Balanced Scorecard Quarterly Report

Transcription

1 Page 0 of 22 Balanced Scorecard Quarterly Report December Balanced Scorecard Quarterly Report April Data updated to December 31,

2 Balanced Scorecard Quarterly Report December 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 Hand Hygiene Audit Score 6 Emergency room wait time (from triage to seen by doctor) 7 Create Centres of Expertise Number of Centres of Expertise established 8 Enhance Community Based Services Hospitalization rate per 1000 population for chronic disease (COPD,CHF,Diabetes) 9 % of youth with depression or anxiety who wait for service longer than the target 10 Enhance Tertiary Care % of NB patients receiving stem cell in province 11 Wait time for cardiac electrophysiology for low & intermediate risk 12 % of treatments that start on time for Chemotherapy 13 Redesign Delivery System % of beds occupied by ALC patients in 5 regional hospitals 14 Strategic Theme: Financial Accountablility Provide me with value for my tax dollars Cost of Health Network/ capita (inflation adjusted) 15 Average number of paid sick leave days 16 Reallocate resources based on need and evidence % of expenditures allocated to Community Service 17 % of expenditures allocated to Tertiary Care 18 Optimize Performance Excellence Dollars saved through Perfromance Excellence 19 Enablers (HR, IT, Performance Excellence Culture) Improved Employee and Physician Engagement Employee Engagement Survey 20 Available Information and technology to improve delivery % of planned technology initiatives completed to improve pt services & communication 21 Committed Leadership and Culture % of Strategy communcation plan implemented 22 Legend for Indicator Symbols: Meets / exceeds stretch Exceeds target / below stretch Meets target performance Improved performance (between base and target) Below base performance Not applicable Legend for Initiative Status Symbols: Complete On Track Somewhat Off Track Off Track On Hold Cancelled Information Required Page 1 of 22

3 Page 2 of 22 Balanced Scorecard Quarterly Report December Health Network -Balanced Scorecard -17 (Updated to December 31, ) 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" Create Centres of Expertise Enhance Community Based Services Enhance Tertiary Care Patient Experience Survey Results (overall rating) Margaret M SA 74.2% (NBHC 2013) 83.0% 85.0% Official Language audit results - Ability to continue in French Margaret M SA 75.5% 80.0% 85.0% Hand hygiene Compliance Margaret M Q 78.8% 85% 90% Emergency room wait time for triage level 3 at 5 Regional hospitals (from triage to seen by doctor) (in minutes) Geri G M % NBHC 81.5% (FY16/17,Q1) 81.2% (FY16/17,Q3) (FY16/17, Q3) Numbers of Centres of Expertise established John A Hospitalization rate per 1000 population for chronic disease 6.34 Jean D Q (COPD, CHF, Diabetes) (FY16/17,Q2) % of youth with depression or anxiety who receive service within 42% Jean D Q 62% 85% 90% the targeted wait times (in the Moncton area). (FY16/17, Q3) % of NB patients receiving stem cell in province Geri G Q 75% 80% 90% 92.3% (FY16/17, Q2) Wait time for cardiac electrophysiology (in days) Geri G Q (FY16/17,Q3) % of treatments that start on time for chemotherapy Geri G Q 94% 95% 98% 95.8% (FY16/17,Q2) 24.4% (FY16/17, Q3) Redesign Delivery Systems % of beds occupied by ALC patients in 5 regional hospitals Geri G M 24% 23% 20% "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 Cost of Health Network/ capita (inflation adjusted) Andrea S M $2,188 $2,260 $2,180 Average number of paid sick leave days Andrea S M % of expenditures allocated to Community Services % of expenditures allocated to Tertiary Care Andrea S/ Jean D Andrea S/ Geri G Q 11.1% 11.2% 11.3% Q 12.4% 12.6% 12.8% Dollars saved through Performance Excellence Andrea S M $3,931,705 $3,000,000 $3,500,000 $2,600,000 $2,225 (FY 16/17, Q3) (FY16/17, Q3) 11.1% (FY 16/17, Q3) 12.5% (FY 16/17, Q3) $2,745,117 (FY 16/17, Q3) Employee Engagement Survey Andrea S A 54% 60% 65% NA % 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 88% 80% 90% % of Strategy communication plan implemented Janet H M 84% 80% 90% 90% (FY16/17, Q3) 91% (FY 16/17, Q3) Last Updated: April 12, 2017

