the usual increased frequency of patients attending with winter gastrointestinal infections. Facility-Associated Methicillin-Resistant Staphylococcus Aureus (MRSA) Incidence Calendar year-to-date rate of facility-associated methicillin-resistant Staphylococcus aureus (MRSA) was 6.2 at the end of November 2014 and on track to meet the target (7.0) for this measure at an organizational level. Annual performance targets at five hospitals are not being met: Ridge Meadows (10.5); Delta (9.3); Burnaby (7.8); Mission Memorial (7.3); and Surrey Memorial (7.3). Delta and Mission Memorial are smaller sites with fewer patient days in the denominator. Random statistical fluctuations may contribute to higher MRSA incidence rates at these sites. Intensification of antibiotic-resistant organism screening is 14

15 % of Employee Compliance leading to the identification of more cases upon admission, some of which are attributed to health care interactions in the previous six months. These improvements in screening are related to a targeted program to increase identification of carbapenemase-producing enterobacteriaceae (CPE). In addition to improvement activities previously reported, funding will be redirected to support an antimicrobial stewardship (AMS) program, to recruit a physician lead for this work as well as site-based pharmacists. These measures will help reduce facility-associated MRSA and CDI rates. At Ridge Meadows there is a specific action plan to address the facility-associated MRSA rate. The plan features maintaining effective hand hygiene, de-cluttering, environmental cleaning, following cohort isolation practices and screening every admission for 30 days (to determine whether a high community prevalence contributes to higher facility-associated MRSA rates). Hospital Standardized Mortality Ratio (HSMR) Fraser Health s Hospital standardized mortality ratio was 82 for the 2013/14 fiscal year. This exceeds the target (100) for this key performance indicator at an organizational level and at every site. Continue with multiple existing strategies to monitor, maintain and continue to improve this measure. Hand Hygiene Compliance 100% 75% 50% 25% 0% Hand Hygiene Compliance Annual Performance Trend Vs Target 38% 61% 72% 79% 84% 2010/ / / /2014 Apr-Nov 2014 Actual Target 15

16 % of Patients The year-to-date rate of hand hygiene compliance was 84% at the end of November The target (80%) is being met for this measure at an organizational level. Targets are not being met at two hospitals: Abbotsford (78%) and Langley (78%). However, these sites are demonstrating consistent improvement and are trending towards the target. Compliance audits each fiscal period provide feedback to staff and physicians on their opportunities to improve. Performance data by staff group is posted at the unit level so staff, physicians, families and visitors know how well hand cleaning is being done. Hand hygiene compliance is a standing agenda item at local infection prevention and control committees and hand hygiene education is now a mandatory requirement for appointment to the medical staff. Increasing physician hand hygiene compliance is discussed at the monthly Health Authority Medical Advisory Committee (HAMAC). The Provincial Health Services Authority (PHSA) cooperative student auditor model has been implemented. Physician leaders are hosting discussions with physicians who demonstrate persistent poor hand hygiene performance. This has led to more requests from physicians for support and education. The cooperative student auditor is actively working with staff at Abbotsford and Langley Hospitals to increase compliance. The student is also doing on-the-spot education so reporting and reviewing is spontaneous. Emergency Patient Experience 100% 75% 50% 25% 0% 77% ED Patient Experience Annual Performance Trend Vs Target 80% 81% 81% 83% 83% 79% Actual Target The year-to-date rate of patient satisfaction with their experience in Emergency was 79% at the end of September The target (90%) is not being met for this measure at an organizational level. The target is being met at Royal Columbian Hospital (90%) but not being met at 11 sites: Surrey Memorial (70%); Langley Memorial (73%); Abbotsford Regional (73%); Delta (75%); Mission Memorial (79%); Eagle Ridge (80%); Chilliwack (81%); Burnaby (82%); Ridge Meadows (82%); and Peace Arch (82%) hospitals. Activities to date to improve the experience of Emergency patients include: pain medication delivered upon patient arrival following their assessment; information brochures for patients and families; Strangers in Crisis training for all Emergency staff and physicians, registration staff, BC Ambulance Service staff and laboratory staff and volunteers; real-time patient satisfaction surveys at Delta, Peace Arch and Surrey Memorial Emergency departments, with plans to expand to Abbotsford Regional Hospital and other sites; discharge packages for patients providing specific information about their visit; and discharge checklists for staff. 16

