HÔTEL-DIEU GRACE HOSPITAL HIGHLIGHTS OF THE BOARD OF DIRECTORS MEETING

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Archibald Long
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1 HÔTEL-DIEU GRACE HOSPITAL HIGHLIGHTS OF THE BOARD OF DIRECTORS MEETING September 24, 2008 FINANCE COMMITTEE REPORT Mr. Allison Mr. Allison reviewed the August 2008 Operating Results and noted that for the five months ending August, there is a deficit from hospital operations of $11,000. Year to date, the plan was to achieve a surplus of $465,000; the result is a $476,000 negative variance from plan. Overtime expense continues to exceed the budget by $168,000 year to date. Staffing vacancies offset this amount with the result that total salaries are $40,000 over budget. Medical Surgical supplies are $487,000 over budget with the majority of the variance occurring in the Operating Room. Higher than planned volumes for Hips and Knees account for some of this variance, however the variance in this area continues to grow. Med Surg supplies and inventory will be the focus of the next Lean project held in October with the view to effect cost reductions in the future. PATIENT SAFETY AND COMMUNITY CARE COMMITTEE The committee welcomed Ms. Angela D Alessadro as a new member at their last meeting. Medical Quality Report It was reported that the re-organization of some of its programs by Cancer Care Ontario has caused some issues to surface regarding Thoracic Surgery. He stated that Hôtel-Dieu Grace Hospital as the trauma centre, has all of the resources in place for thoracic surgery and that discussions are on-going with the LHIN and Cancer Care Ontario. An official designation is expected to be announced some time in the Fall. Risk Management Ms. ShannonTompkins gave a presentation on Patient Safety Culture based on the Accreditation Canada Patient Safety goals. It was reported that HDGH is creating a culture of safety within the organization and that a Required Organization Practice (ROP) indicates that the hospital must carry out one client safety-related prospective analysis per year. Accreditation Update Ms. Sarah Sasso presented an overview of the Accreditation process to the committee. It was reported that six recommendations from the 2005 Accreditation have been completed and that the Mental Health Team review of the practice of physicians dispensing medication to ensure it meets pharmaceutical practice guidelines is still outstanding. Mr. Dollar also noted that physicians no longer dispense sample medication within the outpatient clinic and meetings have been held with CMHA and psychiatric nurses. With the redesign of the Mental Health department flow has improved. It was reported that there are twenty-five required organizational practices that organizations must have in place to enhance patient safety and minimize risk. Non-compliance with any one ROP will result in a conditional award. The Board was advised that in preparation for Accreditation 2008 several resources have been put in place i.e. weekly frontline news articles, intranet accreditation link, accreditation handbook and a Patient Safety video which was viewed by all staff. Quality Improvement Plan A Quality Improvement Plan has been developed and it ties in with the Strategic Plan, supports Accreditation and works well with the LEAN process. 1

