AGENDA OPEN SESSION BOARD MEETING Wednesday, May 23, 2018 Lambton Meadowview Villa, Petrolia, ON 5:00 pm Directors: Marg Dragan, Treasurer Anthony Iafrate Bill Gillam Jenny Greensmith Louis Guimond Brian Knott Dr. Guy Kohlmeier Katherine Mantha Bob McKinley Wayne Pease, Chair Fred Vanderheide Paul Wiersma, Vice-Chair Ex-Officio Directors: Mike Lapaine Dr. Michel Haddad Shannon Landry Dr. Sharon Rutledge Dr. Nathan Taylor Professional Staff Staff and Guests: Dr. Kapil Kohli Samer Abou-Sweid Laurie Zimmer Julia Oosterman Paula Reaume-Zimmer Kathy Alexander Recorder: Melissa Rondinelli *attached NO. TOPIC ACTION TIME PRESENTER 1.0 CALL TO ORDER: WELCOME AND OPENING REMARKS 1 min Paul Wiersma 1.1 Report on April In-Camera Board Meeting 2 mins Paul Wiersma 2.0 AGENDA APPROVAL 2.1 Approval of Agenda Decision 1 min Paul Wiersma 2.2 Declaration of Conflict of Interest Decision 1 min Paul Wiersma 3.0 CONSENT AGENDA 3.1 ITEMS TO BE RECEIVED – REPORTS Paul Wiersma 3.1.1 Board Chair* Information Wayne Pease 3.1.2 Professional Staff Association Report* Information Dr. S. Rutledge 3.1.3 Quarterly Facilities Report* Information Marg Dragan 3.1.4 Analysis of Loans and Investments* Information Marg Dragan 3.1.5 Accreditation Self-Assessment Report and Action Plan* Information Brian Knott 3.1.6 Board Meeting Effectiveness Survey Results* Information Brian Knott 3.1.7 Board Attendance Records* Information Brian Knott 3.1.8 Board Education Record* Information Brian Knott 3.2 ITEMS FOR APPROVAL Paul Wiersma 3.2.1 Open Session Board Minutes – April 25, 2018* Decision 2 mins Paul Wiersma 3.2.2 Chief Financial Officer Certificate* Decision Marg Dragan
Transcript
AGENDA OPEN SESSION BOARD MEETING
Wednesday, May 23, 2018 Lambton Meadowview Villa, Petrolia, ON
5:00 pm Directors: Marg Dragan, Treasurer
Anthony Iafrate Bill Gillam Jenny Greensmith
Louis Guimond Brian Knott Dr. Guy Kohlmeier Katherine Mantha
Bob McKinley Wayne Pease, Chair Fred Vanderheide Paul Wiersma, Vice-Chair
Ex-Officio Directors: Mike Lapaine Dr. Michel Haddad
Shannon Landry Dr. Sharon Rutledge
Dr. Nathan Taylor
Professional Staff Staff and Guests:
Dr. Kapil Kohli Samer Abou-Sweid
Laurie Zimmer Julia Oosterman
Paula Reaume-Zimmer Kathy Alexander
Recorder: Melissa Rondinelli *attached
NO. TOPIC ACTION TIME PRESENTER 1.0 CALL TO ORDER: WELCOME AND OPENING REMARKS 1 min Paul Wiersma
1.1 Report on April In-Camera Board Meeting 2 mins Paul Wiersma
2.0 AGENDA APPROVAL
2.1 Approval of Agenda Decision 1 min Paul Wiersma
2.2 Declaration of Conflict of Interest Decision 1 min Paul Wiersma
3.0 CONSENT AGENDA
3.1 ITEMS TO BE RECEIVED – REPORTS Paul Wiersma
3.1.1 Board Chair* Information Wayne Pease
3.1.2 Professional Staff Association Report* Information Dr. S. Rutledge
3.1.3 Quarterly Facilities Report* Information Marg Dragan
3.1.4 Analysis of Loans and Investments* Information Marg Dragan
3.1.5 Accreditation Self-Assessment Report and Action Plan*
Information Brian Knott
3.1.6 Board Meeting Effectiveness Survey Results* Information Brian Knott
3.1.7 Board Attendance Records* Information Brian Knott
3.1.8 Board Education Record* Information Brian Knott
3.2 ITEMS FOR APPROVAL Paul Wiersma
3.2.1 Open Session Board Minutes – April 25, 2018* Decision 2 mins Paul Wiersma
2.1 Agenda to approve the agenda as presented 3.0 Consent Agenda to receive the reports presented and to
approve the following items in the Consent Agenda:
• Open Session Board Minutes of April 28, 2018
• Chief Financial Officer Certificate for the period ending March 31, 2018
• Revised Board Policy 5.20 – Roles and Responsibilities of an Elected and Ex-Officio Director
