Balanced Scorecard Quarterly Report

Transcription

1 Page 0 of 24 Balanced Scorecard Quarterly Report December 2017 Balanced Scorecard Quarterly Report April Data updated to December 31, 2017

2 Balanced Scorecard Quarterly Report December 2017 Page Strategy Map 2 Balanced Scorecard 3 Strategic Theme: Patient and Family Centred Care Provide me with the best possilbe care experience Official Languages active offer education sessions completed with key departmentsatient 4 Environmental Services (EVS) cleanliness audit score 5 Orthopedic Surgery wait time 6 Improve Patient and Community Engagement Percentage of key committees with Patient Experience Advisor involvement 7 Create Centres of Expertise Collaborative Care Seniors Health - % planned initiative completed to help seniors to optimize their function, improve their wellness and support their independence 8 Increase in research income 9 Enhance Community Based Services % of youth with depression or anxiety who receive service within the targeted wait times 10 Enhance Tertiary Care Wait time for Access to Cardiovascular surgery 11 Redesign Delivery System % of beds occupied by ALC patients in 5 regional hospitals 12 Strategic Theme: Financial Accountablility Provide me with value for my tax dollars Average number of paid sick leave days 13 Percentage of administrative costs to total expenses 14 Lost Time Claims: % of Employees Returned to Work within 12 weeks 15 Reallocate resources based on need and evidence % of increased spend in community 16 % of increased spend in tertiary services 17 Optimize Performance Excellence Dollars saved through Perfromance Excellence 18 Enablers (HR, IT, Performance Excellence Culture) Improved Employee and Physician Engagement Employee Engagement Survey results 19 Percentage of new employees who complete CaRES Orientation 20 Rate of workplace violence incidents reported 21 Available Information and technology to improve delivery % of planned technology initiatives completed to improve pt services & communication 22 Committed Leadership and Culture Number of community leaders meeting with the CEO 23 Percentage of executive leadership and board meetings held in community settings 24 Legend for Indicator Symbols: Exceeds target / Meets / exceeds stretch below stretch Meets target performance Improved performance (between base and target) Below base performance Not applicable Legend for Initiative Status Symbols: Somewhat Off Complete On Track Track Off Track On Hold Cancelled Information Required Page 1 of 24

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5 Page 4 of 24 Balanced Scorecard Quarterly Report December 2017 Official Languages Percentage of patients who always received services in the Official Language of their choice when French is preferred Strategic Objective: Provide me with the best possible care experience Owner: Margaret Melanson Reporting Frequency: Annual Definition: This data reflects the patient experience as it is gathered through patient experience surveys completed by the New Brunswick Health Council (Acute Care Survey) every three years as well as the Horizon Patient Experience Survey conducted by the Horizon s Quality team annually. The survey starts by identifying the patient s language of choice. It then proceeds to ask how often the service was offered in their preferred language. The measure reported on is the percentage of patients who responded that they always received services in their language of choice when French is indicated as preferred language. 42% (NBHC 2016) 90.0% 100% N/A Analysis Summary: No new data for. Horizon is implementing the Horizon Hospital Experiences Survey for all inpatients from January 22 to March 2, The bilingual paper based survey is being distributed to all inpatients who have had at least one overnight stay and been discharged from a Horizon acute-care hospital facility or the Stan Cassidy Centre for Rehabilitation. Data compiled on language of service will allow Horizon to identify areas for improvement, implement initiatives and monitor any changes to improve quality of care. Horizon continues to work on the Active Offer Everyday Dialogue Project described below. So far, over 898 staff members have taken part in a session. Staff members get to explore and define the role of the active offer in patient centred care, and to generate ideas and solutions that can be applied at a unit/department or organizational level. From data collected, managers develop their action plans to improve their unit/department s overall performance and report these initiatives up to their regional directors. Priority Initiatives/Actions Status Comments Active Offer Everyday Dialogue Project Dialogue sessions are intended to rewire the meaning behind the Active Offer, encouraging staff to think about providing quality and safe patient care as part of their everyday work. The dialogue sessions are developed using internal and external engagement tools to allow for a constructive conversation with staff about the challenges, opportunities, and requirements of providing the Active Offer and to help implement changes to their work unit to ensure the Active Offer is provided to all Horizon clients and visitors. The dialogue sessions will be monitored closely and action plans for initiatives post sessions will be tracked and though accountability monitoring.

