Balanced Scorecard Quarterly Report

Transcription

1 Page 0 of 30 Balanced Scorecard Quarterly Report April 2016 Balanced Scorecard Quarterly Report April Data updated to December 31, 2015

2 Balanced Scorecard Quarterly Report April 2016 Page Balanced Score Card 2 Strategy Map 3 Strategic Theme: Patient and Family Centred Care Provide me with the best possilbe care experience Patient Experience Survey Results (overall rating) 4 Official Language Audit Results Ability to continue in French 5 EVS Cleanliness Audit Score 6 Hand Hygiene Audit Score 7 Emergency room wait time (from triage to seen by doctor) 8 Improve Patient and Community Engagement Average hours of active paricipation per patient experience advisor 9 Patient experience advisors satisfaction score 10 Create Centres of Expertise Number of Centres of Expertise established 11 Enhance Community Based Services Hospitalization rate per 1000 population for chronic disease (COPD,CHF,Diabetes) 12 % of youth with depression or anxiety who wait for service longer than the target 13 Enhance Tertiary Care % of NB patients receiving stem cell in province 14 Wait time for cardiac electrophysiology for low & intermediate risk 15 % of treatments that start on time for Chemotherapy 16 % of treatments that start on time for radiation 17 Redesign Delivery System % of beds occupied by ALC patients in 5 regional hospitals 18 Hospitalization Rate per 1000 population 19 % of High Priority Patient Safety recommendations completed (Accredation Canada) 20 Strategic Theme: Financial Accountablility Provide me with value for my tax dollars Cost of Health Network/ capita (inflation adjusted) 21 Average number of paid sick leave days 22 % of administrative costs to total expenses 23 Reallocate resources based on need and evidence % of expenditures allocated to Community Service 24 % of expenditures allocated to Tertiary Care 25 Optimize Performance Excellence Dollars saved through Perfromance Excellence 26 Enablers (HR, IT, Performance Excellence Culture) Improved Employee and Physician Engagement Employee Engagement Survey 27 Available Information and technology to improve delivery % of planned technology initiatives completed to improve pt services & communication 28 Committed Leadership and Culture % of Strategy communcation plan implemented 29 Appendix A Legends for symbols 30 Page 1 of 30

3 Page 2 of 30 Balanced Scorecard Quarterly Report April 2016 Health Network -Balanced Scorecard (Updated to June 30, 2015) Owner Reporting Frequency (M,Q,SA,A) Baseline Measure Full Year Full Year Stretch Q3 Reporting Period Actual Indicator Q1 Indicator Q2 Indicator Q3 "Provide me with the best possible care experience" Improve Patient and Community Engagement Patient Experience Survey Results (overall rating) Margaret M SA 74.2% 83.0% 85.0% Official Language audit results - Ability to continue in French Margaret M SA 71.08% 80.0% 85.0% EVS Cleanliness audit score Andrea S M 89.5% 85.0% 91.0% Hand hygiene Compliance Margaret M Q 73% 80% 82% Emergency room wait time for triage level 3 at 5 Regional hospitals (from triage to seen by doctor) (in minutes) Geri G M (FY14/15) Average hours of active participation per patient experience advisor Margaret M Q % (Cumulative to May 2015) 75.50% s s (FY15/16, Q3) s 94.7% (FY15/16, Q3) 78.3% (FY15/16,Q3) (FY 15/16, Q3) 9.41 (FY15/16,Q3) Patient experience advisors satisfaction score Margaret M A TBD TBD TBD No Data s s s Create Centres of Expertise Numbers of Centres of Expertise established John A s s s Enhance Community Based Services Enhance Tertiary Care Redesign Delivery Systems "Provide me with value for my tax dollars" Reallocate resources based on need and evidence Optimize Performance Excellence Improved Employee and Physician Engagement Available Information and technology to improve delivery Committed Leadership and Culture Hospitalization rate per 1000 population for chronic disease (COPD, CHF, Diabetes) % of youth with depression or anxiety who receive service within the targeted wait times (in the Moncton area). Jean D Q Jean D Q 67% 85% 90% % of NB patients receiving stem cell in province Geri G Q 75% 80% 90% Wait time for cardiac electrophysiology (in days) Geri G Q % of treatments that start on time for chemotherapy Geri G Q 93.8% 95% 98% % of treatments that start on time for radiation Geri G Q 98.60% 100% 100% % of beds occupied by ALC patients in 5 regional hospitals Geri G M 27% 23% 20% Hospitalization Rate per 1000 population Geri G Q % of High Priority Patient Safety recommendations completed (Accreditation Canada) Margaret M Q 87.5% 100% 100% 60% Cost of Health Network/ capita (inflation adjusted) Andrea S M $2,188 $2,188 $2,166 Average number of paid sick leave days Andrea S M % of administrative costs to total expenses Andrea S Q 3.06% 3.10% 3.00% % of expenditures allocated to Community Services % of expenditures allocated to Tertiary Care Andrea S/ Jean D Andrea S/ Geri G Q 10.9% 11.0% 11.2% Q 12.2% 12.2% 12.4% Dollars saved through Performance Excellence Andrea S M $4,898,010 $3,600,000 $5,000,000 $2,600, (FY15/16,Q2) x x 49% (FY15/16,Q3) x x 66.7% (FY15/16,Q2) x x x (FY14/15,Q3) x x x 93.2% (FY15/16,Q2) x 100% (FY15/16,Q2) 24.2% (FY14/15, Q3) 95 (FY15/16,Q2) 30% (FY15/16, Q3) x x $2,149 (FY15/16, Q3) (FY 15/16, Q3) 3.1% (FY15/16,Q3) x 11.2% (FYTD 15/16,Q3) s 12.1% (FYTD 15/16,Q3) s $2,260,689 (FY 15/16, Q3) x Employee Engagement Survey Andrea S A 54% 60% 65% No Data s s s % of planned technology initiatives completed to improve patient services and communication between care giver or patient Strategic Theme: Patient and Family Centred Care Strategic Theme: Financial Accountability Enablers (HR, IT, Performance Excellence Culture): Andrea S M 80% 80% 90% % of Strategy communication plan implemented Janet H M NA 80% 90% 75% (FY15/16,Q3) x 91% (FY15/16, Q3) Last Updated: April 12, 2016

