BOARD OF DIRECTORS MEETING Wednesday November 30, h-2030h CMH Boardroom OPEN SESSION

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1 Vision To provide exceptional healthcare by exceptional people Mission A progressive acute care hospital and teaching facility committed to quality and integrated patient centered care Values Caring, Respect, Innovation, Collaboration, Accountability BOARD OF DIRECTORS MEETING Wednesday November 30, h-2030h CMH Boardroom OPEN SESSION *Agenda Item (* Indicates attachment) (TBC- to be circulated) Time Responsibility Purpose 1. CALL TO ORDER 1845 J. Kane 1.1 Confirmation of Quorum (7) 1.2 Declarations of Conflict 1.3 Consent Agenda (Any Board member may request that any item be removed from this consent agenda and moved to the regular agenda.) Minutes of September 28, 2016* CEO Report* Governance November 10, 2016 Meeting Summary* Policies: (clean copies included in package track changes found on Board Portal) 2-A-20 Role Description of Board Chair* 2-B-5 CEO Role Description* 2-B-32 CNE Role Description* 2-D-4 Board and Committee Annual Work Plans* 2-D-9 Procedure for Members of the Public Addressing the Board* 2-D-32 Board Education for Board Directors and Non- Director Committee Members * Quality Committee THREB Annual Report for 2015* Annual Risk Management & Emergency Preparedness Report* Board Scorecard* Resources Scorecard* HSAA Scorecard* Board Work Plan* 1.4 Confirmation of Agenda 1846 J. Kane Approval 2. PRESENTATIONS ED Patient Flow- Improvement Process* 1847 Kyle Leslie Information 3. DISCUSSION ITEMS 3.1 Chair s Report Upcoming Events Calendar* MSAA Submission April-Sept 2016 confirmation 1910 J. Kane J. Kane Information Information 3.2 Resources Committee (Oct 24/Nov28, 2016) October Financial Statements* Hospital Accountability Planning Submission (HAPS)* Appointment of Trustee for Sinking Fund Account* CRP Subcommittee Update 1920 I. Miles I. Miles I. Miles A. Van Leeuwen Information Approval Approval Information Board Members: Ex-Officio Members: Joseph Kane (Chair), Ian Miles, Denise Smith, Tom Dean, Al Van Leeuwen, Elaine Habicher, Nicola Melchers, Larry Kron, David Pyper, Tim Edworthy, Suren Rao, Rita Westbrook Patrick Gaskin, Sandra Hett, Dr. Kunuk Rhee, Dr. Winnie Lee, Dr. Francois Flamand Page 1 of 2

2 Vision To provide exceptional healthcare by exceptional people Mission A progressive acute care hospital and teaching facility committed to quality and integrated patient centered care Values Caring, Respect, Innovation, Collaboration, Accountability BOARD OF DIRECTORS MEETING Wednesday November 30, h-2030h CMH Boardroom OPEN SESSION *Agenda Item (* Indicates attachment) (TBC- to be circulated) Time Responsibility Purpose 3.3 Quality Committee Oct 19, 2016 Meeting Summary* 2016/17 Patient Experience Survey YTD Results Explored* WWLHIN Collaborative Quality Improvement Plan (QIP)* Nov 16, 2016 Meeting Summary* Quality Improvement Plan (QIP) midyear update* Quality Patient & Safety Plan (QPSP)* - midyear update* 3.4 Medical Advisory Committee Oct 12, 2016 Meeting Summary* Nov 9, 2016 Meeting Summary* Privileges and Credentialing* 3.5 Governance Committee Nominating Committee 2017* 1935 L. Kron Information 1950 Dr. K. Rhee Dr. K. Rhee Dr. K. Rhee Information Information Approval 2005 D. Pyper Approval 3.6 CEO Update Strategic Planning * 2015 P. Gaskin Approval 4. ADJOURNMENT 2030 J. Kane Motion 5. Discussion of Independent Directors and Management J. Kane 6. Discussion of Independent Directors J. Kane 7. DATE OF NEXT MEETING: January 25, 2017 Board Members: Ex-Officio Members: Joseph Kane (Chair), Ian Miles, Denise Smith, Tom Dean, Al Van Leeuwen, Elaine Habicher, Nicola Melchers, Larry Kron, David Pyper, Tim Edworthy, Suren Rao, Rita Westbrook Patrick Gaskin, Sandra Hett, Dr. Kunuk Rhee, Dr. Winnie Lee, Dr. Francois Flamand Page 2 of 2

3 BOARD OF DIRECTORS MEETING Wednesday, September 28, 2016 OPEN SESSION Minutes of the open session of the Board of Directors meeting, held in the CMH Boardroom on September 28, Mr. J. Kane P Mr. T. Edworthy P Mr. I. Miles P Mr. S. Rao P Ms. R. Westbrook P Mr. T. Dean P Mr. D. Pyper P Dr. F. Flamand R Ms. D. Smith P Dr. W. Lee P Mr. A. Van Leeuwen P Mr. P. Gaskin P Mr. L. Kron R Dr. K. Rhee P Ms. N. Melchers P Ms. S. Hett P Ms. E. Habicher P Staff Present: Ms. L. Rodrigues Mr. S. Beckhoff Guest: Recorder: Ms. C. Vandervalk 1. CALL TO ORDER Mr. Kane called the meeting to order at 1910 hours Confirmation of Quorum Quorum requirements having been met, the meeting proceeded, as per the agenda Conflict of Interest Board members were asked to declare any known conflicts of interest regarding this meeting Consent Agenda Minutes of June 28, 2016 (Open sessions 1&2) CEO Report Governance Policies 2-A-26 Role Description for the Board Secretary* 2-A-28 Role Description for a Committee Chair* 2-A-31 Ex-officio Director* 2-A-34 Confidentiality* 2-A-38 Board and Committee Meeting Attendance* Strategic Plan Scorecard Board Scorecard H-SAA Scorecard Q1 CEO Certificate of Compliance Mr. Kane noted that agenda item H-SAA scorecard will be taken out of consent and discussed as agenda item There being no further requests the consent agenda is approved as amended.

4 Board of Directors Meeting (Open Session) September 28, 2016 Page Confirmation of Agenda MOTION: (Habicher/Miles) that, the agenda be approved as circulated with the addition of agenda item H-SAA Scorecard. CARRIED 2. DISCUSSION ITEMS 2.1. Chair s Report WHCC Update Strategic Planning Proposed Approach The Waterloo hospitals have agreed to align their strategic planning cycles and renewals to facilitate coordinated planning. Mr. Kane outlined the approach the actions required to implement noted in the briefing note and opened the floor for discussion. Discussion ensued. Mr. Kane asked for a motion to accept the recommendation. MOTION: (Dean/Habicher) that, the Board accepts the approach and proposed implementation actions for the strategic planning alignment. CARRIED Board Work Plan The Board reviewed and approved the 2016/17 Board Work Plan Upcoming Events Calendar The upcoming calendar of events was reviewed. Board members were encouraged to attend as many of the events as possible in support. Ms. Habicher volunteered to attend the October 12, 2016 WWLHIN Board meeting Resources Committee August 2016 Financial Statements Mr. Miles provided an update: In August, a year-to-date operating surplus of $550k (a $300k positive variance from plan) was realized after building amortization and related capital grants. CMH had an operating surplus of $108k in in the month of August. Sick and over time was over budget by $22k in August, which compared favourably to the $200k over budget position for August The balance sheet reflected a current cash position of $20.5M in operating and $10.5M in restricted cash (including $6.6M received from the Foundation for the hospital s contribution to the CRP sinking fund). CRP increased to $71.1M; a lump sum payment of $65M will be payable to the contractor once CMH takes ownership of the new building. 2.3 Quality Committee Ms. Habicher provided an update in the absence of Mr. Kron. The Quality Committee recently had both the Critical Care Program and the Surgical Services Program present at the meeting. Both presentations were previously circulated. Ms. Habicher highlighted the good work that both programs have done to date.

5 Board of Directors Meeting (Open Session) September 28, 2016 Page 3 Ms. Hett also noted that the newly created Acute Pain Service has introduced a Nurse Practitioner and Anesthesiologist to this dedicated resource team. The mandate of the team is to standardize processes and pain management and improve first case start times as this will now free up an Anesthesiologist to perform cases that present themselves during day such as an epidural. 2.4 MAC Update MAC Update Dr. Rhee highlighted the following from his previously circulated briefing note: 1. M&T Update 2. Clinical Services Strategy 3. Surgical Assist Scheduling Status 4. Medical Assistance in Dying (MAID) Privileges and Credentialing On behalf of the Credentials Committee, Dr. Rhee attested that due diligence was exercised in the credentialing process of the clinical staff listed below. Name Program Specialty Appointment Supervisor Dr. Andrea Anesthesia Anesthesia Associate Privileges a.s.a.p. to Dr. K. Leone Steyn end of credentials process Dr. Jonny Elserafi Dr. Keith Barrett Dr. Mark Hindle Dr. Sheila Russek Emergency Medicine Emergency Medicine Associate privileges from Jul. 1, 2016 to end of credentials process Surgery Urology Courtesy privileges from Jul. 1, 2016 to end of credentials process Anesthesia Anesthesia Associate Privileges August 1, 2016 to the end of the credentials process Oncology Oncology Associate Privileges July 20, 2016 to the end of the credentials process Dr. M. Shafir Dr. J. Daly Dr. K. Leone Dr. E. Chouinard Locums/Temporary Staff for Approval Name Program Specialty Appointment Supervisor Dr. Marcello Medicine ICU Locum Privileges from July 1, Dr. A. Nguyen Schmidt 2016 to December 31, 2016 Dr. Jessie Van Dyk Pediatrics Code Pink Temporary Privileges from May 4-Sept 1, 2016 NA Dr. Michael Ward Internal Medicine Internal Medicine Locum Privileges from October 1, 2016 to October 31, 2016 Dr. A. Nguyen Dr. Ben Pook Surgery Orthopedic Surgery Locum privileges from April 1, 2016 to February 28, 2017 Dr. J. Daly Dr. Han-Oh Chung Internal Medicine Internal Medicine Locum Privileges Aug. 17, 2016 to Feb. 17, 2017 Dr. A. Nguyen

6 Board of Directors Meeting (Open Session) September 28, 2016 Page 4 Dr. Ramona Aslahi Hospital Medicine Hospital Medicine Locum Privileges Jul. 1, 2016 to Dec. 31, 2016 Dr. J. Mathew Dr. Nicole Robichaud Oncology Oncology Locum Privileges July 11, 2016 to October 31, 2016 Dr. E. Chouinard Dr. Melanie Rodrigues Family Medicine Family OB Group Locum Privileges August 5, 2016 to August 31, 2016 Dr. A. Maheshwari Dr. Sandi Plant OTN NA Temporary Privileges July 1, 2016 to June 30, 2017 NA Dr. Dan Charleton Surgery Surgery Locum Privileges July 27, 2016 to Jan 27, 2017 Dr. J. Daly Dr. Ingrid Radovanovic Surgery Orthopedic Surgery Locum Privileges July 15, 2016 to July 17, 2016 Dr. J. Daly MOTION: (Dean/Westbrook) that, the Privileges for Ratification and Granting recommended to the Board be approved. CARRIED 2.5 CEO Update M-SAA Compliance Mr. Gaskin provided background as to the reason for putting forward the M-SAA Compliance document. Twice a year, the hospital needs to submit a report to the WWLHIN indicating its compliance with the M-SAA. This is usually done through the Resources Committee and brought forward to the Board. The Board approves a motion using the prescribed format. It is due on October 31, Our next Board meeting is in November. The reporting period ends September 30, 2016; therefore the report is not available today. The M-SAA compliance is reviewed regularly at the Resources Committee. This will be done at the October meeting of Resources. It will be reported to the Board in November. The Board can delegate to the Chair to sign the document on its behalf. Therefore, subject to the review by Resources Committee of the obligations within the M-SAA in October 2016, the following motion is proposed: MOTION: (Habicher/Westbrook) that, the Board has authorized the Chair, by resolution dated September 28, 2016 to declare as follows: After making inquiries of the President and CEO and other appropriate officers of the HSP and subject to any exceptions identified on Schedule G, to the best of the Board's knowledge and belief, the HSP has fulfilled, its obligations under the service accountability agreement (the "M-SAA") in effect during the Applicable Period. (April 1, Sept 30, 2016) Without limiting the generality of the foregoing, the HSP has complied with: (i) Article 4.8 of the M-SAA concerning applicable procurement practices; (ii) The Local Health System Integration Act, 2006; and

7 Board of Directors Meeting (Open Session) September 28, 2016 Page 5 (ii) the Public Sector Compensation Restraint to Protect Public Services Act, CARRIED BPSO Designation Mr. Gaskin thanked Ms. Hett and her team for their recognition and award of the BPSO designation for Ms. Hett noted that this is validation for all the direct care nurses and Clinical Educators provide to our patients and CMH Annual Community Report Circulated. The Board thanked Mr. Beckhoff for his work on the Community Report; there has been a lot of positive feedback HSAA Scorecard Mr. Gaskin circulated a correction to indicator one ED Length of Stay (ED LOS) in the H-SAA scorecard. 3. Adjournment The meeting adjourned at 2000h. (VanLeeuwen/Dean) CARRIED Ms. Hett, Ms. Rodrigues, Dr. Lee and Mr. Beckhoff left the meeting. 4. Discussion of Independent Directors and Management Discussion took place. Dr. Rhee, Mr. Gaskin and Ms. Vandervalk left the meeting at 2015h 5. Discussion of Independent Directors 6. DATE OF NEXT MEETING Next Meeting: The next scheduled meeting is November 30, Joe Kane Board Director CMH Board of Directors Patrick Gaskin Board Secretary CMH Board of Directors

8 Board Report From CMH President & CEO November 2016 This report provides a brief update on some key activities within CMH as an FYI. While it is organized against our strategic themes, it may include strategic, corporate and other projects as necessary. As always, happy to answer questions and discuss issues within this report or other matters. Goal: To improve ED 90 th Percentile length of Stay from triage to admission from 22.6 hours (2015) to 16 hours in Q3 and Q4 within budget resources Current status YTD we are at hours for this goal. The most recent week at the time of writing this report (Nov ), the length of stay from triage to inpatient bed for 90% of patients was hours. Current activities include a bed allocation process and use of a newly developed tracker board for the inpatient medical units. Evaluation is based on an improved ability to monitor pending ED admissions, view both pending discharges on both units and support pull to the most appropriate medical unit. Related activities to this WIG include: o Continued review of clerical workflows and ensure alignment with clinical pathways o Updating clerical procedure reference guide to ensure accuracy and standardization o Review and confirmation of bed allocation guidelines o Finalization of seasonal surge plan is underway (Xmas onward) that incorporates annual Xmas surgical shutdown (Monday, December 26 to Monday, January 9, 2017) o Refining the bed rounds Rapid Organizational Assessment and patient flow At this time, we are working closely with our partner, Corpus Sanchez International (CSI) consultancy, who is retained to do a rapid organizational Page 1 of 5

9 assessment of our organization. Part of this assessment has been to review the patient flow issues and challenges at CMH. CSI made an on-site visit at the end of October. They brought back some potential initiatives that could be applied at our hospital. CSI is meeting with clinical teams to redevelop patient flow solutions that will work in their patient care environments. A final report is expected soon, which will be summarized and shared with staff and physicians. Projects being pursued this fiscal year to meet our goal Review and refresh clerical expectations regarding the bed board on Meditech Pilot a new tracker board on the Medicine unit that assists with awareness of both medical units and the ED patients to assist with timely bed placement decisions (in progress on B5 with plans for B3 to follow) Review and refresh the bed allocation value stream Install projector into room used for clinical rounds to integrate the use of the electronic Meditech tracker view into bed rounds Continued problem solving surrounding specific Physician Initial Assessment (PIA) and patient delays to understand issue or pattern and implement appropriate solutions Data review, implementation of electronic prompts or automatic data fill when possible to ensure accuracy of clerical data that supports ED metrics Update corporate bed allocation plan that aligns with the ED LOS targets and outlining actions with each phase or stage (e.g. a clear timeframe to bed space or off-service admitted patients) Goal: To meet all defined milestones to ensure a safe and patient centred environment as we prepare to move into the new wing New wing possession date shifts to May 2017 Our contractor gave us notice that they expect to hand over the new patient care wing in May, 2017 While we are happy to be closing in on a possession date, we caution that there is still substantial work to be made in the new build, which may push our ownership of the new wing further into the summer. This is not concerning as our primary focus is on patient safety during construction and quality of build. At this time, all projects related to the possession of, and move into the new wing will be adjusted. Staff and physicians will be apprised of developments as they happen. Page 2 of 5

10 Equipment list being validated Equipment lists are being validated against floor plans as we work with RCG (our move and relocation consultants) and equipment vendors in planning for our occupancy of Wing A. Directors, managers and their teams will be called on to confirm that all rooms are stocked with the right furniture and equipment, that it fits within the space and will be ready for staff to provide exceptional care to our patients on opening day. At this time, the CRP team is urging units to get into the habit of purging those unused, unwanted items from their areas so that they can be ready for the move next year. CRP signage and wayfinding update "Clean Equipment," "Clean Equipment Room," "Utility Room," "Clean Utility Room," "Storage" and "Clean Storage" are all current examples of names rooms that store clean medical equipment. This is not the only instance and can be found to other room types as well. A working group from Infection Control, Environmental Services, Transitional Planning, Supplies Management and the Project office are working on standardizing names for common spaces so staff and physicians will be able to find what they need no matter where they work in the building. Defining our role Improving Quality CMH s new learning management system elearncmh launched CMH launched its new learning management system called elearncmh during the Best Practice Fair the week of November 14. The system is able to deliver on-line instruction, schedule students for both online and classroom instruction, remind students to complete courses or maintain currency of certain skills, plus create reports for administrative and compliance purposes. As we scale the system to include more features, staff will be able to add learning events taken outside of CMH, such as conferences and academic Page 3 of 5

11 courses. This is valuable for clinicians who have to demonstrate they are keeping their knowledge current within their profession. On-line learning can take place anywhere where there is internet connection and it has the ability to track where the student is at within a given lesson. This means the shift worker who may only have ten minutes on any given day, will be able to learn at her own pace. Reception by nurses at the Best Practice Fair has been favourable. A full organization roll out of the system is anticipated for December. CIHI releases report on measuring harm in Canadian hospitals On October 26, the Canadian Institute for Health Information (CIHI) and the Canadian Patient Safety Institute released a report titled Measuring Patient Harm in Canadian Hospitals, and a complementary Hospital Harm Improvement Resource. It is important to note the report only published national-level data. Harm is defined as acute care hospitalizations with at least one (1) occurrence of unintended harm during a hospital stay that could have been prevented by implementing evidence-informed practices. Thirty-one clinical groups under four categories (Health care medication associated conditions, health care associated infections, patient accidents and procedure-associated conditions) were considered. The source of their data comes from CIHI's Discharge Abstract Database. Although no time line is set, CIHI will eventually publish individual hospital performance using this indicator once it is risk and weight adjusted and made comparable between institutions. Their conclusion is that one in eighteen patients will be harmed when visiting a hospital in Canada. Improving Medication Safety Led by our Transformation Office, a quality improvement initiative was planned to improve medication safety. An initial root cause analysis identified over 30 possible actions could lead to a medication omission. Staff helped identify and validate the three main root causes to these omissions: 1) Transcription errors; 2) inconsistent use of standardized administration times and 3). Missed orders on patient charts. Since the analysis, improvement efforts have focused on standardizing practice related to use of standard administration times and flagging of patient orders. Standardizing practice requires trialing new ways of doing things to establish a best practice. As of April, Adult inpatient units (B5, B3, B4, Inpatient MH) and the pharmacy team have collaborated to implement a computer-printed medication administration record (CMAR). CMAR promotes the use of standard administration times and reduces variation in the time that medications are scheduled. From the analysis of our medication incidents we know that when we use standard administration times an omission error is less likely to occur. Page 4 of 5

12 Parallel to the implementation of CMAR staff feedback has been incorporated by pharmacy into the standard administration time s policy. The impact of change was validated through a "plan, do, study and act" (PDSA) cycle. Use of this method helps to continually engage staff feedback and determine if change ideas should be adapted, adopted or discarded. Early results suggest the implemented changes should be adopted as standard practice throughout CMH. BIG SHOT challenge a success! A big thank you to everyone who had their flu shot during our BIG SHOT challenge on October 12 We surpassed last year s number by 10 shots for a total of 224! Of these, 184 staff and physicians were vaccinated, meaning one in six employees now have protection against the flu. In December, we will submit our staff vaccination totals to Region of Waterloo Public Health department. As an incentive, all those who receive a flu shot get a coupon for a free Tim Hortons medium sized hot beverage, courtesy of the CMH Volunteer Association and are entered into a draw to win one of four gift cards.. Strength through People Interim leadership support announced for the Mental Health program On Oct. 31, Paul Bustin assumed the interim Manager role for Inpatient Mental Health, Day Hospital and psychiatric emergency nurses. Paul is located in the main administrative corridor and can be reached at x He reports directly to Sandra Hett, VP Clinical & CNE. Mary McDonald-Young assumed the lead for the Outpatient Mental Health program and is supported by Rita Sharratt Director of Medical Programs. Dr. Kunuk Rhee, Chief of Staff and VP Medical Affairs, will attend external community meetings from an administrative perspective to ensure our partnerships remain strong during this time of change. Recruitment is underway for a Director of Mental Health. Page 5 of 5

13 Agenda Item Coronation Blvd, Cambridge, ON N1R 3G2 Tel Fax COMMITTEE MEETING SUMMARY Date: November 30, 2016, Issue: Board Governance Committee Meeting November 10, 2016 Prepared by: Wade Gramada Approved by: Patrick Gaskin Attachments: 2-A-20 Role Description for Chair of the Board 2-B-5 CEO Role Description 2-B-32 CNE Role Description 2-D-4 Board and Committee Annual Work Plans 2-D-9 Procedure for Members of the Public Addressing the Board 2-D-32 Board Education Items for Approval 2-A-20 Role Role Description for Chair of the Board MOTION: (Torrance/Wohlgemut) that, the Governance Committee recommends to the Board that 2-A-20 Role Description for Chair of the Board be approved with amendments suggested. CARRIED 2-B-5 CEO Role Description MOTION: (Torrance/Wohlgemut) that, the Governance Committee recommends to the Board that 2-B-5 CEO Role Description be approved with amendments suggested. CARRIED 2-B-32 CNE Role Description MOTION: (Torrance/Wohlgemut) that, the Governance Committee recommends to the Board that 2-B-32 CNE Role Description be approved with amendments suggested. CARRIED 2-D-4 Board and Committee Annual Work Plans MOTION: (Torrance/Wohlgemut) that, the Governance Committee recommends to the Board that 2-D-4 Board and Committee Annual Work Plans be approved. CARRIED Page 1 of 2

14 Agenda Item D-9 Procedure for Members of the Public Addressing the Board MOTION: (Torrance/Wohlgemut) that, the Governance Committee recommends to the Board that 2-D-9 Procedure for Members of the Public Addressing the Board be approved. CARRIED 2-D-32 Board Education MOTION: (Torrance/Wohlgemut) that, the Governance Committee recommends to the Board that 2-D-32 Board Education be approved. CARRIED Items of Discussion Medical/Professional Staff By-law Update Dr. Rhee provided the Governance committee with a briefing note outlining the most recent changes to the Medical/Professional Staff By-law. To date the Medical/Professional Staff By-law has been reviewed by Credentials committee, BLG (Hospital lawyers) which will review the By-law one more time, Governance committee and then a final review through MAC, Medical Staff Association then to the Board for final approval. Currently the target is to have the Medical/Professional Staff By-law to the Board for final approval by the end of June Each member of the medical staff is required to receive a copy 30 days prior to final approval. ACTION: Mr. Gaskin will bring comments regarding the Medical/Staff Professional By-law from BLG to the January Governance meeting. ACTION: As the Medical/Professional Staff By-law proceeds through the stages of review, Mr. Gaskin and Dr. Rhee will keep the Governance committee apprised on the timeline for final approval. Page 2 of 2

15 Agenda item BOARD MANUAL SUBJECT: Role Description for Chair of the Board NUMBER: 2-A-20 SECTION: Structure, Roles and Responsibilities APPROVED BY: Board DATE: February 23, 2011 REVISED/REVIEWED: November 28, 2012, November 30, 2016 Role of the Board Chair The Board Chair is the leader of the Board. The Board Chair is responsible for: Ensuring the integrity and effectiveness of the Board s governance role and processes Presiding at meetings of the Board and Corporation Representing the Board within the Hospital and the Hospital in the community, and Maintaining effective collegial relationships with Board members, management and stakeholders. Responsibilities Board Governance The Board Chair ensures the Board meets its obligations and fulfills its governance responsibilities. The Board Chair oversees the quality of the Board s governance processes including: Ensuring that the Board performs a governance role that respects and understands the role of management Ensuring that the Board adopts an annual work plan that is consistent with the Hospital s strategic directions, mission and vision Ensuring that the actions of the Board are in accordance with the Corporation s goals and priorities and the Board s own goals Ensuring that the work of the Board committees is aligned with the Board s role and annual work plan and that the Board respects and understands the role of Board committees and does not redo committee work at the Board level Reporting regularly and promptly to the Board, issues that are relevant to its governance responsibilities Leading the adoption of best practices in corporate governance Meeting proactively with all Board members and seeking their feedback on management performance, Board and committee effectiveness and other matters Providing constructive feedback from the Board s evaluation processes to individual committee Chairs and Board members Intervening when necessary in instances involving breaches of the rules of conduct Ensuring that the Board removes Directors from the Board who are not discharging their responsibilities in an appropriate manner In conjunction with the Executive Committee and the full Board, leading a formal evaluation of the Chief Executive Officer s and Chief of Staff s performance at least annually Ensuring new committee Chairs receive orientation Role Description for Chair of the Board Board Manual 2-A-20 Cambridge Memorial Hospital November 30, 2016 Page 1 of 3

16 Presiding Officer As the presiding officer at Board and Corporation meetings, the Chair is responsible for: In collaboration with the CEO and committee Chairs, setting a schedule and agendas for Board meetings that reflect the Board s role and annual work plan Ensuring that meetings are conducted according to applicable legislation, Hospital Bylaws, and the Hospital s governance policies and procedural rules of order Facilitating and forwarding the business of the Board, ensuring that meetings are effective and efficient for the performance of governance work Encouraging input and ensuring that the Board hears all sides of a debate or discussion In conjunction with the CEO, ensuring relevant information is made available to the Board in a timely manner and that external advisors are available to assist the Board as required Conducting regular sessions of independent directors and reporting the results of such meetings to the CEO as appropriate Representation The Board Chair: Is the official spokesperson for the Board Represents the Corporation at public or official functions Represents the Board in dealings with government and regulatory authorities Reports at each annual meeting of the members Represents the Board within the Hospital, attending and participating in Hospital events as required Relationships The Board Chair: Serves as the Board s central point of official communication with the CEO Maintains a collaborative working relationship with the CEO and Chief of Staff, providing advice and counsel as required In conjunction with the CEO, facilitates the effective and transparent interaction of Board members and management Provides assistance and advice to committee Chairs on governance and other matters Establishes a relationship with individual directors, meeting with each director at least once a year to ensure that each director contributes his/her special skill and expertise effectively Other Duties Ensures through the Board committees the appropriateness and quality of the Corporation s organizational performance reporting and benchmarking Ensures that the Board monitors agreed upon performance indicators at regularly scheduled Board meetings Serves as a member of the Executive Committee; is an ex-officio member of all other committees of the Board Performs such other duties as the Board determines from time to time. Skills, Attributes and Experience The Board Chair will possess the following personal qualities, skills, and experience: All of the personal attributes required of a Board Director Leadership skills Role Description for Chair of the Board Board Manual 2-A-20 Cambridge Memorial Hospital November 30, 2016 Page 2 of 3

17 Facilitation skills Political acuity Ability to effectively build consensus within the Board Ability to establish a trusted advisor relationship with CEO, Chief of Staff and other Board members Ability to communicate effectively with the Board, the management team, the Ministry of Health and Long-Term Care, the Local Health Integration Network and the community Must have the time and flexibility in schedule to meet the requirements of this leadership role Appointment and Term The Board Chair is elected by the Board of Directors on the recommendation of the Governance Committee for a one year term. In accordance with By-law Article 7.1(e), no Director may serve as Chair for more than two consecutive years. The Board Chair is an ex-officio member of all Board committees and sub-committees, except the Medical Advisory Committee. When present at a committee or sub-committee meeting, the Chair may be counted toward quorum. Role Description for Chair of the Board Board Manual 2-A-20 Cambridge Memorial Hospital November 30, 2016 Page 3 of 3