2 PLANNING & PRIORITIES COMMITTEE The board received a report on the status of several construction projects in various stages of completion including the Admitting/Gift Shop renovation and the MRI Replacement Project which are both on schedule. Review Annual Work Plan The Board was advised that the Land Acquisition Policy has been revised and the 20-year Business Plan submitted. However, he stated that the Capital Plan for the Foundation Pharmacy has yet to be approved. He reported that StrategiCare 08 is being monitored and Ms. den Boer Grima will be asked to monitor the ISCM initiative and that Dr. Shamisa is part of the provincial expert panel monitoring the neurosurgery enhancement. It was reported that the cost of the angioplasty addition has increased to $69 million. He stated that the increase in cost is partly due to medical student needs and the ER expansion. He indicated that the Ministry now views it as an infrastructure project which requires LHIN support and that a meeting will be held with the LHIN in October to discuss this. LHIN I.T. Initiative Update It was reported that Mr. Paul Audet, our e-health Lead made a presentation to the committee on the Provincial e-health Strategy and the HDGH IT Strategic Plan. He stated that provincial ehealth initiatives will be considered as important as clinical initiatives and that a plan is in place for a fully functional electronic health record by Ouellette Entrance Closure It was reported that due to security and infection control reasons, closure of the Ouellette entrance has been contemplated. In the event of closure, he indicated that access would be provided from Ouellette to Goyeau via an outside sidewalk. He also reported that the bus company is not willing to change its route; therefore, the sidewalk will start at the bus stop. The cost (including landscaping to make the Ouellette entrance look less like an entrance) is approximately $20,000 which will come from the capital budget. It was reported that the ramp to the basement will need to stay open mainly for Cath lab patients. MANAGEMENT REPORTS REPORT OF THE INTERIM CHIEF EXECUTIVE OFFICER Mr. John Coughlin 2008 HOSPITAL KEY METRICS METRIC TARGET JAN FEB MAR APR MAY JUN JUL AUG PATIENT FLOW OCCUPANCY Percentage AVG LENGTH OF STAY - Days SAFETY OF CARE PATIENT SATISFACTION % FALLS RATE HSMR Rate PEOPLE FRIENDLY PLACE STAFF SATISFACTION %

3 PHYSICIAN SATISFACTION % AFFORDABILITY YTD Margin $ in Millions % Dept Hrs over budget *current forecast for YE Margin is 1.5Million * HSMR - excluding palliative - overall HSMR is currently 102-4th Q 0708 report due September 2008 Occupancy continues to be high even, over the summer months. Average Length of Stay continues to be over 1 day above target. Mortality Ratio (excluding palliative care) is within acceptable range. Year to Date Margin continues to be negative. Number of Departments over budget has increased for the 3 rd consecutive month. Transformation Plan of Care We are making progress with our Transformation Plan of Care. We are running 2 Rapid Improvement Events (RIE s) during the third week of every month. So, to date, we have run a total of 6 RIE s. We began in July on 8 th floor running 2 RIE s dealing with 6S. The objective was to organize certain equipment on the units so that staff would not be wasting their time looking for stuff. We found that not only were we able to organize the equipment, but that we had too much equipment and too many supplies. We have been able to implement positive change and sustain it so that staff have more time to devote to direct patient care. In August, we ran 2 RIE s on 6 th floor, one dealing with communication and the other dealing with infection control. We found that there is an overwhelming amount of communication on the units and we were able streamline it and standardize it so that staff know where to find the communication they need, where and when they need it. The infection control RIE focused on standardizing the whole process of ensuring hand washing and cleaning of equipment, furniture and the patient room and using visual controls to identify to various staff members that these items have been cleaned. In September, we ran another 2 RIE s, one to spread 6S to 4 th and 7 th floors and to develop a model for the further spread of 6S. This had results similar to those for 8 th floor. The other RIE concentrated on making final improvements to the discharge model developed on 2 North and developing a model for spreading those improvements throughout the hospital. On 2 North, this model has facilitated earlier discharge and has reduced our LOS. To date, we have done 6S in areas involving 69% of our beds and our TPOC development, VSA s, Core Team training, Leadership Development and RIE s have involved 97 participants. The Current State of HDGH In furtherance of the Transformation Plan of Care, the Current State of HDGH has been rolled out within the organization. It was presented at a special meeting of the Board on Sept. 8, to the Operations Committee (management) on Sept. 11, to the union leadership on Sept. 15, to the MAC on Sept. 15 th to the quarterly medical staff meeting on Sept. 16 and to the staff at 2 town hall meetings on Sept. 18. A copy has also been provided to the LHIN. It seems to have been generally well received. There is a sense that the openness and transparency was appreciated. There is an understanding of where the hospital needs to go and a willingness on the part of many to help us get there. However, many are unsure precisely how this will happen or if in fact it will happen or whether it is just another flavour of the month. The Senior Leadership Team takes responsibility for moving the organization forward and will report its progress to you in the months to come. 3