17 The implementation and strengthening of multiple existing strategies to monitor, and continue to improve this measure will continue. In addition, two new nurse practitioner positions will begin with the SMH and ARH Forensic Nursing Teams working collaboratively with the Divisions of Family Practice in Surrey and Abbottsford, non-government agencies and other community stakeholders in providing primary care follow-up to patients who have experienced episodic or chronic intentional violence. Falls that Result in an Injury in Residential Care Facilities Not reporting site by site data here as there are more than 80 residential care facilities. The year-to-date rate of falls resulting in injury at residential care facilities was 2.7 falls for every 100 residents at the end of September Although the target (3.0) is being met for this measure at an organizational level, there has been a slight deterioration in performance compared to the previous quarter (2.5). Work continues to maintain and build on multiple existing strategies to monitor, and continue to improve this measure. Other Quality and Safety Activities Outside the Report Card In addition to the report card measures described above, work continues to monitor and take steps to improve on other quality and safety indicators, some of which were identified in the Review. Integrated Plan of Care The integrated plan of care is a patient safety initiative to standardize and strengthen best practice patient care, streamline documentation practices across the care continuum, and improve the patient experience by defining the specific roles and responsibilities of members of their care team. Since this work began in March 2014, a catalogue of standardized abbreviations, acronyms and symbols, has been released and the current Fraser Health Documentation Policy been revised. In addition, standardized practices for signature record of staff and physicians has been implement as have 45 unique bestpractice care standards. The first phase of documentation requirements for the seven largest major allied 17

18 health professions has been developed. Implementation of the care and documentation standards is underway. Implementation of the care and documentation standards will be completed by the end of March Reducing Carbapenemase-Producing Enterobacteriaceae (CPE) Transmissions In 2013/14 there were 41 transmissions of CPE in Fraser Health. The target is a 50% reduction to a total of 21 cases. Screening activities were implemented after the data collection period in 2013/14. The number of transmissions in 2014/15 will likely exceed the target because the screening processes are working effectively (identifying transmission from previous hospital admissions many months ago in some cases). This is expected to self-correct after this year, and 2014/15 will become the base year for comparison at Surrey Memorial Hospital. There are many activities underway to monitor and reduce the incidence of CPE. The multi-drug-resistant organism and CPE screening-and-flagging protocol has been implemented for all patients in intensive care and high acuity units to identify patients at risk to ensure effective communication amongst care providers and allow transmission tracking. All CPE cases are investigated to determine in-hospital transmission and the cause, with case reporting to the provincial surveillance system. Fraser Health is trialing automated surveillance and reporting for CPE. A CPE oversight group has been created at Surrey Memorial Hospital to identify and implement additional actions to reduce transmissions. A protocol is in place to escalate screening on all patients in units where ongoing transmission is evident. Fraser Health has provided extensive education, supported by hand hygiene and personal protective equipment champions, to front line leadership and front line staff. A case to support in-house, same-day molecular testing for CPE and Mycobacterium tuberculosis to allow appropriate proactive precautions against transmission is in development, with the support of Lower Mainland Laboratory Services. Reducing Harm Related to Medication Errors There has been increased attention by the executive team on supporting further implementation and spread of both the Safe Medication Order Writing Policy and the medication reconciliation work already underway. The compliance requirements for the Safe Medication Order Writing Policy have been communicated to all site leadership teams. Passing the provincial safe medication order writing course is now a mandatory requirement before appointment (or reappointment) to the medical staff. Audit data for medical staff have been reviewed with regard to compliance with the Medication Management Policy and demonstrated a small (34 to 28.6%) reduction in use of Do-Not-Use abbreviations. Audits for compliance with the Medication Management Policy for other clinical staff are underway. There is a renewed focus on medication reconciliation as a key strategy to reduce harm related to medication errors. Compiled data regarding medication errors beyond the Patient Safety Learning System (PSLS) will be more broadly shared with a view to broad based learning and the initiation of further quality improvement strategies. 18