18 BOARD MANUAL SUBJECT: Vice President Clinical Programs and Chief Nursing Executive (VP/CNE) Role Description NUMBER: 2-B-32 SECTION: Board Processes APPROVED BY: Board DATE: February 28, 2014 REVISED/REVIEWED: November 30, 2016 Reporting to the CEO, the VP/CNE is responsible for the safe operational and financial management of clinical programs in the reporting portfolio; to uphold and ensure professional standards of practice in nursing and health professional disciplines across the organization; and to create an environment of focused quality, safe and effective patient care that supports the patient experience and strategic directions of Cambridge Memorial Hospital (CMH). As a member of the executive team, the VP/CNE provides leadership for professional practice, patient experience, quality, safety and risk. The VP/CNE is responsible to maintain, develop and support effective collegial relationships with CMH and its internal stakeholders (the Hospital Board, CMH Foundation (CMHF), CMH Volunteers Association (CMHVA), Hospital staff and their committees/associations, etc.). The VP/CNE is responsible for building and maintaining effective collegial relationships with key community external stakeholders including the Local Health Integration Network (LHIN), Ministry of Health and Long Term Care (MOHLTC), Community Care Access Centre (CCAC), community groups and other health care providers, both publicly and privately funded, and the City of Cambridge, Township of North Dumfries and Region of Waterloo, its key staff and elected officials. ACCOUNTABILITY The incumbent is accountable to the CEO: As a member of the executive team and with respect to Excellent Care for All Act to fulfill the governance, leadership and practice domains inherent in the role within the organization and to identify and articulate the strategic direction for the delivery of patient care and the provision of nursing and professional disciplines in care delivery For quality, safe, effective care and patient experience through leadership of quality and safety innovations, maintenance of CMH s RNAO Best Practice Spotlight Designation and ongoing monitoring, intervention and oversight of risk CMH CNE Role Description Board Manual 2-B-32 Cambridge Memorial Hospital November 30, 2016 Page 1 of 4

19 To maintain and develop collaborative relationships across organizations, sectors and regions to best advance the mission, vision and values of CMH in integration and coordinated care delivery To assume accountability for patient care and service that complies with ethical standards and CMH values To ensure annual processes of nursing and health professional credentialing To ensure that obligations under the Regulated Health Professionals Act are upheld To participate as a voting member of the Quality Committee of the Board To participate as a non-voting member of the Board To maintain positive relations in the broader health care community, with the MOHLTC, the LHIN, CCAC and other health care providers in both the public and private sector in the communities of Cambridge, North Dumfries, Kitchener, Waterloo and Wellington County, as appropriate To advocate on behalf of the Hospital and its needs MAJOR RESPONSIBILITIES PATIENT CARE AND EXPERIENCE, QUALITY AND SAFETY Participate as an active member of the executive team and Board Quality Committee Lead the development of annual quality improvement plans and ensure compliance with submission to Health Quality Ontario as well as public posting of the document Propose, lead and direct strategies to improve quality outcomes, patient experience and advance evidence informed care Oversee and report on patient risk, ensure timely follow up, any required mitigation strategies and reporting of sentinel events to the Quality Committee of the Board Ensure a practice environment that enables implementation of evidence informed nursing and health discipline care delivery consistent with the organization s strategic directions and quality improvement plan(s) Ensure the effective use of informatics in practice to support quality and effective care delivery Support the development of appropriate quality, patient experience, patient and employee safety, utilization and risk management programs Lead the process to ensure adequate preparation of the Hospital in order to receive Accreditation status consistent with the requirements set out by the MOHLTC Promote a patient safety culture that supports quality patient care and patient experience CMH CNE Role Description Board Manual 2-B-32 Cambridge Memorial Hospital November 30, 2016 Page 2 of 4

20 Consider safety of self and co-workers while performing their work Work in partnership with the Chief of Staff and Vice President Medical Affairs and communicate with Medical/Professional Staff concerning professional practice, regional initiatives and other matters of mutual focus Attend Medical Advisory Committee meetings Work collaboratively with the Board appointed Chiefs of Departments and the elected Medical/Professional Staff Executive members Maintain collaborative relationships with executive leadership and senior nurse executives across organizations, sectors, and regions to advance nursing and professional practice agendas Ensure a system of collaboration with academic partners, with a focus on nursing programs and health practitioner programs to facilitate appropriate clinical placements and shape curriculum and effective teaching/learning experiences for students and staff OPERATIONS AND RESOURCE MANAGEMENT Provide leadership to all employees of the reporting portfolio and to the professional disciplines across the organization Support and or implement plans for approved new or expanded programs and services through the LHIN and MOHLTC; maintains ongoing contact with the LHIN and the MOHLTC to monitor the status of approvals and funding Direct, co-ordinate and control the operation of the portfolio through directors and managers; ensure that approved plans are implemented; monitor actual capital and operating expenditures against approved budget on a monthly basis or more frequently if required Review and assess daily operating problems; develop and implement plans for corrective action Establish an organizational structure to ensure accountability of all nursing and health professionals to fulfill the professional practice mandate and labour relations parameters Ensure annual performance development processes for direct reports is maintained and that progress reviews occur as per organizational standards Ensure organizational standard work expectations are met within his/her portfolio Review and approve the hiring or appointment of key management and supervisory personnel to fill approved positions Ensure that managers assess the performance of their staff; review and approve their recommendations for their staff pay increases, promotions, transfers, or dismissals Ensure the appropriate utilization of resources within the reporting portfolio CMH CNE Role Description Board Manual 2-B-32 Cambridge Memorial Hospital November 30, 2016 Page 3 of 4

21 Monitor quality metrics, access to services, volumes and utilization targets with corrective action plans as required STRATEGIC VISIONING, ORGANIZATIONAL DECISION MAKING AND PRACTICE INNOVATION Participate as an active member of the Board and executive team Participates as a voting member of the Quality Committee and as a nonvoting member of the Board Provide executive support for the Quality Committee of the Board and in collaboration with the Committee Chair prepare agendas, the annual work plan, ensure minutes are taken and circulated and that the work plan is delivered on over the course of the committee cycle Disseminate the strategic directions and vision across the organization through formal structures and processes and informal opportunities Monitor the strategic planning of the LHIN and translates the alignment to internal stakeholders at CMH Implement annual corporate priorities and operating plan consistent with the strategic plan and the operating and external policy context of CMH OTHER Performs other functions as requested by the CEO The VP/CNE shall not be employed or participate in compensated activities outside of CMH, without the approval of the CEO CMH CNE Role Description Board Manual 2-B-32 Cambridge Memorial Hospital November 30, 2016 Page 4 of 4

22 BOARD MANUAL SUBJECT: Board and Committee Annual Work Plans NUMBER: 2-D-4 SECTION: Board Processes APPROVED BY: Board DATE: November 24, 2010 REVISED/REVIEWED: April 23, 2014, November 30, 2016 Policy Each committee Chair and the Board Chair, together with the designated hospital executive support, will develop the committee s or Board s annual work plan. The Board Chair and CEO will work to ensure the committee work plans and Board work plan are aligned. The work plans will guide the work of the Board/committee and the development of meeting agendas. The work plans will incorporate activities aligned with: the roles and responsibilities of the Board and committees, as defined in the charters the current strategic priorities and objectives of the Hospital the annual objectives, if any, developed by the committees the Hospital s planning process The Board Chair and committee Chairs will prepare an annual summary of accomplishments, outstanding items for completion, and key priorities for the next year. Process 1. Board and committee work plans are developed in September. 2. Work plans will be reviewed by the committee Chair/Board Chair and the designated hospital executive support person, to ensure the charter is addressed. 3. A current work plan will be provided in each committee/board agenda package. 4. Committee work plans will be kept current by each committee Chair and/or the designated hospital executive support. 5. Changes to committee work plans that affect the Board work plan will be sent to the Board Chair for review. If necessary, the committee work plan will be reviewed and approved by the Board. Board and Committee Annual Work Plans Board Manual 2-D-4 Cambridge Memorial Hospital November 30, 2016 Page 1 of 1

23 BOARD MANUAL SUBJECT: Procedure for Members of the Public Addressing the Board NUMBER: 2-D-9 SECTION: Board Processes APPROVED BY: Board DATE: March 30, 2011 REVISED/REVIEWED: April 23, 2014, November 30, 2016 Persons wishing to address the Board concerning matters relevant to the Hospital must follow the procedure outlined below. 1. Delegations wishing to make a presentation to the Board regarding governance and policy matters in relation to the Hospital s vision, mission, values, and directional plans are permitted to do so. Presentations and questions about an individual s care or a staff member s employment record are not permitted. 2. Application to appear before the Board may be made by contacting the CEO s office ( ext. 2350) and by completing a Delegation Application Form (attached). 3. The Delegation Application Form together with a written description of the specific matter to be addressed must be received no later than 10 working days prior to the meeting date (any other date is at the discretion of the Chair). If a group wishes to make a submission, a spokesperson for the group must be identified. 4. Requests to address the Board on a specific item will be granted (generally in order of the receipt of the application) at the discretion of the Chair. The Chair may request that the matter be referred or redirected as appropriate. Persons or groups not permitted to address the Board shall be so notified in advance of the meeting. 5. The Chair is not obligated to grant a request to address the Board. The Board is not obligated to respond to or take any action on the presentation it receives. 6. The Board may limit the number and length of presentations at any one meeting. 7. Delegations addressing the Board will be required to limit their remarks to their allotted time, as determined by the Board Chair. 8. Board members may ask questions of clarification following the presentation. Procedure for Members of the Public Addressing the Board Board Manual 2-D-9 Cambridge Memorial Hospital November 30, 2016 Page 1 of 2

24 DELEGATION APPLICATION FORM Cambridge Memorial Hospital Board of Directors DATE OF BOARD MEETING: LENGTH OF PRESENTATION: NAME OF INDIVIDUAL/ORGANIZATION: ADDRESS: TELEPHONE: CONTACT NAME (Spokesperson for organization): PURPOSE OF PRESENTATION: WRITTEN MATERIALS ATTACHED: YES NO Please return this application form addressed to: Secretary, Board of Directors Office of the President and CEO Cambridge Memorial Hospital 700 Coronation Blvd. Cambridge, ON N1R 3G2 Fax: Procedure for Members of the Public Addressing the Board or Board Committee Board Manual 2-D-9 Cambridge Memorial Hospital November 30, 2016 Page 2 of 2

25 BOARD MANUAL SUBJECT: Board Education for Board Members and Non-Director Committee Members NUMBER: 2-D-32 SECTION: Board Processes APPROVED BY: Board DATE: November 24, 2010 REVISED/REVIEWED: April 23, 2014, November 30, 2016 Policy It is important that members of the Board members and non-director committee members have the skills, knowledge and experience required to fulfill their duties. In addition to the initial orientation program (see Board Manual, Board Orientation), the Board will provide opportunities for ongoing relevant skills development, and to be fully informed with respect to the background and context of the decisions that Board members and non-director committee members are called upon to make. All new Board members must complete the Ontario Hospital Association (OHA) one-day course, Essentials Certificate in Health Care Governance for New Directors (or equivalent) within two years of joining the Board. It is expected that all Board members will participate in continuing education sessions held for Board members. Education may take place in separate educational sessions, during regular Board and committee meetings, or as part of a Board retreat. Other opportunities may include Hospital tours, OHA sponsored education and other governance related programs. Board members and/or non-director committee members who attend conferences or external meetings are encouraged to provide a report to the Board and/or relevant committee. Board members will identify their individual development needs through feedback questionnaires that follow education sessions and an annual self-assessment. Expenses for attending education programs will be reimbursed according to established policy (see CMH Policy, Board Travel and Expenses Policy 2-D-34.) Procedure 1. The CEO s office will inform Board members and/or non-director committee members about upcoming education events. 2. A Board member and/or non-director committee members will communicate interest in attending an education program with associated registration fees or expenses to the Board Chair. 3. If approved, the CEO s office will facilitate registration and payment for the program. Board Education for Board Members and Non-Director Committee Members Board Manual 2-D-32 Cambridge Memorial Hospital November 30, 2016 Page 1 of 1

26 THREB Annual Report Introduction TRI-HOSPITAL RESEARCH ETHICS BOARD ANNUAL REPORT for 2015 To THREB Members and Board of Directors of Cambridge Memorial Hospital Board of Directors of Grand River Hospital Board of Trustees of St. Mary s General Hospital (Submitted by Michael D. Coughlin, Ph.D., Chair of THREB) For the hospitals to create an environment conducive to well-conducted research it is important to have a well-functioning and well-respected Research Ethics Board (REB). To comply with Accreditation Standards, Health Canada Regulations, the Tri-Council Policy Statement (TCPS2), standards of practice and laws around research in general, research done at hospitals in Canada must be approved by a properly constituted REB authorized by the hospital corporation, that is, an "REB of Record" for the institution. Prior to 1998, Grand River Hospital (GRH) had its own research review committee (Committee on Ethical Research). In 1998 a Joint Research Ethics Committee (JREC) was approved by the Board of Directors of GRH and the Board of Trustees of St. Mary s General Hospital (SMGH). It was initially chaired by Terry Dean from Pharmacy at GRH and then by Nancy Martin from Research and Performance Metrics. In 2001, Cambridge Memorial Hospital (CMH) requested to become part of the REB and JREC became the Tri-Hospital Research Ethics Board (THREB). This was an innovative model in Ontario for doing research ethics review at community hospitals and has been emulated by other hospitals. At GRH and CMH, the Ontario Cancer Research Ethics Board has been added as a "REB of Record" for multi-centre cancer studies. Since 2005, the THREB has been chaired by Michael Coughlin. In brief, THREB is a shared resource of the three hospitals, GRH, SMGH and CMH, and reports to the Boards of all three hospitals through an administrative liaison person, i.e. a VP or Senior Administrator from each of the hospitals who sits as a member on the THREB. These administrators are voting members of THREB and attended the monthly meetings. In addition, these administrators take on the role of ensuring that all research that is to be done at their respective hospitals has administrative approval, i.e. that the financial, resource and contract issues have been attended to. All hospitals contribute to support THREB, with each hospital contributing $10,000 per year. Supplementary support comes from fees charged for industry-sponsored research. GRH supplies the THREB with office space, some operating equipment, IT support, web-hosting and, until November of 2015, financial administration. Since November of 2015, SMGH has taken on the financial administration role. Monthly meetings of the full THREB rotate through the three hospitals. 1

27 THREB Annual Report 2015 While THREB has its own budget, for accountability purposes THREB now reports to the SMGH liaison person (currently Diane Wilkinson) for financial and administrative matters and that person also has signing authority for THREB finances. The Tri-Hospital Research Ethics Board operates in compliance with the Tri-Council Policy Statement: Ethical Conduct for Research Involving Humans (2010), the ICH Good Clinical Practice Guidelines, Division 5 Health Canada Food and Drug Regulations and other applicable regulations. 2. THREB Office The THREB office consists of an Administrative Coordinator, Laurie Dietrich, paid as a contract position (2 days per week) and the Chair, Michael D. Coughlin Ph.D., who receives a consultant fee based on a set time of 20 hours per month. The budget report for is included in this document. 3. Membership The membership of the THREB is, according to the Terms of Reference, set up to comply with the TCPS2 requirements and is intended to include three members from each hospital, two community members and the Chair. A continuing challenge for all REBs, and even more so for a community hospital based REB like THREB, is to recruit the necessary mix of members. With the turnover of members following its establishment, the THREB has often not met its expected complement from all the hospitals according to the Terms of Reference for the past several years, especially members from medicine. While the THREB does still meet TCPS and other standards, the hospitals do need to facilitate the recruitment of additional members with medical expertise. The membership for the year was: COUGHLIN, Michael, PhD CHOUINARD, Edmond, MD CHUDLEIGH, Lydia, BASc, MBA JULIUS, Lynne, HBScN, MHS LONGO-WILD, Victoria, RN-EC, MN MAH, Tina, BScOT, MBA, PhD -until September; and beginning in Sept: GIROLAMETTO, Carla, MA, CCRP MOTZ, Paul, BSc QUESNELLE, Heather, CHE (for part of the year; replaced by) HETT, Sandra, MN, BScN, BaS SILLS, Victoria, BScPhm, RPh STAHLKE, Amy, BA, LLB VORSTEVELD, Noela, BScPharm Ethics Medicine Administration, SMGH Nursing Nursing Administration, GRH Manager, GRRCC Community Representative Administration, CMH Pharmacy Community Representative, Lawyer, Privacy Pharmacy 2

28 THREB Annual Report Professional Development of Members The first part of most every THREB meeting is devoted to and educational component, often a discussion of articles in the journal IRB published by the Hastings Center. THREB has a subscription for enough copies of the journal to supply a copy to every member. Alternatively, other issues of research ethics review or REB development are discussed. At the May meeting, a mini-workshop was held to examine issues around what counts as minimal risk. The workshop was facilitated by Catherine Motz, a Kitchener-based consultant who uses her skills and experiences as a lawyer and community volunteer to work with various organizations. She provided help to the THREB on a pro bono basis. It is important that the THREB members be aware of and involved in the wider research ethics community. This year, however, because of budget concerns, none of the members were sponsored to attend the meeting of the Canadian Association of Research Ethics Boards. Hopefully, it will be possible in the coming year to sponsor at least one of the members to attend. 5. Statistics on Projects Reviewed During the 2015 calendar year, THREB carried out a total of 125 reviews, including 20 new studies, and the monitoring of a total of 90 ongoing studies. The THREB office also responded to a number of inquiries regarding the determination of whether studies were to be considered research or quality initiatives. Since some of the projects are at two or more of the hospitals, the sums for the new and ongoing studies will be greater than the number indicated above. Also note that there usually is a difference in numbers of studies submitted in a year and the numbers reviewed in a year, though not for New and Ongoing Studies by Hospital 2015 CMH GRH SMGH New Industry New Other Total Ongoing 2015 New Studies Ongoing Studies Industry Other CMH GRH SMGH

29 THREB Annual Report Projects Reviewed 2015 New Projects Amendments Annual Renewals Studies Completed Total Full Board Delegated New Projects Submitted in New Projects Reviewed in Full Board 13 Delegated 7 Amendments Reviewed 30 Full Board 17 Delegated 13 Annual Renewals 51 Full Board 47 Delegated 4 Studies Completed 24 Total Reviews Project Distribution by Year Industry Non-industry Total Industry Non-industry Total

30 THREB Annual Report 2015 Observations Over the past 10 years, the total number of new studies has remained fairly constant at around 30 per year. The 2015 year saw a marked deviation from that average, with only 20 projects being submitted, and with 2 of those being withdrawn. [Note: As of June of this year, the number of new projects submitted for 2016 had already reached 20.] The distribution between industry-sponsored and other studies, however, has been quite variable, with a downward trend in industry-sponsored studies continuing. Since fees from industry-sponsored studies are expected to provide for approximately half of the THREB budget, this downward trend is of concern. So far, the budget balance carried forward from previous years has served as a buffer for that variation, though that balance has been declining. At some point, this may require an increase in the hospitals contribution to the budget. 6. Federal Wide Assurance In order to receive research grants from United States government agencies such as NIH, the hospitals and the REB (IRB) must be registered with the U.S. Health and Human Services. All three hospitals remain registered and have a Federal Wide Assurance until The THREB registration is for 3 years and is active until February of The THREB registration is reviewed and renewed when membership changes. 7. Ongoing Development of THREB In addition to the usual work of reviewing and monitoring of studies, the THREB attempts to improve its processes and keep up with the changes in the research ethics field. Over the past several years, with encouragement and help from member Paul Motz, the THREB has begun transitioning to a less paper intensive approach to distribution of agenda materials to members. All but a few members receive the materials electronically through Dropbox. While we are still searching for other, more secure methods of electronic distribution, this method has allowed us to move away from a purely paper-based process. Since THREB works on a very small budget, the alternatives are currently limited. Large REBs that have combined database and electronic materials distribution and review systems spend millions of dollars on such systems. However the THREB will continue to look for improvements in our process. There has been for a number of years a push to have accreditation of REBs. With the recent finalization from the Canadian General Standards Board (CGSB) of a new National Standard of Canada for Research Ethics Oversight of Biomedical Clinical Trials, and the introduction of a process for accreditation of REBs for participation in Clinical Trials Ontario (CTO), it is likely that an accreditation process will be required before too long. While the THREB will attempt to meet those standards, it will become difficult for small REBs to meet the necessary infrastructure requirements. However, the timeline for such changes is still very uncertain. The Chair has been working on developing the Standard Operating Procedures required for accreditation. A number of the more essential SOPs have been developed or modified from the now available templates developed and offered free of charge by CAREB and N2 (the Network of Networks) for REBs. 5

31 THREB Annual Report 2015 There are a number of specific initiatives that the THREB has initiated over the past year. 1. The THREB members reviewed the THREB Terms of Reference and approved several changes in response to suggestions by the hospital Boards last year. The revised Terms of Reference are attached for approval. The only change from last year is the clarification that OCREB (Ontario Cancer Research Ethics Board) is an REB of record at CMH and GRH only for multi-centre cancer research studies. 2. Last year, the Chair and the THREB members developed, with research administration at the University of Waterloo, a process to work more closely with the REB at the UW on projects that involve both institutions. A method to coordinate and simplify the processes was considered to be of advantage to both investigators and REBs. The development of the coordinated process was completed last year, approved as in the revised Terms of Reference of last year, and has been used for a number of collaborative projects. The process seems to be working well. 3. The THREB is committed to ensuring that all members shall have completed the TCPS2 tutorial; and all current members have completed it. This is a voluntary research ethics tutorial that is, however, now becoming mandatory not only for REB members, but for all investigators and research coordinators. In the near future, the THREB will have to require it of investigators and all those involved in studies, as is the case in most other institutions. That requirement is already in place for investigators at the University of Waterloo, such as those that collaborate with researchers at the hospitals. 6

32 THREB Annual Report BUDGET 2015/16 THREB BUDGET REPORT April 2015-March2016 Expenses Projected Actual Revenue Projected Actual Balance Year- Beginning $23, Chair Sponsor payments $24, $22, hr/month + HST $27, $24, new projected St. Mary's $10, $10, Administrative Asst. (2d/week) 2d/week pay, benefits, $26, $25, plus some OT or student work Cambridge $10, $10, Monthly lunch $1, $1, Grand River $10, $10, Postage, Courier $50.00 $0.00 Education - conferences, etc $2, $4, Teleconference $ $ General supplies $ $ Replace outdated computer $2, Misc $1, $ TOTAL $58, $59, $54, $ Fiscal year balance ($7,046.75) Year-End Final Balance $16,

33 Agenda Item # Coronation Blvd, Cambridge, ON N1R 3G2 Tel Fax BRIEFING NOTE Quality Committee Date: October 14, 2016 Issue: Purpose: Prepared by: Approved by: Annual Risk Management & Emergency Preparedness Report Information Liane Barefoot, Director Patient Experience, Quality & Risk Sandra Hett, Vice President Clinical Programs & CNE CMH s Risk Management and Privacy Policies Manual Corporate Manual Policy Number Policy Name Risk Management: Critical Incident Management Guide Risk Management: Reporting of Patient Adverse Events Review Date September 2017 September Disclosure of Harm September Enterprise Risk Management September Whistle Blower Policy June Look Back Policy Multi Patient Disclosure April Privacy and Confidentiality October 2018 The Enterprise Risk Management policy is under review and will be updated by December Page 1 of 6

34 Agenda Item #1.3.4 Emergency Preparedness The Emergency Preparedness Committee (EPC) is responsible for the development and review of policies and procedures related to internal and external emergency disaster preparedness, response, and recovery for Cambridge Memorial Hospital. The Committee s goal is to minimize risk and maximize safety for patients, their families, staff, physicians and the community in the event of a disaster or large scale emergency situation. The committee is chaired by the Manager Physical Plant and Property. It includes multidisciplinary representatives with expertise in clinical services, emergency response, security, infection control, environmental services, safety/wellness, and technology. There are also community representatives on the committee from Cambridge Fire Department, Emergency Management Services and the City of Cambridge. In addition, regularly scheduled and ad hoc meetings are held with Waterloo Regional Police Services to review/debrief specific cases, identify and plan education opportunities, and investigate/plan larger system improvements. All polices related to Emergency Preparedness are housed in a separate Emergency Response Manual accessible by all staff on the intranet. All new staff are provided 45 minutes of training at Hospital Wide Orientation and current staff are required to access the self-directed learning module and related quiz on the intranet annually. The Emergency Response Manual contains an overarching Emergency and Response Recovery Plan in addition to twelve (12) specific colour code policies. All code policies were reviewed last Fall 2015 in preparation for our onsite Accreditation Canada visit. A comprehensive review of all Codes is scheduled for Fall Winter 2017 as we prepare to occupy the new wing A. Many mock codes are conducted throughout the year. Mock code reds (fire) are conducted monthly in various locations across the hospital. Off hour (weekend/evening) mock code reds began in November 2015 and going forward they will represent 25% (total of 4 annually) of all mock code reds. The hospital was commended by Accreditation Canada in November 2015 for building off hour mock code reds into our schedule. A debriefing occurs after each mock code red with staff that were present for the code and the manager of the area has the option to request additional training/in-service for staff. Mock code blues (cardiac arrest) are conducted monthly and the results of actual and mock code blues are reviewed by the Code Blue Committee chaired by the Chief of Emergency Medicine and a Clinical Educator. The hospital is required annually to participate with the Cambridge Fire Department in a mock Code Green (evacuation). This is being planned for November 2016 on the 5 th floor medical unit. The last one was in the Spring 2015 on the pediatrics unit. Page 2 of 6

35 Agenda Item #1.3.4 Highlights of the work done by the EPC over the past year and upcoming work includes: Establishment of a Code White (violent individual) committee for specific initiatives related to Code White situations and overall staff safety Development of a Code Silver policy (armed individual) adopted from work done at Guelph General pending final approval Table top mock Code Greens (evacuation) for Mental Health conducted for inpatient and outpatient areas Evacusled (devise used to assist staff in evacuating a non-ambulatory/bedridden patient) audit and policy review underway Re-work overarching Emergency Response and Recovery Plan policy by splitting into two (2) smaller policies o Emergency Response and Recovery Plan all staff, physicians and volunteers expected to be familiar with this policy. High level description of each colour code, the intersection of colour codes, and when/if the Incident Management System (IMS) will be enacted for each of the twelve (12) colour codes. o Incident Management System managers, directors, VPs and CEO responsible to understand when IMS will be enacted and what their role is when IMS enacted. This is a much more detailed and lengthy policy. Targeted education planned for all managers, directors, VPs and CEO in November 2016 related to IMS Formal liaison with City of Cambridge Emergency Planning department myself and Manger Physical Plant and Property will attend quarterly meetings, participate in annual disaster mocks, and attend relevant education sessions Privacy Risk Patient information and their privacy is protected under Ontario s Personal Health Information Protection Act (PHIPA). The key requirements under this legislation are that: we keep a patient s health information confidential and secure we identify a contact person (Privacy Officer) if the patient has any concerns or requests related to the privacy of the information we have a written public statement about our privacy practices their information is only used and disclosed for the purposes for which it was collected While a patient is in the hospital their physical chart is protected by keeping the chart at the Nursing Station, where it is only accessible to the care providers. Once they leave the hospital, the physical chart is kept in a locked environment in Medical Records. The electronic portion of their chart is in our Meditech patient care system and is protected in the following manner. All users must have a valid username and password to access the Meditech System and they are only granted access to the information in Meditech required to perform their role. In addition, the Meditech system allows us to restrict access to patient information based on the location of the terminal being used. For example, a nurse working on the Surgical Unit can be restricted from accessing patients on the Medical Unit. We further protect electronic patient information by running some routine audits for suspicious access of patient information. That would include, for example, the user s last name is the same as the patient s last name. Page 3 of 6