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5 Page 4 of 22 Balanced Scorecard Quarterly Report December 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. 74.2% (NBHC 2013) 83.0% 85.0% 77.2% ( NBHC) 100% 80% Patient Experience Survey Results 74.2% 76.9% 80.8% 77.2% 77.2% 60% 40% 20% 0% 2013 NBHC May 2014 Nov 2014 May 2015 NBHC Analysis Summary: The NB Health Council (NBHC) conducts an Acute Care Patient Experience Survey every three years. has also conducted interim surveys to guide improvement efforts. The NBHC results for showed improvement in satisfaction in paint control, receiving service in preferred language and patient safety. continues to reinforce the basic initiatives earlier introduced (such as proactive rounding) and within specific program teams work toward improvements to their surgical or medical program area. With the new Accreditation Canada Standards pertaining to Patient and Family Centred Care, and these survey results, is planning a re-engagement initiative in early June 2017 to help establish the next priorities for the patient and family centred care strategy. s next internal survey will be conducted in November 2017, allowing for time to implement appropriate interventions. also conducted a successful pilot survey of ambulatory care survey within clinics at the SJRH with broad implementation across undertaken in the winter of Communication White Board Proactive Patient Rounding Patient white boards service as a communication tool between healthcare providers and patients/ families. Feedback from the pilot was evaluated. New boards were designed and will now be tested in other sites. Audit results show patients feel their 4 main care needs are met 94% of time, a 2% increase from last report; Staff introduce themselves & their role 95% of time.

6 Balanced Scorecard Quarterly Report December 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. 75.5% 80.0% 85.0% 81.5% (FY16/17,Q1) Analysis Summary: More targeted initiatives for French language training showed improved results in the first quarter of Results for the remainder of the year are unavailable because audits of the active offer remain on hold as the education work with the external firm Dialogue Partners is wrapping up. There remain significant concerns that the act of auditing may counteract the positive inroads made with the dialogue sessions on the active offer. Other potential Key Performance Indicators are being examined in order to measure progress within the organization. While dialogue sessions continue throughout the organization, other initiatives are also underway: completion of linguistic profiles and contingency plans, process review and improvement project around language proficiency testing, and process improvement of the identification of language of choice in the healthcare continuum. 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: completion of linguistic profiles and contingency plans for each department and service 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 were conducted in Q1; audit results are reviewed with individual managers and performance improvement plans developed. Page 5 of 22

7 Balanced Scorecard Quarterly Report December 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. 78.8% 85% 90% 81.2% (FYTD16/17,Q3) Hand Hygiene Compliance 100% 80% 75% 77% 78% 79% 78% 80% 81% 80% 82% 60% 40% 20% 0% FY 14/15 Q3 FY 14/15 Q4 FY 15/16 Q1 FY 15/16 Q2 FY 15/16 Q3 FY 15/16 Q4 FY 16/17 Q1 FY 16/17 Q2 FY 16/17 Q3 Analysis Summary: A total of 38,129 observations have been completed in Quarters 1-3 utilizing a standardized audit tool which aligns with national hand hygiene auditing practices. Compliance signage is posted on each patient care unit providing monthly results. Work with specific unit areas, and staff / physician groups, is ongoing to reinforce best clinical practice. Over the last two years hand hygiene has gradually improved by 7% primarily due to audits, education and increased visibility on nursing units. Based on audit results, efforts will be focused on improving compliance in areas that have been consistently lower than the average. Facility YTD Dec 31 Facility YTD Dec 31 Facility YTD Dec 31 The Moncton Hospital 76.57% Charlotte County 87.65% Oromocto 77.64% Sackville Memorial 88.32% Sussex Health Centre 83.73% Upper River Valley 85.87% Saint John Regional 79.91% Grand Manan Hospital 82.88% Hotel-Dieu Perth 83.09% St Joseph's 89.10% Dr. Everett Chalmers 82.57% Miramichi Regional 81.60% Priority Initiatives/Actions Status Comments Hand Hygiene Compliance Improvements 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 6 of 22