4 Page 3 of 30

5 Patient Experience Survey Results (overall rating) Strategic Objective: Provide me with the best possible care experience Owner: Margaret Melanson Reporting Frequency: Annual Definition: A Patient Experience Survey is conducted twice each year for inpatients that have stayed in a facility for at least one night. This measure reports on the overall rating question from this survey. The survey will be conducted once each year starting in % (NBHC 2013) 82.0% 85.0% 78.2% (Cumulative May May 2015) Patient Experience Survey Results 100% 80% 74.2% 76.9% 80.8% 77.2% 78.2% 60% 40% 20% 0% 2013 NBHC May 2014 Nov 2014 May 2015 Cumulative May 2014-May 2015 Analysis Summary: continues to engage in discussion at the facility and patient unit level. Working with managers, initiatives are developed to identify individual unit priorities to address patients needs. The Family Presence Policy was implemented February 1, 2016 across all facilities. It was developed in close consultation with patients, families and staff members. Acute care survey results have been disseminated at the facility and patient unit level to inform quality and patient safety activities. The overall fluctuations throughout the survey cycle are not felt to be significant, and it is noted that overall has improved on the majority of parameters surveyed since the 2013 baseline. A 4 month survey is currently being conducted by the N.B. Health Council with results expected later in Communication White Board patient white boards service as a communication tool between healthcare providers and patients/ families Pilot project in progress in two inpatient units (Fredericton and Sussex) Proactive Patient Rounding Implemented on all inpatient units. Monitoring is on-going. Audit results show that 4 main care needs are being met 83% of the time. Page 4 of 30

6 Official Languages Audit Results Ability to Continue in French Strategic Objective: Provide me with the best possible care experience Owner: Margaret Melanson Reporting Frequency: Semi-annual Definition: Audits are conducted to assess employees compliance with providing an active offer (greeting in both official languages) in person and over the telephone. The audits also assess how effectively employees are able to provide service in either language. The measure reflected here is the ability to continue providing service, in person, in either official language, in the four regional facilities. Supplementary information is available to report on the active offer (over the phone & in person) as well as the ability to continue in French over the phone. To obtain data which is more statistically solid on a unit/department level, the audit methodology has been adjusted. Audits will be conducted semi-annually and results will be published at the end of Q1 and Q3 each fiscal year. This will allow Official Languages to better target improvement efforts and initiatives % 80.0% 85.0% 75.50% (FY15/16,Q3) Analysis Summary: The results of the latest audits show a slight increase in the ability to provide services in the language of choice. Results have moved from 71.25% in Q1 to 75.50% in Q2-3. Challenges remain the same. Focus in the next quarter will be put on training and awareness as well as supporting managers in the development of linguistic profiles and contingency plans for their departments. To ensure consistency, Official Language Advisors in each zone will meet with managers to go over a checklist involving the following items: Review of Official Languages Policy, roles and responsibilities Linguistic profiles Contingency plans Review of active offer audits results and/or patient experience survey results (where applicable) Identification of measures and next steps to ensure improvement Review of support offered by the Official Languages team and other stakeholders Ensure English/Français signage is displayed Verify general signage to ensure both languages are present for end of June 2016 is to have the work completed for the following four departments: Admitting and Registration Emergency Diagnostic Imaging Ambulatory Clinics Execute strategies to improve provision of services in language of choice Initiatives will touch on 5 aspects of the organization: Training and Awareness: e-learning module on the active offer, in-person training through the H.E.L.P. and Active Offer Programs, training videos, etc. are available for all employees Organizational Management: new Official Languages Policy for being implemented Recruitment of bilingual staff: development of a recruitment microsite for in progress Tools: French Language Training (offered by Learning), Café de Paris (tutoring and mentoring sessions), Policy Toolkit (including linguistic profile template, contingency plan template and FAQ, etc.) Measuring: Active Offer audits will be conducted in Q3; Patient Experience Survey results and audit results will be reviewed with individual managers and performance improvement plans will be developed. Page 5 of 30