36 Agenda Item #1.3.4 Legislative Risk A list of all applicable legislative acts and regulations was compiled and reviewed by Senior Executive in A most responsible management position was assigned responsibility to review the legislative requirements compared to CMH practice. The most responsible manager/director/vp prepared a briefing note attesting to CMH compliance for the Audit Committee. This process was completed in April 2016 and will be repeated every two (2) years going forward. Accreditation Every 4 years we participate in the large, organization-wide Accreditation Canada on-site survey. This last occurred in November CMH received Accredited status and as such, had to provide Accreditation Canada with additional evidence related to the three (3) cited Required Organizational Practices (ROPs) tests of compliance by April The required evidence was submitted and accepted by Accreditation Canada. CMH is required to submit additional evidence for the cited high priority criteria by April Work is well underway and there is no anticipated delay in submitting adequate evidence. In addition to the large, hospital wide onsite Accreditation Canada survey that occurred in November 2015 there are additional department specific accreditations that occur or are proposed for the near future. Pharmacy In Fall 2013 the Ontario government proposed legislation that would permit Ontario College of Pharmacists (OCP) to inspect and licence hospital pharmacies. Last year each hospital was inspected once as a baseline for criteria/standard development. CMH will have its first official inspection from the OCP on October 19, 2016 at which time two (2) practice assessors will be onsite to assess CMH practices against 383 criteria. The primary focus of the inspection will be on chemotherapy and IV admixture compounding by pharmacy staff but advisors will also be assessing all other areas in the hospital where medications are stored, processed, prepared, compounded, documented on. This could include discussions with any health care professional involved with medications. Laboratory The laboratory accreditation IQMH ISO 15189Plus is a mandated program which assesses quality and competence of all licensed Ontario laboratories. There are over 800 requirements to comply with in the areas of: Hematology, Biochemistry, Microbiology, Pathology, Transfusion Medicine, Point of Care Testing (POCT), Sample Collection, Information Management, and Safety. There is a full on-site peer assessment every 4 years (6 surveyors, 3.5 days), in the 2 nd year, a follow up surveillance visit (2 surveyors, 1 day). CMH achieved 100% on our follow-up surveillance accreditation visit in September The next full on-site peer assessment will be scheduled for September Cardio Respiratory Unit (CRU) The Cardiac Care Network (CCN) as a system support to the Ministry of Health and Long Term Care (MOHLTC) has started the process of accrediting Echocardiography (2D). Once attained, this accreditation will be valid for three (3) years and is anticipated to include one assessor onsite for one (1) day. While the date has not yet been selected for the onsite visit it is expected to take place in September Page 4 of 6

37 Agenda Item #1.3.4 Diagnostic Imaging (DI) There is a proposed accreditation process for Diagnostic Imaging departments under the auspice of the Institute for Quality Management in Healthcare, similar to Lab Accreditation. Requirements are being developed/vetted, and a pilot will be conducted in one hospital this fall. The roll out is expected next year, however at this point no defined dates have been given. No information has yet been provided to know if this is a voluntary or required program. Ruth McKinley, Director of Diagnostic Imaging has participated in the vetting of the requirements. Reputational Risk The Communications Manager responds to positive and negative comments on social media outlets, and provides comments to online newspaper forums when a story about CMH is reported. The Patient Experience Lead and Communications Manager work closely together informing each other of any patient complaints that could have a negative impact on reputation through potential media exposure or other actions such as picketing. As appropriate, notifications are sent to myself and Senior Executive. When the hospital is made aware of pending or actual negative media coverage an all staff communications broadcast is issued to attempt to inform our staff before they hear it in the media. As deemed appropriate, the CEO informs the Board Chair and Board members of potential significant reputational risk issues. Incident Reporting/Trending CMH has an electronic incident management reporting system for all staff to report patient safety incidents, including near misses. The incidents are sent to the appropriate manager for review, corrective action and inform system improvements. All reported events of a critical nature (Level 6) are disseminated via to the department Manager, Quality and Patient Safety Lead, Director of Patient Experience, Quality and Risk, VP Clinical Programs/CNE and the Chief of Staff for immediate review. All critical incidents are reported twice annually (November and May) to Quality Committee. In the late fall 2016 CMH will be implementing the newest platform of our current electronic incident reporting system. This new system will have the capability of capturing patient incidents (similar functionality to our current system), employee incidents (new functionality with this upgrade) and patient feedback (new functionality with this upgrade) in one central electronic repository with significantly improved report generation and trending capability. Introduction of Integrated Risk Management Strategy In April 2016, CMH began the process of developing a formal Enterprise Risk Management (ERM) strategy, which we now call Integrated Risk Management (IRM). Our April kick off was a one day session for the entire Senior Management Team (SMT) with a singular focus on IRM. The morning session was organized and presented by Healthcare Insurance Reciprocal of Canada (HIROC our insurance provider) and was focused on educating the group on the rationale for a corporate wide strategy and suggested approaches on how to move forward with developing a plan. Page 5 of 6

38 Agenda Item #1.3.4 A series of ranking exercises were undertaken between April and the end of June 2016 to reduce the list of risks from ; at each point senior managers were ranking based on likelihood and impact. At another half-day session at the end of June 2016 SMT heard verbal presentations from the assigned leader on each of the identified top ten (10) risks. A final ranking has resulted in four (4) risks and mitigation plans moving forward to the associated Board committees for endorsement in October 2016 and the Board in November These will include action plans and proposed time frames for implementation. Audit Committee will oversee the overarching IRM process. The top four (4) risks identified by the senior management team are listed in the table below. Identified Risk Description Most Responsible Senior Executive Board Committee Capital Redevelopment Project Adverse Medication Events ED Access Transitional planning to safely occupy the new wing A Adverse events involving medications Access to care issues, long wait times, poor patient flow Mike Prociw, VP Corporate Services, CFO Sandra Hett, VP Clinical Programs, CNE Sandra Hett, VP Clinical Programs, CNE Capital Projects Sub Committee Quality Committee Quality Committee Revenue/funding Financial instability, decreased operating revenue Mike Prociw, VP Corporate Services, CFO Resources Committee Management has updated the Board ERM policy (title changed to Integrated Risk Management IRM). This is pending final approval at Audit Committee. As noted earlier in this briefing note the corporate/operational ERM (will also be re-named to IRM) policy is under review and will be updated by December Page 6 of 6

39 Cambridge Memorial Hospital Balanced Scorecard for the Board Committee Fiscal Year Indicator Status & Trends Indicator Number 1 Efficient QIP/HSAA 90th Percentile ED Length of Stay Status Previous Status Year End Projection 2 HSAA Current Ratio 3 4 HSAA HSAA Target Budget Total Margin Patient & People Focused 5 QIP NRC - Would You Recommend (Inpatient)

40 Cambridge Memorial Hospital Corporate Scorecard FY2016/2017 Indicator: 1 Status: Year End Projection: 90th Percentile Emergency Department Length Of Stay for Admitted Patients MRP: SHARRATT,RITA Hours Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Month 2015/ /2017 Detailed Monthly Data Points 01 Apr 02 May 03 Jun 04 Jul 05 Aug 06 Sep 07 Oct 08 Nov 09 Dec 10 Jan 11 Feb 12 Mar 2015/ / Definition: Indicator Details/Components Action Plan Updated: 2016/11/07 12:32 The total emergency room length of stay (in hours) where 9 out of 10 admitted patients completed their visits. ED LOS is defined as the time from triage to the time when the patient leaves the ED. The 90th percentile length of stay is from triage to left ED (in hours) for admitted patients. Excludes Left Without Being Seen, and cases with incomplete date and time stamps Formula: The ED LOS are ranked from lowest to highest, and the number of occurences are multipled by 0.9 to find the 90th percentile rank. The value at this rank is represented. If there is a decimal this is rounded up. Target: Current Year Target is 16 hours. Corridor is 17.6 Hours. HSAA Target is 8 Hours Year End Projection: Projecting green status for year end. Analysis: EDLOS is improving consistently this year, and significantly over 15/16. Stabilization of clinical leadership has helped this indicator. Action Plan: Flow team continues to meet weekly. Realignment of medicine model of care planned which will improve the pulling of patients quicker to medicine from the ED. Work processes regarding discharge planning reengineered to improve patient flow to the community. Focus of inpatient units to pull patients within 60 minutes of admit time. Significant data sharing with ED providers regarding individual provider initial assessment times - sees improvement for last 3 weeks < 3 hour target.

41 Cambridge Memorial Hospital Corporate Scorecard FY2016/2017 Indicator: 2 Status: Year End Projection: Current Ratio MRP: PROCIW,MICHAEL Current Ratio Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Month 2015/ /2017 Detailed Monthly Data Points 01 Apr 02 May 03 Jun 04 Jul 05 Aug 06 Sep 07 Oct 08 Nov 09 Dec 10 Jan 11 Feb 12 Mar 2015/ / Definition: Indicator Details/Components Action Plan Updated: The number of times a hospital's short-term obligations can be paid using the hospital's short-term assets. 2016/11/07 10:58 Formula: (Current Assets + Debit Current Liability (excluding deferred contributions)) / (Current Liabilities (excluding deferred contributions + credit current assets) Target: Performance target is Corridor is Year End Projection: CMH continues to meet and exceed the performance targets established by the HSAA and the Working Funds Deficit Agreement Analysis: There has been a slight delay in capital equipment spending linked to the delay in the construction project. This has led to some increased cash reserve in the short term. The ratio has also had a slight increase linked to the improved financial performance compared o budget YTD. Portions of this reserve will be accessed in the short term should we continue with the regional HIS strategy in absence of matching funding, while other components will go to subsidize the planned three year CRP spend (as per the corporate multi year fiscal strategy). Action Plan: No action is required at this time.

42 Cambridge Memorial Hospital Corporate Scorecard FY2016/2017 Indicator: 3 Status: Year End Projection: Target Budget Year To Date MRP: PROCIW,MICHAEL 2.4M 2M Surplus/Deflict 1.6M 1.2M 800K 400K 0-400K Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Month Actual Budget: 2015/2016 Target Budget: 2015/2016 Actual Budget: 2016/2017 Target Budget: 2016/2017 Detailed Monthly Data Points 01 Apr 02 May 03 Jun 04 Jul 05 Aug 06 Sep 07 Oct 08 Nov 09 Dec 10 Jan 11 Feb 12 Mar 2015/ , , , , , ,864 1,132,421 1,314,131 1,389, ,030 2,056, / ,877-23, , , ,947 Indicator Details/Components Action Plan Updated: 2016/11/07 11:06 Definition: Year To Date operating budget surplus/deficit Formula: Actual Year To Date operating surplus/deficit Target: Target budget surplus of $.87M YTD by March 31, 2017 Year End Projection: As of the end of September, CMH has exceeded its target budget performance. Based on current results and year end projections, it is expected that year end results will hopefully, slightly exceed the targets that have been established. Analysis: YTD CMH results have been driven by improved patient flow, an absence of any significnat patient surge activity in the first six months, less than expected medical remuneration expenditure and improved sick and overtime performance. Recently, we have also been informed that we will receive a small incremental unbudgeted funding increase in the amount of $424K (this has not yet been reflected in the YTD statements) Action Plan: No further action required at this time.

43 Cambridge Memorial Hospital Corporate Scorecard FY2016/2017 Indicator: 4 Status: Year End Projection: Total Margin MRP: PROCIW,MICHAEL Total Margin Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Month 2015/ /2017 Detailed Monthly Data Points 01 Apr 02 May 03 Jun 04 Jul 05 Aug 06 Sep 07 Oct 08 Nov 09 Dec 10 Jan 11 Feb 12 Mar 2015/ / Definition: Indicator Details/Components Action Plan Updated: The percent by which total revenues exceed total expenses, excluding the impact of facility amortization, in a given year 2016/11/07 11:10 Formula: (Total Corporate Revenues - Total Corporate Expenses) / Total Corporate Revenues Target: Performance target is >= 0.0% Year End Projection: September YTD, CMH has exceeded the total margin target that was established. It is anticipated that these results will continue through the end of the year. Analysis: Positive results have been driven by improved salary and wage performance caused by a reduction in surge activity and improved sick and over time performance. There has also been positive results related to general supply expenditure and unplanned savings in medical remuneration. Recently, CMH was informed that they will also receive an unplanned funding increase from the MOHLTC in the amount of $424K. This has not yet been reflected in the YTD financial statements. Action Plan: No further action required at this time.

44 Cambridge Memorial Hospital Corporate Scorecard FY2016/2017 Indicator: 5 Status: Year End Projection: NRC - Would you Recommend (Inpatient) MRP: BAREFOOT,LIANE Positive Score Percentage 85% 80% 75% 70% 65% 60% 55% 50% 45% 40% 35% 30% Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Month 2015/ /2017 Detailed Monthly Data Points 01 Apr 02 May 03 Jun 04 Jul 05 Aug 06 Sep 07 Oct 08 Nov 09 Dec 10 Jan 11 Feb 12 Mar 2015/ % 60.00% 68.18% 62.50% 62.50% 73.10% 70.00% 63.00% 75.00% 76.20% 68.20% 36.40% 2016/ % 43.60% 39.40% 43.60% 56.70% 67.90% Definition: Indicator Details/Components Acute Inpatient Satisfaction Survey measuring the average % of positive responses to the question: "Would you recommend this hospital to family and friends?" Action Plan Updated: 2016/11/08 12:33 Forumla: Number of positive responses to the question divided by the total number of responses to the question. Target: Performance Target is 70%. Corridor is 63%. Year End Projection: Yellow Analysis: Results for Would you Recommend were well below target for almost all of (59.2% YE) and the early part of They rose throughout FY from the previous years results and YE was 65.3%. There has been a significant decline in the early part of FY and a detailed analysis was undertaken in October 2016 for Quality Committee looking at themes of questions most highly correlated. These included questions related to teamwork, communication and basic customer service. Action Plan: The detailed analysis has been presented and discussed with Quality Committee, Medical Advisory and Patient and Family Advisory. Throughout November it will be discussed with Nursing Advisory Council, Professional Advisory Council and Operations to assist in determining a go forward plan.

45 Cambridge Memorial Hospital Balanced Scorecard for the Resource Committee Fiscal Year Indicator Status & Trends Indicator Number 1 2 Efficient HSAA Current Ratio HSAA Target Budget Status Previous Status Year End Projection 3 HSAA Total Margin Patient & People Focused 4 5 QIP QIP Overtime Hours Variance from Budget Sick Hours Variance from Budget

46 Cambridge Memorial Hospital Corporate Scorecard FY2016/2017 Indicator: 1 Status: Year End Projection: Current Ratio MRP: PROCIW,MICHAEL Current Ratio Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Month 2015/ /2017 Detailed Monthly Data Points 01 Apr 02 May 03 Jun 04 Jul 05 Aug 06 Sep 07 Oct 08 Nov 09 Dec 10 Jan 11 Feb 12 Mar 2015/ / Definition: Indicator Details/Components Action Plan Updated: The number of times a hospital's short-term obligations can be paid using the hospital's short-term assets. 2016/11/07 10:58 Formula: (Current Assets + Debit Current Liability (excluding deferred contributions)) / (Current Liabilities (excluding deferred contributions + credit current assets) Target: Performance target is Corridor is Year End Projection: CMH continues to meet and exceed the performance targets established by the HSAA and the Working Funds Deficit Agreement Analysis: There has been a slight delay in capital equipment spending linked to the delay in the construction project. This has led to some increased cash reserve in the short term. The ratio has also had a slight increase linked to the improved financial performance compared o budget YTD. Portions of this reserve will be accessed in the short term should we continue with the regional HIS strategy in absence of matching funding, while other components will go to subsidize the planned three year CRP spend (as per the corporate multi year fiscal strategy). Action Plan: No action is required at this time.

47 Cambridge Memorial Hospital Corporate Scorecard FY2016/2017 Indicator: 2 Status: Year End Projection: Target Budget Year To Date MRP: PROCIW,MICHAEL 2.4M 2M Surplus/Deflict 1.6M 1.2M 800K 400K 0-400K Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Month Actual Budget: 2015/2016 Target Budget: 2015/2016 Actual Budget: 2016/2017 Target Budget: 2016/2017 Detailed Monthly Data Points 01 Apr 02 May 03 Jun 04 Jul 05 Aug 06 Sep 07 Oct 08 Nov 09 Dec 10 Jan 11 Feb 12 Mar 2015/ , , , , , ,864 1,132,421 1,314,131 1,389, ,030 2,056, / ,877-23, , , ,947 Indicator Details/Components Action Plan Updated: 2016/11/07 11:06 Definition: Year To Date operating budget surplus/deficit Formula: Actual Year To Date operating surplus/deficit Target: Target budget surplus of $.87M YTD by March 31, 2017 Year End Projection: As of the end of September, CMH has exceeded its target budget performance. Based on current results and year end projections, it is expected that year end results will hopefully, slightly exceed the targets that have been established. Analysis: YTD CMH results have been driven by improved patient flow, an absence of any significnat patient surge activity in the first six months, less than expected medical remuneration expenditure and improved sick and overtime performance. Recently, we have also been informed that we will receive a small incremental unbudgeted funding increase in the amount of $424K (this has not yet been reflected in the YTD statements) Action Plan: No further action required at this time.

48 Cambridge Memorial Hospital Corporate Scorecard FY2016/2017 Indicator: 3 Status: Year End Projection: Total Margin MRP: PROCIW,MICHAEL Total Margin Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Month 2015/ /2017 Detailed Monthly Data Points 01 Apr 02 May 03 Jun 04 Jul 05 Aug 06 Sep 07 Oct 08 Nov 09 Dec 10 Jan 11 Feb 12 Mar 2015/ / Definition: Indicator Details/Components Action Plan Updated: The percent by which total revenues exceed total expenses, excluding the impact of facility amortization, in a given year 2016/11/07 11:10 Formula: (Total Corporate Revenues - Total Corporate Expenses) / Total Corporate Revenues Target: Performance target is >= 0.0% Year End Projection: September YTD, CMH has exceeded the total margin target that was established. It is anticipated that these results will continue through the end of the year. Analysis: Positive results have been driven by improved salary and wage performance caused by a reduction in surge activity and improved sick and over time performance. There has also been positive results related to general supply expenditure and unplanned savings in medical remuneration. Recently, CMH was informed that they will also receive an unplanned funding increase from the MOHLTC in the amount of $424K. This has not yet been reflected in the YTD financial statements. Action Plan: No further action required at this time.

49 Cambridge Memorial Hospital Corporate Scorecard FY2016/2017 Indicator: 4 Status: Year End Projection: Overtime Variance from Budget MRP: SHARRATT,RITA 0 Overtime Hours Variance K -1.6K -2K -2.4K -2.8K -3.2K Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Month 2015/ /2017 Detailed Monthly Data Points 01 Apr 02 May 03 Jun 04 Jul 05 Aug 06 Sep 07 Oct 08 Nov 09 Dec 10 Jan 11 Feb 12 Mar 2015/ ,267-2,721-1,540-1, ,294-1, /2017-1, Indicator Details/Components Action Plan Updated: 2016/11/07 13:11 Definition: Variance in actual overtime hours from budgeted overtime hours Formula: Budgeted Overtime Hours - Actual Overtime Hours Target: Performance target is 0% variance from budget. Year End Projection: 2016/17 OT hours budget projected to be yellow to year end currently. This is much improved over 2015/16. Analysis: In the beginning of fiscal year of 2016/17, there has been a stabilizing of management leadership in the clinical portfolios. Recruitment and stabilization of Part-time staff and the float team have been the primary focus during these months. 3 of 4 months this fiscal year have shown improvements over last year and is expected to continue. Action Plan: Scheduling meetings continue to occur reviewing actions of previous and future schedules. Executive led oversight committee reviewing and strategizing weekly. Managers and HR continue to work on recruitment efforts and training and orientation of new staff. An Interim Manager was hired April to assist with recruitment of staff and this role continues to the end of October. OT reports including staffing gap reports being done by managers and directors bi-weekly. Proposal to hire an interim Scheduling Manager was approved and commenced Nov 2nd.

50 Cambridge Memorial Hospital Corporate Scorecard FY2016/2017 Indicator: 5 Status: Year End Projection: Sick Hours Variance from Budget MRP: TOTH,SUSAN Sick Hours Variance K -1.6K -2K -2.4K Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Month 2015/ /2017 Detailed Monthly Data Points 01 Apr 02 May 03 Jun 04 Jul 05 Aug 06 Sep 07 Oct 08 Nov 09 Dec 10 Jan 11 Feb 12 Mar 2015/2016-1, ,286-2,263-1,873-1,682-2,164-1,596-1,506-1,653-1,512-1, /2017-1, Indicator Details/Components Action Plan Updated: 2016/11/07 13:00 Definition: Variance in actual sick hours from budgeted sick hours Formula: Budgeted Sick Hours - Actual Sick Hours Target: Performance target is 0% variance from budget. Year End Projection: Red Analysis: Sick time continues to be higher than budget, however total hours ytd are 5604 hours less that last year at this time. Large negative variances exist in Emergency, Operating Rooms, Medical Device Reprocessing, Social Work, Ultrasound, Histology and Medicine. Longer term medical conditions, surgical and upper respiratory absences are of current concern corporately. Action Plan: Employee Health and Wellness, Human Resources and the Managers are meeting to review current cases and determining additional supports required and consideration of accommodation, modified work varied schedules and alternate duties on a case by case basis. The sick and overtime task force is focusing on attendance letter delivery compliance and reporting of leader compliance at stage 4 and 5. Additionally, we are reviewing year over year absence data by issue and duration to identify additional strategies for improvement. ONA has new attendance language that has the attendance management program in abeyance for ONA members. A revised/new program will be developed for this group to ensure compliance with the new language.

51 Cambridge Memorial Hospital HSAA Scorecard Fiscal Year Indicator Status & Trends Indicator Number 1 2 Efficient QIP/HSAA 90th Percentile ED Length of Stay HSAA 90th Percentile ED Wait-Time for Non-Admit Complex Patients Status Previous Status Year End Projection HSAA HSAA HSAA HSAA HSAA HSAA 90th Percentile ED Wait-Time for Non-Admit Minor Patients Day Surgery Weighted Visits Emergency Department Weighted Cases Acute Inpatient Weighted Cases Mental Health Weighted Patient Days Rehab Inpatient Weighted Cases Integrated & Equitable HSAA HSAA HSAA HSAA HSAA HSAA 90th Percentile Wait-Times for Computed Tomography 90th Percentile Wait-Times for Magnetic Resonance Imaging Percentage Alternate Level of Care Days - Closed Cases Percentage Alternate Level of Care Days - Open Cases Computed Tomography Operating Hours Magnetic Resonance Imaging Operating Hours Safe, Effective, Accessible 15 HSAA Ambulatory Care Visits

52 Cambridge Memorial Hospital Corporate Scorecard FY2016/2017 Indicator: 1 Status: Year End Projection: 90th Percentile Emergency Department Length Of Stay for Admitted Patients MRP: SHARRATT,RITA Hours Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Month 2015/ /2017 Detailed Monthly Data Points 01 Apr 02 May 03 Jun 04 Jul 05 Aug 06 Sep 07 Oct 08 Nov 09 Dec 10 Jan 11 Feb 12 Mar 2015/ / Definition: Indicator Details/Components Action Plan Updated: 2016/11/07 12:32 The total emergency room length of stay (in hours) where 9 out of 10 admitted patients completed their visits. ED LOS is defined as the time from triage to the time when the patient leaves the ED. The 90th percentile length of stay is from triage to left ED (in hours) for admitted patients. Excludes Left Without Being Seen, and cases with incomplete date and time stamps Formula: The ED LOS are ranked from lowest to highest, and the number of occurences are multipled by 0.9 to find the 90th percentile rank. The value at this rank is represented. If there is a decimal this is rounded up. Target: Current Year Target is 16 hours. Corridor is 17.6 Hours. HSAA Target is 8 Hours Year End Projection: Projecting green status for year end. Analysis: EDLOS is improving consistently this year, and significantly over 15/16. Stabilization of clinical leadership has helped this indicator. Action Plan: Flow team continues to meet weekly. Realignment of medicine model of care planned which will improve the pulling of patients quicker to medicine from the ED. Work processes regarding discharge planning reengineered to improve patient flow to the community. Focus of inpatient units to pull patients within 60 minutes of admit time. Significant data sharing with ED providers regarding individual provider initial assessment times - sees improvement for last 3 weeks < 3 hour target.

53 Cambridge Memorial Hospital Corporate Scorecard FY2016/2017 Indicator: 2 Status: Year End Projection: 90th Percentile Wait-Times for Emergency Department Non-Admit Complex Patients MRP: SHARRATT,RITA 10 Wait Time in Hours Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Month 2015/ /2017 Detailed Monthly Data Points 01 Apr 02 May 03 Jun 04 Jul 05 Aug 06 Sep 07 Oct 08 Nov 09 Dec 10 Jan 11 Feb 12 Mar 2015/ / Definition: Indicator Details/Components Action Plan Updated: The total emergency room length of stay (in hours) where 9 out of 10 non-admitted complex patients completed their visits. ED LOS is defined as the time from triage to the time when the patient leaves the ED. The 90th percentile length of stay is from triage to left ED (in hours) for admitted patients. Excludes Left Without Being Seen, and cases with incomplete date and time stamps. 2016/09/14 10:31 Formula: Target: Using Disposition Code 01 (discharged home) or 15 (discharged to place of residence), CTAS 1, 2 or 3 and inclusion and exclusion criteria, the ED LOS are ranked from lowest to highest, and the number of occurences are multipled by 0.9 to find the 90th percentile rank. The value at this rank is represented. If there is a decimal this is rounded up Performance target is 8 hours. Corridor is 8.8 hours. Year End Projection: CMH continues to be green in this indicator. Analysis: Status continues to be on track. CMH ED staff continue to assess and care for these patients well within provincial targets. Action Plan: Continuous process improvements discussed regularly at staff huddles. Secondary assessments completed by RNs and charts in line for reassessment with physicians have decreased wait times and improved treatment times. No further actions at this time.

54 Cambridge Memorial Hospital Corporate Scorecard FY2016/2017 Indicator: 3 Status: Year End Projection: 90th Percentile Wait-Times for Emergency Department Non-Admit Minor Patients MRP: SHARRATT,RITA Wait Time in Hours Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Month 2015/ /2017 Detailed Monthly Data Points 01 Apr 02 May 03 Jun 04 Jul 05 Aug 06 Sep 07 Oct 08 Nov 09 Dec 10 Jan 11 Feb 12 Mar 2015/ / Definition: Indicator Details/Components Action Plan Updated: The total emergency room length of stay (in hours) where 9 out of 10 non-admitted minor patients completed their visits. ED LOS is defined as the time from triage to the time when the patient leaves the ED. The 90th percentile length of stay is from triage to left ED (in hours) for admitted patients. Excludes Left Without Being Seen, and cases with incomplete date and time stamps. 2016/11/16 10:11 Formula: Target: Using Disposition Code 01 (discharged home) or 15 (discharged to place of residence), CTAS 4 or 5 and inclusion and exclusion criteria, The ED LOS are ranked from lowest to highest, and the number of occurences are multipled by 0.9 to find the 90th percentile rank. The value at this rank is represented. If there is a decimal this is rounded up. Performance target is 4 hours. Corridor is 4.4 hours. Year End Projection: It is expected that this result will continue red. Analysis: Some improvement in the new fiscal year compared to the end of FY 2015/16. In June and August, able to reach yellow threshold, however in June and September returned to red status. Action Plan: Nurse Practitioner schedule can directly impact this metric. There is a limited ability to replace when sick or on vacation. Volumes in ED decreases on Saturdays with increases on Mondays. Change to NP schedule to occur late November to impact this indicator. Additionally, PIA (provider initial assessment) times shared with all ED Providers. Since this in October, there have been improved PIA times. It is hoped some improvement with be seen in October and November.

55 Cambridge Memorial Hospital Corporate Scorecard FY2016/2017 Indicator: 4 Status: Year End Projection: Day Surgery Weighted Visits - Year To Date MRP: MEYETTE,MICHAEL 2.4K Weighted Visits Year To Date 2K 1.6K 1.2K Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Month Weighted Visits: 2015/2016 Target: 2015/2016 Weighted Visits: 2016/2017 Target: 2016/2017 Detailed Monthly Data Points 01 Apr 02 May 03 Jun 04 Jul 05 Aug 06 Sep 07 Oct 08 Nov 09 Dec 10 Jan 11 Feb 12 Mar 2015/ ,021 1,217 1,407 1,551 1,721 1,746 1, / Indicator Details/Components Action Plan Updated: 2016/11/07 13:00 Definition: Total day surgery visits adjusted for resource intensity Formula: Sum of Day Surgery visits multiplied by the associate weight Target: Performance year end target is 2000 weighted visits. Year end corridor is weighted visits. Year End Projection: We anticipate that we will achieve the target volume by year end. Analysis: Our volumes are slightly higher than last year at this time (15 cases), and are on track to achieve the target volume. The Endoscopy contribution of the volumes remains tracking to target volumes. The weighted surgical cases are slightly higher at.27 per case vs.25 at this time last year. Action Plan: No additional action is needed to achieve the target.

56 Cambridge Memorial Hospital Corporate Scorecard FY2016/2017 Indicator: 5 Status: Year End Projection: Emergency Department Weighted Cases Year To Date MRP: SHARRATT,RITA 3.2K Weighted Cases Year To Date 2.8K 2.4K 2K 1.6K 1.2K.8K.4K 0K Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Month Weighted Cases: 2015/2016 Target: 2015/2016 Weighted Cases: 2016/2017 Target: 2016/2017 Detailed Monthly Data Points 01 Apr 02 May 03 Jun 04 Jul 05 Aug 06 Sep 07 Oct 08 Nov 09 Dec 10 Jan 11 Feb 12 Mar 2015/ ,187 1,420 1,660 1,888 2,138 2,392 2,643 2, / ,197 Indicator Details/Components Action Plan updated: 2016/09/14 10:30 Definition: Total Emergency Department visits adjusted for resource intensity Formula: Sum of all scheduled and non-scheduled ED visits multiplied by the associated weights Target: Performance year end target is 2747 weighted cases. Year end corridor is weighted cases. Year End Projection: Projecting green performance for year. Analysis: CMH is on target to attain target volumes. Weighted cases very similar year over year. Action Plan: No further action at this time.

