Corporate Priorities and Strategic Initiatives for the Period from October 1, 2007 to September 30, 2008 Board of Directors Report

Transcription

1 Corporate Priorities and Strategic Initiatives for the Period from October 1, 2007 to September 30, 2008 Board of Directors Report Revised Seprtember 21, / 13

2 Introduction Each year Hamilton Health Sciences reviews the mission, vision and the strategic goals and determines strategic priorities. Corporate initiatives that contribute to the strategic priorities are identified, change strategies are developed and 90-day milestones and September measures of success are determined. Our Mission, Vision, and Values Mission To provide excellent health care for the people and communities we serve and to advance health care through education and research. Vision Leaders in exemplary care, innovation, and academic excellence. Values Respect: We will treat every person with dignity and courtesy. Caring: We will act with concern for the well being of every person. Innovation: We will be creative and open to new ideas and opportunities. Accountability: We will create value and accept responsibility for our activities. Strategic Goals: 1. We meet or communities 2. We are internationally recognized for the excellence of our patient-centred care, research and education. 3. We have a healthy work environment. 4. We have a 5. We create a sustainable and aligned system through action and leadership Strategic Priorities for Access to Care: The timely access to health services is to achieve the best possible health outcomes. This includes a broad set of concerns that center on the degree to which needed services are available in a timely manner from the health care system. 2. Quality Initiatives: The extent to which health services for individuals and populations are provided in a manner that increases the likelihood of desired health outcomes and are consistent with evidence and best practice. This area includes patient safety, appropriateness of care and application of best practices. 3. Operational Performance: The process of measuring, monitoring and adjusting organizational activity with the goal to optimize operational decisions and improve performance. This area includes initiatives related to efficiency and effectiveness. 4. Healthy People and Environments: The ability to create and sustain a positive work environment. This area includes initiatives related to staff attraction, retention, motivation, culture, safety, teamwork and leadership. 5. System Thinking & Leadership: The ability to provide leadership in creating a sustained health care system that is aligned across the entire system both internally and externally to the organization. This area includes championing partnerships to focus on improving the system from a broad perspective based on overall structures, patterns and cycles rather than specific events. Corporate Strategic Initiatives for contribute to and are aligned with the strategic priorities. This report identifies each corporate strategic initiative, its described, Sponsor, the specific goal/s, corporate priority, and the measure of success for. 2 / 13

3 HHS Strategy Map Vision: Leaders in exemplary care, innovation and academic excellence. Patient, Family, Customer Perspective Strategic Goals 1. We meet or communities 2. We are internationally recognized for the excellence of our patient-centred care, research and education. 3. We have a healthy work environment. Strategic Goals 4. We have a achieve our vision. 5. We create a sustainable and aligned system through action and leadership Fiduciary Perspective Priorities to Achieve Strategic Goals Internal Process Perspective Human Capital Access to Care Quality Initiatives Operational Performance Healthy People and Environments System Thinking & Leadership Learning & Innovation Perspective Information Capital Organization Capital Culture Leadership Corporate Change & Alignment Teamwork Mission: To provide excellent health care for the people and communities we serve and to advance health care through education and research. Values: Respect Caring Innovation Accountability HHS 2007/08 3 / 13

