Performance Measures : Final Report

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Performance s 2013-2014: Final Report Jean Morrison, CEO, St Paul s Hospital July 2014 Approved by: Bill Edwards, St. Paul s Hospital Board Chair

Living the SPH Vision, Mission and Values, Catholic Health Ethics and Partnership 2013/2014 10% Specific Target 4 of 7 Milestones Completed - Evidence the Mission, Vision and Values are being lived by staff (testimonials from patients). - Develop and initiate implementation of a communication strategy to share SPH s place and brand. - Evidence that SPH continues to be a leader in ethical health issues presented through quarterly reporting to the Board. - - CEO d JBA Lean Leader Certification. Trend Analysis and Discussion 4 or 7 d Patient testimonials evidence that the Mission, Vision and Values are being lived by staff Communication strategy developed and under review by Board. Have begun using key messages in communication, presentations and for annual report development. September 25, 2014 initiated Ethics Quarterly Reporting to the Board and 2 deep dive education sessions have been held with Board (Oct. 23 and Nov. 28, 2013). Lean Leader Certification awarded April 23, 2014. 90% threshold None of subsequent 95% 105% 110% Standardized orientation package that includes orientation to Vision, Mission and Values, introduction to Catholic Health Ethics and reference to Catholic Health Ethics Guide, and introduction to SPH/SRHA partnership agreement prepared and provided to managers for application 4 of 7 d - Evidence the Mission, Vision and Values are being lived by staff (testimonials from patients). - Mission integration assessment initiated. - Develop and initiate implementation of a communication strategy to share SPH s place and brand. - Evidence that SPH continues to be a leader in ethical health issues presented through quarterly reporting to the Board. - of SPH-based managers report inclusion of SPH material in staff orientation - CEO s JBA Lean Leader Certification. >4 of 7 All Mission integration assessment d 2

Advance Spiritual Care Services 8% Specific Target 2 of 4 d. - A plan for the ongoing leadership of the Regional Spiritual Care program is implemented. - A plan for a Clinical Pastoral Educator Residency developed and put forward for approval for implementation in 2014-15. - Advanced Spiritual Care Services with 2 d - Senior Leadership Team approved plan for ongoing leadership of Spiritual Care. Corey Miller, VP Integrated Health Services has taken over direct reporting for Spiritual Care. - Clinical Pastoral Educator Residency program plan developed and approved by the board on October 23, 2013. Advertising for candidates occurring now. 95% None of < 3 of 3 of 4 4 of 4 - A plan for the ongoing leadership of the Regional Spiritual Care program is implemented.. - Spiritual Care referral process developed collaboratively with CPAS and Social Work and referrals are being received from those Departments. - Pilot study d and research proposal amended as necessary and submitted for approval of full study. - A plan for a Clinical Pastoral Educator Residency developed and put forward for approval for implementation in 2014-15. All nursing units with designated chaplains consistently make referrals re: Spiritual Care needs. Research project report d. 3

Service to Vulnerable populations with a focus on patients groups requiring hospice (seniors and those living with HIV) 10% Specific Target 3 of 5 d Prepare and submit an outreach and communication plan to the Board to assist in advancing Hospice Assist the Foundation to development of a fundraising campaign Request approval from SHR to initiate fundraising plan - Hospice communication plan embedded in draft communication plan submitted to Executive Committee and communication has proceeded in consultation with Executive Committee. - Director and Fellow worked with Foundation CEO as requested and provided information. In March a full time planning lead for Hospice was assigned. - SHR SLT has given permission for development of fundraising campaign with the intent to initiate the campaign in 2015. - 3 of 5 therefore pay for performance None of < 3 of 3 of 5 5/5 Fundraising initiated in 2013-14. Submit Hospice functional program to SLT and SPH Board Design phase initiated Confirm the site for the hospice Prepare and submit an outreach and communication plan to the Board to assist in advancing Hospice Assist the Foundation to development of a fundraising campaign Request approval from SHR to initiate fundraising plan 4

Optimize infrastructure at SPH. 7% Specific Target 4 of 5 d Plan developed to remove rotunda in order to improve safety and support smoke free environment and submitted to SHR for approval. Development of 1719-20 th Street parking lot. Rejuvenation of Auditorium. C-Wing 2 nd floor mechanical refurbishment. Capital and Facility services recommended not proceeding with full removal of the rotunda at this time instead they recommended removal of the windows and that work was d. Development of 1719-20 th street parking lot and open for use March 2014. Auditorium rejuvenation Grand Opening March 12, 2014. C Wing 2 nd floor mechanical refurbishment. 4 of 5 therefore pay for performance 105% 105% None of < 3 of 3 of 5 Plan developed to remove rotunda in order to improve safety and support smoke free environment and submitted to SHR for approval. >3 of Removal of rotunda initiated. Determine site for a healing garden with consideration to have this designated as sacred space to be used for reflection and healing. Development of 1719-20 th Street parking lot. Rejuvenation of Auditorium. C-Wing 2 nd floor mechanical refurbishment. 5