57 Cambridge Memorial Hospital Corporate Scorecard FY2016/2017 Indicator: 6 Status: Year End Projection: Inpatient Weighted Cases Year To Date MRP: MEYETTE,MICHAEL 12K Weighted Cases Year To Date 10K 8K 6K 4K 2K 0 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Month Weighted Cases: 2015/2016 Target: 2015/2016 Weighted Cases: 2016/2017 Target: 2016/2017 Detailed Monthly Data Points 01 Apr 02 May 03 Jun 04 Jul 05 Aug 06 Sep 07 Oct 08 Nov 09 Dec 10 Jan 11 Feb 12 Mar 2015/ ,681 2,663 3,430 4,122 4,876 5,702 6,511 7,280 8,074 8,783 9, / ,594 2,412 3,062 3,804 Indicator Details/Components Action Plan Updated: 2016/11/16 10:17 Definition: Total acute inpatient cases adjusted for resource intensity Formula: Sum of inpatient discharges multiplied by the resource intensity weight for their associated Case Mix Group Target: Performance year end target is 9700 weighted cases. Year end corridor is weighted cases. Year End Projection: We expect to be within the target Corridor. Analysis: Our inpatient discharges match last year's volumes to the end of August, however our total weighted cases and patient days are lower than last year at this time. The drop in weighted cases and patient days is primarily related to a decreased number of long stay patients this year compared to last year. Last year April to August we discharged 79 Long Stay patients with a total of 759 weighted cases compared to this year with 68 patients and 441 weighted cases. We still expect to finish the year within the target corridor. Action Plan: We will continue to monitor, but since the case volumes are the same and the drop in weighted cases can be explained by improved Length of Stay performance, we are not concerned.

58 Cambridge Memorial Hospital Corporate Scorecard FY2016/2017 Indicator: 7 Status: Year End Projection: Mental Health Weighted Patient Days MRP: SHARRATT,RITA 10K Weighted Cases Year To Date 8K 6K 4K 2K 0 Apr Jul Oct Jan Month Weighted Cases: 2015/2016 Target: 2015/2016 Weighted Cases: 2016/2017 Target: 2016/2017 Detailed Monthly Data Points Quarter 1 Quarter 2 Quarter 3 Quarter /2016 1, , , , /2017 3, Indicator Details/Components Action Plan Updated: 2016/11/16 10:17 Definition: Total mental health patient days adjusted for resource intensity Formula: A weighted total of days based on the SCIPP weighted patient days Target: Performance year end target is 7000 weighted patient days. Year end corridor is 6300 weighted patient days. Year End Projection: The year end projection will be Yellow. Analysis: Our new target has been reduced to 7,000 weighted cases and the performance corridor is 6,300. At the end of Q2 our volumes is just under the target of 3500 but we are within the 10% yellow threshold. We have reconciled the CIHI data to our internal data and have corrected a number of data issues that prevented them from being accepted by CIHI. Note, Q1 data not available due to missed data submission deadline, but the Q2 value is year to date. Action Plan: We continue to assess the processes that have been put in place to identify any assessment errors, that would prevent them from being accepted by CIHI, as well as any missing assessments. This should improve data quality and completeness going forward. We have also completed a review of assessments that were missing in the CIHI data for Q1, Q2 and Q3 and they have been corrected and submitted so that the year end reports will reflect the true volume of activity.

59 Cambridge Memorial Hospital Corporate Scorecard FY2016/2017 Indicator: 8 Status: Year End Projection: Rehab Inpatient Weighted Cases - Year To Date MRP: SHARRATT,RITA 320 Weighted Cases Year To Date Apr Jul Oct Jan Month Weighted Cases: 2015/2016 Target: 2015/2016 Weighted Cases: 2016/2017 Detailed Monthly Data Points Quarter 1 Quarter 2 Quarter 3 Quarter / / Indicator Details/Components Action Plan Updated: 2016/11/07 12:50 Definition: Total rehab cases adjusted for resource intensity Formula: The total Number of inpatient rehabilitation cases, adjusted for resource intensity using Rehabilitation Patient Group (RPG) weights Target: Performance year end target is 236 weighted cases. Year end corridor is weighted cases. Year End Projection: We are on track to achieve the target volume. Analysis: CMH is up year over year for Q1 volumes with 71 patients and an average intensity weight of 1.216, compared to last year at this time with 59 patients and an average weight of 1.16 Action Plan: No action required at this time. Monitoring of patient activity and attention to the regional co ordinated bed access system to ensure timely acceptance of referrals will continue.

60 Cambridge Memorial Hospital Corporate Scorecard FY2016/2017 Indicator: 9 Status: Year End Projection: 90th Percentile Wait-Times for Computed Tomography (CT) MRP: PROCIW,MICHAEL Wait Time in Days Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Month P3: 2015/2016 P4: 2015/2016 P3: 2016/2017 P4: 2016/2017 Detailed Monthly Data Points 01 Apr 02 May 03 Jun 04 Jul 05 Aug 06 Sep 07 Oct 08 Nov 09 Dec 10 Jan 11 Feb 12 Mar P3 2015/ / Apr 02 May 03 Jun 04 Jul 05 Aug 06 Sep 07 Oct 08 Nov 09 Dec 10 Jan 11 Feb 12 Mar P4 2015/ / Definition: Indicator Details/Components Action Plan Updated: The wait time in days that 9 out of 10 patients receive service. P3 are Priority Level 3 patients and have a 90th percentile target of 10 days. P4 are Priority Level 4 Patients and have a target of 28 days. 2016/11/07 10:44 Formula: The 90th percentile of CT scans performed. Wait days are the number of days between the date the CT scan order was received and the date the CT scan was performed. Target: Performance Target is 28 days for Priority Level 4, Corridor is days. Priority level 3 Target is 10 days. Year End Projection: CMH continues to closely monitor CT demand and as much as possible juggle available capacity to accomodate urgent/emergent requests. It is anticipated that CMH will meet its P3 and P4 performance expectations in the current year. Analysis: Action Plan: During the summer, CMH was informed that the WWLHIN has implemented a population based wait time funding allocation model. This will result in a reduction of 398 hours in 16/17. A decision has been made not to reduce CMH's current service complement and to absorb this loss through one time budgetary savings with the hope that additional hours will be provided in Q4 when wait time budgets are redistributed. If this does not occur, CMH will be forced to reduce service offerings in the upcoming year. Despite this, the demand for CT services continues to grow. Managing P3 wait time will remain CMH's main priority with the offset being possible increases in P4 Wait Time. Performance in Aug and Sept has been positive. CMH will continue with the current service offering and do its best to prioritize P3 access.

61 Status: Wait Time in Days Year End Projection: Cambridge Memorial Hospital Corporate Scorecard FY2016/2017 Indicator: 10 90th Percentile Wait-Times for Magnetic Resonance Imaging (MRI) Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Month MRP: PROCIW,MICHAEL P3: 2015/2016 P4: 2015/2016 P3: 2016/2017 P4: 2016/2017 Detailed Monthly Data Points 01 Apr 02 May 03 Jun 04 Jul 05 Aug 06 Sep 07 Oct 08 Nov 09 Dec 10 Jan 11 Feb 12 Mar P3 2015/ / Apr 02 May 03 Jun 04 Jul 05 Aug 06 Sep 07 Oct 08 Nov 09 Dec 10 Jan 11 Feb 12 Mar P4 2015/ / Indicator Details/Components Action Plan Updated: 2016/11/07 10:48 Definition: P3 are Priority Level 3 patients and have a 90th percentile target of 10 days. P4 are Priority Level 4 Patients and have a target of 28 days. Formula: The 90th percentile of MRI procedures performed. Wait days are the number of days between the date the MRI order was received and the date the MRI was performed. Target: Performance target is 28 days for Priority Level 4. Corridor is days. Priority Level 3 target is 10 days. Year End Projection: CMH continues to prioritize urgent/emergent P3 demand for service and in most instances has managed to ensure access within the provincial limits (except for July/August). P4/elective demand for services far outstrip available capacity and in the short term there is very little likelyhood of meeting the provincial P4 targets (whether they be 28 days or 60 days-see below). We will continue to experience variances on P3 wait time as we juggle available slots with peaks and valleys regarding P3 demand. Analysis: Action Plan: During the summer CMH was informed that the WWLHIN has implemented a population based wait time funding allocation model which would result in a reduction of 309 hrs in the current year. CMH has made the decision to not reduce its service offerings in the current year and support the loss with one time savings with the hope that additional hrs will be allocated in Q4 when wait time budget are redistributed. If that is not the case, then we will be faced with the prospect of service reductions.demand for MRI Access continues to grow and is the cause of the gradual increase in comparison to last year. Dialogue with the WWLHIN has also resulted in a recommendation that target wait times for P4 procedures be increased to 60 days Management has begun the process of upgrading its automated requisitioning process to include referral guidelines with the intent of creating appropriateness criteria for MRI referrals. The regional Surgical Council will also be engaged regarding appropriateness criteria for select orthopedic procedures. In addition, a regional initiative is underway to review MRI protcols across the LHIN which may add to further efficiencies. MRI requisitions continue to be reviewed with the intent of juggling available capacity to ensure those in greatest need (P3) have the best possible access. Thus far, this has been fairly successful.

62 Cambridge Memorial Hospital Corporate Scorecard FY2016/2017 Indicator: 11 Status: Year End Projection: Percentage Alternate Level of Care - Closed Cases MRP: SHARRATT,RITA Percentage ALC Days (Closed) Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Month 2015/ /2017 Detailed Monthly Data Points 01 Apr 02 May 03 Jun 04 Jul 05 Aug 06 Sep 07 Oct 08 Nov 09 Dec 10 Jan 11 Feb 12 Mar 2015/ / Definition: Indicator Details/Components Action Plan Updated: The Closed ALC rate is the rate of ALC patient days for discharged patients over the total patient days for patients discharged in the period. An ALC day is a day accrued by a patient who originally was admitted for acute care, and has now completed the acute care phase of their care plan and is waiting for a more appropriate level of care placement while continuing to occupy an acute care bed 2016/11/07 12:36 Formula: Closed ALC Cases = (Total Acute ALC Patient Days / Total Patient Days) x 100. The sum of acute patient days excludes newborn/obstetrics) and patient days for SSR, CCC, and rehab. Calculated using coded data as data source Target: Performance target is 15% ALC Days. Corridor is 16.5%. H-SAA target 9.46%. Year End Projection: Projecting yellow performance based on 16.5% corridor. Analysis: The closed rates has been around the 10% mark for the last 3 months but spiked in September. The closure of a long term challenging ALC case attributed to this increase - LOS of > 450 days. Action Plan: CMH/CCAC Integrated Discharge Planning Manager continues to lead our teams focus to ALC patients. Home First strategies along with CCAC intensive home services plan complex discharge planning with patients and families. ALC rounds continue with managers and discharge team 2x per week. ALC refresh of terms and usage scheduled for Flow Team in early April - improvements for physician, nursing and allied health groups. Concentrated work continues with fewer long term ALC patients.

63 Cambridge Memorial Hospital Corporate Scorecard FY2016/2017 Indicator: 12 Status: Year End Projection: Percentage Alternate Level of Care - Open Cases MRP: SHARRATT,RITA Percentage of ALC days Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Month 2015/ /2017 Detailed Monthly Data Points 01 Apr 02 May 03 Jun 04 Jul 05 Aug 06 Sep 07 Oct 08 Nov 09 Dec 10 Jan 11 Feb 12 Mar 2015/ / Definition: Indicator Details/Components Action Plan Updated: The Open ALC rate is the rate of ALC patient days, including patients still in hospital, over the total patient days in the period. An ALC day is a day accrued by a patient who originally was admitted for acute care, and has now completed the acute care phase of their care plan and is waiting for a more appropriate level of care placement while continuing to occupy an acute care bed 2016/11/07 12:47 Formula: Open ALC Cases = (Total Acute ALC Patient Days / Total Patient Days) x 100. The sum of acute patient days excludes newborn/obstetrics) and patient days for SSR, CCC, and rehab *Calculated using Meditech as data source Target: Performance target is 15% ALC Days. Corridor is 16.5%. Year End Projection: Project green status by year end. Analysis: ALC open cases in green. We continue to see a steady decrease in open cases since October Action Plan: Laser focus on ALC rounds continue bi-weekly planning. Policies for escalation of long term care and discharge planning efforts reviewed and revised. Escalation of any barriers to patient discharge done daily as needed.

64 Cambridge Memorial Hospital Corporate Scorecard FY2016/2017 Indicator: 13 Status: Year End Projection: Computed Tomography (CT) Operating Hours MRP: PROCIW,MICHAEL 3K 2.8K 2.4K Operating Hours 2K 1.6K 1.2K Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Month Operating Hours: 2015/2016 Target: 2015/2016 Operating Hours: 2016/2017 Target: 2016/2017 Detailed Monthly Data Points 01 Apr 02 May 03 Jun 04 Jul 05 Aug 06 Sep 07 Oct 08 Nov 09 Dec 10 Jan 11 Feb 12 Mar 2015/ , , , , , , , , / , Indicator Details/Components Action Plan Updated: 2016/11/07 10:50 Definition: CT Total Operating Hours Formula: CT Total Operating Hours for month Target: Performance year end target is 2,738 hours. Year End Projection: CMH will meet its allocated CT Service volume expectaion Analysis: CMH was informed that its allocated level of CT Hrs would be reduced by 162 hrs in 16/17 based on the LHIN applying a population based allocation methodology. Services will not be scaled back in the current year, with the hope that incremental hrs will be redistributed in January. If that does not occur, the plan will be to cut back service offering in 17/18. Action Plan: No action is required at this time

65 Cambridge Memorial Hospital Corporate Scorecard FY2016/2017 Indicator: 14 Status: Year End Projection: Magnetic Resonance Imaging (MRI) Operating Hours MRP: PROCIW,MICHAEL 4.5K 4.6K 4K 3.5K Operating Hours 3K 2.5K 2K 1.5K 1K.5K 0K Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Month Operating Hours: 2015/2016 Target: 2015/2016 Operating Hours: 2016/2017 Target: 2016/2017 Detailed Monthly Data Points 01 Apr 02 May 03 Jun 04 Jul 05 Aug 06 Sep 07 Oct 08 Nov 09 Dec 10 Jan 11 Feb 12 Mar 2015/ ,139 1,509 1,853 2,221 2,589 2,949 3,311 3,679 4,121 4, / ,152 1,488 1,881 2,552 Indicator Details/Components Action Plan Updated: 2016/11/07 10:52 Definition: MRI Total Operating Hours Formula: MRI Total Operating Hours for month Target: Performance year end target is 4,156 hours. Year End Projection: CMH will achieve its approved MR service level Analysis: CMH was informed that its 16/17 MRI hrs allocation will be reduced by 309 hrs due to the LHIN applying a new population based allocation methodology. Service hrs will not be scaled back in 16/17 with the hope that additional hrs will be redistributed to CMH in Jan/17. If that does not occur, services will be scaled back in fiscal year 17/18 with a resulting impact on P4 wait time. Action Plan: No action is required at this time.

66 Cambridge Memorial Hospital Corporate Scorecard FY2016/2017 Indicator: 15 Status: Year End Projection: Ambulatory Visits - Year To Date MRP: MEYETTE,MICHAEL 90K 80K 70K 60K Visits 50K 40K 30K 20K 10K 0K Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Month Visits: 2015/2016 Target: 2015/2016 Visits: 2016/2017 Target: 2016/2017 Detailed Monthly Data Points 01 Apr 02 May 03 Jun 04 Jul 05 Aug 06 Sep 07 Oct 08 Nov 09 Dec 10 Jan 11 Feb 12 Mar 2015/2016 7,107 13,766 21,160 27,486 32,550 40,824 47,830 54,111 60,688 67,379 74,057 81, /2017 7,330 14,736 21,356 26,839 33,350 40,147 Indicator Details/Components Action Plan Updated: 2016/11/07 12:52 Definition: Number of ambulatory care visits. Formula: Number of ambulatory care visits (clinic, community, and surgery), excludes emergency and telephone visits Target: Performance year end target is visits. Year end Corridor is vsits. Year End Projection: We expect to be a little above target by end of year Analysis: Volumes are just slightly lower than last year at this time, and a little over target. Action Plan: No additional action required as we are on target.

67 Agenda Item November 2016 BOARD WORK PLAN Charter Section #4 Tone at the Top Action (Italics-comments) Committee Responsible Sep Nov Jan Feb May Jun a-i, ii Approve CEO goals and objectives Approve COS goals and objectives Executive Mid-year/Year-end CEO report and assessment Mid-year/Year-end COS report and assessment Executive CEO evaluation/feedback mid-year COS evaluation/feedback mid-year Executive Executive CEO evaluation/feedback year end and performance based compensation COS evaluation/feedback year end and performance based compensation a-iii Reviewing the performance assessments of the VPs summary report provided to the Board (as per policy 2-B-10) Executive Strategic Planning b Strategic Plan: approve process, participate in development, approve plan (done in 2014; will be done again in 2017) Board b Progress report on Strategic Plan Board C b-iii-c Approve annual quality improvement plan Quality b-iii-c Review and approve the Hospital Services Accountability Agreement (H-SAA) Resources, Quality b-iii-c Monitor performance indicators and progress toward achieving the quality improvement plan Quality C Corporate Performance c-i-b c-i-b Critical incidents report (as per the Excellent Care for All Act). (Brought forward to Board as deemed necessary) Monitor, mitigate, decrease and respond to principal risks Quality Audit 25 November 2016 Page 1 of 6

68 Agenda Item November 2016 BOARD WORK PLAN Charter Section #4 c-i-e c-i-f c-i-f c-i-f Action (Italics-comments) Review the functioning of the Corporation, in relation to the objects of the Corporation the Bylaw, Legislation, and the HSAA (Medical/Professional By-law Review ) Receive and review: Resources Scorecard Quality Scorecard HSAA Scorecard Board Scorecard Note: Resources & Quality scorecards are available on the portal in the respective committee sections. HSAA & Board scorecards appear in the Board consent package Declaration of Compliance with M-SAA Schedule G (due Oct 31 and Apr 30 to the WWLHIN) Committee Responsible Sep Nov Jan Feb May Jun Governance Resource Quality Resource Board C C C C Resources C Declaration of Compliance with BPSAA Schedule A (due May 31 to the WWLHIN) Resources Receive and review quarterly the CEO certificate of compliance regarding the obligations for payments of salaries, wages, benefits, statutory deductions and financial statements Resources C C Procedures to monitor and ensure compliance with applicable legislation and regulations Succession Planning Audit C e-i-a CEO succession plan and process Executive e-i-b COS succession plan and process Executive e-i-c Succession plan for executive management and professional staff leadership Receive summary report from Executive/CEO/COS on CEO & COS succession plans Executive Executive Professional Staff f-i-a f-i-b/c Ensure the effectiveness and fairness of the credentialing process Monitor indicators of clinical outcomes, quality of service, patient safety and achievement of desired outcomes (MAC scorecard) MAC/Quality MAC C 25 November 2016 Page 2 of 6

69 Agenda Item November 2016 BOARD WORK PLAN Charter Section #4 Action (Italics-comments) f-i-c Make the final appointment, reappointment and privilege decisions for Medical/Professional Staff Oversee the Medical/Professional Staff through and with the MAC and COS Financial Viability Committee Responsible Board COS Sep Nov Jan Feb May Jun C C C C h-i-a,c h-i-a,c h-i-a, B Review and approve multi-year capital strategy Review and approve multi-year information technology strategy Review and approve annual operating plan service changes, operating plan, capital plan Resources Resources Resources/ Quality Approve the year-end financial statements Board Approve key financial objectives that support the corporation s financial needs h-i-a (including capital allocations and expenditures) (assumptions for following year budget) Review of management programs to oversee compliance with financial principles i-i-c and policies Board Effectiveness Resources Resources i Establish Board Work Plan Board C i-i-a Ensure Board Members adhere to corporate governance principles and guidelines Governance Declaration of conflict agreement signed by directors annually Indemnity Agreement signed by directors annually C C i-i-b Ensure the Board s own effectiveness and efficiency, including monitoring the effectiveness of individual Directors and Board officers and employing a process for Board renewal that embraces evaluation and continuous improvement Governance/ Board i-i-c Ensure compliance with audit and accounting principles Audit i-i-d Periodically review and revise governance policies, processes and structures as appropriate Governance C C Fundraising 25 November 2016 Page 3 of 6

70 Agenda Item November 2016 BOARD WORK PLAN Charter Section #4 Action (Italics-comments) k Support fundraising initiatives including donor cultivation activities. (through Foundation Report and Upcoming Events) Public Hospitals Act required programs Committee Responsible Sep Nov Jan Feb May Jun Foundation C C l-i-a l-i-b l-i-c Recruitment Ensure that an occupational health and safety program and a health surveillance program are established and require accountability on a regular basis Ensure that policies are in place to encourage and facilitate organ procurement and donation Ensure that the Chief Executive Officer, Nursing Management, Medical/Professional staff, and employees of the Hospital develop plans to deal with emergency situations and the failure to provide services in the Hospital Quality Quality Quality I C n Approve Nominating Committee membership (noted in By-law) Governance C Review recommendations for new directors, non-director committee members (2- D-20) Governance Conduct the election of officers (2-D-18) Governance Review evaluation results and improvement plans for the board, the board chair Governance (by the Governance Chair), Board committees, committee chairs (2-D-40) Review committee reports on work plan achievements (2-A-16) Governance 25 November 2016 Page 4 of 6

71 Agenda Item November 2016 BOARD WORK PLAN ON GOING AS NEEDED Charter Charter Item Action (Italics-comments) Committee Section #4 Responsible i-i-e Board Effectiveness Compliance with the By-Law Governance c-i-a, B Corporate Performance Ensure there are systems in place to identify, monitor, mitigate, decrease and respond to the principal risks to the Corporation: Audit, Resources Quality o financial o quality o patient/workplace safety c-i-c Corporate Performance Oversee implementation of internal control and management Resources information systems to oversee the achievement of the performance metrics c-i-d Corporate Performance Processes in place to monitor and continuously improve upon the performance metrics Resources/ Quality c-i-g Corporate Performance Policies providing direction for the CEO and COS in the management of the day-to-day processes within the hospital Governance/ Executive d-ii-a,b CEO and COS Select the CEO, delegate responsibility and authority, and require Executive accountability to the Board d-ii-c CEO and COS Policy and process for the performance evaluation and compensation of Executive the CEO d-ii-d, E CEO and COS Select the COS, delegate responsibility and authority, and require Executive accountability to the Board d-ii-f CEO and COS Policy and process for the performance evaluation and compensation of Executive the COS h Financial Viability Approve collective bargaining agreements Board h Financial Viability Approve salary increases, material amendments to benefit plans, Resources programs and policies h Financial Viability Approve capital projects Resources 25 November 2016 Page 5 of 6

72 Agenda Item November 2016 BOARD WORK PLAN ON GOING AS NEEDED Led by CEO/COS reported in CEO report/quality Presentations Charter Section #4 Charter Item Action (Italics-comments) Committee Responsible g Build Relationships Build and maintain good relationships with the Corporation s key stakeholders Board oversight Led by CEO/COS j-i-a Communication and Community Relationships Establish processes for community engagement to receive public input on material issues Board Oversight Led by CEO j-i-b Communication and Community Relationships Promote effective collaboration and engagement between the Corporation and its community, particularly as it relates to Board Oversight Led by CEO/COS j-i-c Communication and Community Relationships organizational planning, mission and vision Work collaboratively with other community agencies and institutions in meeting the healthcare needs of the community j-i-d Communication and Community Relationships Maintain information on the website j-i-e Communication and Community Establish a communication policy for the Corporation; review Relationships periodically (1-B-15 last reviewed Sept 30, 2015 reviewed every 3 years) m Communications Policy Oversee the maintenance of effective stakeholder relations through the Corporation s communications policy and programs and Chair Board Oversight Led by CEO/COS Quality Board oversight Led by CEO Board oversight Led by CEO Board oversight Led by CEO 25 November 2016 Page 6 of 6

73 Agenda item 2 11/24/2016 Quality Improvement and Patient Flow November 30, 2016 Kyle Leslie, MBA Manager, Transformation Office Caring Respect Innovation Collaboration Accountability Agenda 1) Pay for Results 2) Model for Improvement 3) Evaluation of Improvement Opportunities 4) Quality Improvement Tools 5) Conclusion 2 1

74 11/24/2016 Pay for Results Performance Metric Time to physician initial assessment (PIA) Emergency department length of stay for admitted patients (EDLOS) Time to inpatient bed CMH Target 90 th Percentile < 3 hours 90 th Percentile < 16 hours 90 th Percentile < 60 minutes Ontario s Pay for Results Program: Participating hospitals, including CMH, are ranked based on performance metrics Fixed pool of funding is allocated based on performance rank 3 90 th Percentile Length of Stay Example 1 LOS= 4 hours 2 LOS = 4 hours 3 LOS = 4 hours 4 LOS = 5 hours 5 LOS = 5 hours 6 LOS = 6 hours 7 LOS = 8 hours 8 LOS = 8 hours 9 LOS = 9 hours 10 LOS = 9 hours 11 LOS = 10 hours 12 LOS = 11 hours 13 LOS = 11 hours 14 LOS = 12 hours 15 LOS = 12 hours 16 Wait time = 15 hours 17 LOS= 15 hours 18 LOS = 16 hours 19 LOS = 22 hours 20 LOS = 25 hours A 90 th percentile shows the value at which 90% of the data set is below it In the above example, 90% of the patients had a length of stay (LOS) of 16 hours or less 4 2

75 11/24/2016 Model for Improvement Wildly Important Goal (WIG): By March 31, 2017: Improve ED 90 th Percentile length of stay from triage to admission from 22.6h (2015) to 16.0h in Q3 and Q4, within budgeted resources Patients experience shorter length of stay to see a provider Improved pull-times to the IP areas Improved length of stay for non-admitted patients Quality improvement tools help us design new solutions Evaluation through trial Adapt, Adopt, or Discard? Source: Associates in Process Improvement 5 Physician Initial Assessment (PIA) LOS by Day (Jan 1, 2016 to Nov 6, 2016) First Triage rotation Trial Green zone Triage rotation fully implemented as standard practice1 Nursing Blood Draws Physician engagement 2,3,4,6 Meditech PIA Logic created 3,7 3,4 4,3,5 1,7,5 5,3,6 5,3,6 1,3,4 8,7 4,2,8,6, 3 2,4,8 1,3,4 7,3, ,2,6,7 1,2 1 1,2 1,4 1,6 1 3,6 1,4 7,8,6 8 1,4 Contributing Factor Legend: 1) No Nurse Practitioner 5) Wait-time triage and registration 2) Monday 6) Evening volume 3) Documentation / Data quality 7) Volume 4) Scheduling 8) Acuity Improvements Data source: Local HIS (Not yet coded) 3

76 11/24/2016 Summary Run Chart Physician Initial Assessment (PIA) LOS by Day Step two of the Model for Improvement is to identify how we will know that a change is an improvement, to answer this question, run charts are extremely useful to monitor and measure the impact of change over time The run chart highlights data points and trends to be investigated Trends are investigated through doing a deep data dive to understand and validate contributing factors Validating contributing factors helps to identify opportunities for improvement Data is used to better understand how processes perform and to make decisions about how to improve processes For the purpose of this presentation the focus will be on the improvement work that has taken place to address two contributing factors: 1) LOS between triage and registration 2) data entry errors Emergency Department LOS for Admitted Patients by Day (Jan 1, 2016 to Nov 6, 2016) Bed tracker trial -refresh of MSM bedboard language and terminology -SBAR Process change -ED PSW portering admitted patients to floor 7,6,3 CDU out time automated Real-time clerical entry of Decision to admit times CAIP patients no longer admitted to (ED Hold) 5,8,10 1,6 4,8,3,10 7,3 7,6 6,3 4 4,2,3 1,2,8, 10 5,6,10 5, ,4 3 4,3 6,3,8,10 3 6,7,3, ,7,5 6,8 5,10 1,10 1 5,10 7 9,4,7 9,2 10,5 1 1 Contributing Factor Legend: 1) Pull-times to in-patient bed 7) Medical clearance for MHA patients 2) No beds 8) Correct bed placement on admission 3) Batching (admissions) / delay entering admission order 9) Surgical cases 4) Documentation / data quality 10) Low discharges 5) High admission volume 6) Transfer patients Improvements Data source: Local HIS (Not yet coded) 4