8 Balanced Scorecard Quarterly Report December 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 (FYTD16/17, Q3) ER Wait Time (Triage level 3 at 5 Regional Hospitals) Oct 2015 Nov 2015 Dec 2015 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Analysis Summary: ER wait times continue to be longest at the Moncton Hospital, followed by DECRH and SJRH. Significant reductions in wait time have been seen from SJRH and Moncton, with 12 and 19 min reduction primary due to focused attention on patient congestion Triage Level 3 Wait Times - Oct Dec Q3 FY1516 Q4 FY1516 Q1 FY1617 Q2 FY1617 Q3 FY1617 DECRH URVH MRH TMH SJRH The improvement initiatives are in early stages so full impact on overall wait time is yet to be determined. Other initiatives focused on ER wait time are in the planning stages. Moncton ER Redirect The project has been slow to get started, but has been re-launched with renewed support for the Why Wait campaign. SJRH - One Board Changes in information flow and workflow are being implemented to improve efficiency based on volumes and acuity. Page 7 of 22

9 Balanced Scorecard Quarterly Report December Numbers of Centres of Expertise Established Strategic Objective: Provide me with the best possible care experience Owner: Jean Daigle 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 Analysis Summary: The Centre of Expertise for Aging and Eldercare has been established with an Executive Director and Medical Director reporting to the Vice President Community. An implementation plan has been developed with four key goals: Improve patient outcomes Educate public and staff Drive research Provide strong clinical leadership Initiatives and action plans are being developed and implemented under each of these goals. Going forward the key measure for the Aging and Eldercare Centre of Expertise will be measuring the progress towards completing this plan. Develop Centre for Aging and Eldercare Progressing as noted above. Page 8 of 22

10 Balanced Scorecard Quarterly Report December 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 (FYTD16/17,Q2) Chronic Disease Hospitalization Rate FY 14/15 Q2 FY 14/15 Q3 FY 14/15 Q4 FY 15/16 Q1 FY 15/16 Q2 FY 15/16 Q3 FY 15/16 Q4 FY 16/17 Q1 FY 16/17 Q2 Analysis Summary: COPD is a systemic problem which will take time to see noticeable changes from improvement initiatives. Chronic disease hospitalization rate has remained relatively stable. The slight decrease in Q2 is caused by seasonal fluctuation. We are beginning to see promising results from the INSPIRED program. Hospitalized patients enrolled in INSPIRED are a referral source for EMP Rehab and Reablement for COPD patients over 65 years of age. Regionally as of February 2017, patients where outcome data is available are demonstrating 1064 bed days avoided. The COPD public awareness campaign is being finalized. Preliminary work has begun to identify COPD patients in the Emergency Department with follow-up provided within 48 to 72 hours. Priority Initiatives/Actions Wound Care EMP Status Comments All Extra Mural Program units in are fully implemented. Implement actions from CHNA A $200,000 investment from DH will assist with prevention and early detection activities identified in the Community Health Needs Assessments. Smoking cessation This program continues to expand across. There are strategies for high risk populations where prevalence are higher such as in-patient psychiatry, detox and methadone programs Chronic Disease Standards Chronic Disease Standards have been written with implementation planned throughout over the next few years. The standards address how the system should be redesigned for improved management of chronic diseases. Page 9 of 22