• Authorization for the Board Chair to sign the Delegation of Authority document
5.2 Financial Statements to approve the financial statement for the period ended March 31, 2018 as presented.
5.3 2018-19 Capital Budget to approve the 2018-19 Capital Budget as presented
5.4 Revised 2018-19 Operating Plan to approve the 2018-19 Operating Plan as presented
5.5 Community Accountability Planning Submission (CAPS)*
to approve the CAPS as presented
5.12 Annual General Meeting to approve the Annual General Meeting be held at the Lambton College Event Centre
Board Chair Report
I would like to highlight my activities as Chair for the period of April 21 to May 17, 2018: April 24, 2018 Prepared for and chaired the Nominating Committee Meeting
April 25, 2018 Met with the President and CEO to discuss his annual performance evaluation
April 25, 2018 Prepared for and chaired the Bluewater Health Board Meetings
April 26, 2018 Attended the BWH Annual Recognition Ceremony
May 9, 2018 Prepared for and attended the Governance and Nominating Committee meetings
May 10, 2018 Attended the Resource Utilization and Audit Committee meeting
May 14, 2018 Met with President and CEO to prepare for the March Board meeting
May 14, 2018 Attended the Quality Committee meeting
May 15, 2018 Attended the Community and Rural Health Advisory Panel Meeting
May 17, 2018 Attended the CEEH Foundation Meeting
Various dates Communicated with BWH staff and Board members regarding hospital and Board business
Wayne L. Pease
1
President of the Professional Staff Association (PSA) Report
May 2018 I would like to highlight my activities as PSA President: April 25, 2018 Attended the Bluewater Health Board Meeting May 16, 2018 Attended the Medical Advisory Committee meeting Various dates Canvassed Professional Staff for replacement of PSA
executive positions
Dr. Sharon Rutledge
Resource Utilization & Audit Committee Report Prepared by: Facilities Planning & Development Period Ending Apr. 2018
FPD – RUAC Report – Apr. 2018 Page 1 of 1
Project List CEEH Redevelopment Project Project Budget; $9,000,000 + Funding Source; Ministry Capital Submission Status; In Progress Anticipated Start; Sept. 2015 Anticipated Completion; Summer 2019 Comments;
• Stage 1 submission submitted to Ministry/ESC LHIN, currently under review • Additonal HIRF funding submitted
o Transformer/Switch Gear Replacement and Relocation ($1.3 million) o Medical Gas System ($650,000) o Asbestos Abatement ($250,000) o Sanitary Waste Piping ($150,000)
• HEEP submissions due June 15th will include Boiler/HVAC Systems (Approx. $2.5 million)
• Replacement of 40,000 Litre Underground Diesel Tanks • Completing engineering • Postponed to spring 2019
Resource Utilization & Audit Committee Report Prepared by: Facilities Planning & Development Period Ending Apr. 2018
FPD – RUAC Report – Apr. 2018 Page 2 of 2
Project’s Cont’d Parking Equipment Upgrade Project Budget; $150,000 Funding Source; Capital Status; In Progress Anticipated Start; May 2018 Anticipated Completion; Oct. 2018 Comments;
• Tender package being assembled • Anticipating June release
Medication Room – Access Control Project Budget; 50,000 Funding Source; Capital – 18/19 Status; In Progress Anticipated Start; Mar. 2018 Anticipated Completion; Oct. 2018 Comments;
• Access Control added to all Medication Rooms – Accreditation Recommendation Pneumatics to Direct Digital Controls (DDC) Project Budget; $400,000 Funding Source; Healthcare Energy Efficiency Program (HEEP) Status; Completed Anticipated Start; Dec 2017 Anticipated Completion; Mar. 2018 Comments;
• Replacement of end of life Pneumatic System to digital controls in London building • Will integrate into our existing building automation system
RTLS (Real Time Location Service) Project Budget; $769,000 Funding Source; HIRF Status; Completed Anticipated Start; Jan. 2016 Anticipated Completion; Nov. 2017 Comments; Medical Equipment Tracking – Completed – Temp/Humidity Completed Staff Duress Tags currently refining alerting methods and processes Completed – End user training has begun.
