Report of the President & CEO to the Board of Directors

Report of the President & CEO to the Board of Directors Date: December 2008 To: Board of Directors, Windsor Regional Hospital Happy Holidays to you and your family! We have collectively accomplished a considerable amount this past calendar year. I like to use a funnel as a visual aid in describing what we have collectively accomplished this past year. Above the top of the funnel is where we were at the start of the year. A lot of ideas and lot of stuff going on but lacking a clear focus we lacked a clear Vision. Last December our Board of Directors embraced a focus of Patient Quality and Safety. This started with the commencement of the most inclusive Strategic Planning process ever undertaken by this organization. At the same time the Board of Directors embraced the creation of the new Quality of Care Committee which has resulted in having patient stories told at each meeting of Page 1 of 8

the new committee. This also included being one of the first in the Province to report previously protected data publicly, the commencement of the Clean Hands Saves Lives campaign, the inclusiveness of the Zero Based Budgeting ( ZBB ) process, being awarded two (2) Best of the Best Practices in the Province of Ontario within the same year, the opening of the fitness centre I could go on and on. All of the above and more is what we added to the funnel. As we work our way down the funnel what we are experiencing is a narrowing and sharpening of focus. The focus was created by YOU in developing the six (6) Strategic Directions. Strategic planning and decision processes will culminate with the creation of goals and objectives that will create a roadmap of ways to achieve the six (6) Strategic Directions you created. In 2009 we will be collectively developing the goals and objectives in furtherance of the previously created Strategic Directions. We do not have to look far for our goals and objectives. They will primarily arise from the 250 initiatives you identified in the ZBB process and some of the projects we are already undertaking. What is eventually going to emerge from the funnel is our Vision Outstanding Care No Exceptions! The 2008 accreditation official process has now been completed. There has been a shift to make accreditation an ongoing process rather than an event that takes place every three (3) years. It is meant to be an ongoing learning and development process and a way to showcase our efforts and achievements rather than a test or exam we cram for every three (3) years. We have a lot on tap for 2009. Just to name a couple - the Western Redevelopment will be in full swing. Construction will start in the spring of 09. It will be an exciting three years for the organization and especially the Western campus. In addition, in 2009, we will be embarking on developing a 20 year plan for the Metropolitan Campus. This plan will be created by you and sent to the Ministry of Health and Long Term Care for approval and implementation. You will have a direct impact on the future of healthcare for the residents of Windsor/Essex County. I want to thank each and everyone of you for making the accreditation process a success. We will now take the accreditors comments and suggestions and fold them into our goals and objectives part of the Strategic planning process. We should see a lot of overlap with what you identified in ZBB and what the accreditors identified in the accreditation process. As stated by Ralph Waldo Emerson Trust [people] and they will be true to you; treat them greatly, and they will show themselves great. Page 2 of 8

Strategic Direction Embed Patient Quality and Safety in Our Culture Eliminating Central Line-Associated Primary Bloodstream Infections The Ontario Health Quality Council has contacted Windsor Regional Hospital and has asked the Hospital to submit its success story in identifying, addressing and monitoring the prevention of Central Line-Associated Primary Bloodstream Infections. A copy of last year s Quality Council s report can be found at the following link http://www.ohqc.ca/pdfs/ohqc_2008_report_-_english.pdf. I want to thank and congratulate Karen Riddell and the staff of the ICU, NICU, OR and DI for their dedication to the elimination of central line infections. (a) How did it Start? We started the program in our Diagnostic Imaging department with insertion of PICC lines. At that time whenever a PICC Line was scheduled for insertion a clinical manager would attend and record compliance with the bundle elements. Since that time a Registered Nurse in the department, in collaboration with the radiation technicians, observes and records compliance data for all PICC Line insertions. This information is entered electronically into a WRH home created customized database. Following this successful implementation we rolled this out to both our ICU and OR, as well as our NICU (with modifications for preferred placement). In the Diagnostic Imaging Department, ICU and OR we supplied central line insertion carts which are fully stocked with required elements such as sterile drapes, gowns, gloves and head covering, as well as chlorhexidine skin prep. In the NICU we have a PICC line team of nurses who are all trained in the bundle elements and perform all of the insertions utilizing all components of the bundle. (b) How do we Monitor it? Weekly compliance reports are distributed to the CLI Clinical Lead and weekly meetings occur with the clinical managers for any units that are not meeting targets for compliance with any of the indicators. Short term, rapid action plans are developed to address any deficiencies. A monthly meeting is held with the clinical teams to ensure sustainability and any further improvements required. (c) What have been the results? Our compliance results to date have been excellent in the Diagnostic Imaging, OR as well as the NICU running at 100%. In the ICU we have noted some variability based on the availability of equipment, i.e. head coverings and physician preference for particular skin antisepsis. We have resolved the issue of equipment availability and are working with our department head to ensure compliance with recommended skin antisepsis particularly for new physicians entering the department. Our latest reports show 100% compliance in Page 3 of 8