6 Environmental Services (EVS) cleanliness audit score Strategic Objective: Provide me with the best possible care experience Owner: Andrea Seymour Reporting Frequency: Monthly Definition: Visual audits are conducted after EVS cleaning is completed. For Visual Audits, 19 elements are visually inspected to ensure they appear clean. These audits are currently being conducted in 16 facilities. The measure reflects the pass rate of the visual audit tests. 89.5% 90.0% 95.0% 93% (FY17/18,) 100% 80% 60% 40% 20% 0% 95% 94% 93% 92% 92% 92% 93% 93% 93% EVS cleanliness audit score Horizon Target Analysis Summary: The Horizon monthly average is a composite of approximately 1,000 visual audits that are evaluated in a consistent way, and in a systematic manner. The visual audits are appearance outcomes of our cleaning processes. Each facility has a target number of visual audits to complete each month. The following table shows the 10 high risk/high profile areas within the facilities that are specifically tracked by the EVS Management Group. The table shows the Horizon average by category for Quarter 3 Fiscal Year Emergency Department Ambulatory Clinics Day Surgery Labour and Delivery Main Lobby Oncology Clinics Waiting Rooms Public Washrooms Operating Rooms Inpatient Unit 94% 95% 96% 92% 91% 94% 91% 92% 95% 93% Quarter 3 analysis of visual audit cleaning scores shows good results, particularly in critical areas such as the Operating Room, Oncology Clinics, Ambulatory Clinics and Day Surgery. Some of the other, more public areas have some of the lower scores. The areas with lower scores are an indication that a greater emphasis needs to take place, with cleaning, and rechecking of cleaning processes. Evaluation and work is ongoing. An analysis of the New Brunswick Health Council survey results (specifically patient comments) has been completed by the Environmental Services management team. We are in the process of preparing for the results of the current surveys that are being distributed to patients. Recently, we have begun completing random visual audits, which are being completed in all areas. We are in the process of developing the guidelines for these audits to ensure that we are getting consistent reliable results. Introduce ATP testing procedures to high risk/ high profile areas We have good traction in Emergency and Inpatient units. We will shift resources to add focus in the other areas Staff Training Review current orientation and staff training programs to improve knowledge level and ensure consistency across Horizon Page 5 of 24

7 Orthopedic Surgery wait time Strategic Objective: "Provide me with the best possible care experience" Owner: Geri Geldart Definition: The percentage of Orthopedic Surgeries completed within Target; Category % 75% 80% 71.0% (FY17/18,) Orthopedic Surgery Wait Time (% completed within target) 100% 80% 67.8% 67.2% 70.9% 66.1% 68.8% 69.2% 71.0% 60% 40% 20% Horizon Target 0% Analysis Summary: The Horizon Moncton site has historically had the longest wait time for orthopedic surgery. In the past year The Moncton Hospital has been able to increase the amount of OR time available to Orthopedics resulting in a reduction in the total number of patients waiting for surgery. The addition of several new surgeons in other specialties will impact the availability of OR time in and going forward. The wait list (queued cases) in Moncton has decreased from 1518 in of 2016/17 to 1330 in of 17/18. This is, however, an increase from 2017/18 at 1185 waiting cases. Challenges with anaesthesia impacted numbers, with OR time down overall. That is expected to continue into as recruitment has not occurred. In the Fredericton Area we have had an increase of 27 patients waiting greater than 12 months since April 1, 2017 in Orthopedics. We have had a decrease in available OR time over the past several months due to anaesthetic coverage making it impossible to assign extra lists for the long waiters. The primary reason for the change in Saint john is due to the growth in volumes of cases waiting for Orthopedic procedures. The surgeons are completing the longest waiting cases first. As well, we have significant growth in demand in most of our priority groups. Extended OR Hours at the Moncton Hospital Planned for spring of 2018 Page 6 of 24