19 Work continues to implement the new intravenous infusion pumps in all hospitals and the implementation of admission medication reconciliation at all hospitals. During 2015/16 the automated drug dispensing cabinets at Royal Columbian Hospital will be brought into operation, bringing to five the number of sites using the system. A business case for ongoing operating funds to support the implementation of strip packaging at Peace Arch, Delta and Burnaby hospitals as part of the closed loop medication system (system to reduce errors) will be reviewed for implementation in 2015/17. Clinical Care Management Targets for Venous Thromboembolism (VTE) and Surgical Site Infections (SSI) 19

20 Data to Period 3 (June 19, 2014) shows that the percentage of surgical cases complying with surgical site infection (SSI) prevention and surgical checklist were both at 90%, below the target of 95%. However, compliance with Venous Thromboembolism (VTE) prevention reached a year-to-date average of 97.7% as of Period 3. There are many activities underway to monitor and address clinical care management improvement targets. For VTE prevention, Fraser Health has implemented new standardized pre-printed orders and provides data at the unit and program level so accountable managers have data to share and to develop specific actions to increase compliance. For SSI prevention and surgical safety, data are provided at the unit level and discussed at local surgical quality committees to develop improvement plans. The Surgical Quality Action Network Collaborative is focusing on teamwork and communication to improve the measures. Monitor and reinforce continuation of required practices. Promoting Healthy Living The goal of these measures is to strengthen population health to protect, promote and improve the health and well-being of those living in Fraser Health through integrated and collective actions. By improving the health and the quality of life of the population and by working towards the prevention of disease, long-term health is ensured in the communities, leading to a reduction in the burden to the health care system. These are just three of many measures that Public Health reports and all three are aligned with, and contribute to, the direction outlined in the BC Guiding Framework for Public Health (Promote, Protect, Prevent: Our Health Begins Here) and other Ministry of Health action plans and frameworks (e.g., Healthy Minds, Healthy People; Seniors Healthy Living Framework). 20

21 % Children Increasing Immunization Rates in Young Populations 100% 75% 50% % 2-Year Olds with Up-To-Date Immunizations Annual Performance Trend Vs Target 62% 63% 67% 71% 68% 69% 25% 0% Jan-Sep Actual Target 2014 The year-to-date immunization rate for young populations was 69% at the end of September 2014 which is not currently meeting the year-end target (73%) for this measure at an organizational level. Performance is trending towards target. The target will be raised to 80% by 2016/17. This target is aligned with the BC Guiding Framework for Public Health. Recommendations from the Immunization Review are being studied for short-, medium- and long-term implementation. Short-term recommendations are moving ahead with the addition of targeted immunization clinics for the 18-month age group and implementation of data cleaning processes for improved accuracy and completeness of records. Engagement sessions with each of the 10 Divisions of Family Practice are planned for follow-up collaboration discussions by the end of March These sessions will explore ways to support primary care immunization and will incorporate results of the GP workforce survey. Informatics and primary care teams are engaged in solutions-focused discussions to improve internal business processes and identify means for record sharing with GP partners. The next steps include holding targeted immunization clinics for the 18-month age group to increase reach as well as cleanup of internal and GP immunizations data to improve accuracy and completeness. Percent of Drinking Water Systems Complying with Microbial Monitoring Requirements 21

22 The year-to-date rate of compliance with the microbial monitoring system for drinking water was 95% at the end of September 2014, currently meeting the year-end target (95%) for this measure. The target will be raised to 98% by 2016/17. This target is aligned with the BC Guiding Framework for Public Health goal to improve the safety of drinking water for British Columbians. Environmental health staff members communicate with non-compliant water system operators by phone and mail, and follow up with inspections as part of a routine process. Some water systems still have challenges meeting their responsibilities, and working with the operators of these systems will continue to develop practical solutions. Increased frequency of water-system-monitoring compliance reviews for systems that have not met their prescribed monthly sampling is planned for this next period. Work continues to implement the above strategies. Percent of Communities with Healthy Living Strategic Plans In 2013/14, 60% of communities in Fraser Health had a healthy living strategic plan. The performance target (60%) has been met for the year, exceeding the Ministry of Health Service Plan target of 45% for the 2013/2014 year. The internal and community components for this measure contribute not only to the vision of healthy living and healthy communities outlined in the BC Guiding Framework for Public Health, but also to the goals of preventing injury and harm from substance use, and supporting good mental health. All the values and guiding principles (e.g., across the lifespan, equity) of the Guiding Framework for Public Health underpin this work. Burnaby, Tri-Cities (including Anmore and Belcarra) and White Rock have made significant progress towards a healthy living strategic plan. New Westminster and Maple Ridge have passed enhanced smoking bylaws. It is anticipated these communities will achieve these goals in the next few months. Progress continues to be made with internal engagement and capacity-building in the area of healthy schools. School district engagement planning is underway. 22