7 Environmental Services Cleanliness Audit Score Strategic Objective: Provide me with the best possible care experience Owner: Andrea Seymour Reporting Frequency: Monthly Definition: Visual audits are conducted after EVS cleaning is completed. For Visual audits, 19 elements are visually inspected to ensure they appear clean. These Audits are currently being conducted in 9 facilities. The measure reflects the pass rate of the visual audit tests. 89.5% 85.0% 91.0% 94.7% (FY15/16,Q3) Facility April May June July Aug Sept Oct Nov Dec Saint John Regional Hospital 94% 93% 91% 91% 91% 91% 92% 94% 93% The Moncton Hospital 88% 91% 90% 90% 96% 97% 97% 97% 94% Dr. Everett Chalmers Regional Hospital 92% 94% 94% 95% 95% 96% 96% 96% 96% Miramichi Regional Hospital 93% 92% 94% 94% 95% 97% 95% 94% 96% St. Joseph s Hospital 85% 86% 88% 87% 89% 89% 90% 92% 91% Charlotte County Hospital 88% 90% 92% 87% 90% 92% 93% 94% 91% Upper River Valley Hospital 94% 95% 95% 96% 96% 96% 95% 94% 96% Sussex Health Centre 90% 91% 91% 89% 91% 91% 93% 92% 93% Sackville Memorial Hospital 100% 94% 86% 88% 79% 91% 95% NA* NA* Monthly Average 92% 93% 92% 91% 94% 94% 95% 95% 94% *Staffing shortages left Moncton EVS auditors unable to complete audits in Sackville in October and November. Analysis Summary All the facilities have met targets and have been trending upward. The visual audits are showing at the end of Q3 that we have strong results in telephone, ceilings and carpet/mat for inspection elements. There are still opportunities for improvement in the walls, high dusting and doors inspection elements. Below are functional areas that will begin to be reported on in Q4: Day Surgery Ambulatory Clinics Labour and Delivery Waiting Rooms (high volume) Operating Rooms Oncology Clinics Main Lobbies Public Washrooms (high volume) Future reports will indicate a pre-determined group of departments that all sites will be reporting on. Using these score results and further breaking down the data to determine deficiencies will enable EVS leadership to develop ongoing corrective action plans. Background Info: There are approximately 44 auditors that have been trained in. April to December there have been 7297 visual audits done at the 9 facilities in. All auditors refer to a standardized manual, called EVS Audit Elements Definitions. Monitoring Audits will continue and results monitored. Corrective actions are implemented as identified Page 6 of 30

8 Hand Hygiene Compliance Strategic Objective: Provide me with the best possible care experience Owner: Margaret Melanson Reporting Frequency: Quarterly Definition: This measure reflects the percentage of staff observed to follow the hand hygiene protocol established by the organization as part of safe practices for patients. 73% (FY 2014/15) 80% 82% 78.3% (FY15/16,Q3) Hand Hygiene Compliance 100% 80% 74% 68% 75% 77% 78% 79% 78% 60% 40% 20% 0% FY 14/15 Q1 FY 14/15 Q2 FY 14/15 Q3 FY 14/15 Q4 FY 15/16 Q1 FY 15/16 Q2 FY 15/16 Q3 Analysis Summary: The hand hygiene compliance has been trending up over the last 3 years. The improvements in hand hygiene compliance have been positively influenced by the signage on each patient care unit posting monthly results. This transparency is felt to have enhanced staff and physician vigilance and compliance. Priority Initiatives/Actions Status Comments Hand Hygiene Initiative The hand Hygiene Champions and Infection Prevention and Control (IPC) have completed a total of 24,874 observations year to date utilizing a standardized audit tool which aligns with national hand hygiene auditing practices. This reflects a 23% increase in the average number of observations completed compared to last fiscal year. The audit function is an opportunity to promote the importance of hand hygiene practices by providing real-time teaching moments and ongoing encouragement. IPC is monitoring monthly hand hygiene compliance to identify units within each facility that are not yet meeting target. Meetings are held with unit managers to identify unit specific needs and strategies to improve performance. Page 7 of 30

9 Emergency Room Wait Time for Triage Level 3 at 5 Regional Hospitals (from triage to seen by doctor - in minutes) Strategic Objective: Provide me with the best possible care experience Owner: Geri Geldart Reporting Frequency: Monthly Definition: The average time (in minutes) that a patient waits from the time they are triaged/registered to the time they are seen by a physician. Includes triage level 3. Excludes those patients where the seen by physician time was not documented. The five regional hospitals (TMH, SJRH, DECRH, URVH, MRH) are included in this indicator (FY15/16,Q3) ER Wait Time (Triage level 3 at 5 Regional Hospitals) Apr 2015 May 2015 Jun 2015 Jul 2015 Aug 2015 Sep 2015 Oct 2015 Nov 2015 Dec 2015 Analysis Summary: Patients with urgent needs (level 1 and 2) continue to be seen in a timely manner. Results for December were positive. Wait times were positively impacted by a decreased occupancy rate in the five regional hospitals during this time. Specifically, occupancy rates decreased in December by over 5% for all Regional facilities except URVH, which showed a decrease of 1.5%. Priority Initiatives/Actions Status Comments ER Wait time initiatives Various initiatives are underway to address specific local challenges. Some of these initiatives include: developing of a rapid assessment area at TMH, monitoring of ambulance patient off load delays (pilot) TMH, improving in patient flow in the waiting room at SJRH, improving access to the physician assistants at the DECRH, implementing hospital wide recommendations to improve patient flow at URVH, and implementing a hospital wide overcapacity process MRH. Page 8 of 30

10 Average Hours of Active Participation per Patient Experience Advisors Strategic Objective: Improve Patient Engagement Owner: Margaret Melanson Reporting Frequency: Quarterly Definition: tracks the volunteer hours contributed by each Patient Experience Advisor. This measure reports the average hours of service for the active advisors (FY15/16,Q3) Avg hrs of active participation per Patient Experience Advisor FY 14/15 Q2 FY 14/15 Q3 FY 14/15 Q4 FY 15/16 Q1 FY 15/16 Q2 FY 15/16 Q3 Analysis Summary: From April to December 2015 there were 43 patient experience advisors, an increase of 4 from the previous quarter. The number of patient experience advisors has increased by 400% from the same period the previous year. The total hours of active participation for the reporting period is hours. Some advisors have contributed large numbers of hours as individuals to our facilities. It is felt a balance of numbers of advisors recruited will allow reasonable contributions for each advisor to allow appropriate numbers of hours to be maintained on average. has seen an increase in demand for patient experience advisors as our organization embraces their involvement. There have also been requests from DH, Vitalité and Ambulance NB for patient advisor participation. This has resulted in a stronger program throughout NB. None at this time Page 9 of 30