4 90 Day s and September Measures of Success Achievement of Length of Stay Targets The achievement of length of stay (LOS) targets for applicable Case Mix Groups (CMG s) will ensure HHS is aligned with industry expectations in order to improve patient access to care. Both system and local level strategies have been implemented over the course of the past 2 years as part of the ongoing corporate focus on LOS target 1. Access to Care 2. Discharge Planning 3. CCAC Partnership and Network B. Flaherty Goal # 1. We meet or Goal # 5. We create a sustainable and aligned system through action and leadership 1. Access To Care Regular review of access to care indicators by program leadership Access to care indicators discussed monthly/quarterly at program based meetings with Physician stakeholders Access to care indicators discussed at appropriate unit based staff meetings Program/Unit opportunities for improvement identified and implementation of strategies begins 2. Discharge Planning i) C & DC Role Continue local test of changes on pilot units Finalize role evaluation and unit impact analysis tools ii) Discharge Planning Continue discharge planning education sessions (ad hoc at request of Programs) Regular Discharge Network meetings include dissemination of outcomes and/or discharge improvement strategies Planning for implementation of Discharge Specialist consultation process for patients with LOS greater than 35 days begins Access To Care 1. Access To Care Regular reviews of access to care indicators by program leadership Access to care indicators discussed monthly/quarterly at program based meetings with Physician stakeholders Access to Care indicators discussed at appropriate unit based staff meetings Program/Unit opportunities for improvement identified and implementation of strategies 2. Discharge Planning i) C & DC Role Implementation pilot completed Role evaluation and unit impact analysis complete Evaluation results and recommendations to CRUM (April 2008) ii) Discharge Planning (Phase VII) Continue Discharge Planning Sessions (ad hoc at Program request) Regular Discharge Network meetings include dissemination of outcomes and/or discharge improvement strategies Implementation of Discharge Specialist consultation for patients with LOS greater than 35 days completed 1. Access To Care Regular reviews of access to care indicators by program leadership Access to care indicators discussed monthly/quarterly at program based meetings with Physician stakeholders Access to Care indicators discussed at appropriate unit based staff meetings Program/Unit opportunities for improvement identified and implementation of strategies 2. Discharge Planning i) C & DC TDB ii) Discharge Planning (Phase VIII) Continue Discharge Planning Sessions (ad hoc at Program request) Regular Discharge Network meetings include the dissemination of outcomes and/or discharge improvement strategies Discharge Specialist consultation for all patients with LOS greater than 35 days Program implementation of one unit specific discharge planning strategy Q 6 months from menu of initiatives or alternative strategy Progress/update of Program Discharge Strategy shared at Corporate Access to Care Committee meeting. Discharge of audit of sample units across HHS complete 1. Access To Care Regular reviews of access to care indicators by program leadership Access to care indicators discussed monthly/quarterly at program based meetings with Physician stakeholders Access to Care indicators discussed at appropriate unit based staff meetings Program/Unit opportunities for improvement identified and implementation of strategies 2. Discharge Planning C & DC TBD ii) Discharge Planning (Phase IX) Continue Discharge Planning Sessions (ad hoc at program request) Regular Discharge Network meetings include the dissemination of outcomes and/or discharge improvement strategies Discharge Specialist consultation for all patients with LOS greater than 35 days Program implementation of one unit specific discharge planning strategy Q 6 months from menu of initiatives or alternative strategy Progress/update of Program Discharge Strategy shared at Corporate Access to Care Committee meeting. 1. Program targets for 07/08 length of stay and acute inpatient HAPS volumes have been achieved. 4 / 13

5 90 Day s and September Measures of Success Achievement of Length of Stay Targets continued B. Flaherty Goal # 1. We meet or Program identification of one unit specific discharge planning strategy Q6 months from menu of initiatives or identification of alternate strategy Progress/update of Program Discharge Strategy shared at Corporate Access to Care Committee meeting. 1. Program targets for 07/08 length of stay and acute inpatient HAPS volumes have been achieved. Goal # 5. We create a sustainable and aligned system through action and leadership 3. CCAC/LHIN Partnerships Meetings will SJHS, St. Joseph s Villa, CCAC to develop common operational approach for management of beds/process continue Ministry submission for transitional care bed funding completed Exploration with St. Peters, SJHS, St. Josephs Villa potential other patient populations for transitional care beds Opportunities to assist with CCAC ED Case Manager role identified Continue to work with CCAC to integrate data into HHS Common Clinical Data Warehouse 3. CCAC/LHIN Partnerships TBD this will become more apparent as year unfolds and other creative solutions and funding opportunities emerge 3. CCAC/LHIN Partnerships TBD this will become more apparent as year unfolds and other creative solutions and funding opportunities emerge 3.CCAC/LHIN Partnerships TBD this will become more apparent as year unfolds and other creative solutions and funding opportunities emerge Wait Time Strategy Reducing wait times for key health services is one of the Ontario government s top priorities. Hamilton Health Sciences is in its third year of funding from the Provincial Wait Time Strategy (WTIS) and the first year of the National Pediatric Wait Time Initiative It has many sub initiatives: 1. MRI/ICT 2. Total Joints 3. Surgical Oncology 4. Pediatric Surgery 5. Colorectal Screening 6. Radiation and Systemic 7. Ventilator Assisted Pneumonia 8. Central Line Infection 9. Surgical Site Infection P. Steer Goal # 1. We meet or Goal # 5. We create a sustainable and aligned system through action and leadership 1. Submitted monthly reporting to WTIS 2. Quarterly reporting to Board of Directors 3. On track to achieve HHS volume targets and conditions outlined in MOH wait time funding letter (see attached) 4. Explore participation in required Safer Health Care Now collaboratives (VAP, SSI, CLI) with inventory of current IC reporting and collaboration with Patient Safety Steering committee 1. Submitted monthly reporting to WTIS 2. Quarterly reporting to Board of Directors 3. Achieved HHS volume targets and conditions outlined in MOH wait time funding letter (see attached) 4. Define HHS participation in required Safer Health Care Now collaboratives (VAP, SSI, CLI) and ready for reporting in April Submitted monthly reporting to WTIS 2. Quarterly reporting to Board of Directors 3. On track to achieve HHS volume targets and conditions outlined in MOH wait time funding letter (see attached) 4. Begin participation in HHS defined Safer Health Care Now collaboratives (VAP, SSI, CLI) 1. Submitted monthly reporting to WTIS 2. Quarterly reporting to Board of Directors 3. On track to achieve HHS volume targets and conditions outlined in MOH wait time funding letter (see attached) 4. Continue participation in HHS defined Safer Health Care Now collaboratives (VAP, SSI, CLI) 1. Appropriately resourced processes delivering against all MOHLTC reporting requirements 2. Achievement of agreed HHS operational / financial wait time targets across all waiting time strategies with tolerable variance of (+/-) 5%. 5 / 13