8 Percentage of key committees with Patient Experience Advisor involvement Strategic Objective: Improve Patient and Community Engagement Owner: Margaret Melanson Definition: The percent of 30 Horizon key committees with Patient Experience Advisor (PEA) involvement. Key committees include clinical networks and committees with focus on quality & safety. Involvement means inclusion in focused groups or as a standing committee member. 56.6% 80% 90% 86.7% (FY17/18, ) Analysis Summary: The improvement over last year is the result of a focused effort to identify committees where PEA involvement is appropriate and matching volunteers with the committees. A few of the committees without PEAs have submitted requests and work is ongoing to find the appropriate match for the committee. We have successfully assigned PEAs to most clinical networks and the PEAs have become more involved with Quality and Patient Safety initiatives. We continue to strategically address patient engagement and work toward fully supporting our PEAs and our Horizon committees who interact with them. Our PEAs are very engaged with working with our accreditation preparation teams. Development of PEA engagement process. Screening, orientation and training materials have been developed. The engagement tool kit is being rolled out to networks and committees within Horizon Health Network. Page 7 of 24

9 Collaborative Care Seniors Health - % planned initiative completed to help seniors to optimize their function, improve their wellness and support their independence Strategic Objective: Create Centres of Expertise Owner: Jean Daigle Reporting Frequency: Semi-annual Definition: A list of collaborative care seniors health initiatives were identified for completion, or progress, in this fiscal year, with target milestones. This measure will track the percent of those milestones that were met. These initiatives help seniors to optimize their function, improve their wellness and support their independence. N/A 90% 95% 100% (FY17/18,) Initiatives Total Develop a Governance Structure for the Collaborative 2 2 Recruit and Hire a Regional Director, Senior Medical Director and Clerical Support 1 1 Create Task Forces with Co-Chairs to Carry Out the Strategic Work of the Collaborative 3 3 Develop a Year One Initial Work Plan for these Task Forces 6 6 Develop A Communication Strategy for the Collaborative 1 1 Secure ancillary staff from other departments within Horizon 2 2 Total Milestones Achieved 7 % Milestones Achieved 100% Analysis Summary: Collaborative Care initiative is progressing as planned. Dr. Feltmate and Danny Jardine presented a progress update to public session of the Board of Directors of Horizon in January The three Task Forces and the Strategic Leadership Council have approved the work plans and work is beginning to move forward with associated timelines and metrics. The Research Task Force has secured funding from an endowment fund and recruitment is underway to hire a Research Coordinator who will be instrumental in moving their work plan forward. With the movement of Extra-Mural to Medavie we have expanded our Strategic Leadership Council to include Medavie which is an important link to move our work forward. Develop a Governance Structure for the Collaborative Create Task Forces to Carry Out the Strategic Work of the Collaborative Develop a Year One Initial Work Plan for these Task Forces A Strategic Leadership Council for the Collaborative has been meeting monthly since February 2017 (Council has 33 members from across the senior care space) Three Task Forces of four have been developed, with Co-Chairs, in the areas of Research, Education and Clinical Leadership (40 additional collaborative partners from across senior care space are engaged here) Work plans have been approved. This work plan includes 10 strategic initiatives across the three Task Forces. Develop A Communication Strategy for the Collaborative The Communications Strategy has been approved. Secure ancillary staff from other departments within Horizon No action yet Page 8 of 24

10 Strategic Objective: Create Centres of Expertise Owner: Edouard Hendriks Balanced Scorecard Quarterly Report December 2017 Increase in research income Definition: This metric captures all income research funds received from external sources (i.e. outside of our departmental budget) and represents income received from pharmaceutical companies, granting agencies, and other sponsors of research. Baseline Target Stretch Target Actual Indicator $3,955,515 $4,500,000 $4,800,000 $3,375,000 $4,203,946 (FY17/18, ) FYTD Increase in research income $5,000,000 $4,500,000 $4,000,000 $3,500,000 $3,000,000 $2,500,000 $2,000,000 $1,500,000 $1,000,000 $500,000 $0 $2,786,515 $3,801,092 $969,555 $1,701,289 $2,874,492 $3,955,515 $1,691,913 $2,772,119 $4,203,946 Horizon Target Analysis Summary: The total income received by end of ($4,203,946) significantly exceeds the total income received at end of last year ($2,874,492) as well as the target. It is trending to exceed the annual target. The overall increase can be explained by the income received for some of our larger projects that have been funded by Canada Infoway, MindCareNB, and the New Brunswick Health Research Foundation. It should be noted that other institutions within New Brunswick (e.g. UNB) have received significant income related to health research through their strategic partnership with Horizon. Implement actions from the Research Services Strategic Plan Research Services is developing a business model to increase the services we can provide to clinician researchers who partner with private industry. This is increasing the external funding we receive. We have also partnered with University New Brunswick, Dalhousie Medical School NB, and New Brunswick Community College to develop a proposal for a Health Research Institute that was submitted to Government of New Brunswick in February Page 9 of 24