11 Balanced Scorecard Quarterly Report December 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 19 less 1 day 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 Q2, 2015/16, this measure was revised to state the wait time met rather than not met.) 62% 85% 90% 42% (FY16/17, Q3) 100% % of youth with depression or anxiety receiving service within target wait time 80% 60% 40% 20% 0% 67% 62% 49% 54% 57% 42% 35% FY 15/16 Q1 FY 15/16 Q2 FY 15/16 Q3 FY 15/16 Q4 FY 16/17 Q1 FY 16/17 Q2 FY 16/17 Q3 Analysis Summary: 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. Slight decrease in performance for quarter 3 is the result of temporary vacancies for maternity leave positions which have subsequently been filled. Two new social worker positions have now been filled. Two new psychologists positions are expected to be filled in the 4 th quarter. With this full complement of staff, each clinician will take on 40 clients over the period of a few weeks, thus allowing us to meet our target once the positions are filled and practicing at capacity. We should see a notable improvement in Q4. Integrated Service Delivery (ISD) is a partnership with Education, Public Safety and Social Development to develop and implement appropriate child and youth centred interventions to ensure the positive growth and development. We expect this to have a positive impact on service in the Moncton Area. Integrated service delivery On track for full implementation in Moncton in September 2017 Page 10 of 22

12 Balanced Scorecard Quarterly Report December Strategic Objective: Enhance Tertiary Care Owner: Geri Geldart Reporting Frequency: Quarterly Percent of NB Patients Receiving Stem Cell in Province 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. The data is available one quarter behind because it comes from the national CIHI database. 75% 80% 90% 92.3% (FYTD16/17, Q2) % of NB patients receiving stem cell in NB 120.0% 100.0% 80.0% 60.0% 40.0% 100.0% 66.7% 66.7% 66.7% 66.7% 83.3% 85.7% 100.0% 90.0% 20.0% 0.0% FY 14/15 Q2 FY 14/15 Q3 FY 14/15 Q4 FY 15/16 Q1 FY 15/16 Q2 FY 15/16 Q3 FY 15/16 Q4 FY 16/17 Q1 FY 16/17 Q2 Analysis Summary: From April September, there were 13 adult patients from the province of New Brunswick who received an autologous stem cell transplant within Canada. Of those patients, 12 of them had the procedure completed within their home province, at the Saint John Regional Hospital. One patient, from the Moncton Area, had the procedure completed in Nova Scotia, at the QEII. We are starting to see change in referral pattern, particularly from the Moncton area. This is a positive change for New Brunswickers. We will continue to monitor services provided within the province to ensure continued optimization of services provided by. None at this time. Page 11 of 22

13 Balanced Scorecard Quarterly Report December 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 (FY16/17,Q3) Wait time for Electrophysiology (in days) FY 15/16, Q1 FY 15/16, Q2 FY 15/16, Q3 FY 15/16, Q4 FY 16/17, Q1 FY 16/17, Q2 FY 16/17, Q3 Analysis Summary: Wait times for access to services are tracked from the time of initial consultation with the Electrophysiolgist until the time the procedure is completed. The significant reduction in wait times for elective electrophysiology studies is the result of limiting the number of new, non-urgent referrals seen in consultation. This action was necessary due to our limited MD resources in Electrophysiology and consequently enabled the program to address the backlog of elective cases waiting in the queue. There is now a significant list of patients waiting for initial consultation; however, all are categorized as non-urgent. All cases that are urgent in nature are prioritized to the top of the queue and are accessing services within reasonable timelines. The official opening of the new device lab was held in November. The laboratory was fully operational in January with minor additions still required. Recruitment for a second Electrophysiologist was successful with a new physician starting in the new fiscal year. Enhancement of electrophysiology service The device lab was upgraded. A new Electrophysiologist will start in the spring of Page 12 of 22