6 90 Day s and September Measures of Success Accreditation Accreditation provides an organization with the opportunity to assess the quality of its care and services against established standards, showcase areas of excellence, and identify opportunities for growth and improvement. B. Flaherty Goal # 1. We meet or Goal # 2. We are internationally recognized for the excellence of our patientcentred care, research and education. 1. Corporate milestone, indicators, outcomes and targets: 2. Accreditation process and infrastructure is developed and communicated to the organization. 3. Education has been provided to the senior leaders (75% of target audience) 4. Education provided to managers and educators (75% of target audience) 5. Accreditation teams are identified and developed. 6. Responses to the 2005 recommendations have been prepared 7. Monitor progress of ROPs and relevant corporate initiatives 8. Launch events held and tools developed for communication and engagement in September Completion of the Patient Safety Culture Survey and Self Assessment Questionnaires and Submission of Indicator data to CCHSA by October 31, Accreditation teams review quality performance roadmap and develop organizational action plans. Quality Initiatives 1. Required information for 2008 survey is submitted to CCHSA by deadline 2. Communication materials are developed for widespread distribution in organization 3. Collect required evidence for ROPs and standards 4. Plan and deliver a mock survey 5. Accreditation teams continue to develop organizational action plans and implement as appropriate. 6. Organization wide themes identified from Quality Performance Roadmap 1. Preparations for the accreditation survey are finalized (for e.g. documents, schedule, hospitality) 2. Participate in accreditation survey in May Review preliminary report received from CCHSA and respond as necessary. 4. Develop process for evaluation prior to accreditation. 5. Evaluate accreditation process 6. Celebrate completion of accreditation 7. Continue with implementation of organizational action plans as appropriate 1. Plan for full transition to new accreditation is complete. 2. Preparations for any recommendations requiring a report or focused visit are underway. 3. Continue with implementation of organizational action plans as appropriate 1. The on-site accreditation survey is completed. 2. The organization is prepared to participate in ongoing accreditation activities as an integrated component of quality improvement and corporate initiatives. 6 / 13