11 Percentage of youth with depression or anxiety who receive service within the targeted wait times (Moncton Area) Strategic Objective: Enhance Community Based Services Owner: Jean Daigle Definition: Youth, aged 19 less 1 day and younger, who are diagnosed with depression or anxiety should receive services within a targeted wait time of 90 days. This measure tracks the percentage of these patients who received the service within the target wait time in the Moncton area where the wait time has been an issue. These numbers include youths waiting for psychiatrist and/or therapist. 40% 85% 90% 100% (FY17/18, ) 100% % of youth with depression or anxiety receiving service within target wait time 100% 80% 60% 40% 20% 49% 62% 54% 57% 42% 40% 56% 32% Horizon Target 0% Analysis Summary: Integrated Service Delivery (ISD) is a partnership with Education, Public Safety and Social Development to develop and implement appropriate child and youth centered interventions to ensure the positive growth and development. With the full implementation of ISD in the Moncton Area, all patients are now receiving service within the target time frame. The teams are now located in the schools and files have been transitioned to the Child and Youth Teams. ISD has been fully implemented in all areas of Horizon. Integrated Service Delivery Fully implemented across Horizon Page 10 of 24

12 Strategic Objective: Enhance Tertiary Care Owner: Geri Geldart Balanced Scorecard Quarterly Report December 2017 Wait time for Access to Cardiovascular Surgery Definition: The Canadian Cardiovascular Society has established recommendations for access to elective (scheduled) cardiac surgery in Canada. When a cardiac surgeon has deemed that surgery is indicated, and the patient is both eligible for surgery and has agreed to proceed, the surgery should be performed within 42 days in 90 percent of cases. This indicator excludes TAVIs. 19% 20% 25% 27.3% (FY17/18, ) % of elective cardiovascular surgery performed within guidelines 30% 25% 20% 15% 10% 5% 0% 21% 27% 23% 15% 17% 22% 20% 12% 27% Horizon Target Analysis Summary: The NBHC program has seen the wait list and wait times for cardiac surgery grow over the last few years. Surgery cancellations were frequently occurring as a result of bed shortages, primary in the Surgical Intensive Care Unit (SICU). Plans to extend bed capacity are underway. In an effort to gain the greatest efficiency with the resources available, several initiatives have been implemented. We have seen some improvement in wait times as a result of diligently addressing patient flow. SICU remains our primary bottleneck and until additional beds are available, cancellations will continue to occur. Strategic scheduling of TAVI cases TAVI cases are scheduled to avoid bottlenecks in SICU Enhancement to patient flow/ reduction in overall post-operative LOS The use of a discharge promotion board is contributing to completion of discharge tasks in a timelier manner. Repatriation facilitation Improved communication with referring sites and an escalation process allow for a patient s quicker return to their home facility. Introduction of DOSA Processes to support Day of Surgery Admission (DOSA) for eligible patients is expected to improve patient flow. Additional SICU Beds In progress. Target fall/winter Page 11 of 24

13 Strategic Objective: Redesign Delivery Systems Owner: Geri Geldart Reporting Frequency: Monthly Balanced Scorecard Quarterly Report December 2017 Percent of Beds Occupied by ALC Patients in 5 Regional Hospitals Definition: The percentage of beds occupied by Alternative Level of Care (ALC) patients. Includes ALC patients in all beds, regardless of bed classification, and is based on the MIS Nursing Unit functional centres. The measure includes only the five regional hospitals (TMH, SJRH, DECRH, URVH, MRH). 24.4% 23% 20% 25.0% (FY17/18,) % of beds occupied by ALC patients 50% 40% 30% 20% 10% 0% 25% 22% Jul 2016 Aug % 24% 24% 22% 24% 24% 25% 23% 24% 23% 24% 26% 25% Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017 Mar 2017 Apr 2017 May 2017 Jun 2017 Jul 2017 Aug 2017 Sep 2017 Horizon Target Analysis Summary: ALC remains a significant cause of hospital congestion. This is a complex problem with no simple solution. 30% of our ALC patients are dependent on Department of Social Development (DSD) processes, mostly waiting for assessment. 66% are waiting for outside services (ex. Nursing Home). There was a slight shift (1%) from DSD to Waiting outside services. Internal services (ex. rehab) remain steady at 5% of the ALC population. There is a steady climb in ALC patients for SJRH, DECRH and URVH. Horizon is collaborating with Vitalité, DSD and DH to develop actions to help reduce the number of inpatients waiting for community services. We hope to see a positive impact with the various Home First initiatives. Expanded long term care capacity will be an important part of the solution. None at this time. Page 12 of 24