the ICU and we are aiming for sustainability. All nursing units are reporting 100% compliance with maintenance. Our last reported central line blood stream infection was in May of 2008 in the ICU. No other central line infections have been reported in the last 12 months. Strategic Direction Cultivate an Environment of Accountability and Transparency Attendance at Provincial Conference Members of the Hospital s infection control team were invited to attend to present at a conference on November 26, 2008, entitled The Art of the Possible: Reducing the Incidence and Transmission of MRSA in Health Care Settings. Windsor Regional Hospital presented on the topic: Using the Website for Public Reporting. This is as a result of Windsor Regional trailblazing as one of the first Hospitals in the Province to publicly report normally private information. Sharing our Strategic Plan This past month I had the pleasure of being invited to meet with members of the Rotary Club of LaSalle and also the Human Resources Professionals Association of Windsor and District to share with them our Strategic Plan. It is always enlightening to receive feedback from the community on our Vision and how we are impacting their lives. The feedback I am receiving on our new Vision, Mission, Values and Strategic Directions is very positive. Our staff have a lot of fans in the community. Welcoming Letter to Patients Last month I started a practice a best practice of providing every new patient at both campuses a welcoming letter. The letter outlines the importance to receive feedback from the patient and their family on their stay. In addition, I highlight our Above and Beyond Program if they wish to recognize the efforts of our staff. Also, I provide them with the ability to call me at the Hospital, my cell phone or at home if they have anything they wish to discuss with me about their stay. Strategic Direction Build and Sustain Financial Health The implementation of the Zero Based Budgeting ( ZBB ) initiatives has started. As previously indicated the Board of Directors, Executive Committee and Medical Advisory Committee are committed to i) reducing the impact of the initiatives on patients and families; ii) reducing the impact on staff and iii) implementing the first nine (9) initiatives by no later than March 31, 2009. Page 4 of 8

The most recent worldwide economic crisis is impacting all of us. Previously announced funding levels from the Ministry of Health and Long Term Care are now in jeopardy. The economic environment is very fluid at this point in time. The fact that all of us started this process in April 2008 places us in a better position to address changes in the environment. This proactive rather than reactive approach to our financial situation is being commended by many leaders across the Province. Strategic Direction Enhance our status as an employer of choice Free Skate On November 22nd and 29 th, 2008, through the generous support of the HCA Group, Charterhouse Printing, VIP Shuttle, Susan Craig & Associates and Meddworx we were able to have a FREE SKATE for all staff, volunteers and retirees and their families at the Windsor Arena. Polar Express In addition, on December 14 th and 15 th, 2008, we will be once again having our 2 nd annual Holiday Movie showing of the Polar Express for all staff, volunteers and retirees and their families. More details to follow on times and where to pick up tickets. Again, thanks to the generous support of HCA Group, Charterhouse Printing, VIP Shuttle, Susan Craig & Associates and Meddworx. Strategic Direction Distinguish ourselves through superior performance, innovation, and exceptional customer service Ontario Hospital Association Awards Windsor Regional Hospital has been notified that of the 131 submissions received from provinces, regions, hospitals, health care institutions and health management organizations from Ontario and abroad, three (3) of its submissions have been accepted as Best Practices in the 2008 Ontario Hospital Association International Leading Practices Electronic Display Competition. This year s Leading Practices displays related to the following Best Practice categories: Access to Care, Education, Family and Patient Centered Care, Leadership, Patient Safety and Technology. Eight (8) of the 131 submissions were voted as Best Practices from across Canada and abroad. Windsor Regional Hospital was honoured by having three (3) of these eight (8) Best Practices. A record number of Best Practices for any individual Hospital in Ontario. The three Best Practices from Windsor Regional Hospital are: Page 5 of 8