7 90 Day s and September Measures of Success The Medication Safety Initiative P. Faguy (MSI) N. Fram Implementation of Medication Safety Initiative will standardize medications, processes and ordering through delivery methodologies. Financial efficiencies will be realized through decreased wastage and improved pharmaceutical inventory control. Automatation of previous manual work will improve staff efficiencies and effectiveness. Goal # 1. We meet or Goal # 2. We are internationally recognized for the excellence of our patientcentred care, research, and education. 1. Implementation of AcuDose to majority of Critical Care Areas 2. Planning and ordering for completion of AcuDose to final Critical Care areas pending capital expenditure approval 1. Prepare/renovate AcuDose Space Allocations completed as approved through capital process 2. cmar Planning underway 3. Meditech Enhancement 1. AcuDose rollout completed to Critical Care and select Clinical areas in alignment with capital approval 2. cmar Planning - requirements determined to move toward one standard MAR format for HHS 3. Planning, selection and ordering completed for next clinical areas for AcuDose implementation 1. AcuDose rollout completed to select clinical areas 2. Scope document for cmar submitted to MSI 1. AcuDose rollout completed to select clinical areas target of implementations of these two final phases will complete AcuDose implementation plan as committed to in proposed 5 yr MSI strategy) in alignment with capital expenditure approval and current project resources 2. Scope document for cmar submitted to MSI Point of Care Testing (POCT) The Hamilton Regional Laboratory Program (HRLMP) participated in a mandatory peer assessment as part of the Ontario Laboratory Accreditation (OLA) process during the week of April 30th May 4th, OLA assessors identified two major and ten minor non-conformances that must be addressed in order to achieve a 5-year accreditation status related to Point of Care Testing and compliance of operators across all areas. P. Faguy Goal # 1. We meet or Goal # 2. We are internationally recognized for the excellence of our patientcentred care, research and education. 1. Identify scope of practice changes that need to be addressed with POCT clinical users to meet OLA requirements 2. Establish a POCT Expert group to support process for practice changes that ensure compliance with OLA nonconformances 3. Ensure practice changes are supported and address within the development of the e-learning program 1. Completion of development of e- learning refresher training package. 2. Roll out plan established and facilitated by CP&E staff 3. Budget approved for 2.0 FTE Laboratory POCT Specialists to implement OLA action 4. Plan and sustain compliance with existing POCT. Action plan cannot be implemented in future milestones without approval of resources 1. Roll out of e-learning training program with a target of 40% of clinical staff, who currently use POCT equipment, trained using refresher program 2. Action plan to address nonconformances approved by OLA and initiated with laboratory 3. contingent of approval of resources 1. 80% of clinical staff trained on refresher module 2. Action plan to address OLA nonconformances to be implemented by the laboratory with monitoring of user compliance 3. Mechanism approved by POCT Advisory Committee and in place for addressing new for POCT 1. E-learning tool rolled out to 80% of clinical users of POCT 2. Laboratory has secured and successfully recruited 2.0 FTE POCT Specialists to implement compliance monitoring as outlined in action plan 3. A structured process is in place for reviewing and approving any requests for POCT 7 / 13