77 11/24/2016 Summary Emergency Department Length of Stay by Day Similar to the run chart for physician initial assessment (PIA) LOS, the run chart for Emergency Department LOS for Admitted Patients helps to determine data points and trends to be investigated The data analysis helps to identify opportunities for improvement The green flags are identifying where quality improvement work (process changes) took place Identifying where process changes took place on the run chart helps to monitor the impact over time On both run charts the down trend shown on the black trend line indicates that the LOS for a physician initial assessment and the LOS for a in-patient bed is improving Root Cause Analysis PIA 5

78 11/24/2016 Automated data checks Tactic Data Quality Clerical standards and guide Physician Initial Assessment (PIA) Data Entry Errors (PIA after Disposition Time) by Month Jan 2016 to Nov 2016 Physician Initial Assessment (PIA) Data Entry Errors (PIA before Triage/Reg time) by Month Jan 2016 to Nov Meditech PIA Logic created 50 Meditech PIA Logic created Number of Errors 30 Number of Errors /2016 2/2016 3/2016 4/2016 5/2016 6/2016 7/2016 8/2016 9/ / / /2016 2/2016 3/2016 4/2016 5/2016 6/2016 7/2016 8/2016 9/ / /2016 Data source: Local HIS (Not yet coded) CMH ED Triage Value Stream Old process: New process: Link value added process steps Drum (Source: Goldratt, 2004) 12 6

79 11/24/2016 Length of Stay Triage to Registration by Day (Jan 1, 2016 to Sep 30, 2016) Triage changes introduced and trial (PDSA) cycles began Triage rotation enforced as standard practice 60 90th%tile LOS Between Triage to Registration th%tile LOS Between Triage and Reg Median LOS Between Triage and Reg for Month Current state observations (baseline): -Max observed LOS from end of triage to registration = 22 min -Arrival to registration 90 th %tile (Meditech) =69 Min PDSA Observations: -Max observed LOS from end of triage to registration = 5 min (17 Min Improvement over baseline) -Arrival to registration 90 th %tile=34 min (35 Min improvement over baseline) -Arrival to registration 90 th %tile = 38 Min (31 min improvement over baseline) Data source: Local HIS (Not yet coded) Summary Run Chart Length of Stay Triage to Registration by Day The third step of the Model for Improvement is to identify what changes can be made that will result in an improvement Value stream mapping was applied to analyze and design a new process for triage and registration Following the Model for Improvement, Plan, Do, Study and Act (PDSA) cycles were conducted to gather feedback and validate through observation and data analysis that the change was an improvement and should become standard practice On the run chart we can see where the PDSA cycles took place as well as where the change became standard practice The down trend shown on the black trend line indicates the LOS between triage and registration is improving The red line reveals the monthly median which has improved gradually month over month compared to the baseline 14 7

80 11/24/2016 Impact on Our Care Metric 2015 (Jan 1 to Nov 6) 2016 (Jan 1 to Nov 6) Forecasted % Improvement 90 th Percentile Physician Initial Assessment LOS (Hours) 90 th Percentile Admitted EDLOS (Hours) % % Funding Rank % Data source: Local HIS (Not yet coded) Key Messages - Board s Impact on Quality 1) Vision: Set reasonable but aggressive quality improvement aims Ensure direction is clear and communicated to all stakeholders Continue to make the delivery of exceptional care top priority 2) Foundation: Enable and encourage the spirit of inquiry Develop transformational leaders with exceptional improvement skills Continue to build capacity for quality improvement Ensure strategic focus to make every stakeholder in the care process aware of their role to drive quality forward 3) Execution: Review progress and monitor performance Challenge and ask difficult questions Ensure results are measured, sustained and spread throughout the organization Source: 5 Million Lives Campaign. Getting Started Kit: Governance Leadership Boards on Board How-to Guide. Cambridge, MA: Institute for Healthcare Improvement; (Available at

81 Agenda Item Coronation Blvd, Cambridge, ON N1R 3G2 Tel Fax BRIEFING NOTE - OPEN SESSION Date: November 30, 2016 Issue: Purpose: Prepared by: Approved by: Upcoming Meetings & Upcoming Events Information Cheryl Vandervalk, Executive Assistant Patrick Gaskin, President & CEO December 2016 Executive Committee December 12, :00pm-7:00pm January 2017 Governance Committee January 12, :30pm-6:00pm Quality Committee January 18, :00am-9:00am Capital Projects January 23, :00pm-5:00pm Resources Committee January 23, :00pm-7:00pm Board of Directors January 25, :00pm-8:00pm February 2017 Quality Committee February 15, :00am-9:00am Capital Projects February 27, :00pm-5:00pm Resources Committee February 27, :00pm-7:00pm WWLHIN Board Meetings December 12, :00pm 50 Sportsworld Drive, Kitchener, ON OHA Conferences 2016/17 Events, Fall/Winter: Foundation Events: Community Celebration Dinner With Dr. Richard Heinzl, Founder of Doctors without Borders March 9, 2017 Armenian Centre, Cambridge Page 1 of 1

82 Agenda Item Coronation Blvd, Cambridge, ON N1R 3G2 Tel Fax BRIEFING NOTE Resources Committee Date: November 23, 2016 Issue: Purpose: October Financial Statements Review of October Financial Statements Prepared by: Mike Prociw Approved by: Patrick Gaskin Summary CMH has a October year to date operating surplus of $1,101K after building amortization and related capital grants which represents a $ 558K positive variance from budget. In October, CMH had an operating surplus of $153K. The positive YTD variance is primarily due to positive variances in salaries, medical remuneration and supplies offset by negative volume variances in QBPs and medical surgical supplies. It is expected that some of the variances will be reversed in future months as reflected in the annual forecast. Revenue A brief summary of some of the major year to date revenue variances include: MOH Funding: For the elective QBPS, the knee replacements are 9% (20 procedures) above target and hips are 2% (2 procedures) below target. Cataracts are 14% below target. Additional elective QBPs in breast cancer surgery are 30 procedures above target, thyroid cancer surgery is 6 procedures above target, knee arthroscopy is 71 procedures under target and tonsillectomy is 9 procedures below target. The hospital is in the process of negotiating elective volumes with the LHIN with the objective of maintaining the number of hips and knees that are performed at CMH and reducing the knee arthroscopy and tonsillectomy procedures. The LHIN had requested that the number of hip and knee procedures be reduced and the funding reallocated to emergent QBPs such as COPD and Pneumonia. All elective QBP funding is expected to be realized by year end. For the remaining QBPs, coded data is available up to the end of August and previous year s actuals are used as estimates for September and October Page 1 of 7

83 Agenda Item volumes. It is expected that all QBP revenue for emergent QBPs will be realized by year end. The number of unfunded cases for COPD and Pneumonia at year end will in part be determined by negotiations with the LHIN to reallocate volumes. The MOH Onetime/Other funding is less than budget due to the change in the ability to utilize the new grad program and the alignment of revenue with expenses for the Hospital On Call Coverage funding. There is a corresponding decrease in the Medical Remuneration expenditures. Billable Patient Services The negative YTD variance of $344K is primarily due to less than expected revenue from out of country patients, semi-private accommodations and the billing of professional fees partially offset by higher than expected WSIB revenue. In the month of October there were positive variances in preferred accommodation. Recoveries and Other Revenues The year to date positive variance is primarily due to higher than expected revenue from parking and interest. Amortization of Deferred Equipment Capital Grant The YTD positive variance is a result of the timing of capital purchases. Expenses Salaries and Wages There is a negative variance of $ 98K for the month and a positive variance of $181K year to date. The major drivers to the positive variance are the capitalization of IT salaries for work on capital implementations and the vacancies in the nursing float pool. Part of the positive variance is offset by pressures in the Emergency department and negative variances in sick and overtime Sick and overtime was over budget in the month by $50K (2015 over budget $145K). The YTD sick and overtime is over budget by $286K (2015 over budget $912K). The table below provides a summary in hours for sick and overtime. October YTD HOURS Actual Budget 2015 Actual Budget 2015 Overtime 1,767 1,568 3,130 14,539 10,871 20,819 Sick 4,120 2,694 4,447 22,507 18,552 27,576 A brief overview of the year to date over time variance is as follows: The emergency department has a YTD negative variance of $121K. The major cause of the overtime has been the length of time it has taken to recruit staff to fill vacant positions. It has been very difficult to attract and retain part time staff in the department. Overtime pressures are expected to continue over the Page 2 of 7

84 Agenda Item remainder of the fall with increased sick time and maternity leaves and until staffing positions have been filled. In the month of October a large amount of sick time created a negative overtime variance. The medicine units have a YTD negative variance of $24K which has resulted from a negative sick variance and a greater number than expected patients requiring one to one care. The average number of patient days has remained within the current compliment of beds. A brief overview of the year to date sick variance is as follows The medicine units and housekeeping have a combined negative YTD variance of $70K. This variance is offset by savings in the Nursing Float Pool, Labs and Mental Health. Work continues with the timely delivery of letters and meetings with staff that have a high number of sick days/occurrences. Other variances in salaries and wages are The emergency department has a YTD variance of $ 388K which is due to overtime, training costs of new staff hired, staff on modified work and unbudgeted salaries used for EMS ambulance offload which are fully funded by EMS. The registration department has a negative YTD variance of $ 104K which is primarily due to additional costs resulting from the training of new staff hired. The inpatient mental health department has a YTD negative variance of $105K primarily due to one to one care provided to a patient and challenges in implementing some changes to their staffing. The nursing float pool has a positive YTD variance of $143K due to the timing of hiring and training new nurses for the float pool The IT department is now following a new practice of capitalizing salaries for staff who work on capital projects. The practice is consistent with the accounting of peer hospitals. The new practice has contributed to a YTD positive variance of $152K. Benefits The YTD maternity top up expense has a $ 75 K negative variance. Past practice was used to determine the budget allocation. The entire maternity top up is recognized at the inception of the leave and therefore the expense is subject to fluctuations during the year The YTD percentage in lieu expense is $ 50K in excess of budget. The variance is a result of having more part time staff then what was budgeted. The part time staff is used to fill the vacant full time positions. Medical Remuneration The volume in nuclear medicine and ultrasound is $ 160K less YTD then last year. The change in billing for hospitalists has resulted in $ 150K YTD of positive variance in hospitalist expenses. Some of this positive variance will be reduced in future months as the medicine unit surges to meet the increase in demand. The surge will result in additional hospitalist hours The ER AFA expenditures are $ 214K YTD less than budget. These items are fully funded resulting in a similar variance in revenue. Page 3 of 7

85 Agenda Item The YTD positive variance of $ 140K in ECG and ICU is expected to be reduced in future months due to the surge of medical patients. Medical and Surgical Supplies There is a $ 311K YTD negative variance attributed to the utilization of medical surgical supplies within the Operating Room. A review is currently being undertaken to determine the source of the increase. Approximately 25% of the negative variance is attributed to increased number of joints that have been performed year to date. Expected savings YTD in inventory in the OR have not materialized resulting in a negative YTD variance of $ 50K. The remaining variance has been attributed to increased volume of utilization of expenditures by vendor and the cause of the increase is still being reviewed. Drug Expense The previous year s large negative variance has been reduced due to an increase in budget for systemic treatment. There is a YTD positive variance for oncology drugs of $ 127K which represents a 6% reduction in drug utilization from last year. Other Supplies and Expenses The clinical areas have a positive YTD surplus of $80K. This variance is consistent with the previous year s expenditures and is considered a timing difference which will be diminished throughout the year. $ 91K of the variance is a result of the timing of expenditures within the Lab and Diagnostic Imaging. Administration and HR contribute $115K of the positive variance. As in past years the variance will vary based on the need to engage professional services. Amortization The positive variance is due to the timing of capital purchases during the year Balance Sheet and Statement of Cash CMH s current cash position is $20.3 M in current operating and $ 10.1M in restricted cash. The restricted cash includes $ 6.6 M for the hospitals contribution to the sinking fund as required under the terms and condition of the Capital Redevelopment Project. The sinking fund payment was received from the Foundation. The working capital ratio meets the requirements of the Working Funds Agreement. The Capital Redevelopment Project has increased to $82.2M. In accordance with the agreement with the Ministry of Health CMH will make a lump sum payment of $ 65M to the general contractor once CMH takes ownership of the building. $ 59M of the payment will be funded by the Ministry with the remaining amount, $6.6M, will be funded the CMH Foundation Activity Volumes The medicine floors have averaged YTD 48 patients per day. During the month of October there was a decline of 8% in patient days. Page 4 of 7

86 Agenda Item The surgical floor has an average of 21 patients per day YTD. The volume for the month is 5% less than the average for the year. The mental health unit has an average of 17 patients per day YTD. During the month of October there was a decline of 6% in patient days. The summer has historically resulted in fewer days in the unit and September and October have been slow to catch up to the YTD average. The average numbers of YTD visits in the Emergency Room are 148 per day. The month of October was trending at the same rate as the yearly average. Forecast The forecast remains unchanged from September The forecasted surplus of $ 1,272K for the year is $ 310K higher then budget. The projected increase is due to net savings in medical staff remuneration and savings within the supplies budget. The YTD positive variance in salaries and wages will be offset by increases in sick and overtime plus the utilization of saving from the vacation savings in the summer. MOH Onetime / Other The New Grad funding is being reduced ($ 100K) due to the hospitals inability to utilize new grads in anticipated areas where there is a need for hiring. There is a corresponding decrease in salaries The ER AFA has been decreased ($250K) to reflect the first six months of funding. Medical staff remuneration has been adjusted downward by the same amount. Billable Patient Services The professional fees have been adjusted downward ($300K) to reflect reduced volumes in diagnostic imaging and labs. There is a corresponding decrease in medical staff remuneration WSIB and Out of Country revenue has been forecasted upward by $ 300K to reflect the current utilization and similarly uninsured procedures and preferred accommodations have been forecasted downward by $ 200K. Recoveries and Other Revenue There has been a forecasted increase in parking, interest and donations from the Foundation (for operational use) of $ 350K. There has been no budget for the recovery of nursing staff for EMS ambulance offload. $ 150K is forecasted offset by a similar amount in salaries Due to a combination decrease in volume in the oncology clinic plus a change in mix of drugs used the forecast reflects a reduction of $ 100k for revenue for oncology drugs. There is a corresponding decrease in the drug budget Page 5 of 7

87 Agenda Item Salaries and Wages The improvement in the sick and overtime has resulted in a forecast increase of $455k. The 2015/16 year end actual sick and overtime variance was $ 1,029K. A forecasted pressure in the ED and Registration is offset by savings within the nursing float pool, the capitalization of IT salaries and positive variances in lab and diagnostic imaging. Benefits Based on the current trend it is forecasted that the maternity benefit will increase by $ 125K Medical Remuneration The forecast reflects a reduction in expenditures for ER AFA and distribution of P fees. There is a corresponding decrease in revenue Based on the introduction of a new funding model for hospitalists there is a anticipated reduction in expenditures of $ 200K Medical Surgical Supplies Drugs The increase in forecast of $ 300K is due to the increased utilization of supplies within the OR. Budgeted savings in inventory adjustments will not be realized. Due to a combination decrease in volume in the oncology clinic plus a change in mix of drugs used the forecast reflects a reduction of $ 111k for oncology drugs. There is a corresponding decrease in revenue. Supplies It is anticipated that there will be $ 100K of savings within administration and an additional $ 50K of savings within the clinical departments. The savings are based on positive YTD variances Assumptions Depending on the saving strategies that are implemented for the 17/18 fiscal year there may be severances that will be accrued at year end. No severances have been reflected in the forecast. There is uncertainty in some QBP volumes such as COPD, CHF, Pneumonia and Hip Fractures. This uncertainty can have a negative impact on revenue or a negative impact on expenditures depending on activity in the last 2 quarters It is assumed that all incremental costs associated with the move into the new building will be fully funded Page 6 of 7

88 Agenda Item The forecast assumes that the ALC rate will remain in the low teens for the remainder of the year The budget assumes that a surge of 10 beds will occur for 5 months Page 7 of 7

89 Agenda Item Nov-16 CAMBRIDGE MEMORIAL HOSPITAL STATEMENT OF INCOME AND EXPENSE CONFIDENTIAL Month of October 2016 Year to date ending October 31, /17 16/17 15/16 prior year actuals Actual Plan Variance % var YTD Actual YTD Plan YTD Variance % var Plan Forecast Oct 15 YTD Oct 15 15/16 YE Operating Income MoH Funding $ 3,780,977 $ 3,779,598 $ 1, % MoH Base $ 26,101,083 $ 26,105,502 $ (4,419) (0.0%) $ 44,518,245 $ 44,518,245 $ 3,787,432 $ 26,159,610 $ 44,362,011 2,477,916 2,476, % MoH HBAM 17,105,614 17,108,491 (2,877) (0.0%) 29,175,463 29,175,463 3,008,811 17,568,322 29,521,147 1,565,202 1,416, , % MoH QBP 9,720,570 9,824,640 (104,070) (1.1%) 16,810,061 16,810,061 1,200,505 8,513,420 15,773, , ,792 (52,653) (9.9%) MoH Onetime / Other 3,418,885 3,666,140 (247,255) (6.7%) 6,311,790 5,961, ,784 3,900,659 7,163,712 8,302,234 8,204,354 97, % Total MoH Funding 56,346,152 56,704,773 (358,621) -0.6% 96,815,559 96,465,559 8,768,532 56,142,011 96,820,023 1,150,786 1,227,142 (76,356) (6.2%) Billable Patient Services 8,131,556 8,475,847 (344,291) (4.1%) 14,454,017 14,254,017 1,134,340 8,269,503 13,843, , ,093 41, % Recoveries and Other Revenue 5,888,216 5,669, , % 9,841,370 10,191, ,707 5,528,230 10,426, , ,088 21, % Amort'n of Deferred Equip Capital Grants 1,385,858 1,218, , % 2,089,611 2,089,611 36,169 1,127,778 2,303, , ,683 62, % MoH Special Votes Revenue 2,024,197 2,000,833 23, % 3,441,458 3,441, ,454 1,813,979 3,430,094 10,854,177 10,707, , % Total 73,775,979 74,069,163 (293,184) (0.4%) 126,642, ,442,015 10,951,202 72,881, ,823,889 Operating Expense 4,971,495 4,873,960 (97,535) (2.0%) Salaries & Wages 33,265,743 33,446, , % 57,272,674 57,269,674 5,148,627 32,979,996 56,564,531 1,203,023 1,192,228 (10,795) (0.9%) Employee Benefits 9,011,385 8,823,368 (188,017) (2.1%) 15,084,319 15,358,299 1,245,518 8,731,714 15,369,312 1,375,626 1,504, , % Medical Remuneration 9,729,054 10,404, , % 17,772,751 17,022,751 1,533,399 10,392,877 17,868, , ,565 (59,686) (8.5%) Medical & Surgical Supplies 5,240,768 4,846,859 (393,909) (8.1%) 8,285,146 8,585, ,172 4,829,625 8,428, , ,651 30, % Drug Expense 3,182,854 3,374, , % 5,782,859 5,601, ,789 3,356,886 5,650,439 1,138,939 1,060,595 (78,344) (7.4%) Other Supplies & Expenses 7,094,185 7,451, , % 12,617,746 12,467,746 1,095,143 7,010,028 12,055, , ,665 24, % Equipment Depreciation 2,687,069 2,739,746 52, % 4,672,148 4,672, ,189 2,416,169 4,648, , ,371 (70,751) (25.1%) MoH Special Votes Expense 2,024,244 1,998,314 (25,930) (1.3%) 3,441,458 3,441, ,460 1,843,379 3,430,094 10,637,882 10,504,141 (133,741) (1.3%) Total 72,235,302 73,085, , % 124,929, ,418,970 10,756,297 71,560, ,014, , ,219 13, % MOH Surplus (Deficit) 1,540, , , % 1,712,914 2,023, ,905 1,320,827 2,808,959 Other income (expense): -156,336 $ (157,104) 768 (0.5%) Building Depreciation (1,096,916) (1,085,113) (11,803) 1.1% (1,850,462) (1,850,462) (152,724) (1,067,825) (1,823,703) 93,488 93, % Amortization of Deferred Build Capital Grants 657, ,524 13, % 1,099,123 1,099,123 90, ,880 1,072,179 $ 153,447 $ 139,431 $ 14, % Net Surplus (Deficit) for the period $ 1,101,394 $ 542,921 $ 558, % $ 961,575 $ 1,271,706 $ 132,469 $ 881,882 $ 2,057,435

90 Agenda Item CAMBRIDGE MEMORIAL HOSPITAL COMPARATIVE BALANCE SHEET OCT MARCH ASSETS Current Assets Cash and short-term investments $ 20,307,484 $ 22,450,973 Due from Ministry of Health/LHIN 1,992,898 1,356,162 Other receivables 1,972,177 2,214,715 Inventories 1,689,189 1,775,585 Prepaid expenses 1,062, ,218 27,024,216 28,737,653 Non-Current Assets Cash and investments restricted - Capital 10,064,287 3,891,693 Endowment and special purpose fund cash & investments 187, ,427 Capital Assets 74,600,852 75,016,310 Capital Redevelopment Construction in Progress 82,176,723 51,690,998 TOTAL ASSETS $ 194,053,505 $ 159,524,081 LIABILITIES & EQUITY Current Liabilities Due to Ministry of Health/LHIN $ 450,719 $ 490,879 Accounts payable and accrued liabilities 18,356,630 21,592,823 18,807,349 22,083,702 Long Term Liabilities Employee future benefits 4,198,561 4,090,000 Capital Redevelopment Construction Payable 81,857,109 51,371,669 Deferred Capital Grants and Donations 66,389,569 60,278,429 Deferred Capital Grants Capital Redevelopment 2,245,400 2,245, ,690, ,985,498 Net Assets: Unrestricted 4,018,306 2,563,952 Externally restricted special purpose funds 187, ,427 Invested in Capital Assets 16,349,784 16,703,502 20,555,517 19,454,881 TOTAL LIABILITIES & EQUITY $ 194,053,505 $ 159,524,081

91 Agenda Item 2.1 CAMBRIDGE MEMORIAL HOSPITAL STATEMENT OF CHANGES IN FINANCIAL POSITION For the Month Ending October 31, 2016 Cash Provided By (used in) Operations: YTD OCT16 YTD SEP16 FY 2015/16 Excess (deficiency) of revenue over expenses $ 1,101,394 $ 554,108 $ 2,057,435 Items not involving cash: -Amortization 3,783,985 2,724,162 6,472,106 -Loss on Disposal of Assets 30,418 - (10,000) -Amortization of deferred grants and donations (2,043,491) (1,461,473) (3,375,924) Change in non-cash operating working capital (3,706,404) (2,843,809) 526,052 Change in employee future benefits 108,561 76,178 2,211 (725,537) (950,834) 5,671,880 Investing: Acquisition of capital assets & CRP (33,884,671) (21,787,946) (53,465,062) Grant receivable Endowment and special purpose investments ,060 (33,884,671) (21,787,946) (53,350,002) Financing: Sinking Fund contribution from CMH Foundation 6,633,923 6,622,850 Capital donations and grants & CRP 1,520,707 1,349,337 6,305,853 Construction payable 30,485,440 19,457,161 44,586,313 38,640,070 27,429,348 50,892,166 Increase (Decrease) In Cash for the period 4,029,862 4,690,567 3,214,044 Cash & Investments - Beginning of Year 26,342,666 26,342,666 23,128,622 Cash & Investments - End Of Period $ 30,372,528 $ 31,033,233 $ 26,342,666 Cash & Investments Consist of: Unrestricted Endowment and Special Purpose Investments $ 29,668 $ 29,668 $ 29,668 Cash & Investments Operating 20,278,573 20,514,795 22,421,305 Cash & Investments Restricted 10,064,287 10,488,770 3,891,693 Total $ 30,372,528 $ 31,033,233 $ 26,342, Nov-16

92 Agenda Item CMH Sick Hours Total 24Month Moving Average 95,000 90,000 85,000 80,000 75,000 70,000 65,000 60,000 55,000 50,000 O 14 N 14 D 14 J 15 F 15 M 15 A 15 M 15 J 15 J 15 A 15 S 15 O 15 N 15 D 15 J 16 F 16 M 16 A 16 M 16 J 16 J 16 A 16 S 16 O 16 Series1 81,305 78,859 79,042 79,468 80,833 82,429 82,136 81,238 80,616 81,722 82,644 83,110 84,634 85,505 85,710 86,134 86,290 85,958 85,953 85,352 84,875 85,096 86,031 83,577 88,267 Series3 68,413 68,504 68,643 68,780 69,139 69,397 68,779 68,181 67,614 67,057 66,459 65,876 65,278 64,735 64,191 63,619 63,176 62,506 62,089 61,672 61,278 61,056 60,867 60,673 60,470 CMH Over Time Hours Total 24Month Moving Average 65,000 60,000 55,000 50,000 45,000 40,000 35,000 30,000 25,000 20,000 O 14 N 14 D 14 J 15 F 15 M 15 A 15 M 15 J 15 J 15 A 15 S 15 O 15 N 15 D 15 J 16 F 16 M 16 A 16 M 16 J 16 J 16 A 16 S 16 O 16 Actual 48,164 47,771 46,436 46,860 46,702 45,044 45,066 45,719 46,453 48,240 50,639 52,580 54,638 55,024 56,267 56,273 55,912 55,372 56,489 56,113 56,459 56,843 57,519 57,766 57,421 Budget 35,736 35,886 36,047 36,200 36,333 36,483 36,433 36,397 36,371 36,371 36,200 36,040 35,868 35,714 35,655 35,466 35,322 35,235 35,127 35,005 34,891 34,837 34,777 34,740 34,708

93 Agenda Item Coronation Blvd, Cambridge, ON N1R 3G2 Tel Fax BRIEFING NOTE Resources Committee Date: November 23, 2016 Issue: Purpose: Prepared by: Approved by: Hospital Accountability Planning Submission (HAPS) Motion Mike Prociw, Vice President, CFO & CIO Patrick Gaskin, President & CEO Attached is the Hospital Accountability Planning Submission (HAPS), submitted to the LHIN on November 21, and requiring Board approval. The Resources Committee is asked to review the submission for discussion with management, with the intent of obtaining the Committee s recommendation for Board approval. Recommendation That the Resources Committee of the Board recommends to the Board of Directors, approval of the HAPS, submitted to the WWLHIN on November 21, 2016 Page 1 of 1

94 HAPS Narrative Hospital Name: Cambridge Memorial Hospital Facility Number: 661 SECTION 1- General Narrative Planning Assumptions: The HAPS forms include the assumptions used to create the budget for All other planning assumptions built into the HAPS are included on the HAPS submission form There is no need to duplicate those planning assumptions unless the assumptions are material and you wish to highlight them to the LHIN. All other major planning assumptions not built into the HAPS forms should be highlighted here Health System: Who is served and why? In November 2016, the hospital, together with St. Mary s General Hospital and Grand River Hospital, undertook a review of our market share/utilization information. This focus of this work was to update the work undertaken in 2014 (by Hay Group as part of our collective strategic planning effort at that time). The 2016 work was completed by Health Stats Inc. Since this data was only recently compiled, a fulsome analysis of it has not been undertaken. This work will be undertaken as part of our strategic planning refresh which is scheduled to be completed by June The full analysis of our market share analysis from 2014 is available on our website. The following summary of the 2016 information is provided: o CMH provides greater than 67% of the care for primary/secondary care for residents from 6 postal codes that encompass Cambridge (see below). These postal codes make up the primary catchment area for CMH. Page 1 of 33 V2017-1

95 HAPS Narrative o For your information, the postal codes associated with Cambridge are N1P, N1R, N1S, N1T, N3H, N3C and N3E (see below) Page 2 of 33 V2017-1

96 HAPS Narrative o o o o From the data analysis in 2014, (data not yet updated for 2016) residents of Cambridge Memorial s primary catchment area receive 73% of their inpatient hospital care from CMH: 87% of ED care 82% of primary inpatient hospital care 71% of secondary inpatient hospital care 25% of tertiary/quaternary inpatient hospital care In terms of why, Cambridge Memorial Hospital is committed to serving its local community with as much as their local primary and secondary hospital care as possible The table below shows the distribution of emergency visits for 2015/16 by CTAS score. CMH has the highest proportion of CTAS 4/5 (semi-urgent, non-urgent) than any other large community hospital in Waterloo Wellington. This percentage has been reduced over the past few years which may be attributed to the introduction of new walk-in/urgent care clinics in the area. Page 3 of 33 V2017-1