Bluewater HealthBank Loan AnalysisFor the period ending March 31, 2018
Bank Loan Description Purpose Mar 18 Dec 17 Sep 17 Jun 17 Mar 17 Approved Limit
Bank Loans - Long TermDemand loan, 2.39%, repayable in blended monthly Honeywell Energy Project 1,648,219 1,776,616 1,904,248 2,031,122 2,157,240 3,800,000 payments of principal and interest of $46,252, matures April 2021Demand loan, 2.38%, repayable in blended monthly payments of principal and interest of $53,083, 2,428,187 2,572,418 2,715,793 2,858,319 3,000,000 4,500,000 matures March 2022TOTAL DEBT 4,076,406 4,349,033 4,620,041 4,889,440 5,157,240 8,300,000
Less: Current Portion of Long Term Debt (1,106,892) (272,627) (543,636) (813,035) (1,080,834) 2,969,514 4,076,406 4,076,406 4,076,406 4,076,406
TOTAL BANK LOANS PAYABLE 2,969,514 4,076,406 4,076,406 4,076,406 4,076,406 TOTAL CURRENT PORTION OF LONG TERM DEBT (OTHER LIABILITIES) 1,106,892 272,627 543,636 813,035 1,080,834
2016/17 Capital Expenditures
Charlotte Eleanor Englehart Hospital of Bluewater HealthEnglehart Estate InvestmentsAs at March 31, 2018
Cash Accounts:Revenue Cash 3,521.41 Capital Cash 318.61
Total Endowment Cash per TD Waterhouse Stmnt 3,840.02
Total Held for Trading Investments 762,386.94 769,727.34
Total Investments and Cash Accounts 766,226.96 773,567.36
GOVERNANCESELF ASSESSMENT
1
Criteria Flag High Priority
ROP Strongly Agree
Agree Neutral Disagree Strongly Disagree
Don't Know
N/A
1.1 The roles, responsibilities, and legal obligations of the governing body are defined and regularly reviewed.
G Yes X
1.2 There is written documentation that identifies the governing body's roles and responsibilities, as well as how those roles and responsibilities are carried out.
G Yes X
1.3 The governing body approves, adopts, and follows the ethics framework used by the organization.
R Yes X
1.4 The governing body adopts a code of ethical conduct for its members.
G Yes X
1.5 There is a process to develop the governing body's by-laws and policies and update them regularly.
G X
1.6 The governing body's by-laws and policies are consistent with its mandate, roles, responsibilities, accountabilities, and the organization's ethics framework.
R Yes X
2.1 The mix of background, experience, and competencies needed in the governing body's membership is identified.
G Yes X
2.2 There are established mechanisms for the governing body to hear from and incorporate the voice and opinion of clients and families.
G X
2.3 The governing body includes clients as members, where possible. G X
2.4 There is a documented process that is followed to elect or appoint the chair of the governing body.
R X
2.5 The roles and responsibilities of the chair are described in a position profile, terms of reference, or by-laws.
G Yes X
2.6 There are written criteria and a defined process for recruiting and selecting new members of the governing body.
G X
2.7 New members of the governing body receive an orientation before attending their first meeting.
G X
2.8 Each member of the governing body signs a statement acknowledging his or her role and responsibilities, including expectations of the position and legal duties.