8 90 Day s and September Measures of Success RNAO Best Practice Guidelines Hamilton Health Sciences was designated as a Registered Nurses Association of Ontario (RNAO) Best Practice Guidelines (BPG) Spotlight Organization (SO) in March, The program is designed to trigger an evidence-based culture in health care organizations, improve patient care and enrich the practice environment of nurses and other health care providers. HHS will implement nursing best practice guidelines that will decrease the incidence of pressure ulcers and patient falls. N. Fram Goal # 1. We meet or Goal # 2. We are internationally recognized for the excellence of our patientcentred care, research and education. Continued integration of the Assessment and Prevention of Pressure Ulcer BPG on designated Acute Medicine, Surgical and Rehabilitation Units Pressure Ulcer Assessment and Prevention: Integration of the Assessment and Prevention of Pressure Ulcer BPG on designated Acute Medicine, Surgical and Rehabilitation Units Fall Prevention: Awareness of Prevention of Falls and Fall Injuries in Older Adults Strategy in all HHS clinical units Pressure Ulcer Assessment and Prevention: Integration of the Assessment and Prevention of Pressure Ulcer BPG on 'designated' Acute Medicine, Surgical and Rehabilitation Units. Fall Prevention: Implementation of Prevention of Falls and Fall Injuries in Older Adults BPG on designated acute medicine, surgical and rehabilitation units. Pressure Ulcer Assessment and Prevention: Sustained integration of the Pressure Ulcer Guideline implementation on designated Acute Medicine, Surgical and Rehabilitation Units Fall Prevention: Full implementation of fall prevention BPG on designated units Identification of additional educational and other resources (tools) required (course correction) 1. Sustained integration of Pressure Ulcer Assessment and Prevention BPG in 15 implementing clinical units (Acute Medicine (6), Surgical (7) and Rehabilitation Units (2)) evidenced by increasing documentation of pressure ulcer risk using the Braden Scale. 2. Full Implementation of Prevention of Falls and Falls Injury BPG in implementing clinical units (Acute Medicine (6), Surgical (7) and Rehabilitation Units (2) % of all clinical staff have received 1 hour of fall prevention education Verification Processes- Teamwork and Communication Best Practices This is a multiphase, multi-year initiative related to teamwork and communication. The first phase will specifically concentrate on verification processes while the later phases will focus on broader work related to communication and teamwork. In year 1, a pilot will be completed to improve verification processes (e.g.. Critical test readbacks, independent checks for highrisk medications, two patient identifiers for invasive procedures, procedural and surgical pauses). C. Daniels Goal # 1. We meet or Goal # 2. We are internationally recognized for the excellence of our patientcentred care, research and education. 1. Project plan will be developed, teams established, literature review completed; and communication and engagement strategies will be developed. 2. Assessment of current reality/status related to existence and compliance of verification and surgical pause policies will be conducted. 3. Initial project work will commence for both sub initiative teams 1. Proposed processes, and protocols developed for both sub initiatives (verification and surgical/procedural pauses) 2. Pilot area(s) for improving verification processes will be determined and staff and physicians engaged; 3. Surgical / Procedural pauses processes and protocols will be developed and tested (pilot) with rapid tests of change 1. Pilot for verification processes will be completed and be evaluated, course corrections completed 2. Rapid tests of changes for surgical and procedural pauses will continue and spread initiated as appropriate 1. Given evaluation, begin to prepare to spread initiative beyond pilots (engagement, communication, work plan ) 1. Processes and protocols developed for both verification and surgical/procedural pauses initiatives 2. Pilots for both verification and surgical/procedural pauses initiatives 3. Based on evaluation spread discussion completed 8 / 13

9 90 Day s and September Measures of Success Operational Performance Active Integration Central Client Registry Hamilton Health Sciences is mandated, as part of the Provincial Client Registry Initiative, to implement Active Integration as part of the provincial strategy for a single master patient number M. Glendining Not planned to start in this quarter Project Planning with MOHLTC/CCO Active Integration team, including Meditech Vendor involvement Testing of interfaces and new processes Training and Orientation of all registration areas in change in process with Go-Live date set 1. Able to exchange data with the EMPI at the provincial level and access it via registration screens. (Dependant on the MOH/SSHA timelines which have yet to be defined) 9 / 13

10 90 Day s and September Measures of Success Case Costing and Workload K. Watts Measurement N. Fram This initiative will enable evidence based, internal resource allocation. HHS will be able to more accurately reflect true costs provided to complex cases versus average costs as determined by the provincial case costing database HHS will be able to more accurately reflect true costs provided to complex cases. This will enable HHS to advocate for volume and service expansion and resource allocation within the LHIN environment Workload Measurement Specific: 1. Education and implementation of Auditing (IRM) begins on inpatient and ED areas (Nursing Only) 2. Begin development of auditing Allied Health for internal purposes 3. Schedule established and inpatient and ED chart reviews/revisions for Nursing and Allied Health begin 4. Program/Unit identification of workload data integration and application 5. Workload education strategy developed 6. New workload measurement system identified 7. Consideration of Meditech as an alternative workload tool will require the completion of an impact analysis. a. WLM milestone (need to add indicators if accepted) b.it/meditech "workload" demonstration(s)/ education for key stakeholders completed. c. Resource requirements (IT/Human/Fiscal) to support Meditech WLM identified. d. Impact analysis comparing "traditional" WLM, "proxy" and "Meditech solutions completed to identify approach that will provide the most complete//valid/reliable workload data for CC. (DSS/IT/CARE collaboration to complete analysis) e. Corporate decision for WLM solution finalized 8. Implementation of a new workload system will impact milestones. Workload Measurement Specific: 1. Education/implementation of Auditing process 2. Review the revisions of Allied Health Audit Tool 3. Chart reviews/revisions for Nursing and Allied Health 4. Program/Unit identification of workload data integration and application 5. Additional s r/t WLM dependent upon identified solution. Workload Measurement Specific: 1. Education/implementation of Auditing process 2. Review the revisions of Allied Health Audit Tool 3. Chart reviews/revisions for Nursing and Allied Health 4. Program/Unit identification of workload data integration and application Workload Measurement Specific: 1. Audit education completed and Program/Service monitoring of auditing in place. 2. Allied Health audits completed 3. Chart reviews/revisions for Nursing and Allied Health 4. Program/Unit identification of workload data integration and application Workload Measurement Specific: 1. Audit education completed and Program/Service monitoring of auditing in place. 2. Allied Health audits completed 3. Chart reviews/revisions for Nursing and Allied Health 4. Program/Unit identification of workload data integration and application 10 / 13