23 The plan is to leverage these community partnerships to strengthen internal activities in four strategic priority areas: chronic disease prevention; substance use prevention, and mental health and well-being; unintentional injury prevention; and healthy aging. Committees are implementing regional health promotion and prevention strategies, with a focus in the following areas: Chronic Disease Prevention: Smoke-free Fraser Health Substance Use Prevention, Mental Health & Well-being Staff awareness and education to create a more inclusive culture, and to reduce stigma related to mental health and substance use Unintentional Injury Prevention concussion awareness and capacity building among community primary care providers for providing appropriate treatment for selfmanagement Healthy Aging - healthy aging and dementia-friendly awareness campaign for staff Work continues to implement the strategies outlined in the priority action plan. Engaging Staff and Physicians A health system is only as strong as the health care providers who work within it. Engaged, skilled, healthy and well-led health care professionals provide the backbone of our health system and the goal of any health care employer should be to ensure their staff is supported to use their full knowledge and expertise in a supportive, healthy environment. This strategy will invariably produce better patient, resident and client quality outcomes. Any strategies focused on health human resources in the health system must incorporate strong and effective change management and engagement principles that emphasize a culture of collaboration with key stakeholders, such as unions, in a disciplined and purposeful manner, while building on the Fraser Health values of respect, caring and trust. Aspects of this strategy will focus on the skills of the people leading the change, transparent communication with those impacted by the change, and ongoing assessment and review of the change to ensure it is sustainable into the future. Enabling effective change management and engagement capacity across the system is a key driver of successful, timely and efficient change. The recommendations that came out of the Review related to health human resources support the direction Fraser Health is taking and emphasize the critical nature of this work. They validate the need for deliberate and targeted strategies to ensure that staff and physician planning continues to provide a strategic basis for making proactive human resource decisions that are aligned with the Ministry of Health s priorities. 23

24 Sick Time and Overtime Rates Overall, Fraser Health is meeting or exceeding the targets for these measures at an organizational level. In December, individual letters were issued to employees whose sick time is trending up against the Fraser Health benchmark. Fraser Health s workforce optimization team collaborates with managers to help them create vacation schedules and rotations that promote increased attendance and overtime reduction. Implementation of site-specific and team specific plans will continue to focus on reducing sick time and overtime in areas not meeting targets. 24

25 WorkSafeBC (WSBC) Claims Duration and WorkSafeBC Claims Rate WorkSafe claims rate was 5.8 for the three-month period between July and September 2014, meeting the performance (7.0) target as an organization in this period. Health Benefits Trust s Quarter 3 report ranked Fraser Health s claims activity (claims in and claims out) as one of the highest in the province based on the change in total claim numbers when standardized for 1000 lives covered. Fraser Health closed more claims than it opened. In addition, the quarterly incident rate continues to improve, with the rate of claims per 1000 lives covered trending down. The annualized incident rate is trending down and Fraser Health is now below the industry average rate for new claims. A project was initiated to examine the implementation of violence prevention initiatives and to develop, pilot and evaluate metrics of health and safety management practices in health care. This will enable Fraser Health to evaluate its violence prevention program and will align with Fraser Health s WorkSafe BC Health Safety In Action (HSIA) partnership work. Implementation planning will begin to utilize the HSIA funding from WorkSafe BC, which is targeted towards violence prevention and is expected at the beginning of 2015/2016 fiscal year. 25