14 Strategic Objective: Provide me with value for my tax dollars Owner: Andrea Seymour Reporting Frequency: Monthly Balanced Scorecard Quarterly Report December 2017 Average Number of Paid Sick Leave Days Definition: This measure is an annualized average number of paid sick days per employee eligible to receive the benefit (FY17/18, ) Average number of paid sick days Horizon Target Analysis Summary: Historically paid sick trends show an increase. While it continues to follow the same seasonal trends ( includes December holidays), a 3% improvement from was achieved. We have seen a drop in sick usage this fiscal year which follows the introduction of the monthly HR Report. This may be evidence that the report, which provides Managers with a status update of team attendance performance, is increasing managers ability to address attendance issues. Managers are encouraged to act proactively with employees who are trending toward attendance issues and to address employees who have exceeded the Horizon attendance trigger. We will continue to use the Attendance Management tools to manage and monitor attendance. The HR team will continue to educate and support its use by managers. Additionally the rapid referral process for WorksafeNB physiotherapy assessments is having a positive impact. Complete roll out WorksafeNB rapid referral Progressing as planned. Scheduled to complete by fiscal year end. Page 13 of 24

15 Percentage of administrative costs to total expenses Strategic Objective: Provide me with value for my tax dollars Owner: Andrea Seymour Definition: Examining administrative costs in relation to total expenses can help improve cost-efficiency. This indicator looks at the percentage of the legal entity s total expenses that were spent in administrative departments such as general administration, finance, human resources and telecommunications. 3.11% 3.15% 3.20% 2.95% (FY17/18, ) % of administrative costs to total expenses 3% 3% 3% 3% 3% 3% 3.02% 3.06% 3.06% 3.00% 3.06% 3.11% 2.99% 2.94% 2.95% Horizon Target 3% Analysis Summary: When comparing of 2017/18 with of 2016/17, Horizon decreased its percentage administrative expenses. The drop for the current fiscal year was mostly due to a change in the accounting structure for the Executive Director departments. The Executive Director functional centres have been remapped from the Executive Office to Nursing Administration. This change better aligns Horizon s reporting with national standards. Except for this adjustment, the ratio of administrative costs to total expense continues to follow a similar pattern to other years, where the ratio remains relatively flat with a very slight increase as the year progresses. Horizon continues to be very lean on administrative costs and has the 3 rd lowest ration in Canada. You will note that our target is an increase over the previous fiscal year as our administration function has been operating too lean for the volume of work required to support the operations of a regional health authority this size. (sixth largest regional health authority in Canada). None at this time Page 14 of 24

16 Lost Time Claims: % of Employees Returned to Work within 12 weeks Strategic Objective: Provide me with value for my tax dollars Owner: Andrea Seymour Definition: Our goal for employees who lose work time because of injury is to have them return to work within 12 weeks. This indicator measures the percentage of employees who returned to work within the target timeframe. 65% 70% 80% 69.11% (FY17/18, ) Analysis Summary: Monitoring lost time claims as a percentage of employees returned to work within 12 weeks is an indication of evaluation of Horizon's performance with regards to WorksafeNB claims management. The vast majority of Horizon s workplace injuries are musculoskeletal in nature sprains, strains and overexertion called soft tissue injuries (STI). Studies show early assessment and treatment is essential to helping injured employees safely return to their pre-injury state; hence, Horizon has partnered with WorkSafeNB to provide our employees with direct referral to physiotherapy. A licensed physiotherapist has the necessary skills to assess an injury and treat it, provide the employee with symptom management strategies and assess what tasks are safe to do at work. Once the referral is made, employees are assessed within 2 business days and reports are forwarded within 1 business day to WorkSafeNB, the employee s family physician and Horizon s Disability Management (DM) staff. The employer report assists Horizon in offering stay-at-work or early/safe return to work options while the employee continues to recover. Completion of the launch of a Direct Referral Program for soft tissue injuries is anticipated to improve performance. In, 48 STI were reported by employees with 25 employees referred to the program. The early assessment and intervention supported 19 of these employees to either fully return to work or be supported with modified hours and/or duties. Direct Referral to Physiotherapy Program In, 49 STI were reported by employees with 31 employees referred to the program. The early assessment and intervention supported 22 of these employees to either fully return to work or be supported with modified hours and/or duties. The program has been well received by employees and managers. The final area to implement will be Miramichi in March. Page 15 of 24

