Campbellford Memorial Hospital

Campbellford Memorial Hospital

Our Vision Campbellford Memorial Hospital's vision is to be a recognized leader in rural health care, creating a healthy community through service excellence, effective partnerships and the development of innovative hospital services. Our Mission Campbellford Memorial Hospital is dedicated to relief of illness, pain and suffering, and to promotion of health for the communities we serve.

Campbellford Memorial Hospital Services 34 medical inpatient beds 2 OR s general surgery, endoscopy, ENT, dental Restorative Care Program 20,612 Emergency Room visits annually Community Mental Health Services Diabetes Education Program 4,324 Ambulatory care visits with new Respirology and Nephrology Clinics Diagnostic and Laboratory Services

Our culture in one single idea: People looking after people The CMH Attitude: We passionately pursue excellence, and create a better experience by putting our best selves forward every day. How our culture shows up every day: We put patients first. We smile. We call people by name. We talk about our mission, and share the story of what makes our hospital different. We say Thank you. We always take the time to help visitors to our hospital. We trust each other implicitly. We invest in our people. We never say that s not my job. We are good at what we do, but remain humble. Our Unique Culture, The Key to Our Success

Engagement Scores The hospital s employee engagement 2008 survey results identified it as one of the leading Ontario hospitals. 2010 survey results improved significantly with the employee commitment score went up an incredible 18.5%, from 61.9% in 2008 to 80.4% in 2010. According to NRC Picker Canada, who administers the confidential survey, an improvement of 3% is considered significant and an increase of over 18% is unprecedented.

Engagement Scores The hospital s commitment to staff and patient safety shone throughout the survey results: 100% of respondents said that CMH promotes hand washing. 90% of respondents said senior management is committed to high-quality care. 88% of respondents believe senior management is committed to improving workplace safety.

Engagement Scores CMH values learning and excellence, and staff scores show that the hospital walks the talk Almost 81% of respondents had some form of education or training paid for by the hospital in the last 12 months. Over 94% of respondents said they would want family or friends to receive care at CMH. 87% of respondents said they were proud to tell others they were part of the hospital and 84% rated CMH as a great place to work.

Partnerships Trent Hills Family Health Team Campbellford Memorial Multicare Lodge PRHC Information Technology RMH Pathology & Lab NHH PACS COHPA Ontario Shores Mental Health clinical supervision WPI Inmate diagnosis, treatment and medical assessment CE CCAC office in Emergency department Community Care Northumberland Community Living Partnered in Integrated Chronic Disease Management

Catchment Area Service from HBAM Acute Inpatient and Day Surgery (Acute) Module 2010-11 Community Name Facility Acute Weighted Activity From Community Percent of Facility Total Weighted Activity Northumberland County 979 49.7% Peterborough County 523 26.6% Hastings County 417 21.2% Victoria County 10 0.5% Prince Edward County 5 0.2% Other Communities 34 1.7%

Catchment Area Service from HBAM Emergency Room Module 2010-2011 Community Name Facility ER Weighted Activity From Community Percent of Facility Total Weighted Activity Northumberland County 364 46.0% Hastings County 196 24.8% Peterborough County 183 23.2% Scarborough 4 0.5% Oshawa 3 0.4% Other Communities 40 5.0%

Strategic Directions 1. Ensure quality care and diagnostic services to our patients both now and in the future. 2. Share the CMH story with our community and the broader health care community. 3. Recruit and retain the best people. 4. Enhance our physical plant, diagnostic, patient care equipment and technological infrastructure.

Accomplishments Opening of the Restorative Care Unit Reduction of ALC days (555 days in first 6 months of 2012/13 or 36%) Managing and recognizing 3Ds (delirium, dementia and depression) Blood Conservation Program and standardized transfusion protocol Wound care management Palliative Care LEAN/continuous improvements in Emergency Department, Pharmacy, Laboratory, Operating Room, Inpatient Unit

Accomplishments (Continued) Feature story in Hospital News about our Patient Safety Advocates who support our values and our commitment to patient safety Hospital News profiled a partnership between CMH and Trent Hills Family Health Team with respect to diabetic patients receiving the full circle of care to manage their disease CMH s Antibiotic Stewardship Program featured in the OHA leading practice guidebook Weekly Q&As printed in the local paper