11 90 Day s and September Measures of Success Case Costing and Workload Measurement continued K. Watts N. Fram Case Costing Specific: 1. Successful completion of 2 phase 1 audit by MOHLTC/OCCI 2. Installation of provincial software solution at HHS and testing of data Case Costing Specific: 1. Development of Internal HHS reports using case costing data and education to HHS Leadership on these reports. 2. Additional s r/t WLM dependent upon identified solution. Case Costing Specific: 1. Development of Internal HHS reports using case costing data and education to HHS Leadership on these reports. Case Costing Specific: 1. Successful implementation of 2 - phase 1 Audit by MOH/LTC/OCCI 2. Successful installation of provincial case costing software solution at HHS. 3. Development of internal HHS reports using new case costing software and education to 75% of HHS Leadership on these reports. Case Costing Specific: 1. Successful implementation of 2 - phase 1 Audit by MOH/LTC/OCCI 2. Successful installation of provincial case costing software solution at HHS. 3. Development of internal HHS reports using new case costing software and education to 75% of HHS Leadership on these reports. Critical Care Information System (CCIS) As the demand for critical care increases with an aging population, the need for reliable, real-time information about our critical care system also increases. Hamilton Health Sciences is mandated, as part of the Provincial Wait Times Office, to implement the Critical Care Information System (CCIS) starting in September 2007 and with GO-LIVE January C. Daniels 1. Project planning and implementation by Go-live January Further details to come over the summer of 2007 from the MOHLTC on CCIS implementation plans and timelines 1. Integration into ongoing Operations the processes and data collection for CCIS 2. Integration of reporting requirements and data management into ongoing processes 3. Feedback and debriefing on implementation and follow-up on any outstanding issues 1. Project live in all of our Adult ICU's. 2. Functioning as part of the daily operations of the units. 11 / 13

12 90 Day s and September Measures of Success ICT 2010 Vision: Phase 1 It is important for HHS to realize that the effective and efficient use of technology to move us forward within the Health Care environment will be critical to our success as an organization. It will also be the cornerstone to the wider vision of providing a longitudinal view of the patient, ensuring a safer environment for the patient and a foundation for the Electronic Health Record (EHR). This initiative is intended to start the first phase of a three year plan to meet that vision. M. Glendining Goal # 1. We meet or Goal # 2. We are internationally recognized for the excellence of our patientcentred care, research and education. Goal # 3. We have a healthy work environment. 1. Committees and Clinical Informatics in place and preparation work underway to develop detailed timelines. 2. NUR/PCS review underway 3. OE and NUI dictionary additions being developed. 4. EDIS phase II components identified and development started 5. WLM milestone (need to add indicators if accepted) 6. IT/Meditech "workload" demonstration(s)/ education for key stakeholders completed. 7. Resource requirements (IT/Human/Fiscal) to support Meditech WLM identified. 8. Impact analysis comparing "traditional" WLM, "proxy" and "Meditech solutions completed to identify approach that will provide the most complete//valid/reliable workload data for CC. (DSS/IT/CARE collaboration to complete analysis) 9. Corporate decision for WLM solution finalized 1. OE and NUI changes implemented and rollout. 2. NUR/PCS work. 3. EDIS phase II components identified and development 4. Additional s r/t WLM dependent upon identified solution. 1. OE and NUI review and development. 2. EDIS phase II completes identified and development. 3. EDIS phase II planned and phased rollout in process 4. EDIS phase II rollout to go live. 5. Training plan developed for NUR/PCS 1. Continued development of dictionaries and training plans for NUR/PCS 2. Start build for MAR and BMV 1. Committees and Clinical Informatics in place and work underway to develop detailed timelines. 2. NUR/PCS review complete, build underway, pilot of HOBIC forms 3. OE and NUI dictionary completed. 4. EDIS phase II components developed and rolled out 5. IT/Meditech "workload" demonstration(s)/ education for key stakeholders completed. 6. Corporate decision for WLM solution finalized 7. Meditech 5.6 upgrade completed Quality Documentation Strategy Documentation by healthcare providers currently takes place on paper (forms) or electronically. The content and timeliness of this documentation is an issue, across many healthcare disciplines. The scope of this initiative is to focus on Physician Documentation K. Watts J. Everson Goal # 1. We meet or 1. Communications and education plan for improved general documentation has been create and approved by MAC 2. Documentation templates for each of discharge summaries, Operative Reports and History and Physical have been created and approved by MAC 3. New templates have been rolled-out across HHS 4. New standard for discharge summary requirement, including compliance policy, will be established and approved through MAC and Operations Committee. 1. Comprehensive education and communications plan will be implemented across all appropriate clinical departments regarding the value of quality documentation, provincial standards, and related HHS policy. 2. Monitoring and evaluation plan developed 3. Policy reinforcement plan to be implemented across all appropriate clinical departments by clinical chiefs. 1. Sustainability phase monitoring and evaluation occurring and reported. 2. Create plan for quality review of documentation practices. 1. Creation of new standard for discharge summary requirement, including compliance policy, will be established and approved through MAC and Operations Committee. 2. Implememation of the new standard for discharge summary requirement, including compliance policy 3. Revised documentation requirements will be incorporated into the incomplete records process 12 / 13