17 Percentage of increased spend in community Strategic Objective: Reallocate resources based on need and evidence Owner: Jean Daigle Definition: The percentage increase in spending for community services (excluding Extra Mural) when compared to the same period the previous year. Community Services include Extra Mural, Community Mental Health and Addictions, Public Health, Community Health centres, Corporate Admin for VP Community, population health and clinics. (Excludes addictions and psychiatry inpatient services. Data included for Community Services does not include outpatient services that are hospital based, such as outpatient physiotherapy or diabetes clinics). 7.1% 7.1% 7.5% 8.0% (FY17/18,) Dollars spent in community (millions) $25.0 $20.0 $15.0 $10.0 $5.0 $17.7 $16.9 $17.5 $16.2 $18.2 $18.7 $18.6 $17.8 $19.7 Horizon Target $0.0 Analysis Summary: The goal set out in the strategic plan is to increase the percent of expenditures allocated to community care by 2% over 5 years. While at this point, no major shifts in spending have occurred, there have been many new Department of Health initiatives and some Horizon directed spending in this area. Spending continues to trend up in this area and tends to be higher in the last two quarters of the year. We show an increase of 8.0% when comparing the third quarter this year versus last year. Community mental health expenditures increased by over $850,000, while primary care increased by $625,000 for the same quarter over the previous year. The increase in spending is a result of new community initiatives funded by the Department of Health, such as Flexible, Assertive Community Treatment (FACT), Supportive Community Care (SCC) and Integrated Service Delivery (ISD). Resources added to primary care include Nurse Practitioners, Community Developers and Community Access Coordinators. Various community initiatives Community initiatives are progressing as planned. Page 16 of 24

18 Percentage of increased spend in tertiary services Strategic Objective: Reallocate resources based on need and evidence Owner: Geri Geldart Definition: The percentage increase in spending for tertiary services when compared to the same period the previous year. Includes Oncology, Heart Centre, Trauma, Stem Cell, Stan Cassidy, Critical Care (ICU, CCU, Peds ICU, Neuro ICU) and Interventional Radiology, Expenses exclude medical compensation and amortization. 1.5% 1.8% 2.0% 8.1% (FY17/18,) Dollars spent in tertiary services (millions) $40.0 $30.0 $31.2 $31.5 $31.0 $29.7 $31.6 $32.5 $31.9 $31.9 $34.1 $20.0 $10.0 Horizon Target $0.0 Analysis Summary: The goal set out in the strategic plan is to increase the percent of expenditures allocated to tertiary care by 2% over 5 years. While at this point, no major shifts in spending have occurred, there have been strategic Department of Health initiatives to increase support in this area and the impact will be seen during the current year. The areas representing the increased program costs are split between the Oncology and NB Heart Centre activities. As a result of the targeted spending initiatives in the NB Heart Centre spending has increased $172,000 in the interventional area and $827,000 in the Electrophysiology program. The increases vary due to the timing of arrival of the physicians for these major programs. The medical oncology program shows an overall increase of over $1,700,000. Overall, this reflects an increase of 8.1% over the same quarter in the previous year. Various Initiatives in the NB Heart Centre, Oncology and Specialized Surgeries Initiatives are progressing as planned in the Regional Health and Business Plan. Page 17 of 24

19 Dollars Saved Through Performance Excellence Strategic Objective: Optimize Performance Excellence Owner: Andrea Seymour Definition: This measure will track the hard and soft savings through process improvement. Savings include: reduction in spending, cost avoidance, revenue generation, and savings in productivity and efficiency as a result of continuous improvement including Lean Six Sigma projects, waste walks and other continuous improvement activities. Baseline Annual Target Stretch Target Actual Indicator $4,325,487 $2,500,000 $2,800,000 $1,875,000 $2,285,831 (FY17/18,) Analysis Summary: Many of the projects initiated this year have focused on quality improvement and patient flow which results in improved service to patients, and improved productivity, as measured in soft savings. There has been less focus on hard savings that impact expenditures. Hard savings total $108,200 year to date while soft savings amount to $2,186,823. The NB Heart Centre projects continue to report strong results. YTD, these projects have generated nearly $1.3M in productivity gains (soft savings) which result in the volume of patients being seen increasing by 8.9 %. Roll-out of the INSPIRED program to support patients with COPD has reduced the number of inpatient days resulting is a cost avoidance of $276,000. Waste walk projects continue to be met with enthusiasm by staff. Year to date, reductions in waste of over $281,000 savings ($46,800 hard savings, $234,200 soft savings) have been reported. Staff Scheduling Progressing as planned with a focus on the Horizon Saint John Area. NB Heart Centre initiatives Progressing on schedule. Patient Flow initiatives Various initiatives to address inpatient congestion are expected to result in savings near the end of the fiscal year. Page 18 of 24