14 Balanced Scorecard Quarterly Report December 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). 94.0% 95% 98% 95.8% (FYTD16/17,Q2) % on time for Chemotherapy 100.0% 94.2% 94.5% 96.4% 94.4% 93.2% 92.8% 94.0% 97.1% 94.8% 80.0% 60.0% 40.0% 20.0% 0.0% FY 14/15 Q2 FY 14/15 Q3 FY 14/15 Q4 FY 15/16 Q1 FY 15/16 Q2 FY 15/16 Q3 FY 15/16 Q4 FY 16/17 Q1 FY 16/17 Q2 Analysis Summary: The Moncton and Fredericton areas have been tracking above the target with 100% for FY16/17, Q1 & Q2. In the Saint John area, 91.3% of patients have received their first treatment within the target time in Q2, down slightly from FY15/16, Q2 (93.2%). Patients in the Miramichi area receive their first treatments at the Moncton hospital. We are evaluating the impact a new pharmacy resource may have on our ability to extend the treatment day at SJRH within current nursing hours, and within the existing space limitations. Space remains the primary constraint, impacting our ability to improve services in Saint John. Enhancement of Oncology Service Budget for enhancement was approved as part of the Regional Health and Business Plan. Recruitment is complete. Additional resources will address workload issues in several key areas, but it is unlikely to affect the wait time for chemo as space remains the critical bottleneck. Page 13 of 22

15 Balanced Scorecard Quarterly Report December Strategic Objective: Redesign Delivery Systems Owner: Geri Geldart Reporting Frequency: Monthly Percent of Beds Occupied by ALC Patients in 5 Regional Hospitals 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). 24% 23% 20% 24.4% (FYTD 16/17, Q3) 50% 40% % of beds occupied by ALC patients 30% 20% 10% 26% 24% 25% 25% 22% 24% 26% 25% 25% 25% 22% 26% 24% 24% 22% 0% Oct 2015 Nov 2015 Dec 2015 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Analysis Summary: In the Month of December MRH has a drop in ALC due to community nursing home beds reopening following renovations. In the last quarter 30 new nursing home beds opened in Woodstock, and 30 beds in Neguac. This accounts for the percentage drop in Q3. New nursing home beds are also planned in Sussex and Moncton. ALC remains a significant cause of hospital congestion, particularly in Moncton and Miramichi. 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. Roll-out planned for 2017/18. Page 14 of 22

16 Balanced Scorecard Quarterly Report December 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 $2,260 $2,180 $2,225 (FY16/17, Q3) $2,300 Cost per Capita $2,250 $2,200 $2,150 $2,125 $2,129 $2,150 $2,160 $2,160 $2,188 $2,244 $2,226 $2,195 $2,205 $2,210 $2,214 $2,225 $2,100 $2,050 Oct 2015 Nov 2015 Dec 2015 Jan Feb Mar Jun Jul Aug Sep Oct Nov Dec Analysis Summary: This indicator continues to run below target for Q3. The target has increased 3.3% over the previous year as a result of the incorporation of three major union contracts which were settled during the previous year, an increase in budgeted maintenance activity, continuation of retirement allowance payout program, and normal inflationary changes. Performance in follows the trend of previous years. Costs are below budget in all expense categories except benefits. Higher than anticipated WorksafeNB costs, account for variance in benefit costs. We continue to have significant savings on salary and drug costs, as well as, additional savings in surgical supplies and other supply categories. None at this time Page 15 of 22

17 Balanced Scorecard Quarterly Report December Average Number of Paid Sick Leave Days Strategic Objective: Provide me with value for my tax dollars Owner: Andrea Seymour Reporting Frequency: Monthly Definition: This measure is an annualized average number of paid sick days per employee eligible to receive the benefit (FY 16/17, Q3) Average number of paid sick days FY 16/17 Q1 FY 16/17 Q2 FY 16/17 Q3 Analysis Summary: Paid sick time in Q3 is typically higher than Q2. Some Q3 impacts on paid sick usage may include: continuing Staff Scheduling Transformation Project rotation challenges; on-going workforce adjustment activity; increased prevalence of influenza. In addition, there is an on-going issue of some employees using paid sick leave instead of filing a WorksafeNB claim due to salary impacts. The calculation of this indicator was adjusted slightly this fiscal year for more consistency with Department of Health and Vitalité when reporting provincially. Consequently, comparisons data for previous year is not available. Attendance Management There is continued focus on attendance management. Planning sessions are being held and opportunities for improvement have been identified. Reporting enhancements for managers are being explored. Page 16 of 22