97 HAPS Narrative o Consistent with the HAPS submission last year, the table below shows that Waterloo Region has lower than average (Ontario) utilization of hospital emergency departments. While we don t have information specifically for the Cambridge catchment area, the low rate of utilization could be as a result of our undersized emergency department that may result in patients not seeking care at CMH due to the inadequacy of the facilities o The table below examines the age/gender standardized patient days per 10,000 population residents of Waterloo Wellington have one of the lowest rate of utilization of acute care services among peer counties and the 2 nd lowest rate in Ontario Page 4 of 33 V2017-1

98 HAPS Narrative The table below shows that Waterloo Region has low rate of ALC days among peer counties; however there may be opportunities to explore to reduce ALC even further Use of CCC Services by Cambridge Residents In 2010, CMH closed its CCC beds and transferred resources to GRH and St. Joe s Guelph to provide services for the residents of Cambridge and the surrounding communities. An analysis of the utilization Page 5 of 33 V2017-1

99 HAPS Narrative of services was undertaken recently to determine the longer term impact of this change. The data is being reviewed with WWCCAC at this time so no definitive issues or conclusions can be drawn. The preliminary data review does show that Cambridge and North Dumfries residents have a significant lower access to CCC services than do residents from other parts of Waterloo Wellington for example, residents of Wellington use CCC resources at a rate 3 times that of residents of Cambridge and North Dumfries (see table below). As stated, more analysis is needed prior to drawing any conclusions; however, CMH believed this was important to inform the WWLHIN of this preliminary information as part of the HAPS process. Population health The hospital participates as an active member of the sub-lhin s Health Links and Connectivity Table. We are a full partner at the table and working with system partners within the health care system and beyond (e.g. Waterloo Regional Police Services) to address the needs of the most vulnerable individuals within our community. We continue to work with our partners to develop strategies through Health Links to improve the coordination of services for the most vulnerable individuals within our sub- LHIN. Aboriginal health and wellness and French languages Recognizing the importance of strong communication between the health care provider and the patient, we employ a variety of methods to meet the language needs of these patients, depending upon the situation. In terms of considerations related to care for the health and wellness of aboriginal patients, as we do for all our patients, we endeavor to meet their health needs in a manner that treats them as an active partner in their care, that is consistent with the Hospital values and the approved Waterloo Wellington Patient Declaration of Values. With the assistance of our clinical bioethicist, our Ethics Committee has established cultural competency as a priority. To date, we have introduced these concepts at our Medical Grand Rounds and during ethics consultations. Page 6 of 33 V2017-1

100 HAPS Narrative How are provincial and local priorities (including the IHSP) being met The table below outlines the alignment of CMH initiatives with the provincial and local priorities. In terms of the detailed plans for CMH for , this work will unfold as we refresh our strategic plan this year ( ). The current strategic plan for CMH is set to conclude in March A new strategic plan for for CMH is planned to be ready for Board approval by June The timing for the strategic planning process at CMH has changed (from a 3 year plan to a 2 year plan) to allow for alignment of the CMH strategic plan with the WWLHIN IHSP. While we have not yet fully developed our strategic directions for , many of the initiatives will be carry-forwards from the work currently underway at CMH. To the best our abilities at this stage, we have attempted to align our strategic planning thinking and anticipated projects with the health system directions in the table below. Strategic Directions included in all health system changes Delivering integrated care care close to home in the four integrated geographic service delivery areas and through integrated clinical programs delivering bestpractice care across Waterloo Wellington Improving the patient experience Alignment with Our Strategic Plan Clear focus within our strategic plan clear priority focused on Defining How We Work with Others Within the Local Community Such examples include -work associated with the integrated program councils (IPC) -project evaluation work related to the Health Information System (HIS) -Health Links -ongoing participation in Regional on-call programs and collaborative efforts to evaluate future Regional on-call opportunities -work being planned with staff at the WWLHIN to engage a discussion locally on geographic service area planning and integration for Cambridge (WWLHIN taking lead to do this) -the 3 hospitals in Waterloo Region completed a recent clinical governance review to determine strategies to strengthen clinical relationships among the hospital. The recommendations of the report have been reviewed by the Waterloo Hospitals Collaborative Committee and a work plan to advance the recommendations is in the draft stages Clear focus within our strategic plan clear priority focused on Page 7 of 33 V2017-1

101 HAPS Narrative We are committed to improving our patients experience Championing population health and health equity for Francophone, Aboriginal, and all residents Building bridges with other sectors - linking health care with public health, community and social services, schools, universities/colleges, and others Such examples include -a newly established Patient Experience Lead, which began this year -CMH has established and is advancing the role of the Patient Family Advisory and the Patient Family Advisory Council (PFAC) -The hospital has established a hospital wide PFAC that is cochaired by 2 PFAC members -PFAC members have been actively involved in the transition planning -The Mental Health program has established a FAC (Family Advisory Committee) and it is actively involved in supporting work within the Mental Health program -customer service program under consideration -all Managers and Directors have attended educational sessions on Experience-based co-design (EBD). -CMH is actively exploring how to improve real time feedback from patients given the recent improvements and changes to the patient experience reporting and surveys (linked to work being done by the OHA) This is clearly a focus for our work at the Connectivity Table and with Health Links, ICPs and as part of the work described in the first direction (previous page) -links with university and colleges for education exploring opportunities to improve medical education linkages with other hospitals in Waterloo Region underway -links with public health regarding well babies, off load delay, EMS -Joint Grand rounds with Waterloo Regional Police. -work is underway to incorporate Page 8 of 33 V2017-1

102 HAPS Narrative Providing faster access to the right care Ensure timely, accessible, supportive primary health care for all including enhancing access for specific populations Provide seamless, high quality service delivery in the four integrated service delivery areas Improve access to mental health and addictions services the interrai risk assessment tool completed by the WRP for our mental health patients in the community, into the ED workflow to better serve these patients. -planning work underway to integrate mental health services into primary care Alignment with Our Strategic Plan -transition of care to the community is a clear focus for our strategic plan -working closely with Lang s, our community FHTs and FHO s (and supported by some consulting resources secured for this project), we have developed a project charter for safer transitions of care for low-moderate and high-risk CHF patients. -we have developed several operating strategies to enhance this discharge checklists for patients, post-discharge follow up phone calls to ensure patients are transitioning successfully -active participation in community led initiatives focused on improved transitions especially for chronic disease management See above -Active participant in planning and service coordination through the Mental Health and Addictions Integrated Program Council and part of the work of Health Links and the Connectivity Table -participation in the regional bed board which assists matching demand to system capacity -working with CMHA and Grand River to develop oversight of the co-ordination of specialty mental services -restructuring outpatient mental health clinic to address growing wait list, by incorporating an Page 9 of 33 V2017-1

103 HAPS Narrative Transform palliative and end-of-life care Delivering better coordinated and integrated care in the community, closer to home Strengthen home and community care increased volume of new referrals weekly. Concurrent goal to partner more effectively with community partners to support transition and care in the community with consultation support. -the Tiered Model of Mental Health Care has been under active discussion with CMHA and Lang s leadership. Continued discussions as to how to advance this are progressing -CMH is an active partner with Hospice of Waterloo Region to support patient transition -CMH follows the CCO best practice infrastructure of GP Oncologists who follow patients through the entire cancer continuum from active treatment to end-of-life care -CMH partners with WW hospice palliative care network -we participate in the Regional MAID Committee -regional leadership is being provided by a member of our Medical/Professional Staff Alignment with Our Strategic Plan -approximately one year ago, CMH and CCAC established the integrated manager role to strengthen the relationship with home and community care -recently, an integrated discharge planner for mental health has been hired -active participation in ALC designation work aimed at reducing barriers to discharge. -CMH benefits by having the Chief of Family Medicine as an active member of the Medical Advisory Committee -ongoing support to our community family physicians to provide community-based on-call services Page 10 of 33 V2017-1

104 HAPS Narrative Support caregivers health and wellbeing Integrate hospital care to deliver consistent, evidencebased best practice as a specialized resource on the health journey (to LTC, critical lab values etc.) -CMH continues to participate in and has developed education for primary care: i.e. Multi-part education series in Primary Care Mental Health For our formal caregivers (i.e. staff and physicians) -focused and ongoing efforts on work place violence and creating a safe working environment for all staff. A system of flagging charts and broadening our Code White training within the organization -continued efforts to support wellbeing of staff such as recognition and celebration events and scheduling committees to ensure staff feedback on work schedules -wellness work piloted successfully in Diagnostic Imaging: Mindfulness and Meditation program developed and implemented by one of our staff physicians. Considering to roll this out to other departments -on-call clinical Bioethicist for ethically challenging cases (including debriefing and support). For informal caregivers -implemented a policy to minimize restrictions on visiting hours so that care partners can support inpatients fully -implemented hospital directive associated with parking rate changes to support patients and caregivers -ongoing work associated with our PFAC support this -have implemented discharge phone calls, discharge checklist all support informal caregivers as well as the patient -evidence based care is being advanced through the electronic patient order set project being implemented in Waterloo Page 11 of 33 V2017-1

105 HAPS Narrative Wellington -continued focus on implementing QBP guidelines and active participant in LHIN-wide plans -support medical leadership in Quality Management Partnership (QMP) through CCO -support clinician participation in Multi-disciplinary Case Conferences (MCCs) Support people and patients providing the education, information and transparency they need to make the right decisions about their health Enhance transparent access to information to support professional, patient, and caregiver decision-making and transitions of care Increase access to linguistically and culturally appropriate services and care that is welcoming for all Promote access to information to support selfmanagement and illness prevention Alignment with Our Strategic Plan -have implemented Transfer of Accountability at the patient bedside, improved discharge planning and discharge information -have started faxing the psychiatric emergency services consultation note to the community practitioner post ED visit to accompany the ED health record. -we work to ensure that we meet the needs of our community and this can be enabled through active use of translation services and through the work of our PFAC -embedded in operational activity -education material provided, e.g. COPD, diabetes that promotes this philosophy. -adoption of standardized education material e.g. adopting the CHF education tools developed by regional cardiac centre Protect our universal public health care system making evidence-based decisions on value and quality, to sustain the system for generations to come Engage patients, caregivers and community stakeholders in the design and implementation of health system improvements Alignment with Our Strategic Plan -clearly this is work of our PFAC and has included work associated with the design of our new visiting hours policies -also PFAC has been actively engaged in planning new programs and design within our capital Page 12 of 33 V2017-1

106 HAPS Narrative Reduce duplication and unnecessary testing, assessment and service delivery Integrate services and pursue new models of care to reduce inefficiencies and redirect funding to front-line care project -work of the integrated program councils - Choosing Wisely standards embraced by CMH physicians -Introduce HQO Quality Standards for specific diseases -operationally we are always open to discussions and dialogue with other health service providers to explore the ways to integrate services Patient Experience: We expect that in our new strategic plan, patient experience will remain as one of our three key organizational strategic priorities. The Patient s First provincial document underpins this work. Three years into our patient experience, we have established the key foundational elements of an effective patient experience-focused culture at CMH. They are: strong engagement of the patient and patient voice/perspective, a data driven framework and Medical/Professional Staff engagement. We will continue to grow the size and mandate of our strong Patient and Family Advisory Council (PFAC). Building on our monthly PFAC meetings and annual work-plan, their involvement in recruitment will expand, their input into our capital redevelopment project will expand and their involvement in key strategic initiatives is anticipated to grow. We will continue to use robust data to drive our patient experience framework. From in-depth analysis into the drivers of the net promoter score, to the evaluation of best practices, to the ongoing refinement of our internal patient experience survey tools, this important work will continue. Leadership rounding has provided a new dimension of real time patient and family feedback to incorporate into our plans. Finally, our relentless efforts to engage our leadership and staff will continue. Building on the strong foundation of daily and weekly generative discussion at department huddles and the advocacy of our MAC and Quality Committee, the HQO standards framed to describe quality from a patient perspective will assist and inform our care maps and workflows moving forward. Integrated discharge planning CMH continues to embrace this concept recognizing the risk to patients during transitions from hospital to the community. There is an imperative to do this well to achieve utilization benchmarks and improve patient satisfaction. The corporate goal of reducing emergency department length of stay for admitted patients will only be fully achieved with attention to the discharge component. Tangible efforts to demonstrate and advance this goal are the following: 1) active participation with Langs on the Health Links & Connectivity Table initiative to reduce the dependency of high users of the Emergency Department for health needs that can be safely met in the community with an interprofessional, intersectoral approach to care planning. 2) Collaboration with CCAC in 2014/15 to introduce an integrated discharge planning model that aligns the CMH discharge planning staff and the CCAC case managers, clarify accountabilities and streamline processes. A successful refresh of the Home First philosophy with relentless focus on discharge planning has assisted to reduce our ALC days and volumes. Page 13 of 33 V2017-1

107 HAPS Narrative 3) Active participation with WWLHIN partners to standardize to a common discharge policy and practice supporting all priority initiatives such as: stroke, rehabilitation, palliative care. 4) Meeting with local family practitioners to discuss a more supported transition of mental health patients and rapid access to specialist consultations that can assist maintenance in the community setting. 5) Internal review of mental health program, including outpatient programs to determine ability to create capacity and better serve our community. A new consultation clinic model in the outpatient mental health program will assist to reduce the current waitlist and encourage co-management with primary practitioners. 6) Expansion of current discharge phone call protocols that currently include day surgery, medicine and surgery to support transition to home. One of the components of these phone calls is a reminder of the importance of making follow up appointments with primary care providers. For high risk readmission patient populations such as congestive heart failure, appointments are made prior to discharge and communicated to the CCAC rapid response nurse who visits the home 24 hours post discharge. The psychiatric emergency nurse consultant assessment note completed in the ED will be sent out to community providers as this will assist in continuity of an established care plan. Flow: Foundational work has begun in this fiscal year. Through the collaboration of our Chiefs of Mental Health and Family Medicine (via a mandate by our MAC), five key deliverables have been established to serve this underserved patient population s journey through our acute system (Client Flow) and into the Community (Transitions of Care). The consensus goals are: 1. Dedicated medical leadership in the form of a Medical Director mandated to strengthen discharge processes and community partnerships (a business plan is being developed for submission to the LHIN); 2. Focused educational and training outreach in the form of didactic learning events and job-shadow opportunities to move the Shared Care model forward in our community with a highly engaged family medicine group; 3.Continue the work of building system capacity through Shared Care models and streamlining referral processes and our Day Hospital utilization; 4. Forge stronger links between our Psychiatrists and Community Family Physicians (telephone support, corridor consultations etc.) through learning events; 5. Leverage data and technology to track the ED LOS for our Mental Health and Addictions patient (this will be added to our current physician LOS dashboard and brought into our weekly Flow Committee work-plan). From the standpoint of patient flow, significant organizational focus over the past year has been on improving patient flow measured through an overall proxy measure of Emergency Department length of stay from triage to inpatient bed and through numerous process measures. An aggressive patient flow target was set as a widly important goal for the organization to establish an overarching aim and to create tension for change. Programs have aligned departmental goals around the organization s flow target and quality improvement tools have been applied to establish root causes and a value stream of the patient journey through the ED to an inpatient bed. The quality improvement work has engaged physicians through the establishment of physician specific indicators, improved communication and efficiency in the bed allocation model through use of technology and establishment of a standard transfer of accountability process. It has engaged information technology to create system improvements to increase accuracy of data and documentation. The quality improvement work has focused tactics to realize improvements to the following key metrics: 1) Physician initial assessment (PIA) and nurse practitioner initial assessment (NPIA) wait-times 2) Discharge planning, targeted daily discharges, re-admissions and collaboration and integration Page 14 of 33 V2017-1

108 HAPS Narrative with CCAC to reduce ALC volumes 3) Appropriate admissions and conservable bed days 4) Pull-times to inpatient beds and ED LOS for admitted patients 5) Emergency Department (ED) Length of Stay (LOS) for non-admitted patients 6) Ambulance off-load times 7) Improved accuracy of clerical documentation 8) Effective utilization of virtual clinical decision unit (CDU) 9) Optimal resource allocation to match demand. This quality improvement work and organizational focus has ultimately had a positive impact on our year to date results as measured on the key performance indicators stated above. As part of the quality improvement work, emphasis has been made to collaborate with patients and to capture the patient s experience with care through customer rounding. Post-discharge follow-up: Regarding Discharge summaries, our performance has dramatically improved since October 2014 (and will continue to improve) with our new Nuance Software install. Our current TAT (turn-around-time) is 24 to 48 hours for weekday discharges and 72 to 96 hours for weekend discharges. The implementation of the ehealth HRM (hospital report manager) will make the transmission of data seamless. The interface is in place and going through testing and adjustment. Our survey of the Central LHIN suggests that this will have two intended results that will improve the percentage of patients who have follow-up within 7 days of discharge: first, by expediting a request for follow-up (through clinic administrators like Two Rivers post-discharge case manager), and second, it will trigger the receiving family medicine provider to contact the patient for follow-up if a follow-up has not been initiated by the hospital. EHealth Strategy Throughout the past year, CMH has continued to work in partnership with the other hospitals in the region towards developing a common hospital information system (HIS). CMH believes that this will be an important tool to drive clinical standardization and back room service integration. Management, physicians, front line staff and the Board have been involved in the development of an RFP, proposal review/evaluation, organizational due diligence and the development of a governance structure to oversee a shared operation of a common system within Waterloo-Wellington. Currently, CMH management and the Board are in the process of evaluating options regarding a proposed timeframe for system implementation. Two options are being considered: 1) concurrent implementation with that of GRH and St Mary s beginning late in fiscal year 18/19; 2) deferred implementation timed with that of GGH and North Wellington (2022/23). The final decision will be dependent on proposed costs of implementation, available internal capacity and fiscal affordability. It is anticipated that a final decision will be made early in calendar year What are the planned or future service changes that are included in the HAPS submission At this point, there are no planned service changes. Are there any discrete integration opportunities that the hospital will be exploring during the fiscal year? (Where the hospital would rather not document these opportunities at this time, they may engage in a direct discussion with the LHIN ) CMH has an ongoing commitment to collaboratively work on the 19 regional program integration initiatives and is currently leading the focus on the regional Diagnostic Imaging (DI) strategy. Page 15 of 33 V2017-1

109 HAPS Narrative On the DI front, tremendous progress has been made towards developing a multi-year strategy for regional integration which includes a vision and implementation plan for centralized intake. A partnered relationship has been developed with System Coordinated Access with the intent of developing and utilizing a regional e-referral solution. Staff resources to support the work have been supplied by Mohawk Shared Services (via the hospitals in LHIN 3 and 4) and there has been active participation in the deliberation and work from all hospitals within the region. Parallel work also continues regarding Wait Time funding and the challenge of refining allocation models to support improved patient access within the region. CMH is partnering with CMHA to discuss how to enhance the alignment of the CMH outpatient psycho geriatric team to Lang s. This allows a stronger relationhip with a broader community team which currently works together and will maximize efficacy for patients and families treated. Based on the current capacity and projected growth of Chronic Kidney Disease (CKD) within our region, CMH has partnered with GRH to establish CKD services within Cambridge in order to meet the growing demands for kidney care, and provide services closer to home for residents. Currently, the Cambridge area has over 550 patients travelling to GRH to receive their renal care. A service proposal has been submitted to the Ontario Renal Network and has received endorsement and recommendation to proceed. The availability of CKD and dialysis services in Cambridge aligns with the goals of the Ontario Renal Plan (ORP) , and has received local endorsement from the Regional Integrated Renal Council, and the Regional Renal Steering Committee. The proposal remains consistent with the regional renal program s hub and spoke model of care, and allows the regional renal program to accomplish its strategic plan and meet its accountability agreements with Cancer Care Ontario. A joint Pre Capital Submission Form was submitted to the MOHLTC the WWLHIN in May During the summer the hospitals worked with external consultants to complete the Functional Program, Block Schematics and cost estimate. Both organizations look forward to working with the Ministry and the WWLHIN in the current and subsequent year to complete the requisite reviews and to obtain approvals to move to the next stage of planning and eventual construction. As mentioned previously, CMH has also committed to be a part of the process for selection and implementation of the regional Hospital Information System (HIS) and has been actively involved in various processes (as mentioned previously) throughout the past year. Hospital Performance: Efficiency and Effectiveness: Areas the hospital has identified that require the most improvement with regard to efficiency, effectiveness, and performance Strategies planned and/or adopted to manage such desired improvements Where savings will be reinvested, if applicable From the standpoint of effectiveness and efficiency, CMH continues its ongoing efforts to improve its patient flow, cost per case metrics and working capital reserve to address future capital equipment demands and regional HIS requirements. From the standpoint of patient flow from the Emergency Department, the work and priorities of the organization were described above. From the standpoint of cost per case and efficiency, CMH s current foci are on sick and over time Page 16 of 33 V2017-1

110 HAPS Narrative performance, as well as developing improvements in the patient journey as characterized by improvements to flow, patient hand offs, discharge planning, system coordination and optimum staffing models to support each of these functions. From the standpoint of sick/over time, CMH has made tremendous progress in improving financial performance and over the past 6 months has reduced 11,700 sick and overtime hours (approximately $.5M) as compared to our performance last year. CMH has also engaged the assistance of an external consultant and they are assisting the organization with strategies in targeted clinical areas (Medical unit, ICU and Emergency Department) and in refining the medical service delivery model which ultimately is targeted at refining a series of key processes that will improve patient flow and turnover and result in key operational efficiencies. Savings will be reinvested to address some critical clinical priorities that have been identified including expanded service offerings anticipated in the Emergency department linked to the opening of the new facility; expanded non-invasive surgical offerings; models to support medication reconciliation and order set development and roll out; quality leads to address new quality standards in Pharmacy and Diagnostic Imaging; new operating procedures mandated by the Ontario College of Pharmacists. At the same time, CMH has an ongoing commitment to generate an operating surplus that covers the cost of building amortization. This will assist CMH with obtaining critical capital resources to fund next year s capital equipment needs as the Foundation continues to address the local share requirement of the Capital Redevelopment Project. Service Delivery : Service Delivery Service Changes Change Form.docx process - slide deck.p Service changes proposed to improve the local health system and/or achieve a balanced budget (with supporting justification) and the expected impact on patients/clients and costs Describe how health partner engagement will be/has been utilized in determining proposed changes to ensure a sustainable system for the region Critical risks to success and mitigation/management plans to proposed changes Choices made to achieve a balanced budget At this point, there are no plans to change CMH s proposed service offerings to the community. Health partner engagement N/A Stakeholder/Community engagement N/A Critical risks to success and mitigation/management plans N/A Alignment and System Contributions Initiatives in place or to be implemented to contribute to the achievement of provincial and LHIN priorities and contribute to a more integrated health system. There are many initiatives that CMH is participating in to contribute to a more integrated health system. These include the work associated with governors forums, integrated service provision with WWCCAC, System Coordinated Access and the work of the integrated program councils. Each is briefly described Page 17 of 33 V2017-1

111 HAPS Narrative below. Beyond that, in the subsequent sections, initiatives supporting ehealth, Health Links, quality improvement plans and others are described. Governors Forum: Throughout the past year, governors of the health service providers within the Cambridge and North Dumfries communities have met on several occasions to advance the discussion concerning health services integration. In November 2015, a workshop held in Cambridge with health services governors developed a collective view of the preferred future a system with a single point of entry, improved patient experience, a focus on health and wellness, integrated health records and seamless/timely access. In that workshop an action plan was drafted. The WWLHIN has helped advance this action plan through continued collaborative discussions among the governors. This has included an interactive workshop on collaborative quality improvement and Health Links on February 1, 2016 and subsequent follow up session in September and November Further work on this is planned to occur in the near future. Integrated Service Provision with WWCCAC: As mentioned earlier, CMH and WWCCAC have implemented an integrated manager position for discharge planning. This position is cost shared between the organizations and has worked successfully to streamline the processes between the organizations and improved our performance. The aggregate LHIN performance for ALC as measured by the % of hospital beds occupied by ALC patients is below the performance target of 12.7% - WWLHIN is the second best performing LHIN. For ALC closed cases, the WWLHIN is the 3 rd best performing LHIN, although nearly all hospitals, including CMH, are performing above the provincial target. System Coordinated Access (SCA): As earlier noted, as the sponsor organization for the Diagnostic Imaging Program Council (see below), we have a strong interest in the emerging work associated with System coordinated access and support the goal of embedding enabling technology within the local health system to better support timely and more equitable care for residents. We look forward to continuing to advance this work in diagnostic imaging as part of the longer term plans for SCA. Integrated Program Councils: CMH, together with the other hospitals and WWCCAC and with the support of WWLHIN, are advancing an integrated health system through the work of the Integrated Program Councils. The focus for the program councils is to create a system where residents have access to quality patient care, regardless of where they reside within Waterloo Wellington. CMH is the sponsor organization for the Diagnostic Imaging Integrated Program Council and in the future we will also lead the program councils for obstetrics and paediatrics. In Waterloo Wellington, an integrated program has been defined as: An Integrated Program supports the planned and coordinated delivery of consistent, high quality health care by Health Services Providers across the region intended to improve the health of Waterloo Wellington residents. The purpose of an integrated program is to ensure a single standard of high-quality care and access, regardless of where one resides that is based on best practices for specific identified patient groups. The Institute for Healthcare Improvement Triple Aim is a useful framework to articulate the purpose and objective of Integrated Programs. The Triple Aim refers to the simultaneous pursuit of: Improving the patient experience of care, Improving the health of populations, and; Improving the value of health care dollars. The integrated program approach has two major objectives: Page 18 of 33 V2017-1

112 HAPS Narrative To improve the quality of care across the entire region by standardizing access to best practice care; To deliver care planned across the continuum of care, create a better balance of care options and close system gaps, by shifting resources to wherever in the continuum of care they will achieve greatest benefit. Provincial and LHIN Priorities (examples) ehealth initiatives Health Links Development Hospital initiatives to contribute towards the achievement of priorities Throughout the past year, CMH has continued to work in partnership with the other hospitals in the region towards developing a common hospital information system (HIS). CMH believes that this will be an important tool to drive clinical standardization and back room service integration. Management, physicians, front line staff and the Board have been involved in the development of an RFP, proposal review/evaluation, organizational due diligence and the development of a governance structure to oversee a shared operation of a common system within Waterloo-Wellington. Currently, CMH management and the Board is in the process of evaluating options regarding a proposed timeframe for system implementation. Two options are being considered: 1) concurrent implementation with that of GRH and St Mary s beginning late in fiscal year 18/19; 2) deferred implementation timed with that of GGH and North Wellington (2022/23). The final decision will be dependent on proposed costs of implementation, available internal capacity and fiscal affordability. It is anticipated that a final decision will be made early in calendar year The hospital continues as an active participant in coordinated care plan development. The total number of different Coordinated Care Plans (CCP) completed year-to-date (from April 2016 is 97). Langs-Heritage has led 17, our system navigators have led 29 and our in homes teams have led 51 year-to-date. Physician links continue to be formed with 23 physicians contacted in September and October of this year. Indeed 66% of our Health Link referrals come from primary care providers (as compared to 34% from social services agencies). Connectivity now has 20 agencies participating and there have been 25 new situations reviewed year-to-date. Top Connectivity risk factors as of end of October 2016: mental health at 15%; criminal involvement at 11%; drugs at 7%. The hospital will continue as an active participant in Connectivity with dedicated time from two clinicians protected from CMH. Connectivity Waterloo Region s evaluation project rolled up preliminary results and will produce a final report in March Future funding for the Health Links is in discussion between WWLHIN and Langs and may be dependent on the Patients First Page 19 of 33 V2017-1

113 HAPS Narrative Participation in Health System Funding Reform Quality Improvement Plans legislation CMH has a multi-faceted approach to support the needs of Health System Funding Reform. Components of that strategy include: 1) the utilization of the case costing system in partnership with physicians to identify variances in practice patterns and to target opportunities for improvement; 2) the development and implementation of QBP order sets and pathways in alignment with QBP handbooks. Continuing the journey of implementation of additional QBP standardized electronic patient order sets in partnership with technology supplied by THINK Research, thus allowing improved control and analytics; 3) continued regional dialogue with a view to standardize order sets on a regional basis; 4) Commitment to monitor QBP quality indicators as they are developed and published; 5) improved documentation and ongoing coding review, along with a physician based targeted education to ensure increased accuracy in the documentation of clinical activity; 6) targeted strategies to improve patient flow and shorten length of stay thus improving patient throughput within existing capacity; 7) Partnership with the OHA/Ministry to utilize the HSFR funding tool as a means to attempt to improve our predictive ability to estimate future funding allocations. The 2017/18 planning aligns with the annual Quality Improvement Plan in the common explicit goals to improve access and flow (ED time to admitted bed is the proxy measure), ongoing focus and improvements to quality metrics (e.g. reduce healthcare associated infection rates, ensure quality and safety is not compromised during CRP, reduce ALC etc.). CMH has advanced our medication safety plan with computer generated medication administration records and now implementing dedicated medication carts for nurses to deliver the medication to the bedside and meet accreditation standards. An upgrade to the electronic risk reporting database is underway and incorporates staff incidents and facilitates improved trending reports to prioritize staff and patient safety. Led by the WWLHIN, CMH is poised to partner with Cambridge North Dumfries community providers in creating a collaborative Quality Improvement Plan (submission April 2017) that improves health care for residents. CMH has introduced an acute pain service to standardize pain protocols and address variation in practice. This service provides dedicated anesthesia resources that will concurrently support the birthing program in provision of timely access to pain relief. Page 20 of 33 V2017-1