13 90 Day s and September Measures of Success Implementation of Clinically Appropriate and Efficient Staffing Plans The most valuable asset in the delivery of healthcare is our human resources. Hamilton Health Sciences wants to deliver the right care by the right care provider at the right time and in the right place. To achieve this goal there is a need to have clinical programs and units review and implement appropriate staffing plans that utilize the skills and expertise of a finite supply of health care providers. N. Fram Goal # 3. We have a healthy work environment. 1. Staffing Plans Communication and engagement plans implemented related to staffing plans and integration with skill mix 1. Staffing Plans a) Establishment of HHS staffing plans in select adult medicine units b) Any challenges to HHS staffing plans heard and resolved 1. Staffing Plans 1. Staffing Plans a) Begin implementation of staffing plans in select medicine units a) Complete implementation of pending budget availability standard HHS staffing plan for select adult medicine units pending budget availability Target: 100% of select adult medicine units have implemented standard HHS HPPD and/or made case for exemption including endorsement from third party observer (Professional Affairs) b) Establish HHS Staffing Plans for select critical care units 1. HHS staffing plan for select adult medicine and critical care established 2. 50% of units in identified population(s) - select adult medicine and critical care - have completed implementation HHS standard staffing plan (pending budget availability) and/or made case for exemption including endorsement from third party observer 2. Skill Mix 2. Skill Mix Phase I - VII a) Provide in-service related to RN/RPN skill mix, scope of practice and collaborative RN/RPN model to Directors and Managers b) Henderson RN/RPN site group will provide in-services (February 2007, Framework) to Clinical Managers at each site. c) Project plan developed with Managers and Chiefs of Nursing to introduce skill mix changes d) Begin skill mix implementation on selected clinical units with positive feasibility assessment related to RN/RPN skill mix. Chiefs of Nursing will meet with each inpatient clinical manager to review skill mix and complete taxonomy. a) Begin skill mix implementation on all in-scope clinical units with positive feasibility assessment related to RN/RPN skill mix. Chiefs of Nursing will meet with each inpatient clinical manager to review skill mix and complete taxonomy. b) Continue skill mix implementation on all clinical units with positive feasibility assessment related to RN/RPN skill mix 2. Skill Mix Phase VII-XI a) Continue skill mix implementation on all clinical units with positive feasibility assessment related to RN/RPN skill mix Target: 100% of in-scope units with positive feasibility continue RPN/RN skill mix implementation 2. Skill mix: Phase VII-XI a) Complete skill mix implementation on all clinical units with positive feasibility assessment related to RN/RPN skill mix % of in-scope units with positive feasibility have begun RPN/RN skill mix implementation 13 / 13