18 Balanced Scorecard Quarterly Report December 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.). 11.1% 11.2% 11.3% 11.1% (FY 16/17, Q3) 40% 30% % of Expenditures Allocated to Community Services 20% 10% 0% 10.9% 10.9% 11.1% 10.9% 11.2% 11.1% 10.8% 10.8% 11.1% FY 14/15 Q3 FY 14/15 Q4 FY 15/16 Q1 FY 15/16 Q2 FY 15/16 Q3 FY 15/16 Q4 FY 16/17 Q1 FY 16/17 Q2 FY 16/17 Q3 Analysis Summary: Analysis Summary: The goal set out in the strategic plan is to allocate 12% of the total budget to community-based programs, an increase of 2% or approximately $23 million over 5 years. The /17 Regional Health and Business Plan outlined a plan to increase community-based programs by $933,000 annualized over two years. In the current year there have been investments from new funding to enhance community services. Many of these additions will only be implemented near the end of the fiscal year, causing a delayed impact on this indicator. 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. Community Health Needs Assessment The last six assessments were completed in the third quarter. Page 17 of 22

19 Balanced Scorecard Quarterly Report December 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. 12.4% 12.6% 12.8% 12.5% (FY 16/17, Q3) 40% % of Expenditures Allocated to Tertiary Services 30% 20% 10% 12.9% 12.1% 12.6% 12.7% 12.3% 12.3% 12.6% 12.4% 12.5% 0% FY 14/15 Q3 FY 14/15 Q4 FY 15/16 Q1 FY 15/16 Q2 FY 15/16 Q3 FY 15/16 Q4 FY 16/17 Q1 FY 16/17 Q2 FY 16/17 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. It is anticipated that expenditures will increase in the second half of the current year. Recruitment of specialists is currently under way and we anticipate increased investment in tertiary care in the second half of the current fiscal year as a result. Increased investment in the NB Heart Centre is the first major targeted change to the funding in tertiary services. Overall expenditures are up over previous quarters in this measure. Costs in the NB Heart Centre, combined medical/surgical ICU and neurosurgery are all up, while oncology has shown a slight decrease. However, given s overall 3.3% increase in expenditures masks improved performance on this measure. Specialist recruitment in NB Heart Centre Currently underway. Page 18 of 22

20 Balanced Scorecard Quarterly Report December 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 Stretch Q3 Actual Indicator $3,931,705 $3,000,000 $3,500,000 $2,600,000 $2,745,117 (FY 16/17,Q3) Analysis Summary: Q3 savings were much more modest than the previous quarter. Savings are normally reported monthly for 12 consecutive months. Two major projects were reported as lump sums in Q2, which boosted the savings for that period. Other projects are wrapping up their monthly reporting, so reported savings for the last three months were low as several new projects are in the beginning stages and not yet realizing savings. Year to date results are strong and we expect to meet, or come close to the target for the year. Staff Scheduling Currently addressing shift rotation issues and change management challenges. Joint Services RFP - Environmental, Food and Portering Contract negotiations continue. NB Heart Centre initiatives Progressing on schedule. First focus is on OR optimization and reducing patients average length of stay Extramural Productivity Improvements Increased the average visits per day by 7.8% CIU Registration wait time reduction Reduced wait time for blood collection Patient Flow initiatives Various initiatives to address inpatient congestion are expected to result in savings as well Page 19 of 22