114 HAPS Narrative Senior Friendly Hospital Strategy / Senior Friendly Improvement Plan French Language Services Act CMH has retained its RNAO Best Practice Spotlight Organization (BPSO) status and many of the best practices are common to QBP (e.g. integrated smoking cessation program aligns with COPD QBP). CMH is an active participant in the WWLHIN patient order set implementation initiative which focuses on QBP s. This ensures standardization to best practices. CMH remains committed to the concept of a senior friendly hospital. The capital redevelopment plan will remain an intense focus for 17/18 to ensure transitional planning that maintains a focus on quality which includes monitoring those care processes that are specific to the elderly (e.g. delirium screening/protocols). With the ongoing efforts to improve care processes and patient experience, mindfulness on the frailty of aging will be embedded into planning. As per the recent survey related to FLSA, the relevant responses are below. 1. Does your organization have a process in place to identify French-speaking clients/residents or clients/residents who prefer to receive services in French? Yes x No Additional comments Click here to enter text. 2. What methods does your organization use to respond to a request for services in French? (check all that apply) No action Use of family member Use of volunteer interpreter Use of professional interpretation services Use of French-speaking health care staff Use of French-speaking nonhealth care staff Refer to other HSPs that provide FLS If other, specify Provide professional interpretation services over phone or in person with the patient / SDM (substitute decision maker). 3. Is there a process in place in your organization to identify French-speaking staff? Yes No Additional comments Human Resources Page 21 of 33 V2017-1

115 HAPS Narrative identifies at time of hire Other LHIN Initiatives (Please describe) 1. Initiative 1 2. Initiative 2 3. Initiative 3 4. Initiative 4 5. Initiative 5 4. Does your organization have health care/social service staff able to provide services in French? Yes No Risks What are the Key risks and mitigation strategies included in your plan? Key risks and mitigation plans are addressed below. Strategic Risks CMH s Capital Redevelopment Project (CRP) is ongoing with interim completion (Phase 2 completion of new tower) planned for the end of May 2017 and substantial completion (Phase 3 completion of the renovations to the existing facility) planned for the end of September Phase 2 was originally planned for completion at the end of November 2016 with move in scheduled for January Currently, the contractor is 6+ months behind schedule and completion has been deferred until the end of May 2017, at the earliest. There is great uncertainty whether that date will be achieved. The project has three significant risks for CMH: Transition Planning - Staff orientation and planning to prepare to safely use the new clinical space Delay Claim Gaps in Ancillary Funding Transition Planning - Significant effort over the past year has taken place in orienting management and staff to the new space and in the respective departments developing plans for providing care and identifying perceived service gaps in the new addition. The focus has been on ensuring that the organization is fully prepared to operate safely within the new and existing spaces, including: Patient, care partner, and visitor flow Workflows for physicians, midwives, staff, and volunteers Emergency Preparedness Understanding of the new building layout and nomenclature, including department adjacencies, unit layouts, wing and level designations, and paths of travel Training and orientation on new equipment and systems Some of our critical challenges that remain include: Financial and human resources availability to complete the outstanding work identified in the transition planning consultations Building handover date uncertainty which impacts the ramp up and ramp down of all CMH operations, HR Plans, and community stakeholders Competing priorities and operational changes ongoing in organization Page 22 of 33 V2017-1

116 HAPS Narrative Opportunity to ensure all staff receive the minimum amount of orientation and training before building occupancy Coordination and readiness of all new and existing IT systems requirements CMH has developed a comprehensive risk management strategy (as part of our integrated risk management (IRM) strategy) to address these ongoing risks and is monitoring monthly at both a management and Board level. The success of this undertaking will be critical to ensuring there is a smooth transition to the new facility with minimal impact and risk to patient and staff safety going forward. Delay Claim The current delay in the project, and the prospect of a significant financial penalty to the contractor at interim completion, has resulted in a significant threat of large delay claim that will be filed by the contractor at the end of the project. Over the past year and a half, the contractor has submitted four delay claims that CMH has dismissed because the contractor did not follow the process identified in the Project Agreement and because they did not demonstrate an impact to the critical path linked to the incidents identified in the claims. Infrastructure Ontario (IO) and the Capital Branch at the MOHLTC are aware of the issues and the related financial risk that may arise later on in the project. CMH and IO legal representatives as well as senior IO staff have been regularly engaged and actively involved with the contractor and their representatives. However, the potential financial risk and liability has not been addressed or rectified. Gaps in Ancillary Funding With the extension of the project, CMH will incur significant incremental ancillary costs associated with the project. This includes the entire capital project team (inclusive of the Transition Planning Team), incremental interim staffing that was required as a result of displaced departments, Contract Administration, scheduling oversight, warehouse rental, legal costs, hiring staff in advance of the move in (which most likely be hired in advance of when they should be because of uncertainty as to when building will be completed), lost revenue from inability to resale equipment that is being replaced, the need to buy extended warranties for equipment that is bought of advance of move in and use date, and training duplication. Many of these costs are funded by the Ministry but there is no certainty that any incremental costs will be reimbursed if we are unable to recapture these costs from the contractor. Clinical Risks For 2017/18, the clinical risk remains the ongoing risk of our capital reconstruction project (CRP) and the move of programs to new and temporary decant spaces. To mitigate this risk, planning involving the clinical teams is already underway in partnership with the CRP team. Dedicated resources for purchasing, transition planning as well as dedicated clinical resources are identified and will be mobilized, escalating in hours, as the planning progresses. A clinical educator to support the transition orientation work has been hired and work is underway to develop the transition plan that includes updating of all policies, protocols and workflows as well as orientation to the new space. Physician partners have been identified for inclusion and MAC has supported mandatory attendance at orientation sessions. Representation from either the Patient Family Advisory Committee members or community members is in place on the program transition planning committees. Access and flow is a corporate goal and this will continue to be a focus into 2017/18 and incorporate new pathways related to CRP. The corporate strategy is multi-faceted and patient flow pressures may be partially relieved with the move to the new space. With assistance from the CMH Manager Transformation Office who has assisted with the introduction of new quality improvement tools and data collection to better understand current performance, plan and evaluate changes, the changes incorporate both current and future CRP space and workflows. As previously described, the initiatives underway with community partners will contribute to the ED flow with goals of reduced readmissions, Page 23 of 33 V2017-1

117 HAPS Narrative support EMS with decreased offload time and WRP with improved handover of mental health patients. Medication Management and Administration is an ongoing corporate clinical risk with the emerging standards from Accreditation Canada and Ontario College of Pharmacists standards. There are well developed mitigation strategies in place for many aspects of this clinical risk however the lack of a closed loop medication administration system that includes computerized physician order entry is an outstanding gap. Longer term an upgraded computer system will address this clinical risk. Additional standards will require capital investments and renovations to the pharmacy space. The required organizational practice of medication reconciliation at admission and discharge (2019) is under review for an interim organizational solution until a hospital information system plan is confirmed. Financial Risks Besides the capital risks identified previously, CMH faces two other significant financial risks: financing its share of the Regional HIS initiative should it choose to proceed with the project in the short term; and the pending PCOP negotiations. HIS initiative CMH is currently in the middle of major capital redevelopment project. The CMH Foundation has committed to raise the $36.75M local share obligation. The capital campaign is taking longer than originally planned to complete which will have an extended impact on the availability of resources to fund the Hospital s other capital needs in the short term. Although, CMH had contemplated the need for a system upgrade, the regional HIS initiative potentially comes at a much more significant cost than a system upgrade. The incremental cost is anticipated to be a significant stretch for the organization. CMH is currently awaiting a final cost estimate which will allow management and the Board to complete its due diligence and to make a decision as to whether it will be affordable to proceed as originally hoped in the next couple of years (although, finances will be a significant determinant going forward, so will staff capacity in the context of the planned move, managing through 2+ years of Hospital renovations, plus prioritizing all the other strategic initiatives on CMH s agenda in comparison to the time required to implement the new system). PCOP Funding - CMH has been involved in negotiations with the Ministry regarding its eligibility for PCOP funding linked to the opening of the new addition. There are a number of significant risks associated with these negotiations: CMH s facility costs will be funded at historical spending rates which are inadequate to cover all the incremental costs associated with the new facility; Certain programs (most notably the Emergency Department (ED)) have grown significantly since the Functional Program was completed thus making them ineligible for funding related to any future growth. At this point, the most significant risk is associated with the opening of the new ED and the potential for a large influx of patients and the resulting incremental cost that CMH may experience; Capital Branch divestment of PCOP related QBP funding to the LHIN and Cancer Care Ontario and the lack of resources at both of these organizations to adequately support the required growth in these areas; Concerns regarding how the funding formula is reconfigured and the possibility that CMH will be negatively impacted upon receipt of PCOP funding from the standpoint of net HBAM and Globe funding allocation as compared to what we would be eligible for in absence of PCOP funding. CMH has engaged a number of other hospitals and the OHA and begun dialogue with the HSFR Secretariat. A decision has been made to organize a PCOP task group as part of the HSFR Governance structure through the formulae and tools sub-group to address a series of PCOP concerns that are shared by the group of hospitals. Page 24 of 33 V2017-1

118 HAPS Narrative Other/Reputational Risks Delays in the CRP may dampen the CMH Foundation s ability to engage community partners in the fundraising campaign that is required to support the capital long term plan. Quality Please describe how the submission aligns to the quality improvement initiative and targets included in the hospital s annual QIPs Note specifically how the hospital will be achieving the best practice guidelines for the QBPs The CMH Quality & Safety Improvement Plan is a multi-year strategy ( ) that is based on a scorecard approach with 4 dimensions: safe, effective & accessible, people and patient focused, efficient and integrated and equitable. Performance continues to be monitored regularly by the Quality Committee of the Board. The emphasis in 17/18 will continue to be ED wait times, reduction in ALC & readmission rates for chronic diseases, progress on the medication reconciliation program and reducing HAI. As previously mentioned the emphasis has increased recently on quality indicators in programs that are transitioning to new or temporary space during CRP. As mentioned, the improvement in patient experience tactics will be increasingly robust with the input, from leader rounding, direction of the Patient and Family Advisory Council and clarity from HQO on specific patient expectations. The Cambridge North Dumfries collaborative QIP will expand our quality and safety work in a much focused manner. CMH continues to monitor the clinical outcomes for the QBP s and works within the WWLHIN to standardize pathways and order sets across organizations and as mentioned previously has started to implement the electronic QBP order sets in partnership with Think Research. Page 25 of 33 V2017-1

119 Agenda Item Hospital Accountability Planning Submission Hospital Name: Cambridge Memorial Hospital HAPS Revenue and Expense Form Return to Main Page Category Line # Reference YE Actual Annual Budget 2016/17 Annual Funded Annual Budget Variance Annual Budget to Annual Budget Notes REVENUE LHIN Global Allocation 1 44,362,011 45,261,980 45,418,245 45,841, ,965 HBAM Allocation 2 29,521,147 29,521,147 29,175,463 29,623, ,314 Quality Based Procedures (QBP) 3 12,249,947 12,426,481 12,778,423 12,778, ,942 Post Construction Operating Plan (PCOP) LHIN One-time payments 5 2,030,417 1,070, , ,200 (375,202) MOH One-time payments LHIN/MOH Recoveries Other Revenue from MOHLTC 8 5,133,295 5,624,510 5,450,929 5,450,929 (173,581) Paymaster Sub total LHIN/MOHLTC 10 93,296,817 93,904,520 93,518,260 94,389, ,438 Cancer Care Ontario 11 6,786,479 6,928,086 7,379,783 7,478, ,098 Recoveries and Misc. Revenue 12 6,919,723 4,138,367 5,345,505 5,260,505 1,122,138 Amortization of Grants/Donations Equipment 13 2,303,745 2,089,611 2,089,611 2,089,611 0 OHIP Revenue and Patient Revenue from Other Payors 14 11,023,331 12,102,735 11,393,152 11,393,152 (709,583) Differential & Copayment Revenue 15 2,819,898 2,933,581 3,060,865 3,060, ,284 TOTAL REVENUE ,149, ,096, ,787, ,672,275 1,575,375 EXPENSES Salaries and Wages (Worked+Benefit+Purchased) 17 56,065,294 56,035,279 56,701,462 57,588,045 1,552,766 Benefit Contributions for Employees 18 15,083,354 14,980,063 14,974,673 15,550, ,643 Employee Future Benefits Costs , , , ,662 65,262 Medical Staff Remuneration 20 From MSR Form 17,845,329 18,010,609 17,016,351 16,753,851 (1,256,758) Nurse Practitioner Remuneration , , , ,397 52,090 Supplies and Other Expense (excl. M/S, Drugs) 22 12,535,540 12,423,023 13,196,497 13,835,997 1,412,974 Amortization. of Software Licenses and Fees Medical /Surgical Supplies 24 7,285,539 8,648,267 7,420,022 7,635,725 (1,012,542) Drugs & Medical Gases 25 5,576,493 6,049,980 5,545,971 5,647,457 (402,523) Interest - short term 26 66, ,349 20,349 20,349 Interest on Major Equipment Loans Amortization of Equipment 28 4,647,920 4,672,148 4,672,148 4,672,148 0 Rental/Lease of Equipment , , , ,476 67,776 Bad Debts ,665 80,000 80,000 80,000 0 TOTAL EXPENSES ,316, ,761, ,675, ,832,629 1,070,853 SURPLUS/(DEFICIT) FROM HOSPITAL OPERATIONS 32 2,833, ,124 2,111, , ,522 Financial Instruments Held for Trading Unrealized Gain/Loss on Financial Instruments held for trading SURPLUS/(DEFICIT) FUND TYPE ,833, ,124 2,111, , ,522 R&E Page 1 of 3 29/11/ :28 AM

120 Agenda Item Hospital Accountability Planning Submission Hospital Name: Cambridge Memorial Hospital HAPS Revenue and Expense Form Return to Main Page Category Line # Reference YE Actual Annual Budget 2016/17 Annual Funded Annual Budget Variance Annual Budget to Annual Budget Notes Other Amortization and Interest on Long Term Liabilities FUND TYPE 1 Amortization of Grants/Donations of Land Improvements, Building and Building Service Equipment Amortization of Land Improvements, Building and Building Service Equipment, Leasehold Improvements 35 1,072,179 1,099,123 1,099,123 1,099, ,823,703 1,847,630 1,850,462 1,850,462 2,832 Interest on Long Term Liabilities (Excl Facilities) Interest on Long Term Liabilities (Facilities) Total Interest on Long Term Liabilities SURPLUS/(DEFICIT) FROM ITEMS ABOVE 40 (751,524) (748,507) (751,339) (751,339) (2,832) SURPLUS/(DEFICIT) INCL'G OTHER ITEMS IN FUND TYPE ,082,137 (413,383) 1,360,013 88, ,690 OTHER VOTES (FUND TYPE 2) Other Votes - Revenues excluding line ,430,094 3,324,615 3,441,458 3,441, ,843 Amortization of Grants/Donations of Land Improvements, Building and Building Service Equipment Total Revenue - Other Votes 44 3,430,094 3,324,615 3,441,458 3,441, ,843 Other Votes - Expenses excluding line 46 and ,430,094 3,324,615 3,441,458 3,441, ,843 Other Votes: Amortization of Land Improvements, Building and Building Service Equipment, Leasehold Improvements Other Votes: Interest on Long Term Liabilities (Excl Facilities) Other Votes: Interest on Long Term Liabilities (Facilities) Other Votes: Total Interest on Long Term Liabilities Total Expenses - Other Votes 50 3,430,094 3,324,615 3,441,458 3,441, ,843 Surplus/(Deficit) from Activities Less: Amount to be Returned to LHIN/MOH SURPLUS/(DEFICIT) FROM OTHER VOTES OTHER FUNDING SOURCES (FUND TYPE 3,8& 9) Other Funding Sources - Revenues excluding line , , , ,381 (133,793) Amortization of Grants/Donations of Land Improvements, Building and Building Service Equipment Total Revenue - Other Funding Sources , , , ,381 (133,793) Other Funding Sources - Expenses excluding line 58 and , , , ,688 (45,486) Other Sources: Amortization of Land Improvements, Building and Building Service Equipment, Leasehold Improvements Other Sources: Interest on Long Term Liabilities (Excl Facilities) Other Sources: Interest on Long Term Liabilities (Facilities) Other Sources: Total Interest on Long Term Liabilities Total Expenses - Other Funding Sources , , , ,688 (45,486) Surplus/(Deficit) from Activities 63 (25,713) 0 (88,307) (88,307) (88,307) Financial Instruments Held for Trading Unrealized Gain/Loss on Financial Instruments held for trading TOTAL SURPLUS/(DEFICIT) FROM OTHER FUNDING SOURCES 65 (25,713) 0 (88,307) (88,307) (88,307) R&E Page 2 of 3 29/11/ :28 AM

121 Agenda Item Hospital Accountability Planning Submission Hospital Name: Cambridge Memorial Hospital HAPS Revenue and Expense Form Return to Main Page Category Line # Reference YE Actual Annual Budget 2016/17 Annual Funded Annual Budget Variance Annual Budget to Annual Budget Notes SURPLUS/(DEFICIT) - ALL FUND TYPES 66 2,056,424 (413,383) 1,271, ,383 Total Margin (consolidated all sector codes and fund types) 67 2,807, ,124 2,023, , ,215 Total Margin (consolidated all sector codes and fund types) percent % 0.27% 1.60% 0.59% 0.32% Total margin (hospital sector only) 69 2,833, ,124 2,111, , ,522 Total margin (hospital sector only) percent % 0.27% 1.72% 0.68% 0.40% R&E Page 3 of 3 29/11/ :28 AM

122 Agenda Item Coronation Blvd, Cambridge, ON N1R 3G2 Tel Fax BRIEFING NOTE Resources Committee Date: November 15, 2016 Issue: Purpose: Appoint a Trustee for the Sinking Fund Trust Account With the Sale of FI Capital CMH Requires a new Trustee to Oversee Sinking Fund Trust Account Prepared by: Mike Prociw Approved by: Patrick Gaskin Summary The Capital Redevelopment Project, Development Accountability Agreement between CMH and the Ministry of Health and Long Term Care mandates that the Hospital have a Sinking Fund Account. FI Capital and Mr. Terry Bodnar are no longer able to fulfill the role of Trustee for this account. As a result, CMH has to appoint a new Trustee for this account. Background The Hospital has signed a Development Accountability Agreement (DAA) with the Ministry of Health to govern many aspects of the Capital Redevelopment Project (CRP). One of the requirements is to create a Sinking Fund Account. It is to serve two purposes: 1) to hold the funds that have been raised by the CMH Foundation to fund the local share obligations; and 2) to hold/segregate our local share contribution for the three milestone payments to the contractor (interim and substantial completion plus payout of final holdback payment). This account requires a Trustee to jointly oversee the account for the period of time that funds are held in that account. Previously, the Board appointed FI Capital and Mr. Terry Bodnar. Recently, FI Capital has been sold and was amalgamated with Rae & Lipskie Investment Counsel Inc. on October 31, As a result, we now need a new individual/organization to serve in that capacity. Section 9 of the DAA (attached) provides an overview of the role that the Trustee fulfills. Page 1 of 2

123 Agenda Item Analysis CMH and CMHF have jointly made a decision to retain the funds generated by the Foundation, that are targeted for the capital project with the Foundation. As payment obligations for the CRP come due (and there will only be three as mentioned above) funds are moved by CMHF to the sinking fund account, 90 days in advance of payment. The funds sit in this account for 90 days and then get moved to the hospital to pay out the general contractor. As such, the role expectations of the Trustee would be extremely minimal. CMH management approached Rae & Lipskie, TD Wealth and CIBC Wood Gundy to ask if they would serve in this role and they all declined. We then decided to approach Mr. David Thomas who is the Senior Financial Advisor at Manulife Securities Inc. and Treasurer of the CMH Foundation to see if he could assist in identifying someone who could function in this role. Although he does not meet the requirements identified in the DAA, he has agreed to serve in this role assuming we obtain Ministry approval. Mr. Thomas has four professional designations in financial planning (Chartered Professional Accountant, Chartered Accountant, Certified Financial Planner and Chartered Life Underwriter) in addition to a university degree in business. David is responsible for providing a comprehensive offering of financial advice (investments, taxation, financial planning and insurance) with a view to investment strategy covering a wide range of investment products, including stocks and bonds. His previous experience includes acting as a tax specialist and partner in two public accounting firms, a financial advisor at Graham Mathew Investment Services Inc. and as a life insurance advisor at Manulife Securities Insurance Inc.. Mr. Thomas has agreed to assist the Hospital in this capacity and therefore we would request that the Board approve Mr. Thomas in this role. Recommendation That Mr. David Thomas, Senior Financial Advisor at Manulife securities Inc. and Treasurer of the Cambridge Memorial Hospital Foundation Board be appointed the Trustee of the CMH Sinking Fund Trust Account with joint signing authority, along with Mr. Mike Prociw, Vice President Finance and Corporate Services, CMH for that account. Page 2 of 2

124 Agenda Item # Coronation Blvd, Cambridge, ON N1R 3G2 Tel Fax COMMITTEE MEETING SUMMARY - OPEN Date: October 20, 2016 Issue: Quality Committee of the Board Meeting, October 19, 2016 Prepared by: Iris Anderson, Administrative Assistant, Clinical Programs Approved by: Sandra Hett, VP Clinical Programs & CNE Attachments*: 2016/17 Patient Experience Survey YTD Results Explored WWLHIN Collaborative Quality Improvement Plan (QIP) Board Oversight (FYI information) Program Presentation: Emergency Department (ED)* (ppt circulated in package 2) Guests: Ms. Sharratt, Director of Medical Programs, Mr. Laranjo, Manager of Emergency, Dr. Shafir, Chief of Emergency, Dr. Eugenio, Deputy Chief of Emergency, Mr. Leslie, Manager of Transformation Office Ms. Sharratt provided a summary of several slides, and noted the following: The current ED space which has 25 stretcher spaces was built for 30,000 visits per year; in the new build, the ED space will have 40 stretcher spaces for approximately 60,000 visits per year. Current volumes are ~ 55,000 annually The ED works collaboratively with Emergency Medical Services (EMS), Police, CCAC, Homewood, and many others Hand Hygiene results are lower than previous YTD; the staff may view Moments 1 and 4 same, however the auditor may view this and document differently In reference to Pay for Results (P4R), CMH performance rank of 59 th in 2015 to 29 th YTD; the funding rank has gone from 57 th 2015 to 39 th currently With the help of an Off-Load RN (since December 2015)funded via Region of Waterloo EMS, Ambulance Off-Load Time has improved; current performance is 27 minutes, ranking CMH 25 in the province and best in WWLHIN for that service There are currently 40 full-time staff and 20 part-time staff in the ED There has been a slight increase in Sick time due staff in modified work and sick programs Page 1 of 3

125 Agenda Item # The implementation of the new electronic Canadian Triage Assessment Score (e-ctas) is planned for Feb 2017 RNs doing phlebotomy Prior to the new build, enhanced security initiatives will be reviewed to ensure a caring and respectful patient environment Ms. Sharratt introduced Mr. Laranjo to the Committee. Mr. Laranjo referred back to the pre-circulated presentation and shared a patient story regarding a visitor to the ED with concerns, which led to improving customer services for ED staff. Discussion ensued. Mr. Kron then opened the floor for questions and comments. A committee member requested further information on e-ctas. Mr. Laranjo explained the process and guidelines by the Ministry of Health and Long Term Care. A question regarding Guelph General s P4R performance was directed to Dr. Shafir. Dr. Shafir explained a few of the differences including additional physician hours, historical compensation differences, larger physical space, and physicians working shorter shifts as well as different hospitalist program. Homewood also provides the mental health services for GGH so this population is managed externally. Another member asked clarification of Value Based Conversations (VBCs) data. As Mr. Laranjo is new to the organization and getting familiar with staff, formal VBC staff meetings will commence in the New Year. Mr. Kron thanked the guests for their presentation. 2016/17 Patient Experience Survey YTD Results Explored* In follow-up to the September 21, 2016 meeting, Ms. Barefoot spoke to the previously circulated briefing note. She drew attention to the chart at the end of the briefing note where the themes of team work, communication and overall customer service are highlighted in red. The committee commented how frequently the word courteous appears in the highly correlated questions. The overall correlation concepts will be forwarded to Director s Council for input. WWLHIN Collaborative Quality Improvement Plan (QIP)* Ms. Hett referred to the pre-circulated WWLHIN Collaborative Quality Improve Plan report. On September 13, 2016, Mr. Kron and Ms. Hett attended the 2016 Governor Quality Symposium. In this session, governors joined in discussions to create a Page 2 of 3

126 Agenda Item # governance plan for a collaborative quality improvement plan within the WWLHIN. Ms. Hett and Mr. Kron will be attending a second session on November 2, 2016 (previously scheduled for October 25). ACTION: Following the November 2, 2016 WWLHIN session, Ms. Hett and Mr. Kron will provide the Committee with an update at the November Quality Committee meeting. One committee member required clarification of the Quality Indicators Table. Mr. Kron noted that the Quality Indicators Table was a summary of how issues are carried through each sector. Ms. Barefoot added that P indicator refers to a priority indicator and an A indicator refers to an additional indicator. Page 3 of 3

127 Agenda Item # Coronation Blvd, Cambridge, ON N1R 3G2 Tel Fax BRIEFING NOTE Quality Committee Date: October 14, 2016 Title: Purpose: Patient Experience Survey YTD Results Explored Information Prepared by: Liane Barefoot, Director Patient Experience, Risk & Quality Approved by: Sandra Hett, VP Clinical Programs & CNE Background As of April 1, 2016 all hospitals in Ontario participating in the Ontario Hospital Association Patient Reported Performance Measurement (OHA-PRPM) contract transitioned to a new patient experience survey tool. National Research Corporation Canada (NRCC) was awarded the contract to distribute and compile the survey results; however, the new surveys are no longer NRCC proprietary as they used to be. These are brand new surveys developed and validated by the Canadian Institute for Health Information (CIHI). Over time they will be implemented in provinces beyond Ontario allowing pan-canadian benchmarking. Corporately on the scorecards CMH reports results to the question Would you Recommend CMH to family and friends? for the combined Medical and Surgical inpatient units only. In addition, there are surveys sent to non-admitted patients seen in the emergency department as well as admitted patients to Obstetrics and Pediatrics. These results are provided to the specific departments. Timing of Mail Out Due to some challenges finalizing the contract, creating and populating a new electronic file to be uploaded monthly to NRCC, there was a delay in sending out the April and May 2016 surveys. This has been resolved and the June, July and August files were uploaded to NRCC in a timely manner. Each survey is mailed out in two waves the first when the file is received from the organization and the second 24 days after the first. This means that the results will be considered complete approximately 15 weeks + 3 days after the first wave survey has been sent out. Surveys that are still in the field or have incomplete data are denoted by the double dagger symbol ( ) in Catalyst (the online viewing system). The table below illustrates when the surveys for CMH were mailed out and when the files will be considered closed. Page 1 of 5