G Yes X
GOVERNANCESELF ASSESSMENT
G R
Indicates a response of Agree or Strongly Agree
Indicates a response of Neutral or Lower
GOVERNANCESELF ASSESSMENT
2Criteria Flag High Priority
ROP Strongly Agree
Agree Neutral Disagree Strongly Disagree
Don't Know
N/A
2.9 Members of the governing body receive ongoing education to help them fulfill their individual roles and responsibilities and those of the governing body as a whole.
G X
2.10 The governing body's membership policies and/or by-laws address term lengths and limits, attendance requirements, and compensation.
G X
2.11 The governing body's renewal cycle supports the addition of new members while maintaining a balance of experienced members to support the continuity of corporate memory and decision-making.
G Yes X
3.1 The ethics framework and evidence-informed criteria are used by the governing body to guide decision making.
R Yes X
3.2 Areas where decision making is shared with government, funding authorities, and other health organizations are identified.
G X
3.3 The information required to support decision making is available and accessible to the governing body.
G X
3.4 The governing body has processes in place to oversee the functions of audit and finance, quality and safety, and talent management.
G Yes X
3.5 Required information and documentation is received in enough time to prepare for meetings and decision making.
G Yes X
3.6 The governing body reviews the type of information it receives to assess its appropriateness in helping the governing body to carry out its role.
G X
4.1 The governing body works in collaboration with the organization's leaders to develop the organization's mission statement.
G Yes X
4.2 When developing or updating the mission statement, input is sought from team members and external stakeholders, including clients, families, and partners.
G X
4.3 Government or the organization's shareholders are regularly consulted to confirm the appropriateness of the organization's mandate and core services and to develop a common understanding about performance expectations.
G X
4.4 The organization's mission statement is regularly reviewed and revised as necessary to reflect changes in the environment, scope of services, or mandate.
G X
5.1 The governing body works with the organization's leaders to define or update the organization's values statement.
G Yes X
GOVERNANCESELF ASSESSMENT
3Criteria Flag High Priority
ROP Strongly Agree
Agree Neutral Disagree Strongly Disagree
Don't Know
N/A
5.2 The governing body collaborates with the organization's leaders to seek input from team members, clients, and families to define or update the organization's values statement.
G X
5.3 The governing body provides oversight of the organization's efforts to build meaningful partnerships with clients and families.
G Yes X
5.4 The governing body monitors and evaluates the organization's initiatives to build and maintain a culture of client- and family-centred care.
G Yes X
5.5 The governing body has a formal process to understand, identify, declare, and resolve conflicts of interest.
G X
6.1 The governing body oversees the strategic planning process and provides guidance to the organization's leaders as they develop and update the organization's vision and strategic plan.
G Yes X
6.2 The governing body, in consultation with the organization's leaders, identifies timeframes and responsibility for achieving the strategic goals and objectives.
G Yes X
6.3 The governing body works with the organization's leaders to conduct an ongoing environmental scan to identify changes and new challenges, and ensures that the strategic plan, goals, and objectives are adjusted accordingly.
G Yes X
7.1 The governing body oversees the recruitment and selection of the CEO.
G Yes X
7.2 The governing body follows a policy on CEO compensation. G X
7.3 The governing body develops and updates the position profile for the CEO.
G Yes X
7.4 In partnership with the CEO, the governing body sets performance objectives for the CEO and reviews them annually.
G X
7.5 The governing body supports and commits resources to the ongoing professional development of the CEO.
G X
7.6 The governing body has a mechanism to receive updates or reports from the CEO.
G Yes X
7.7 The governing body, with the input of the organization's leaders, evaluates the CEO's performance and achievements annually.
G X
7.8 The governing body has a succession plan for the CEO. R X
GOVERNANCESELF ASSESSMENT
4Criteria Flag High Priority
ROP Strongly Agree
Agree Neutral Disagree Strongly Disagree
Don't Know
N/A
7.9 The governing body oversees the development of the organization's talent management plan.
G Yes X
8.1 A documented process is followed for granting privileges. G Yes X
8.2 A documented process is followed to review and evaluate the performance of health care professionals who have been granted privileges.