11 Patient Experience Advisors Satisfaction Score Strategic Objective: Provide me with the best possible care experience Owner: Margaret Melanson Reporting Frequency: Annual Definition: A survey measures satisfaction of the Patient Experience Advisors who have provided input to projects and committees. (Council members and 38 advisors). The satisfaction is rated on a scale from 1 to 5. NA NA Analysis Summary: The first patient advisor satisfaction survey was conducted in Quarter 3 with results available in Quarter 4. None at this time Page 10 of 30

12 Numbers of Centres of Expertise Established Strategic Objective: Provide me with the best possible care experience Owner: John McGarry Reporting Frequency: Annual Definition: will establish new centres of expertise that foster strong clinical leadership, improve patient outcomes and drive research activities. This measure represents the number of centres of expertise established NA Analysis Summary: A project manager was hired in January to develop an implementation plan for the Aging and Eldercare centre of expertise. He will be conducting a stakeholder analysis to outline concerns, issues, and gaps that will help move the planning forward. The steering committee for this project are focusing on branding, mission, vision, mandate and organizational structure. A regional clinical group has been approved by Regional Medical Advisory Committee (RMAC) for the Geriatricians. Define framework for Centres of Expertise Develop Centre for Aging and Eldercare Planning is underway for this initiative. Page 11 of 30

13 Hospitalization Rate per 1000 Population for Chronic Disease (COPD, CHF, Diabetes) Strategic Objective: Enhance Community Based Services Owner: Jean Daigle Reporting Frequency: Quarterly Definition: The number of patients discharged from hospital with a diagnosis of COPD, CHF or Diabetes per 1000 population. Population base for communities is 537,106. Data is available with a lag of one quarter (FY15/16, Q2) Chronic Disease Hospitalization Rate FY 14/15 Q1 FY 14/15 Q2 FY 14/15 Q3 FY 14/15 Q4 FY 15/16 Q1 FY 15/16 Q2 Analysis Summary: The hospitalization rate for chronic disease has increased by 2.7% when compared to the same quarter in the previous fiscal year. All Areas showed an increase with the exception of the Miramichi Area. Year to date data shows that COPD accounts for 56% of discharges for these chronic hospitalizations. Respiratory Therapy is working with Extra Mural to provide education and supportive self-management to inpatients, increasing the number of COPD referrals to EMP. COPD is a systemic problem which will take time to see noticeable changes from improvement initiatives. An inventory of COPD related initiatives has been completed. Patient flow committees are in the early stages of identifying initiatives to improve hospitalization rates. Wound Care - Extra Mural Program The implementation of new equipment and related training is underway, but experiencing some delays for all Extra Mural areas Have ordered equipment, licensing done and training plan in place. Implement recommendations from community health needs assessment Smoking cessation Community needs assessment recommended the Inspire Clinic, which was included in the Regional Health and Business Plan (approval for funding pending) This program continues to expand across, with the program s overall reach increasing 38% over last year. Programming is at various stages of implementation across all areas of clinical environments. Page 12 of 30

14 Percent of Youth with Depression or Anxiety Who Receive Service Within the Wait Times Strategic Objective: Enhance Community Based Services Owner: Jean Daigle Reporting Frequency: Quarterly Definition: Youth, aged 17 and younger, who are diagnosed with depression or anxiety should receive services within a targeted wait time of 90 days. This measure tracks the percentage of these patients who received the service within the target wait time in the Moncton area where the wait time has been an issue. These numbers include youths waiting for psychiatrist and/or therapist. (Note: in Quarter 2, this measure was revised to state the wait time met rather than not met.) 67% 85% 90% 49% (FY15/16, Q3) % of youth with depression or anxiety receiving service within target wait time x 100% 80% 60% 40% 20% 0% 67% 49% 35% FY 15/16 Q1 FY 15/16 Q2 FY 15/16 Q3 Analysis Summary: Manual collection of data began in Q2, which resulted in more accurate results. The process for assigning a physician has been streamlined. All previously vacant positions have been filled as well as adding an additional casual employee. The acuity of depression or anxiety at the time of assessment impacts how quickly a client is seen. Depression and anxiety are often assessed as medium priority. High priority clients (for depression or any condition) are being seen within target times. However medium priority clients tend to wait longer. We continue to make progress on the medium priority, down from 11 months reported last quarter to 7 months this quarter. At this point, these improvements have plateaued and in the absence of investments in clinical resources it is not expected to move much more. The NB Health council reports that the Moncton area has the lowest ratio of clinician to 10,000 population in the province. The staffing level has not kept up with the population growth in this area. Funding for additional resources was submitted in the Health and Business Plan (RHBP) and will be resubmitted with this year s RHBP. Improve Services for Youth Depression and Anxiety - wait list in Moncton Case assignment: File assignment will move from bi-weekly to weekly starting in January. Waiting list review: Waiting list is reviewed on a timely basis to ensure that the clients that are waiting for services still need services. Clients are provided with information about alternative service options in the community Page 13 of 30