21 Balanced Scorecard Quarterly Report December 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 Analysis Summary: The last staff engagement survey was completed in The 2014 survey highlighted deficiencies in both the survey tool selected, and in the process followed. Major initiatives including revamp of the orientation program, introduction of values workshops, introduction of workplace violence program and creation of the Bravo! Online recognition program have had a positive impact. This has been demonstrated at our CEO forums. A new engagement survey will be undertaken in the fall of Staff Engagement Strategy Development and Implementation. Workplace Violence Prevention Program Implementation Implementation of key employee engagement initiatives began in May in the area of Values and Recognition; with on-going work continuing in the areas of Leadership and new employee On- Boarding. Code White project is rolling out to each facility. Pilots in community settings have been completed. The first initiative has wrapped up and a second initiative to operationalize the program is underway. Bravo! On-line recognition program This program is values-based and will enable recognition of staff contributions on a daily basis. Launch on November 15,. CaRES (Caring, Respect, Excellence and Service) Smoking Cessation Initiative This is a values-based approach to on-boarding new staff that integrates general orientation and departmental orientation. Pilot to start in Q3. All Regional facilities are now smoke free. The initiative is rolling out to the remaining community facilities. Nearly 700 employees have taken advantage of support resources to quit smoking. Page 20 of 22

22 Balanced Scorecard Quarterly Report December 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 percent of those milestones that were met (include list here when available). Projects are: Dictation Project, Patient Wireless Project (Phase 2), and the new Electronic Fetal Monitoring and Documentation System (Navicare WatchChild) in Moncton. Baseline Stretch Actual Q1 Indicator 88% 80% 90% 90% (FY16/17,Q3) INDICATOR % of planned technology initiatives completed to improve patient services and communication between care giver or patient Row Labels Q1 Q2 Q3 Q4 Grand Total Dictation Patient Wireless (Ph2) OBS Documentation System (Watch Child) Grand Total Milestones Achieved in Quarter % Milestones in Expected Quarter Achieved 100% 75% 80% % Cumulative Milestones Achieved to Date 100% 83% 90% Analysis Summary: The Dictation project continues to move into the final stages with work being actively completed in Fredericton. This project will have the majority of diagnostic imaging departments using a single Dictation platform at the end of Quarter 4 with DI in Moncton going live May 1, The patient wireless project added 3 new hospitals in partnership with local foundations and Auxiliaries. These were Charlotte County Hospital, Upper River Valley Hospital, and Oromocto Public Hospital. A fetal monitoring and electronic documentation system went live in Moncton in Q3. This provides comprehensive electronic charting for the mother and newborn from pre-birth monitoring to birth and discharge (including OR and high risk care). This builds on the Miramichi solution, improving continuity and standardization of care. Navicare WatchChild Project was implemented in Moncton. Complete replacement of dictation system Implement patient wireless It is our intention to implement the front end voice recognition digital dictation system for physician use in all Health Record departments immediately following conclusion of DI deployment. Currently working to obtain support for the final 2 inpatient hospitals (Hotel Dieu St. Joseph and Sussex Health Centre). Page 21 of 22

23 Balanced Scorecard Quarterly Report December Percent of Strategic Communication Plan Implemented Strategic Objective: Committed Leadership and Culture Owner: Janet Hogan Reporting Frequency: Monthly FY16/17, Q1 FY16/17, Q2 FY16/17, Q3 FY16/17, Q4 Scheduled for completion % Achieved 86% 88% 100% % Cumulative Achieved 86% 87% 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. 84% (FY15/16) 80% 90% 91% (FY16/17, Q3) Analysis Summary: Communications has established 44 milestones for completion this year, seven (or 16%) of which are scheduled for completion in the third quarter. A significant portion of these milestones are in support of strategic initiatives, as well as internal communications and community engagement goals. As new strategic or operational initiatives are identified, Communications continues to evaluate and prioritize communications plans in support of these projects. 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 Four projects have been identified under this priority. These four public awareness campaigns are all currently in development, and scheduled for completion in Q4. Four initiatives have been identified under this priority, with milestones that span through the last three quarters of the year. One initiative has been scheduled for completion in Q3, and was completed ahead of schedule. Approximately 34% of Communications projects this year are in support of ELT priorities, and all four (or 100%) of the milestones slated for completion in the third quarter have been completed. Approximately 48% of the Department s communications projects are in support of this initiative. This priority deals specifically with s ability to engage with staff and stakeholders effectively and consistently. Of the two milestones scheduled for completion in Q3, both have been completed. Page 22 of 22