G Yes X
8.3 A documented process is followed for reviewing and renewing privileges (including processes for addition of new privileges or alteration of privileges) on a regular basis.
G Yes X
8.4 There is a documented process to address any performance issues identified with health care professionals with privileges.
G Yes X
8.5 The governing body verifies that documented processes for appeals of decisions regarding privileges are followed.
G Yes X
9.1 The governing body approves the organization's capital and operating budgets.
G Yes X
9.2 The governing body ensures the integrity of the organization's financial statements, internal controls, and financial information systems.
G Yes X
9.3 The governing body reviews the organization's financial performance in the context of the strategic plan and key performance areas such as utilization, risk, and safety.
G Yes X
9.4 The governing body reviews and approves the organization's capital investments and major equipment purchases.
G Yes X
9.5 The governing body oversees the organization's resource allocation decisions as part of its regular planning cycle.
G Yes X
9.6 When reviewing and approving resource allocation decisions, the governing body assesses the risks and benefits to the organization.
G Yes X
9.7 When approving resource allocation decisions, the governing body evaluates the impact of the decision on quality, safety and client experience.
G Yes X
9.8 The governing body anticipates the organization's financial needs and potential risks, and develops contingency plans to address them.
G X
9.9 The governing body addresses recommendations in financial reports and from the CEO and the organization's leaders.
G X
GOVERNANCESELF ASSESSMENT
5Criteria Flag High Priority
ROP Strongly Agree
Agree Neutral Disagree Strongly Disagree
Don't Know
N/A
10.1 The governing body adopts patient safety as a written strategic priority for the organization.
G Yes X
10.2 The governing body monitors organization-level measures of patient safety.
G Yes X
10.3 The governing body addresses recommendations made in the organization's quarterly patient safety reports.
G X
10.4 The governing body regularly reviews the frequency and severity of safety incidents and uses this information to understand trends, client and team safety issues in the organization, and opportunities for improvement.
G Yes X
10.5 The governing body regularly hears about quality and safety incidents from the clients and families that experience them.
G Yes X
11.1 The governing body works with the CEO to identify stakeholders and learn about their characteristics, priorities, interests, activities, and potential to influence the organization.
G X
11.2 In consultation with the CEO, the governing body anticipates, assesses, and responds to stakeholders' interests and needs.
G X
11.3 The governing body works with the CEO to establish, implement, and evaluate a communication plan for the organization.
G X
11.4 The communication plan includes strategies to communicate key messages to clients and families, team members, stakeholders, and the community.
G X
11.5 The governing body promotes the organization and demonstrates the value of its services to stakeholders and the community.
G X
11.6 The governing body regularly consults with and encourages feedback from stakeholders and the community about the organization and its services.
G X
11.7 The governing body, in collaboration with the organization's leaders, share reports about the organization's performance and quality of services with teams, clients, families, the community served, and other stakeholders.
G X
12.1.1 The governing body is knowledgeable about quality and safety principles, by recruiting members with this knowledge or providing access to education.
G Yes Yes X
12.1.2 Quality is a standing agenda item at all regular meetings of the governing body.
G Yes Yes X
GOVERNANCESELF ASSESSMENT
6Criteria Flag High Priority
ROP Strongly Agree
Agree Neutral Disagree Strongly Disagree
Don't Know
N/A
12.1.3 The key system-level indicators that will be used to monitor the quality performance of the organization are identified.
G Yes Yes X
12.1.4 At least quarterly, the quality performance of the organization is monitored and evaluated against agreed-upon goals and objectives.
G Yes Yes X
12.1.5 Information about the quality performance of the organization is used to make resource allocation decisions and set priorities and expectations.
G Yes Yes X
12.1.6 As part of their performance evaluation, senior leaders who report to the governing body (e.g., the CEO, Executive Director, Chief of Staff) are held accountable for the quality performance of the organization.