15 Percent of NB Patients Receiving Stem Cell in Province Strategic Objective: Enhance Tertiary Care Owner: Geri Geldart Reporting Frequency: Quarterly Definition: has the resources and expertise to provide stem cell transplants at the Saint John Regional Hospital. Some patients are being referred out of province. This indictor tracks the proportion of adult NB patients requiring stem cell treatment who received that treatment within New Brunswick. 75.0% 80% 90% 66.7% (FY15/16,Q2) x % of NB patients receiving stem cell in NB 120.0% 100.0% 80.0% 60.0% 75.0% 100.0% 66.7% 66.7% 66.7% 66.7% 40.0% 20.0% 0.0% FY 14/15 Q1 FY 14/15 Q2 FY 14/15 Q3 FY 14/15 Q4 FY 15/16 Q1 FY 15/16 Q2 Analysis Summary: There were 15 patients from NB who received autologous stem cell transplants in an acute care facility within Canada for the first 2 Quarters of Fiscal Year 2015/2016. Of the 15 New Brunswick residents who received stem cell transplants, 10 of those patients had the procedure completed in the Province of New Brunswick. Five patients went out of province (4 to QEII & 1 to Ottawa General) for stem cell transplants. The remaining 10 patients, from the Saint John, Moncton, and Fredericton Areas, received their transplants at the SJRH. The Stem Cell program has been expanded to meet the needs of New Brunswick residents. The New Brunswick stem cell advisory committee has been established and has discussed the objective of reducing out of province transfers for stem cell treatment. Following the advisory committee meeting, members of the stem cell transplant team met with colleagues of the Moncton Hospital and collaboratively created a plan for stem cell transplant referrals to the NB program. As a result the first patient referral was received. The patient education guide is being revised to include specific patient referral information for patients referred from Moncton. The patient information guide will also include post-transplant care for patients transferred back to Moncton on day plus one. Oncology - Stem Cell Transplant Budget approval was received to expand the NB Stem Cell program Page 14 of 30

16 Wait Time for Cardiac Electrophysiology Strategic Objective: Enhance Tertiary Care Owner: Geri Geldart Reporting Frequency: Quarterly Definition: Patients who await cardiac electrophysiology are assessed as urgent, high, intermediate or low risk. For intermediate and low risk patients the target wait time is 90 days. This measure focuses on the average wait time for intermediate and low risk patients. The measure reflects patients who have had procedures completed. Other patients, who remain on the wait list, may be waiting longer (FY15/16,Q3) x Wait time for Elecrophysiology (in days) FY 08/09 FY 09/10 FY 10/11 FY 11/12 FY 12/13 FY 13/14 FY 14/15 FY 15/16, Q1 FY 15/16, Q2 FY 15/16, Q3 Analysis Summary: The wait time for electrophysiology is far beyond the target wait time of 90 days, set by the Canadian Cardiovascular Society. has not been able to meet the demand since the program began in A presentation was made to the Department of Health in October 2014, followed by a funding proposal included in the 2015/16 budget for expansion of the service at the NB Heart Centre. The proposal will be resubmitted as part of the Regional Health and Business Plan. We continue to prioritize the patients waiting. The most urgent patients are given priority for treatment. Patients are given an option to be referred out of province. We are actively recruiting for a second electrophysiologist. Enhancement of electrophysiology service Pending budget approval Page 15 of 30

17 Percent of Treatments That Start on Time for Chemotherapy Strategic Objective: Enhance Tertiary Care Owner: Geri Geldart Reporting Frequency: Quarterly Definition: The number of patients who received their first treatment within 7 days of being ready to treat proportionate to the total number of patients who received their first treatment (outpatients). 93.8% 95% 98% 93.2% (FY15/16,Q2) x % on time for Chemotherapy 100.0% 90.3% 94.2% 94.5% 96.4% 94.4% 93.2% 80.0% 60.0% 40.0% 20.0% 0.0% FY 14/15 Q1 FY 14/15 Q2 FY 14/15 Q3 FY 14/15 Q4 FY 15/16 Q1 FY 15/16 Q2 Analysis Summary: The Moncton and Fredericton areas have been tracking above the target with 100% and 97.7% respectively for Quarter 2. In the Saint John area, 89.6% of patients have received their first treatment within the target time. Patients in the Miramichi area receive their first treatments at the Moncton hospital. An increase of two chairs in the Chemo clinic in Saint John will be introduced in the March We continue to advocate for increased resources for the oncology program in the Saint John Area. Enhancement of Oncology Service Budget approval is outstanding. The plan for the enhancement will be submitted with the Regional Health and Business Plan. Page 16 of 30

18 Percent of Treatments That Start on Time for Radiation Strategic Objective: Enhance Tertiary Care Owner: Geri Geldart Reporting Frequency: Quarterly Definition: The number of patients who received their first treatment within 28 days of being ready to treat proportionate to the total number of patients who received their first treatment (both inpatients and outpatients). Radiation is only provided at the SJRH. 98.6% 100% 100% 100% (FY15/16,Q2) 100.0% % on time for Radiation 97.7% 98.5% 99.5% 99.5% 100.0% 100.0% 80.0% 60.0% 40.0% 20.0% 0.0% FY 14/15 Q1 FY 14/15 Q2 FY 14/15 Q3 FY 14/15 Q4 FY 15/16 Q1 FY 15/16 Q2 Analysis Summary: is being maintained over time. The booking process continues to work effectively. A new medical physicist was added to the program to match the workload requirements and remove a bottleneck in the treatment planning process. Recruit new medical physicist Anticipated start date of March 2016 Page 17 of 30

19 Percent of Beds Occupied by ALC Patients in 5 Regional Hospitals Strategic Objective: Redesign Delivery Systems Owner: Geri Geldart Reporting Frequency: Monthly Definition: The percentage of beds occupied by Alternative Level of Care (ALC) patients. Includes ALC patients in all beds, regardless of bed classification, and is based on the MIS Nursing Unit functional centres. The measure includes only the five regional hospitals (TMH, SJRH, DECRH, URVH, MRH). 27% 23% 20% 24.2% (FY15/16, Q3) 50% % of beds occupied by ALC patients 40% 30% 20% 29% 29% 29% 28% 24% 26% 25% 22% 23% 23% 24% 25% 26% 24% 25% 10% 0% Analysis Summary: The percent of beds occupied by ALC patients remains relatively flat. We may see a modest improvement near the end of the fourth quarter as some community nursing home beds are expected to open in Fredericton. Plans for additional nursing home beds in Miramichi and Saint John will also improve occupancy in those communities. We continue to stay engaged with partners through the home first steering committee. Proposals to increase bed capacity to accommodate increased ALC number until long term care services are available to meet demand. Proposals have not been approved. Hospitals continue to cope by exercising over-capacity protocols. Standardize ALC tracking and reporting process. The objective is to improve consistency of ALC data and enable real time reporting with more data analysis capability and more detailed data. Page 18 of 30