Accomplishments (Continued) Celebrating our 2011 Quality Healthcare Workplace Gold Award in recognition of excellence for quality healthcare workplaces Recruitment success with nursing new graduate initiative Recruitment of physicians and other clinical support staff Professional Development Program for leaders and staff to support grow our own talent philosophy Health promotion/fitness facility for staff, funded by bursary award Lowest in LHIN absenteeism (6.6 days in 2011)

Accomplishments (Continued) Implementation of the Emergency Neurosurgery Image Transfer System Achieving a financial surplus of $142,953 in 2011/12 Developing unique partnerships like the Campbellford Memorial Hospital Foundation, Campbellford Memorial Hospital and the Canadian Cancer Society partnership in our joint battle to fight cancer with the launch of the joint Relay to Life. Additional funds will be used by the hospital towards the purchase of a digital mammography machine

Future Plans Chronic Disease Management program Behavioral Support Ontario program Revision of Falls Prevention program Partnerships Quality Based Procedures & Funding Quality Improvement Plan

QIP 2011/12 Level 1 Priorities: Antibiotic Stewardship Program Readmission Rates CHF & COPD Patient Satisfaction Total Margin

QIP 2011/12 Antibiotic Stewardship Program Indicators 2010/11 Current 2011/12 Target Q1 Q2 Q3 Q4 Antibiotic Stewardship Program N/A 100% Initiated June 2011 12.5% 35% 100% Number of C. Difficile* 0.37% or 4 cases 0% 0.43% or 1 case 0% 0.32% or 1 case 0.64% or 2 cases Total Discharge Days 10,940 2,317 2,106 3,117 3,549

QIP 2011/12 Readmission Rates CHF & COPD Indicators 2010/11 Current 2011/12 Target Q1 Q2 Q3 Q4 Readmission Rates CHF & COPD 13.3% or 21 pts 12% or 19 pts 20.4% or 10 pts 7.1% or 2 pts 10.0% or 3 pts 16.0% or 5 pts Total Cases 158 158 49 28 29 32

QIP 2011/12 Patient Satisfaction Indicators 2010/11 Current 2011/12 Target Q1 Q2 Q3 Q4 Discussed when to resume normal activities 45% or 37 pts 50% or 41 pts Not Available (sample size too small) Not Available 56.5% (based on 58 surveys ret d) 37.5% (based on 56 surveys ret d)

QIP 2011/12 Total Margin Indicators 2011/12 Target 2011/12 Standard Q1 Q2 Q3 Q4 Total Margin 0% 0% -1.41% 1.13% 0.77% 0.77%

Level 1 Priorities: QIP 2012/13 Antibiotic Stewardship Program Hand Hygiene Total Margin ER Length of Stay for Non-Admitted Minor / Uncomplicated Patients Patient Satisfaction Inpatient Days Designated as ALC Days Readmission Rates CHF & COPD

QIP 2012/13 Antibiotic Stewardship Program Indicators 2012/13 Target Antibiotic Stewardship Program Number of C. Difficile* Daily alerts for use of targeted antibiotic Root cause analysis of all non-compliant prescribed orders Total Discharge Days Q1 Q2 Q3 Q4 (To be completed) 100% 100% 0% 0.72% or 2 cases 100% 100% 100% 100% 2,741

QIP 2012/13 Hand Hygiene Indicators 2012/13 Compliance to hand hygiene before and after patient contact for all disciplines Q1 Q2 Q3 Q4 Target (To be completed) 92.0% 92.0% Number of Audits 100 31

QIP 2012/13 Total Margin Indicators 2012/13 Target Q1 Q2 Q3 Q4 Total Margin 0% -0.85%

QIP 2012/13 ER Length of Stay for Non-Admitted Minor/Uncomplicated Patients Indicators 2012/13 Target Q1 Q2 Q3 Q4 ER LOS for Non-Admitted Minor/ Uncomplicated Patients 4.3 hrs 4.8 hrs

QIP 2012/13 Patient Satisfaction Indicators 2012/13 Target Q1 Q2 Q3 Q4 Overall how would you rate the care and services you received at CMH? 96.5% Not Available

QIP 2012/13 Inpatient Days Designated as ALC Days Indicators 2012/13 Target Q1 Q2 Q3 Q4 Total Number of ALC Days 3,537 days 667 days

QIP 2012/13 Readmission Rates CHF & COPD Indicators 2012/13 Target Q1 Q2 Q3 Q4 Readmission Rates CHF & COPD Total Cases 12% or 19 pts 0 pts 158 32