20 Employee Engagement Survey Strategic Objective: Improved Employee and Physician Engagement Owner: Andrea Seymour Reporting Frequency: Annual Definition: The employee engagement survey consisted of 7 categories: Your Job, Training and Development, Your Co-Workers, Your Immediate Supervisor, The Organizations Senior Management, Safety and Health and Your Overall Experience. This indicator reports the percentage of respondents who agreed or strongly agreed. 54% 60% 65% 64.6% (FY17/18) Analysis Summary: The Accreditation Worklife Pulse Engagement Survey was completed by employees during November We are pleased to see the increased employee participation rate of 40%. This participation rate provides statistically significant data to use in the development of our action plans. The employee engagement score of 64.6% reflects a 10.6% increase in the engagement level of Horizon employees. Highlights include strong agreement on understanding job requirements, providing top quality patient care, and helping each other. Although we are very encouraged by these results we recognize there are still areas where we can improve upon. The Executive Leadership Team will continue to focus on improving employee engagement across Horizon as a strategic enabler. Moving forward, key areas of focus will be Health & Safety, Communication and Our Culture. The work that has been started on employee recognition, disability management, new employee orientation, workplace violence prevention will also continue. Staff Engagement Strategy Development and Implementation. Work is continuing in the areas of Leadership development and new employee On-Boarding. An approach to embedding values sustainability into all HR initiatives is underway. Page 19 of 24

21 Percentage of new employees who complete CaRES Orientation Program Strategic Objective: Improved Employee and Physician Engagement Owner: Andrea Seymour Definition: The percentage of new employees who receive the CaRES (Caring, Respect, Excellence, Service) orientation program post implementation. Data does not include salaried physicians, nursing home employees or board members. N/A 100% 100% 92.4% (FY17/18, ) Analysis Summary: By the end of there were 659 who had completed CaRES of the 713 individuals identified as New Employees which results in the 92.4% value. A few factors contributing to the current rate are: A few new hires received their CaRES orientation subsequent to the reporting period (eg. Hired in December, orientation in January). A few employees missed part of the orientation and attended the remainder of the program subsequent to the reporting period. According to the new draft orientation policy, employees rehired within 24 months are exempt from reorientation. The Human Resources department monitors staff attendance to orientation to ensure the program is provided to all new hires. Implementation of CaRES program across Horizon Rollout was completed in the fall Page 20 of 24

22 Rate of workplace violence incidents reported Strategic Objective: Improved Employee and Physician Engagement Owner: Andrea Seymour Definition: The number of recordable Workplace Violence incidents per 100 full time employees. To accurately reflect trending, this indicator is calculated on a rolling year. Recordable: includes Parklane Incident Reporting System recorded incidents of Health Care and Lost Time (Health Care: MD seen, treatment received, no lost-time; Lost Time: MD seen, treatment received, lost time). Includes Salaried Physicians but does not include Nursing Home personnel (FY17/18,) Rate of workplace violence incidents reported Horizon Target Analysis Summary: Our overall objective is to reduce workplace injuries. In order to do that, we need to be confident that all incidents are reported. reflects an overall increase in the rate of reported workplace violence incidents. This reflects an increase in the number of health care incidents reported; the number of lost time incidents remains the same as. Use of the incident tracking system is providing useful data to identify trends or most likely causes of incidents, which enables targeted responses. Workplace Violence Prevention Program Implementation Phase 2 Project Significant progress in various project elements Example: KPI s, Least Restraints, Code White Training, Hazard Assessments and other educational components. Page 21 of 24