20 Strategic Objective: Redesign Delivery Systems Owner: Geri Geldart Reporting Frequency: Quarterly Hospitalization Rate per 1000 Population Definition: The number of patients discharged from hospital (excluding Newborns) per 1000 population. Population for is 537, (FY15/16, YTD Q2) Hospitalization Rate FY 14/15 Q1 FY 14/15 Q2 FY 14/15 Q3 FY 14/15 Q4 FY 15/16 Q1 FY 15/16 Q2 Analysis Summary: The number of discharges for decreased by 478 in the first two quarters of FY15/16 compared to the first two quarters of FY14/15. s hospitalization rate has decreased by 2.1% when compared to the same time frame last fiscal year. All areas except Saint John show a decrease. The New Brunswick hospitalization rate for Q2 of 2015/2016 is 103 which is a slight decrease over the 2014/15 rate of 105. NB has been trending down for the last four fiscal years, however Q2 still reports higher than the Maritime rate (84) and the Canadian rate (82). In Canada, Saskatchewan and NB have the same rate (103) which is higher than any other province. The next highest is Alberta at 94. Hospitalization rate is a key factor in hospital congestion. The Patient flow framework is planned to be rolled out by the end of March 2016, which will look at short stays, COPD and readmissions. Seniors at Home Initiative - Extra Mural Program Rehab/ re-ablement Patients continue to receive rehab/re-ablement services to prevent hospitalization in the Fredericton and Upper River Valley area. Page 19 of 30

21 Percentage of Required Organizational Practices and High Priority Recommendations Completed (from Accreditation Canada) Strategic Objective: Redesign Delivery Systems Owner: Margaret Melanson Reporting Frequency: Quarterly Definition: Percentage of Accreditation Standard Required Organizational Practices (ROP) and High Priority (HP) recommendations completed as a follow up from the September 2013 survey visit. Year Baseline Full Year 2015/16 0% 100% 60% 75% Q3 Q3 Stretch Q3 Actual Q3 Indicator 30% (FY15/16, Q3) x Analysis Summary: 1. Breakdown of 23 Accreditation Standard ROP / HP Patient Safety Recommendations ( s review) 7 ROP / HP completed 13 ROP / HP on track 3 ROP / HP somewhat off track 2. Status of 3 ROP / HP Somewhat off track: Emergency (Med Rec Transition) draft evidence of action being reviewed, tool being piloted to identify at risk population. Emergency 15.1 (threatening clients) draft evidence of action under review. Substance Abuse (Med Rec Transition) draft evidence of action under review. 3. A number of recommendations are in the review and/or approval stage so Q4 target of 100% should be met. 4. At the request of Accreditation Canada, will be deferring its on-site survey from September 2017 to September Accreditation Canada has extended s Accreditation Award with Commendation to 2018 indicating their confidence in s ongoing ability to provide quality safe patient care. A number of ROP/HP recommendations have a draft evidence of action document prepared and are in the review or approval stage. Next Steps: Patient Safety Consultants and Quality Consultants continue to work with identified teams. Evidence of action taken to demonstrate compliance to standard submitted to VP for final approval. to complete 23 ROP/HP recommendations: Quarter 4. Page 20 of 30

22 Cost of Health Network per Capita (inflation adjusted) Strategic Objective: Provide me with value for my tax dollars Owner: Andrea Seymour Reporting Frequency: Monthly Definition: This measure looks at the cost of services, identified as total expense per capita. Population base for communities within the areas is 537,106. $2,188 $2,188 $2,166 Cost per Capita $2,149 (FY15/16,Q3) $2,250 $2,200 $2,150 $2,100 $2,105 $2,102 $2,111 $2,120 $2,146 $2,168 $2,123 $2,106 $2,108 $2,125 $2,129 $2,149 $2,050 $2,000 $1,950 $1,942 $1,900 $1,850 $1,800 Oct 2014 Nov 2014 Dec 2014 Jan 2015 Feb 2015 Mar 2015 Jun 2015 Jul 2015 Aug 2015 Sep 2015 Oct 2015 Nov 2015 Dec 2015 Analysis Summary: The cost per capita calculation shows that continues to run below the baseline and target for costs to Q3. Savings in Medicare costs, which are a significant portion of our savings, continue to grow at a slower pace, but it should be noted that we will see a corresponding reduction in revenues. Cost per capita has increased over Q2 due to recent collective bargaining agreements contract settlements, which includes both retroactive payments and ongoing salary adjustments. Drugs continue to run under plan overall at this time. We continue to face a challenge in Oncology drugs with continued high demand and rising costs. Increase in spend in other supplies such as energy costs, equipment maintenance, general supplies, travel, telephone and small equipment. Due to factors such as weather and scheduling, we cannot be sure that we can rely on maintaining savings generated to this point throughout the year. None at this time Page 21 of 30