Child Friendly Preparation for MRI and CT Scans A program designed by Diagnostic Imaging and Child Life Services in collaboration to make the experience of having a CT or MRI easier for paediatric patients. By giving parents information prior to a procedure has led to a decrease in the use of sedation. Interactive websites and online brochures are made available to parents to prepare their child for a procedure while still at home. Once at the hospital, miniature play versions of the machines are used to help the child practice the steps of the test through medical play. By working together, a family-centered care environment has been developed where parents can feel satisfied their child s care is foremost when in the hospital. -Submitted by Allison Riggs, Child Life Specialist, Paediatric Services Lung Diagnostic Assessment Program This is a virtual program aimed at shortening the wait time for suspicion to definitive diagnosis for patients with possible lung cancer. The program began November 2007, where a Nurse Navigator triages, registers and facilitates the diagnostic process for persons with possible lung cancer. In the first ten months, several initiatives were developed to better focus on primary care, provide education to support an expedited diagnostic process and patient information brochures to prepare patients and families for early diagnostic test and procedures. Measurable outcomes include 150 patients treated to date; the time from the patient s first physician assessment of a symptom to referral to the Lung Diagnostic Assessment Program has decreased by 11.7% for ninety percent of the patients; wait time for referral to consultation with a specialist is 13.9 days and the median wait time from suspicion to diagnosis has decreased from 120 to 16 days. -Submitted by Joyce Sauve, Windsor Regional Cancer Centre Meeting Community needs through Integrated Care In collaboration with three local organizations, Windsor Regional Hospital, Windsor Regional Children s Centre and Maryvale Adolescent and Family Services, have been able to provide immediate access to child psychiatry consultation, multidisciplinary assessment and treatment for families with children who are suicidal, experiencing onset of mental illness and/or exhibiting seriously dangerous behaviors at home and in the community. Funding for the initiative which involves three Ministries of the Provincial Government (Health & Long Term Care, Child & Youth Services and Education), has made the project possible. The results are reduced wait times in emergency rooms and decreased lengths of stay in hospital. -Submitted by Dr. Mary Broga, Windsor Regional Children s Centre - Maryvale Adolescent and Family Services In addition, Meeting Community needs through Integrated Care was selected as Best of the Best out of all the Best Practices. Way to go Team! These selected electronic displays were showcased along with several others during HealthAchieve 2008 (Inspiring Ideas and Innovation) International Conference and Exhibition that took place at the Toronto Convention Centre, November 3 and 4, 2008. Page 6 of 8

The annual Ontario Hospital Association HealthAchieve Conference and Exhibition attracts approximately 10,000 health care professionals, suppliers and associates to one of the largest health care gatherings in North America. The 2008 Leading Practices Electronic Display is sponsored by Healthcare Quarterly, a leading health care magazine. Cancer Quality Council of Ontario and the Canadian Cancer Society Award Cancer Quality Council of Ontario and the Canadian Cancer Society announced Jeff Richer as a recipient of a Quality & Innovation Award for achievements in Radiation Treatment Wait Time Reduction Strategy. Congratulations to the Radiation Team at the Cancer Centre from moving from the longest wait time in the Province to the shortest wait time during a period of increasing demand without adding additional resources. Strategic Direction Strengthen our relationships with external partners Relationship with Windsor Family Health Team This month we announced an affiliation with the Windsor Family Health Team (WFHT). Approximately 40,000 Windsor/Essex County residents lack a primary care physician. As a result their healthcare suffers and instead of preventative healthcare they become so ill that they have to attend the Hospital and possibly be admitted as a patient. This results in great strain on the healthcare system especially at a time when 30% of our population (i.e. baby boomers) are now entering their 60 s and are generally not healthy suffering from a higher rate of diabetes, obesity and heart ailments. The WFHT will become the primary healthcare provider to 15,000 patients when fully up and running. We cannot afford it to fail. Also, we cannot afford either Windsor Regional Hospital or the WFHT to duplicate each other s efforts. Either of us cannot be a second opinion facility for these 15,000 patients. We need to work collaboratively and in concert for a seamless patient experience. In order to accommodate this affiliation we have agreed with WFHT to jointly employ the Executive Director. Mr. Mark Ferrari will become a member of the Hospital s Senior Team. You will see Mark at the Hospital. Please take the time to introduce yourself to Mark. Together we will make the WFHT a success. LHIN Update The Strategicare Process is back underway. There was a revisioning day that was held on Saturday, November 15, 2008. In attendance was the Boards of the three Hospitals, the LHIN Board and members of the Hospital Medical Advisory Committees. Once a written report is created I will share it with you. Page 7 of 8

Roots of Violence Report The Honourable Roy McMurtry and Dr. Alvin Curling have just released the Roots of Violence Report. The report was commissioned by the Ontario Government in response to the increase of teen violence, especially violence with weapons which was especially evident in the past year in Toronto. In their report, the authors highlight the role of children s mental health and its connection to violence. According to the authors, children s mental health affects many aspects of the roots of violence, including the stability of families and the ability of parents to work and parent; how youth develop with their peers; how they do in school; how they interact with the justice system; and their life changes overall. They recommended to the Premier of Ontario that the Province must take steps to bring youth mental health out of the shadows. The Province should enhance prevention though programs that promote health, engagement and activity for youth. It should also provide locally available mental health services that afford early identification and treatment for children and youth in the context of their families and schools, that are culturally appropriate and are integrated with the community hubs we propose. This report may have a profound effect on addressing the underfunding of children s mental health services. Partnership with CAS This month the residential program at Regional Children s Centre began providing weekend residential respite for children in the care of the Children s Aid Society. These children have complex special needs and a weekend away from their foster home placements offers the foster parents an opportunity for relief so that they can resume their duties on Monday. The Children s Aid Society pays for this service on a per diem basis. However the important benefit is that they have a greater chance of remaining with the foster home if the foster parents are able to have a weekend break. This program pays for itself as it occupies the empty beds of children who return home for the weekend. Page 8 of 8