23 Percent of Planned Technology Initiatives Completed to Improve Patient Services and Communication between Caregiver and Patient Strategic Objective: Available Information and technology to improve delivery Owner: Andrea Seymour Reporting Frequency: Monthly Definition: A list of Information and Technology projects will be identified for completion, or progress, in this fiscal year, with target milestones. This measure will track the percent of those milestones that were met. 90% 80% 90% 83% (FY17/18, ) Initiatives Total Allscripts edoc Expansion to St. Joseph's Hospital Core Dictation Implementation on Project 1 1 Electronic Record Expansion in Primary Healthcare Facilities Expansion Oncology Services via Telehealth in Miramichi 2 2 Front End Speech Dictation (Initial Sites) Organ, Tissue, Ocular Management (RFP) Patient Wireless 2 2 Provincial Incident Management (RFP) Total Milestones Achieved in Quarter % Milestones in Expected Quarter Achieved 100% 58% 62% Cumulative Milestones Achieved % Cumulative Milestones Achieved to Date 100% 67% 83% Analysis Summary: Most inpatient electronic orders and documentation at St. Joseph s Hospital were completed in quarter 3. Some outpatient eorders / edocumentation are expected to go beyond quarter 4 due to the Allscripts Clinical Information system upgrade. Provincial patient incident management system is on track to award the contract before the end of quarter 4. Deployment of Front End Speech Dictation for high volume physicians was completed in the Moncton area. Organ, Tissue, and Ocular Management system Request for Proposal was issued as planned. A lack of responses may affect quarter 4 deliverables as a solution that addresses operational needs is not yet confirmed. Two milestones for for Expansion of Oncology services via Telehealth in Miramichi were achieved in, ahead of schedule. Upgrade to the community health centre electronic health record platform has been delayed a few months, affecting the subsequent go live dates and expansion to new sites (specifically Charlotte County Collaborative Wellness Centre and the Petitcodiac & Oromocto Health Centres). Saint John area will be completed in quarter 4. Development of an IT Strategy for Horizon This initiative is actively underway with current state deliverables in quarter 4. Complete replacement of dictation system Renew IT Operating Structure Front end dictation to other physician groups is expanding in quarter 4 to increase turnaround of patient information to appropriate clinical providers. 4 of the 4 IT Business Resources within Horizon have been recruited. Page 22 of 24

24 Percentage of community leaders meeting with the CEO Strategic Objective: Committed Leadership and Culture Owner: Janet Hogan Definition: Horizon s CEO plans a tour throughout Horizon to meet with staff and community leaders. This indicator measures the percentage of the 48 Mayors within Horizon who met with the Horizon CEO. NA 50% 60% 50% (FY17/18, ) Analysis Summary: The CEO tour began in October and finished in early December. The purpose was to share the new vision for Horizon and to continue to build relationships with staff, physicians and the community. Of those that met with the CEO, an overwhelming majority agreed with the new vision. The CEO visited 12 hospitals and 12 community health centres/clinic. In these areas she held 34 staff and physicians meetings with a total of more than 500 participants. She met with 15 of the 17 Foundations, all 18 Auxiliary and 6 of the 8 Alumnae within Horizon, for a total of 129 participants. Meetings were arranged for all 48 mayors within their geographic area within Horizon and there were 24 participants. CEO Tours A schedule for the CEO tour has been developed for Fall It will include meetings with staff and community leaders. Page 23 of 24

25 Percentage of executive leadership and board meetings held in community settings Strategic Objective: Committed Leadership and Culture Owner: Janet Hogan Definition: There are 16 board related meeting and 26 executive leadership meetings per year. The goal is to increase the presence of Horizon leadership in the community. This indicator tracks the percentage of total Executive Leadership and Board meetings that are held in community settings. N/A 50% 60% 56.6% (FY17/18, ) Analysis Summary: The schedule of Executive Leadership and Board committee meetings held in the smaller rural communities began in June Holding board meetings in the community has allowed the board members the opportunity to visit community facilities, broadening their knowledge of the organization and the health care system. By hosting the ELT meetings in the community, the front-line staff members have the opportunity to meet the executive. The following communities have hosted ELT and/or Board Meetings in : Campobello Island Saint John ELT and Board Meetings in Community A schedule for the Executive Leadership Team is developed and meetings are scheduled in communities in the spring and fall. The Board committee meetings are held in the community settings whenever possible depending on the logistics pertaining to space, videoconferencing equipment, wireless equipment and weather. Page 24 of 24