23 Average Number of Paid Sick Leave Days Strategic Objective: Provide me with value for my tax dollars Owner: Andrea Seymour Reporting Frequency: Monthly Definition: There continues to be a high absenteeism rate at. A reduction in absenteeism will help reduce costs associated with lost productivity, as well as, staff replacement costs. This measure is an annualized average number of paid sick days per employee eligible to receive the benefit (FY 15/16, Q3) Average number of paid sick days FY 14/15 Q1 FY 14/15 Q2 FY 14/15 Q3 FY 14/15 Q4 FY 15/16 Q1 FY 15/16 Q2 FY 15/16 Q3 Analysis Summary: Q3 & Q4 trend up each year; Q3 15/16 average is lower than previous fiscal year. Workforce adjustments impact sick time usage. In November 2015, changes to the Retail Cafeteria Services were announced; subsequent workforce adjustment activity happened in December Discontinuation of Nursing Workload Measurement System (Emerald) was announced in September 2015; minimal workforce adjustment activity resulted; however, discontinuation of the Emerald had organizational impacts in the Nursing areas across. In December 2015, Staff Scheduling Transformation project became a reality in Miramichi with position impacts due to central scheduling in the Saint John area. Kronos Workforce Absence Manager Software Implementation Task force with GNB to analyze and act on sick time initiatives Currently in the planning and assessment stage. This is a new committee formed with GNB, DoH and Vitalité. Preliminary discussions held in December. Page 22 of 30

24 Percent of Administrative Costs to Total Expenses Strategic Objective: Provide me with value for my tax dollars Owner: Andrea Seymour Reporting Frequency: Quarterly Definition: Examining administrative costs in relation to total expenses can help improve cost-efficiency. This indicator looks at the percentage of s total expenses that were spent in administrative departments such as Finance and Human Resources. 3.06% 3.1% 3.0 % 3.1% (FY15/16,Q3) 15% % of administrative costs (fiscal cumulative) 10% 5% 3.1% 3.1% 3.1% 3.1% 3.2% 3.1% 3.1% 0% FY 14/15 Q1 FY 14/15 Q2 FY 14/15 Q3 FY 14/15 Q4 FY 15/16 Q1 FY 15/16 Q2 FY 15/16 Q3 Analysis Summary: Current year results are consistent with the previous fiscal year. continues to meet target and reports well below the national average of 4.4%. Discontinue current nursing workload measurement process and system Complete. This will save the equivalent of 17 FTEs in daily nursing time as well as reduce admin FTEs by 5.6. Page 23 of 30

25 Percent of Expenditures Allocated to Community Services Strategic Objective: Reallocate resources based on need and evidence Owner: Andrea Seymour/Jean Daigle Reporting Frequency: Quarterly Definition: Proportion of overall expenditures incurred by Community Services including Extra Mural, Community Mental Health and Addictions, Public Health, Community Health Centres, Corporate Admin for VP Community, population health and clinics. (Excludes addictions and psychiatry inpatient services. Data included for community services does not include outpatient services that are hospital based, such as outpatient physiotherapy or diabetes clinics.). 10.9% 11.0% 11.2% 11.2% (FYTD 15/16, Q3) 40% 30% % of Expenditures Allocated to Community Services 20% 10% 0% 11.0% 11.0% 10.9% 10.9% 11.1% 10.9% 11.2% FY 14/15 Q1 FY 14/15 Q2 FY 14/15 Q3 FY 14/15 Q4 FY 15/16 Q1 FY 15/16 Q2 FY 15/16 Q3 Analysis Summary: The goal set out in the strategic plan is to increase the percent of expenditures allocated to community care by 2% over 5 years. We continue to trend the same as last year. Efforts continue to identify resources that can be shifted from institutions into the community where there is better opportunity to influence health promotion, prevention and management of chronic conditions. None at this time Page 24 of 30

26 Percent of Expenditures Allocated to Tertiary Care Strategic Objective: Reallocate resources based on need and evidence Owner: Andrea Seymour/Geri Geldart Reporting Frequency: Quarterly Definition: Proportion of overall expenditures incurred by tertiary services including Oncology, Heart Centre, Trauma, Stem Cell, Stan Cassidy, Critical Care (ICU, CCU, Neonatal ICU, NeuroICU, Peds ICU) and Interventional Radiology. Expenses exclude medical compensation and depreciation. 12.2% 12.2% 12.4% 12.1% (FYTD 15/16, Q3) 40% % of Expenditures Allocated to Tertiary Services 30% 20% 10% 12.4% 12.4% 12.4% 12.2% 12.2% 12.3% 12.1% 0% FY 14/15 Q1 FY 14/15 Q2 FY 14/15 Q3 FY 14/15 Q4 FY 15/16 Q1 FY 15/16 Q2 FY 15/16 Q3 Analysis Summary: The goal set out in the strategic plan is to increase the percent of expenditures allocated to tertiary care by 2% over 5 years. For the first year, the target is to maintain the baseline ratio. No major changes to the funding in these tertiary services have been made. In subsequent years, savings will be identified for reallocation from secondary acute care to specific tertiary services. None at this time Page 25 of 30

27 Dollars Saved Through Performance Excellence Strategic Objective: Optimize Performance Excellence Owner: Andrea Seymour Reporting Frequency: Monthly Definition: This measure will track the hard and soft savings through process improvement. Savings include: reduction in spending, cost avoidance, revenue generation, and savings in productivity and efficiency as a result of continuous improvement including Lean Six Sigma projects, waste walks and other continuous improvement activities. Baseline Annual Q3 Q3 Stretch Actual Indicator $4,898,010 $3,600,000 $2,600,000 $3,400,000 $2,260,689 (FY 15/16, Q3) x Analysis Summary: has accomplished 86.9% of the year to date targeted savings. Of the total savings realized, $1,437, was in hard dollar savings, and $823, was realized in soft savings. Waste Walks contributed to $713, of overall savings. As project work cycles continue to fluctuate, some projects will not report until next quarter and beyond. Many of the projects over this fiscal have been focused on patient focused care and quality of care and service. Emphasis continues to be on ensuring Process Improvement Facilitators are working on high priority projects with a balance of patient focused care, and cost savings. Complete GL Consolidation Staff Scheduling/Kronos Fredericton, Miramichi and Saint John have transitioned to the consolidated GL. Moncton is on track to finish at the end of the fiscal year Currently addressing some technical issues and change management challenges. NEW Benchmark Initiatives Savings identified fell short of potential as identified by consultant s report. Joint Services RFP - Environmental, Food and Portering Energy Efficiency Initiative Contract negotiations continue. An energy management information system has been implemented to enable energy monitoring and cost avoidance Page 26 of 30