4 Accreditation Our entire organization continues its extensive preparations for the Accreditation Survey, which takes place the week of Oct. 19 th. We are organizing material and communicating with our staff about the many initiatives we have begun and had underway over the past couple of years that demonstrate how we meet the various organizational practices identified by the Canadian Council on Health Services Accreditation. We thank the many members of our Board who have taken a very active role in these preparations particularly around the organizational practices involving governance. Erie St. Clair LHIN StrategiCare 08 We continue to work with the ECS LHIN in order to meet the terms of our accountability agreement with them. We have an open, transparent and cooperative relationship with them. We are working with the ESC LHIN and the other hospitals in Windsor/Essex and Chatham and Sarnia, to strengthen integration in the areas of Health Information Management Services, IT Governance, Pharmacy and Diagnostic Services, and Emergency Room Coordination, as well as a Windsor/Essex Vision and Strategy. This last area presents some significant challenges for all of us, but we are working in a cooperative and exploratory way with our colleagues to bring about meaningful integration that improves the care we provide to the patients of our community. Leadership I would like to acknowledge the support our Senior Leadership Team has received from the Board Chair, the Executive Committee Members and many other Board members. I would also like to thank them for their attendance at the presentations of the Current State, the RIE Report-Outs and the media events such as the Shoppers Drug Mart Tree of Life Campaign of which HDGH is the prime beneficiary. I would also like to thank the Senior Leadership Team for their support over the last month and their commitment to transforming our organization. REPORT OF THE CHIEF NURSING EXECUTIVE Mrs. Patricia Somers Angioplasty Update A teleconference was recently held with the MOH and the LHIN to update them on the continuing growth of our angioplasty service. In June the cath/pci lab received 190 referrals. In July the lab did 186 angiograms and 46 angioplasties. The cath/pci lab is on track to achieve the projected volumes for this year. We are currently refreshing the operational dollars that will be required to support the anticipated growth over the next 3 5 years. The MOH and the LHIN have committed to ongoing discussions once they receive our refreshed operational projections. On September 30, 2008 a formal presentation will be made to LHIN representatives on the growth of our cath/pci service and the limitations of one lab. The HDGH Master Plan Business Case envisions 2 cath/pci labs located in a new addition called the Angioplasty Building. Discussions occurred with the capital planning branch of the MOH in early August. They have advised HDGH to get formal endorsement from the LHIN Board on our Business Case. This endorsement is needed to allow the MOH to take our Business Case forward and hopefully get it onto the MOH Capital Plan for 09/10. Once the presentation occurs on September 30, 2008, the LHIN representatives will get this issue onto the LHIN Board agenda. Transformation Plan of Care: Rapid Improvement Events The third week of September saw the launch of a new rapid improvement event and the spread of an earlier RIE event to other patient care areas. One of the RIEs focused on the discharge planning process and the red light green light initiative. This RIE built on the successes of 2N and the Flow collaborative. There is now a plan in place to implement the RIE to all units in the hospital over the next 12 months. The Spread RIE took the de-cluttering work that occurred on the 8th floor to the 7E, 7W and 4Medical units. This is all very exciting as we are now advancing the RIE initiatives across the organization. Once again the RIE weeks are proving to be integral to the Transformational Plan of Care. 4