128 Agenda Item #4.1 Encounter Month 1 st Wave Survey Sent Out File to be Closed on April 2016 June 14, 2016 September 30, 2016 May 2016 June 14, 2016 September 30, 2016 June 2016 July 13, 2016 October 29, 2016 July 2016 August 9, 2016 November 25, 2016 August 2016 September 6, 2016 December 23, 2016 Changes to Questions In the new survey the scale for the Would you Recommend? question has changed from a 3- point scale (Yes, definitely; Yes, probably; No) to a 4-point scale (Definitely yes; Probably yes; Probably no; Definitely no). OHA and NRCC are recommending that hospitals view the results to this question as the Top Box responses which only reflect the % of patients that selected Definitely yes. Results Table 1 below illustrates the % positive responses when viewing the Top Box responses vs. the Top 2 Boxes (i.e. Definitely yes + Probably yes) for fiscal year YTD for both the Inpatient Medical/Surgical areas. Table 2 shows the same data for the non-admitted Emergency patient surveys. The NRCC Average represents any Canadian hospital, of any size, using this survey tool. Response months shaded in red are statistically significant (lower) from the NRCC Average. Table 1: % Positive Responses to Would you Recommend for Medical & Surgical Inpatient Units: Top Box vs. Top 2 Box Views Fiscal YTD Inpatient Medical and Surgical Surveys Would you Recommend Top Box Responses Would you Recommend Top 2 Box Responses NRCC Avg 73.6% n= % n=2946 Current fiscal YTD ( ) 50.8% n= % n=132 Apr % n= % n=31 May % n= % n=32 Jun 16 ( ) 47.8% n= % n=23 Jul 16 ( ) 39.1% n= % n=23 Aug 16 ( ) 50.0% n=20 100% n=20 Table 2: % Positive Responses to Would you Recommend for non-admitted Emergency patients: Top Box vs. Top 2 Box Views Fiscal YTD Non-admitted Emergency Surveys Would you Recommend Top Box Responses Would you Recommend Top 2 Box Responses NRCC Avg 64.6% n= % N=2333 Current fiscal YTD ( ) 43.7% n= % N=135 Apr % n= % N=31 May % n= % N=32 Jun 16 ( ) 33.3% n= % N=24 Jul 16 ( ) 38.5% n= % N=26 Aug 16 ( ) 52.4% n= % N=21 OHA and NRCC are emphasizing to hospitals across Ontario the fiscal year is to be considered a baseline year and advising hospitals against comparing results from the old NRCC proprietary survey questions to similar sounding questions in the new survey. Page 2 of 5

129 Agenda Item #4.1 Analysis Undertaken Given that the CMH n-size for the surveys is extremely small, that three (3) of the five (5) months are still considered in the field, and that it is a brand new survey and therefore the NRCC average n-size is also small, a look-back analysis focused on combining and rolling up fiscal years and Correlated Questions First ran a correlation report to the question Would you Recommend for the inpatient survey (medical/surgical) and non-admitted emergency patient survey. In both cases the most highly correlated survey question was Rate your overall care from 1 to 10. Inpatient Survey (medical/surgical) correlation coefficient = Non-admitted emergency correlation coefficient Then ran a correlation report for the question Rate your overall care from 1 to 10 again for the inpatient survey (medical/surgical) and non-admitted emergency patient survey. In both cases the most highly correlated survey question was How well did doctors and nurses work together? Inpatient Survey (medical/surgical) correlation coefficient = Non-admitted emergency correlation coefficient The two graphic/pictorial depictions below illustrate the interrelationship between the target (improve Would you Recommend) and the questions and corresponding correlation coefficients influencing reaching our target. Figure 1: Emergency Department Survey Results 2 years aggregate data Would you Recommend ED Services at CMH to family and friends (average % of positive responses for 2 years = 45.7%) Most highly correlated with 'Rate the Overall ED care you received' question (0.707). Average % positive responses for 2 years to Rate the overall ED Care you received = 23.1% 'Rate the overall ED care you received' question is most highly correlated with the question: 'How well did the nurses and doctors work together?' (0.824). Average % positive responses for 2 years to 'How well did the nurses and doctors work together?' = 30.5% Page 3 of 5

130 Agenda Item #4.1 Figure 2: Inpatient (Medical/Surgical) Survey Results - 2 years aggregate data Would you Recommend services at CMH to family and friends (average % of positive responses for 2 years = 62.2%) Most highly correlated with 'Rate the overall care you received' question (0.729). Average % positive responses for 2 years to 'Rate the overall care you received' = 36.3% 'Rate the overall care you received' question is most highly correlated with the question: 'How well did the nurses and doctors work together?' (0.778). Average % positive responses for 2 years to 'How well did the nurses and doctors work together?' = 35.0% The table below provides a list of all questions with correlation coefficients greater than to the question rate your overall care from 1 to 10 in descending order of correlation coefficient (i.e. ability to influence). Red font highlights words or phrases that relate to teamwork, communication or basic customer service. Very few of these strongly correlated questions relate to themes that the clinical teams/providers tend to think would be the most important to patients such as having to wait too long, pain control, or condition of the environment. While these are important and they appear on the correlation lists they are not nearly as high as the questions related to teamwork, communication and basic customer service. Question Inpatient Survey Correlation Coefficient Question non-admitted emerg Correlation Coefficient Rate how doctors & nurses Rate how doctors & nurses worked together worked together Availability of nurses Explanation of what ED did Courtesy of nurses Courtesy of ED staff Would recommend for stay Courtesy of ED doctors Got bathroom help in time Rate availability of ED nurses Received all services needed Would recommend for ED services Treated you with respect & Courtesy of ED nurses dignity Confidence/trust in nurses Rate amount of time spent in ED Courtesy of admission Received all ED services needed Explained test results understandably Confidence/trust in ED doctors Page 4 of 5

131 Agenda Item #4.1 Next Steps 1. Present overall correlation concepts/themes (teamwork, communication, basic customer service) to MAC, Quality Committee & Director s Council for input Page 5 of 5

132 Quality Improvement Plans 101 Sub-LHIN Collaborative QIPs Waterloo Wellington LHIN September 2016 Health Quality Ontario The provincial advisor on the quality of health care in Ontario

133 Objectives Review the purpose of a Quality Improvement Plan (QIP) and introduce its components Review the context of QIPs in Ontario Provide information to support organizations with aligning organizational and provincial priorities Provide guidance about key roles and questions for boards to consider when reviewing and finalizing their organization s QIP 1

134 QIP FOUNDATIONS 2

135 What is Quality Improvement? Quality improvement can be defined as a systematic approach to making changes that improve clinical practice and health system performance, enhance professional and/or organizational development, and improve patient and population health outcomes. In other words: Quality improvement is an approach to making changes that improve quality of care and how the health system performs. 3

136 What is a Quality Improvement Plan? A QIP is a commitment that a health care organization makes to its patients, staff, and community and to the Ontario public as a whole to improve quality through focused targets and actions. a way to focus organizations, sectors and the system as a whole on key priorities (provincial and local) a way of harmonizing dialogue and encouraging peer-topeer sharing and benchmarking one means to help entrench quality improvement culture as a system-wide effort 4 Health Quality Branch 4

137 Quality Improvement Plans One of the largest, jurisdiction wide quality improvement efforts in the world is in Ontario On April 1 st, 2016 HQO received 1044 Quality Improvement Plans reflecting organizations commitment to improvement for 2016/17 - Publicly Posted: Insights to Quality Improvement Reports have been developed providing summary of progress, spotlight on change ideas and organizations Combination of sector-specific and cross-sector reports cross sector report on patient engagement in the QIPs released in June 2016 General trends: alignment with strategy, collaborative efforts to improve delivery of integrated care, engagement of patients, communicating plan to community. Multi-sector QIP now possible. 5

138 Quality Improvement Plans Quality Improvement Plans (QIPs) submitted yearly to HQO as per ECFAA and SAAs April 1, 2016 HQO received QIPs as follows: Sector Expected Submitted % Hospital % Primary Care % Home Care % Long-Term Care % Total % *New for this year: A total of 22 organizations submitted a multi-sector QIP 6

139 Who submits a QIP? Currently, the following organizations are required to develop and submit their QIP to HQO; All public hospitals in Ontario All inter-professional team-based primary care modelsᵟ, including: Family Health Teams, Nurse Practitioner-Led Clinics, Community Health Centres, and Aboriginal Health Access Centres All community care access centres (CCAC)ᵟ All long-term care homesᵟ As per ECFAA. ᵟ As per Ministry requirements. 7

140 Who is involved in the development of the QIP? 8

141 Components of a QIP QIPs include aims, measures, targets, and change ideas for how an organization will work to improve the care they offer to patients. There are three parts to a QIP: A document that provides an executive summary of the plan (Narrative) A report on progress and lessons learned from implementing the previous year s plan (Progress Report) The plan itself (Workplan): Organizations to identify: the topics they are working on (we encourage them to focus on provincial priority issues), how they are doing currently (current performance data), where they want to go (target), and how they plan to get there (change ideas) 9

142 QIP Priorities Priorities selected through an extensive consultation process involving HQO s Patient, Family, Public Advisory Council, QIP Cross-Sector Advisory Committee, LHINs, Ministry, and sector and professional associations QIPs are a balance between provincial and local needs organizations are not required to select the recommended priorities, but they should consider them While indicators are important, organizations should not lose sight of the broader quality issue behind the indicator 10

143 2017/18 Quality Issues and Indicators (A): Additional indicator Quality Dimens n Quality Issue Topic Hospital Primary Care Home Care LTC Effective Effective transitions Readmissions for select conditions and mental health Post-discharge follow up Patient perception of transition Avoidable ED visits Readmission for select HIGs (A) Readmission for one of CHF, COPD or Stroke (QBP) Rate of inpatient readmission within 30 days for mental health and addiction (A) Leaving hospital, did you receive enough information (NEW) Percent discharge summaries sent within 48 hours of discharge (A) (NEW) 7 day post discharge follow up Post discharge follow up (any provider) (A) (NEW) Hospital readmission for select HIGs (A) Hospital readmissions Unplanned ED visits Potentially avoidable ED visits for ACSC Effective Coordinating care (NEW) Care coordination within and between organizations Narrative Identify complex patients (Health Links) (A) (NEW) Narrative Identify complex patients (Health Links) (A) (NEW) Narrative Identify complex patients (Health Links) (A) (NEW) Narrative Effective Population health Understanding populations Diabetes management Cancer screening Narrative Narrative HbA1C (A) Colorectal and cervical cancer screening (A) Narrative Narrative Patientcentred Palliative care Home support Preferred place of death Home support for discharged palliative patients (P) End of life, preferred place of death (P) (NEW) Patientcentred Person experience Would you recommend? Involved in decisions Narrative Would you recommend (IP, ED)? Narrative Involved in decisions about care Narrative Client experience Narrative Resident experience Efficient Access to right level of care Alternative level of care ALC rate ALC rate for home care patients (A) Timely Timely access to care, services Wait times for service provider Wait times in ED Access to primary care provider ED length of stay (complex) Timely access to primary care (patient perception) Wait time for home care (PSW, Nursing) Safe Safe care Falls Pressure ulcers Restraints in mental health Pressure ulcers (A), physical restraints in mental health (A) Falls for long-stay clients Pressure ulcers,(a) restraints (A), falls (A) Safe Medication safety Medication safety Appropriate prescribing Medication reconciliation (admission) Medication reconciliation (discharge) (P) Medication reconciliation (A) (NEW) Prescribing of antipsychotic medication Equitable Equity (NEW) Applying equity lens to health care and services Narrative Narrative Narrative Narrative Safe Workplace safety (NEW) Workplace violence Narrative Narrative Narrative Narrative Note: While each sector has their own set of issues (and accompanying indicators), they have been laid out in a matrix to highlight how issues are carried through each sector. For example, effective transitions impacts each sector and the selected indicators address specific topics within that sector, under the broader theme of effective transitions. There are also blank areas where there may not yet be an indicator for that indicator and sector (for example, palliative care in primary and long-term care). Legend: Blue text refers to a new addition or modification for the 2017/18 QIPs. P refers to a priority indicator and A refers to an additional indicator. Narrative means that this issue has been included in the QIP via a question in the narrative section of the QIP. This is often used in cases where a specific indicator may not be ready or may not be appropriate. Text in italics refers to indicators that have not yet been confirmed.

144 PROVINCIAL CONTEXT 12

145 Evolving QIPs for Different Purposes Multi-sector Focussed QIPs (Collaborative QIP in future) Multi-org, cross sector or collaborative QIP e.g. SubLHIN Organizational or Group Practice QIP Continue and expand to other sectors / types Programmatic QIP Advance specific and focussed quality issues e.g.. Standards, NSQIP/Surgical quality 13

146 The Role of HQO and the LHIN in QIPs HQO s Responsibilities LHINs Responsibilities Work with the LHINs and other partners to identify priority areas for system-wide improvement Provide guidance on selecting indicators and setting targets Increasingly may strengthen guidance for low performers Receive QIPs from HSPs Report back on progress and support access to LHIN-specific data and highlevel analysis Provide advice to the MOHLTC on when to bring on other sectors to QIPs Work with HQO and other partners to identify priority areas for system-wide improvement Engage HSPs in QIP development to support sector-wide or cross sector alignment in support of the LHIN s IHSP Receive QIPs from HSPs when submitted to HQO Review QIP submission summaries from HQO to determine opportunities for improvement Note: HQO has no role with HSPs in relation to the SAAs. Note: While this chart identifies separate responsibilities, they are meant to be executed in a collaborative manner, always reinforcing the complementary relationship 14

147 How QIP and SAA Align: Current State Service Accountability Agreement Quality Improvement Plan Required contract between every funded Health Service Provider (HSP) and LHIN Priorities set by LHIN with reference to the Ministry-LHIN Accountability Agreement (MLAA) Multi-sector HSPs may have more than one SAA Required plan submitted by some sectors (HSPs) to HQO Some sectors such as CSS do not (currently) submit QIPs to HQO Priorities set by HQO, through extensive stakeholder consultation and with reference to the Common Quality Agenda HSPs with multiple sectors (i.e. hospital with long term care home) submit only one QIP *Processes to align priorities and identify opportunities to use both to advance quality have not been explicitly linked to date 15

148 ROLES OF BOARDS AND EXECUTIVE LEADERSHIP 16

149 Key Role of Boards in Quality Questions for boards to consider: Improving transitions and experience across the system: How are we contributing to quality care as our patients move across the system? Quality and Strategy: How is quality a focus of the organization? Is it explicitly linked to the strategic goals? Dimensions of quality: Do our efforts to ensure quality cover the six dimensions of quality in the Quality Matters framework? Involving patients: Are patients engaged in our efforts to improve quality? Routine reflection on data: As governors, what data and information about the quality of care is reviewed? How do we compare with others? Board skills: Are board members sufficiently trained and equipped to support responsibilities related to quality as described in ECFAA? Organizational skills and leadership: What is the capacity, knowledge and skill for quality improvement in the organization? 17

150 A Final Thought We need to manage improvement projects as if the future of the health care we offer to our patients depends on it. Adapted from Dr. Ross Baker, Leatt Lecture, September 8,

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152 Collaborative QIP Guidance Document Waterloo Wellington LHIN Board Quality Symposium September 2016 What is a Collaborative QIP? A Collaborative QIP is a formal, documented set of quality commitments that a health care organizations make to their patients, clients, or residents, staff and community on an annual basis to improve quality through focused targets and actions that specifically address agreed upon sub-region needs. Each Collaborative QIP is submitted by a lead organization using a shared sub-region template, however it is owned by each organization. Importantly, Collaborative QIPs are an improvement tool. While they are not an accountability or performance management tool, the board, senior leadership, and the organization as a whole are accountable for the commitments made (e.g., targets set and undertaking the improvement activities) in your plan. Why is a Collaborative Quality Improvement Plan (C-QIP) important? In many areas, the Ontario healthcare system is performing better than it was 10 years ago. That said, as identified in HQO s Measuring Up report, there are many areas in which health status and quality care is lagging. 1 In most cases, these areas for improvement are related to system-level issues given that patients move across the system, there is a need to improve how various components of the health care system come together to support care that is safe, effective, patient-centred, efficient, timely, and equitable. To date, Quality Improvement Plans (QIPs) have largely focused on organizational rather than system-level improvement. Collaborative QIPs, which are coordinated at the sub-region level, focus on system-level change and issues that require cross-sectoral collaboration to achieve improvement. Are organizations required to submit a Collaborative QIP? And are organizations still required to submit their regular QIP? Organizations that are currently required to complete a QIP must still submit their organizational QIP to HQO on or before April 1 st every year via the QIP Navigator. (The QIP Navigator is an online portal where organizations can develop and submit their organizational QIP, as well as search and review QIPs from other organizations.) Given this pilot, organizations in Waterloo Wellington LHIN may also choose to submit a collaborative QIP. While the collaborative QIP would be in addition to their organizational QIP, HQO would expect that the organizational QIP would be leaner, likely with fewer indicators. Organizations can also reference the submission of the collaborative QIP in their organizational QIP. Like the organizational QIPs, collaborative QIPs are due to HQO by April 1, though collaborative QIPs will not be submitted via the QIP Navigator in As for organizations that currently do not complete a formal organizational QIP (i.e. that is submitted to HQO), they are encouraged to participate in the collaborative QIP though they are not expected to submit an organizational QIP to HQO. How do organizations submit their Collaborative QIP? At this time, the C-QIP will be submitted by a lead organization in each sub-region. Practically, the lead organization will submit the C-QIP to HQO via (QIP@HQOntario.ca) using an excel template by April 1, (The excel template will be provided by HQO.) After submission, it will be uploaded and publically posted on HQO s website. We would anticipate that they would be submitted to the LHINs as well. By its very definition, a C-QIP like organizational QIPs is a formal, documented set of quality commitments that participating health care organizations make to their patients/clients/residents, staff and community; to support shared learning and transparency, organizations are encouraged to post their C-QIP on their website as well. When should we begin developing our C-QIP? How do we get started? As is the case with the organizational QIP, the work of the QIP takes place year-round as organizations work to develop their plans, implement their plans, and then develop the next plan based on progress and lesson s learned from the previous year. At a very practical level, organizations will need to leave plenty of time to ensure that the C-QIP can be reviewed and signed-off on by 1 Health Quality Ontario. (2015) 1

153 Waterloo Wellington LHIN Board Quality Symposium September 2016 participating organizations boards before the April 1 submission deadline. Typically, groups begin developing their organizational QIPs in the fall. In terms of how to get started, the first step is understanding the needs of the sub-region and selecting which issues participating groups would like to profile in their C-QIP the board quality symposia in September are a first step in this process. These needs are identified using sub-region data as well as health service provider and board perspectives. Once areas of need have been established, governors and health service providers from across the sub-region should work together to develop a shared plan for addressing these needs. Organizations will also need to work together to develop indicators to measure their progress, data collection methods, targets, and change ideas that reflect their shared commitment. This shared work may require new and innovative partnerships, as well as new or modified structures to support communication, collaboration, and on-going monitoring. Organizations will also need to consider how patients, providers, and the public will be engaged in this work. What role does the board, leadership / others have in developing the C-QIP? Development and successful implementation of the quality improvement initiatives outlined in your C-QIP depends on the involvement and engagement of your organization s board, senior leadership, clinicians, staff, and patients/clients/residents. Their interaction can be depicted as follows, with the blue arrows representing the board roles and the accompanying text below outlining the HSP roles. Governor and HSP Roles (Figure 1.0) Define Common System Needs Commit to Address Common Issue(s) Oversee C-QIP Review sub-region data and identify common needs Attend Regional Engagement Sessions to build concensus on common system needs Ensure board is fully informed of system-level needs and C-QIP process Identify population(s) of interest Initiate partnerships with HSPs planning to address common system and population needs Select Lead organization Select indicators and targets for system-level improvement Establish mechanisms for ongoing and regular oversight. Further questions to consider Do you have enough information to get started? What governance issues might be raised in the sub-lhin QIP? Who will sign-off on the sub-lhin QIPs? Each organization s individual board? How will this process be organized? Who will oversee progress? What are the tools and resources that are needed to make this pilot successful? How do you envision the role of the lead organization and how that organization will be selected? 2

154 Agenda Item # Coronation Blvd, Cambridge, ON N1R 3G2 Tel Fax COMMITTEE MEETING SUMMARY - OPEN Date: November 17, 2016 Issue: Quality Committee of the Board Meeting, November 16, 2016 Prepared by: Iris Anderson, Administrative Assistant, Clinical Programs Approved by: Sandra Hett, VP Clinical Programs & CNE Attachments*: Collaborative Quality Improvement Plan (c-qip) Quality Scorecard Quarterly* Quality Improvement Plan (QIP) and Quality Patient Safety Plan (QPSP) Board Oversight (FYI information) Presentations circulated in Package 2 Medicine and Patient Story Ms. Sharratt, Director of Medical Programs, Ms. Leversidge, Manager of 3B/5B Medicine, Dr. Nguyen, Physician Director of Medicine Programs, Dr. Mathew, Chief of Hospital Medicine, joined the meeting at 0703h. Ms. Sharratt introduced Ms. Villarreal, CMH/CCAC Integrated Manager and Ms. Hurley, Manager of Rehabilitation, who also joined the meeting at 0703h. Ms. Leversidge provided a summary of the previously circulated presentation, and highlighted several slides: There has been an increase in medication errors on the 5B Medicine unit; the Medicine Program has the highest reporting of near miss incidents. The majority are low level in severity. Some causes for increase is implementation of CMARhyper-vigilance prior to and during transition of changes. New staff change in safety culture The number of falls on the Medicine units have slightly increased due to the least restraint practices and prolonged length of stay patients with multiple fall incidents, and difficult to place patients with behaviour Patients with repeat falls have been flagged as high risk 30 of 42 Value Based Conversations have been completed thus far and are on track to complete requirements by the end of the fiscal year; zero were done last fiscal year due to the change in clinical leadership The increased response rate to patient satisfaction survey s from patients is attributed to the follow-up discharge calls by the Charge Nurses Feedback from patients and families are shared at daily huddles Page 1 of 3

155 Agenda Item # Increased acuity patients and the requirement to change nursing skill mix has incurred significant overtime; ; hence, August 2016 a change in skill mix occurred to address safety concerns related to acuity. Ms. Sharratt referred back to the pre-circulated presentation and shared a patient story regarding a Long Term Care Home (LTCH) patient with behavioural issues unable to remain in a LTCH in Cambridge. After a significant period of time on the Medicine unit, the patient was transferred to the TCU (transitional care unit on Rehab). Ms. Hurley spoke of the patient s behavioural history, family involvement, care planning and patient discharge plans to the community. This patient is currently under family care, awaiting placement into LTCH. Work continues at the management levels between CMH, CCAC and the WWLHIN. Ms. Sharratt opened the floor for questions and comments. A committee member requested further information on mental health available beds. Specialized mental health beds are not available in the Waterloo-Wellington area. In the specific case of this patient, one LTC home would accept the patient if there was available private room funding. Ms. Villarreal spoke of the challenges and barriers when placing an LTCH patient, costs of private room in a LTCH, and gaps in the system. Ms. Leversidge continued with the presentation. A question regarding physician specialties was raised. Dr. Nguyen responded and reported there is a lack of medical support services in the region, specifically in neurology, hematology, endocrinology and rheumatology. Due to a number of factors, recruitment for these positions has been challenging. Mr. Kron thanked the guests for their presentation. Rehabilitation Ms. Hurley referred to the previously circulated presentation, and provided an overview: Falls rate has increased despite significant efforts by the team; this continues to be an area of focus Falls are discussed at team huddles The multidisciplinary teams reviews falls prevention strategies regularly and modifies individual care plans It is estimated that approximately 80% of patient falls are related to patients going to the bathroom. VBCs are on track to meet goal to complete all reviews by April 30, 2017 The target Rehab length of stay is 20 day; current performance in the first quarter is 15.9 days Sick and overtime are in a favourable position this fiscal year MSK injuries are down from previous year; training has been provided related to safe lifts and transfers Weekly Leader Rounding continues; feedback very positive Model of CCAIR has been successful with the integration of the PSWs Page 2 of 3

156 Agenda Item # Ms. Hurley noted the challenges of the new build in that Rehab will remain in the older part of the hospital, where rooms are quite small with limited space and access to bathrooms. The CRP transition planning team for Rehab has been very engaged in the process. Ms. Hurley directed the Committee members to the Rehab Pamphlet, which further explained the program services and activities. Dr. Rhee noted the challenges encountered by the Rehab unit over the years to establish an optimal physician coverage model. Several physician model changes have occurred, however this remains a challenge to have the continuity and support that would align with the clinical work. With no further questions. Mr. Kron thanked Ms. Hurley for the presentation. Ms. Hett distributed a copy of the WWLHIN s Rehabilitation/Complex Continuing Care Integrated Clinical Programs Metrics Scorecard. Ms. Hett referred to CMH s performance rate of 41.7 for stroke admissions. The WWLHIN Rehab Council is currently reviewing this metric as with a central intake model, each program has no ability to determine the mix of stroke patients or their severity at any time. Collaborative Quality Improvement Plan Governor Symposium Workshop* On November 3, 2016, Mr. Kron, Ms. Hett and Dr. Rhee attended a follow-up governors session hosted by the WWLHIN. The WWLHIN intends to move forward with a Collaborative Quality Improvement Plan (c-qip) for system change. Health Quality Ontario and the WWLHIN will be organizing further local sessions to provide guidance to the interested parties in the development of a c-qip and associated framework. ACTION: The Quality Committee will review the draft c-qip and CMH QIP in January 2017 with final sign-offs required by March Quality Scorecard - Quarterly* Mr. Meyette read the results of the pre-circulated Quality Scorecard and the data was briefly discussed. Quality Improvement Plan (QIP) and Quality Patient Safety Plan (QPSP)* Ms. Barefoot directed the Committee members to the previously circulated briefing note, and opened the floor to questions and comments. Ms. Barefoot provided a summary of the mid-year by performance highlighting Flow, commitment to medication safety, quality improvement and HSMR and patient experience as an area for improvement. Page 3 of 3

157 700 Coronation Blvd, Cambridge, ON N1R 3G2 Tel Fax BRIEFING NOTE Quality Committee Date: November 7, 2016 Issue: Purpose: Prepared by: Approved: Update on Cambridge North Dumfries Collaborative Quality Improvement Plan (c-qip) Information Sandra Hett, Vice President Clinical Programs & CNE Patrick Gaskin, President & CEO At the October Quality Committee (QC) of the Board, a short verbal report was provided regarding a LHIN-sponsored event to introduce the concept of a collaborative Quality Improvement Plan (c-qip) to governors and leaders of health care providers in Cambridge North Dumfries. At this time, QIP s are not mandatory for all community provider organizations. Attendance at this introductory meeting from CMH included Patrick Gaskin, Sandra Hett, Board Chair Joe Kane, QC Chair Larry Kron and QC member Nicola Melchers. Members of Health Quality Ontario (HQO) were present and provided some background information which was distributed with the October QC agenda. The QC update included the CMH position of philosophical support for the concepts of system planning, goals and collaboration with community partners. There was lack of clarity on how this collaborative QIP (c-qip) would align with legislative requirements under (ECFAA). There were questions raised about the governance framework to guide the governors from the various provider organizations recognizing this is a new provincial initiative and not all providers are required to submit a QIP. Appendix A (Leading Together Committed to Quality Report Back) summarizes the first session. A follow up governors session was hosted by the WWLHIN on November 3 rd to continue this discussion and Larry Kron, Sandra Hett and Dr. Kunuk Rhee attended on CMH s behalf. This second session built on the initial premise of the benefits to patients of increased collaboration to close gaps between system partners who may all be providing best clinical care albeit often in silos. It is often the gaps or transitions between the partners where the risk can occur. It was also acknowledged by the WWLHIN staff that there are currently many initiatives underway supported by multiple providers to improve transitions, communications and patient experience. An example is the discharge transition committee work that is led by Langs (with CMHA, CCAC, Cambridge Family Health Teams and CMH all as active participants). Page 1 of 2

158 The primary challenge identified was the added value of a c-qip in an already collaborative and collegial environment in our sub-region. Health Quality Ontario and the LHIN Board shared their bias that a greater systems-focused framework with robust oversight could drive improved integration and collaboration performance. In short, we could get more done more effectively if we all adhere to a common goal. In turn, our sub-region would receive some project support from Health Quality Ontario (HQO). WWLHIN has declared an intention to move forward with the c-qip framework for collaborative system change. It is the LHIN s primary tool in achieving the system integration that is central to the Patient s First mandate. Governors present were in agreement with this direction however they had questions and concerns regarding how this collaborative QIP goal may or may not align with corporate goals that had been approved by their respective corporations. The project support offered by HQO was deemed insufficient and Board Directors would need to instruct management to realign priorities and resources to achieve c-qip development and implementation in the timelines suggested (April1st, 2017). Preliminary pre-work identified six areas in need of improvement: See Appendix B. 1. Low primary care follow up following acute discharge 2. High % of ALC days 3. High rate of readmission for CHF 4. High wait time for Mental Health housing 5. Long wait time for community psychiatry in LHIN 6. Many residents do not die in their place of choice Three transitions areas were identified from the above: Mental Health, Palliative Care and Chronic Disease Prevention and Management. Chronic Disease Prevention and Management was identified as an area of local need that could realize benefits from a c-qip and greater system collaboration. Next Steps: The Cambridge North Dumfries sub-region will be organizing local sessions supported by Health Quality Ontario members and the WWLHIN for the end of November to provide guidance to interested parties in the development of a c-qip and its associated governance/oversight framework. These are intended to be operational sub-region workshops with QI leads to review templates and develop the c-qip. The Quality Committee will review the draft c-qip in January 2017 and final sign-offs are required by March 2017 in the intended timeline from the LHIN. Page 2 of 2

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