26 Employee Engagement (measuring employees only at this time) The Gallup Q12 employee engagement score for 2013/2014 was Although the organizational target (3.75) was not met, Fraser Health s performance is trending towards the target with improvements in both staff engagement scores and staff participation. Strategies are underway to create a culture of performance and accountability for staff and physicians. Fraser Health s organization-wide engagement strategy targets four key areas: frontline engagement; manager excellence; physician partnerships; and senior leader engagement. It was confirmed that health authorities will include physicians in the upcoming 2015 provincial engagement survey. The suggested survey tool is a customized physician engagement tool recommended by Gallup for use with professional stakeholders. Work continues to address physician engagement through Fraser Health s leadership and governance practices. Based upon a recently completed strategic review on physician leadership development, three areas of focus for action were identified: creation of a plan to influence strategy; culture and relationships between physicians and administrators; and a review of the design and delivery of physician development opportunities to ensure maximum impact. Much of the work in the next quarter will be dedicated to the preparation required for the rollout of the Gallup Q12 survey. The survey is administered every two years. Difficult-to-Fill Positions 26

27 The year-to-date performance rate on filling positions that are difficult to fill was 0.7% at the end of November 2014, which is currently meeting the target (1.6%) at an organizational level, with a favorable downward trend in this indicator. Vacancies are the product of many human resource indicators, indicating that staffing supply is not meeting staffing demand, either through direct shortfalls in people and skills, low productivity or engagement, or over-creation of specific types of jobs. A vacancy is reported as difficult to fill when it remains open for 90+ days. Exceptions to the trend exist in specialty nursing areas, pharmacy, respiratory therapy, occupational therapy and physiotherapy. Work continues looking for opportunities to fill these vacancies. There is a range of difficult-to-fill jobs in the management and management support group. In the clinical area, nurse practitioner is the single largest position with nine vacancies. Because of the requirement for non-bc nurse practitioners to re-write exams, Fraser Health is limited to recruiting within the province where the supply is presently inadequate. Other difficult-to-fill positions within the management/support group are typically non-clinical, which means Fraser Health is competing against a broader market. Some roles require both business and health care experience, making the candidate pool more limited. In the tables above, difficult-to-fill vacancies for management/support postings are shown in the total vacancy rate but are not assigned to an acute care site. The pharmacy residency program has a cohort of students graduating and obtaining positions in Fraser Health and the Lower Mainland Health Authorities. An overall decrease in the vacancy rate is expected as a result. Physiotherapist recruitment is a focus in Abbotsford, Chilliwack and Home Health. Fraser Health continues to promote practicum placements at schools in British Columbia and other provinces along with a campaign to promote the lifestyle in these communities. Fraser Health is addressing critical care nursing vacancies at Langley Memorial Hospital with a trial rotation between Langley Memorial and Surrey Memorial to provide nurses with experience at a higher acuity site. Balancing the Budget Fraser Health is committed to a balanced budget each year built on improving patient, resident and client quality, safety, access and experience. Budget Performance Work has focused on ensuring no program area runs a deficit. The Board s Finance and Audit Committee reviews results monthly to ensure this outcome is achieved. As of Period 9 (December 4, 2014), Fraser Health reported a year-to-date surplus. A policy outlining accountabilities, responsibilities and variance control protocols has been implemented along with variance follow-up protocols that include involvement of the Finance and Audit Committee. Policy enforcement includes regular budget meetings with the vice presidents and executive directors at 27

28 least semi-annually and quarterly with others where significant challenges exist. Targeted budget mitigation strategies are presented to the Chief Financial Officer and Chief Operating Officer (COO) and, as necessary, following COO approval, to the Finance and Audit Committee. Hospital-specific financial reports have been developed to complement program-focused reports and are now part of a regular review process amongst the executive team, executive directors and program directors. A process to control and monitor staff hiring into vacancies continues. Work continues to monitor and reinforce required practices. Direct Care Hours per Patient Day (Acute Nursing Inpatient) and Expenditures Per Separation (All Acute) Year-to-date average of direct care nursing hours per patient day was 6.8 at the end of November 2014, and has not changed over the past two years. Fraser Health is not meeting the annual target (6.7) at an organizational level. Productivity gains will help achieve this target. The average cost of providing health services to a patient admitted in a hospital, as of the third quarter of the year, was $11,149, which is now below the established target of $11,200. This measure shows a favourable downward trend during the last quarter. There is some appropriate variation between sites due to size and economies of scale, patient population and services. Monitoring the direct care hours per patient day by both hospital and program continues. Any strategies focused on health human resources will incorporate strong and effective change management and engagement principles that emphasize a culture of collaboration with key stakeholders, such as unions, in a disciplined and purposeful manner while building on Fraser Health values of respect, caring and trust. 28