5 Blood Pressure Screening Clinic One Hundred and forty five people (93, staff, 47 visitors, 5 volunteers) participated in the Blood Pressure (BP) Screening Clinic offered in August. The Clinic, sponsored by the Workplace Wellness and Communications Committee, was provided by the staff of the District Stroke Centre Initiative. The Clinic was the brainchild of Cheri Shepley RN, Stroke Prevention Nurse. Of the 145 participants, 17 were found to have blood pressures above 140/90. This translates to 11.7% of the total participants. The Clinic offered the opportunity for health promotion and education as well as heighten overall awareness regarding the importance of BP monitoring as one of the key metrics of health. The BP Screening Clinics will continue to be offered throughout the year. Late Career Initiative Our proposal for late career funding was submitted to the Nursing Secretariat in August. Although we have not heard of any funding announcements as yet, we remain hopeful that we will be successful. Last year we utilized all of the late career dollars we were allocated. REPORT OF THE BOARD CHAIR Mr. Egidio Sovran Mr. Sovran thanked board members for meeting with the chair and sharing their suggestions. He also acknowledged the work of Mr. Paul Dollar on developing the board SASH scorecard and his efforts with the upcoming accreditation. Mr. Sovran also recognized the senior leadership team for their hard work on a number of critical projects including the development of our strategic plan, the transformation plan of care and the compilation of the current state of the hospital report. REPORT OF THE FOUNDATION Mrs. Kim Spirou Ms. Spirou reported that the HDGH Annual Golf Tournament raised $61,000 after expenses, doubling the revenue brought in the previous year. She updated the board on some other up and coming activities within the foundation, including the following events: * Hooves for Healing - aquestrian event supporting the Mental Health Program - October 5 & 12 * Dunks for Dialysis - HDGH vs WRH Docs to support the Regional Renal Program - October 28 * HDGH Tree of Life Campaign - Make a gift to honour a loved one - November 5 (Campaign Launch) * Heart and Soul Gala - HDGH Annual Hospital Gala at the Ciociaro Club - November 14 Ms. Spirou reported that the Beyond Medicine -- Medicine Beyond campaign continues to progress nicely. She unveiled the campaign marketing document which outlines the tremendous case for supporting this hospital. To date, the foundation has raised $3.6 million or 28% of our goal. We are at the point now where summer is over and it is time for our 33 campaign cabinet volunteers to be out making calls to solicit their peers. It is the only way this campaign will be successful. Ms. Spirou invited board members to attend the Campaign Cabinet Social on Monday, October 6th at the Windsor Club and asked that they RSVP their attendance to Jason Patterson in the foundation office. Mr. Sovran stressed to the board members that it will be important to have a 100% personal financial commitment from them to insure the campaign's success. He said that peer-to-peer solicitation includes members of the board and that either Bill Marra or himself will be calling them beginning Monday, September 29 to set up one on one meeting to discuss your gift to the campaign. 5

6 ISSUES UPDATE Senior Leadership Team The board received an update on two issues: strategic planning process and on an operational review. In terms of the strategic plan, the board was informed that the plan is tracking well to the timelines set out. Northstar Consulting has completed its SWOT analysis and focus groups. A report from Northstar will go to the senior leadership team and then up to the Board. The feedback received will serve to further shape and evolve our strategic plan. In terms of the operational review, the board is supporting the engagement of an outside facilitator to conduct this review. REPORT OF THE CHIEF OF STAFF Dr. Art Kidd Dr. Kidd reported that HDGH has been approved as a pilot site for a clinical decision unit in the Emergency Room. Essentially this will enhance the observation of patients by physicians and enable physicians to possibly avoid some unnecessary admissions. REPORT OF THE MEDICAL STAFF Dr. Bacchus Dr. Bacchus and Dr. Vail reported that a review of the medical leadership model is being undertaken. They are taking a LEAN approach to this review and are involved in mapping out the current and future states and analyzing the gaps. Plans are to report back to MAC, medical staff and the board on progress. REPORT OF THE ASSOCIATE DEAN OF THE MEDICAL SCHOOL Dr. Raphael Cheung Dr. Cheung reported that presently 24 first year and 24 second year medical students are enrolled in Windsor s medical school program. He also indicated that the medical school building is not quite finished and in the interim period of time students are taking their classes at WRH. He added that the clerkship program continues to be very successful and indicated that for the 5 th year in a row graduates are being matched with their first choice for placement. Meeting adjourned at 7:50 p.m. 6

Balanced Scorecard Highlights

Balanced Scorecard Highlights Highlights from 2011-12 fourth quarter (January to March) Sick Time The average sick hours per employee remains above target this quarter at 58. Human Resources has formed