28 Employee Engagement Survey Strategic Objective: Improved Employee and Physician Engagement Owner: Andrea Seymour Reporting Frequency: Annual Definition: A formal survey was conducted in November 2014 with employees and physicians. The survey consisted of 12 categories: Communication, Customer Focus, Engagement, Goals and Objectives, Health and Safety, Job Autonomy, Job Challenge, Leadership, Management, Quality and Resources, Teamwork and Collaboration, and Training and Development. A 54% favourable aggregate score is used as the baseline. 54% 60% 65% NA NA Analysis Summary: Staff engagement activity commenced in Information gathered from these activities has been used to develop an Employee Engagement Strategy and associated communication plans. Subsequent SOMIA initiatives will be determined from this strategy. Future staff engagement survey timelines are currently being established. The strategy has been drafted and will be presented to Leadership and the engagement summit participants in January. Staff Engagement Strategy Development and Implementation. HR Leadership Team planning and assessing key focus areas for Engagement Strategy. Workplace Violence Prevention Program Implementation itacit Training and Education Module Software Implementation December 2015: Code White Pilot completed in Saint John; WVPP Flowchart and Prevention Tip sheet were developed and distributed; and information sessions held with Nurse Managers. This technology enables the management information system to support employee engagement through training and development. Currently in the implementation planning phase. Parklane Software Implementation Smoking Cessation Pilot Saint John Area This technology enables the management information system to support employee engagement through workplace safety. Currently in the planning and assessment stage. September 2015: Saint John implemented smoke-free policy. Employee Health provided staff support to those who wished to quit smoking or manage cravings; achieved through counselling and nicotine replacement therapy. In Q3 there were approximately 900 Employee Health visits to provide support and counselling. Page 27 of 30

29 Percent of Planned Technology Initiatives Completed to Improve Patient Services and Communication between Caregiver and Patient Strategic Objective: Available Information and technology to improve delivery Owner: Andrea Seymour Reporting Frequency: Monthly Definition: A list of Information and Technology projects will be identified for completion, or progress, in this fiscal year, with target milestones. This measure will track the %age of those milestones that were met (include list here when available). Projects are: Dictation Project, Patient Wireless Project, Saint John Hospital Information System (Allscripts Sunrise) Upgrade. Baseline Stretch Actual Q1 Indicator 80% 80% 90% 75% (FY15/16,Q3) x Analysis Summary: The Saint John Hospital Information System (Allscripts) upgrade is currently scheduled to be completed in April 2016 (shortly after the end of the Quarter). This is contingent on 2 related projects that have experienced some technical issues. The majority of activities will be completed in Q4. The Dictation project has been making good progress but 2 deliverables were pushed to early January to accommodate the availability of key staff. The patient wireless project started a pilot of the service at the Dr. Everett Chalmers Hospital in Fredericton before the holiday period. Other deliverables were moved to Q4 due to technical challenges. The initial group of 6 hospitals are due to be completed by the end of the fiscal year. Expansion to additional facilities is being reviewed. Allscripts Clinical Information System Upgrade Preparation work and kick off were completed in Q2. The majority of the detailed project activity has started in Q3. Complete replacement of dictation system Saint John radiology implementation was completed in August. Implementation has started in Miramichi Implement patient wireless Slight schedule delays due to technical issues. Page 28 of 30

30 Percent of Strategic Communication Plan Implemented Strategic Objective: Committed Leadership and Culture Owner: Janet Hogan Reporting Frequency: Monthly FY15/16, Q1 FY15/16, Q2 FY15/16, Q3 FY15/16, Q4 Scheduled for completion % Achieved 100% 100% 89% % Cumulative Achieved 100% 100% 91% Definition: This measure will track the percentage of tasks completed specific to the communication plan. This includes initiatives to improve corporate communication and community engagement; support strategic priorities; and manage risks to corporate brand and reputation. Baseline Stretch Q3 Actual Indicator N/A 80% 90% 91% (FY15/16, Q3) Analysis Summary Communications had established nearly 40 milestones for completion this year, the bulk of which were scheduled for the last two quarters. A significant portion of these milestones were based on our support of s Regional Health and Business Plan, and though work was begun or completed, they will not be implemented. This does not, however, diminish the need for Communications to be engaged at the onset of projects in order to receive timely and accurate advice and to plan for changes that will affect staff and/or community effectively. Of the 8 major milestones that were completed in the last quarter, the most significant of these was the Internal Communications Framework which was approved by ELT. Create engagement opportunities to better condition general public for change Promote greater awareness of Strategic Plan Support ELT priorities by developing communications plan and materials, and providing advice and expertise for internal and external communications objectives Minimize risk through consistent Corporate Reputation Management While the RHBP was not been adopted on the whole, there are milestones within it that have received approval to move forward (e.g. parking, cafeteria changes). Of the 14 milestones in this priority, 11 will not be moving forward. The others are on track. Eight initiatives were identified under this priority, and significant work has been invested to ensure milestones are met within our scope of control. Communications is actively working on 11 communication plans/campaigns, which are in various stages of completion. 4 have been completed. Seven other plans are also expected to move forward before the end of the fiscal year. Most are progressing well and will be completed on or about year end. This priority deals specifically with s ability to engage with staff and stakeholders effectively and consistently. Of nine action plans, almost half are near completion. Page 29 of 30