G Yes Yes X
12.2 The governing body works with the CEO and the organization's leaders to develop an integrated quality improvement plan.
G Yes X
12.3 The governing body ensures that an integrated risk management approach and contingency plans are in place.
R Yes X
12.4 The governing body receives summary reports of client and family complaints received by the organization.
G X
12.5 The governing body monitors and provides input into the organization's strategies to address client flow and variations in service demands.
G X
12.6 The governing body promotes learning from results, making decisions that are informed by research and evidence, and ongoing quality improvement for the organization and the governing body.
G X
12.7 The governing body demonstrates a commitment to recognizing team members for their quality improvement work.
G X
13.1 The governing body publicly discloses information about its governance processes, decision-making, and performance.
G Yes X
13.2 The governing body's activities and decisions are recorded and archived.
G Yes X
13.3 The governing body shares the records of its activities and decisions with the organization.
G Yes X
13.4 The governing body follows a process to regularly evaluate its performance and effectiveness.
G Yes X
13.5 The governing body conducts or participates in an assessment of its structure, including size and committee structure.
G Yes X
GOVERNANCESELF ASSESSMENT
7Criteria Flag High Priority
ROP Strongly Agree
Agree Neutral Disagree Strongly Disagree
Don't Know
N/A
13.6 The governing body regularly evaluates the performance of the board chair based on established criteria.
R Yes X
13.7 The governing body regularly reviews the contribution of individual members and provides feedback to them.
G Yes X
13.9 The governing body prepares an annual report of its achievements. G X
13.10 The governing body identifies and addresses opportunities for improvement in how it functions.
G Yes X
GOVERNANCEFLAGGED HIGH PRIORITY GUIDELINES AND ROPs
8
Criteria Flag High Priority
Response Accreditation Canada Guidelines and Required Organizational
Practice1.3 The governing body approves,
adopts, and follows the ethics framework used by the organization.
R Yes Neutral
1.6 The governing body's by-laws and policies are consistent with its mandate, roles, responsibilities, accountabilities, and the organization's ethics framework
R Yes Neutral
3.1 The ethics framework and evidence-informed criteria are used by the governing body to guide decision making.
R Yes Neutral
12.3 The governing body ensures that an integrated risk management approach and contingency plans are in place.
R Yes Neutral
13.6 The governing body regularly evaluates the performance of the board chair based on established criteria.
R Yes Neutral
GOVERNANCEACCREDITATION CANADA FLAGGED HIGH PRIORITY GUIDELINES
AND REQUIRED ORGANIZATIONAL PRACTICES (ROP)
Guideline 1.3
Guideline 1.6
Guideline 3.1
Guideline 12.3
Guideline 13.6
GOVERNANCEADDITIONAL GUIDELINES
9
Criteria Flag Response Guideline
2.4
There is a documented process that is followed to elect or appoint the chair of the governing body. R Disagree
7.8
The governing body has a succession plan for the CEO.
R Neutral
ADDITIONAL GAPS TO BE INCLUDED IN ACCREDITATION WORK PLAN
Guideline 2.4
Guideline 7.8
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Board Meeting Effectiveness Survey - April 25, 2018Monday, April 30, 2018
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Date Created: Wednesday, April 18, 2018
12 of 15Total Responses
Complete Responses: 12
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Q1: Did you receive the materials in sufficient time for you to prepare for the meeting?Answered: 12 Skipped: 0
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Q2: Were relevant materials provided?Answered: 12 Skipped: 0
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Q3: Were the materials sufficient to assist you in forming an option on decisions made by the Board?Answered: 12 Skipped: 0
Comments: In the In Camera, regarding Performance Targets related to Exec. Comp., there was a bit of repetition in reports. Would love to save the staff some time by limiting duplication
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Q4: The meeting started on time.Answered: 12 Skipped: 0
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Q5: The agenda was clear and realistic for the allotted meeting time.Answered: 12 Skipped: 0
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Q6: Agenda topics were appropriate (e.g. reflected roles, responsibilities of the Board, topical issues)Answered: 12 Skipped: 0
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Q7: The time spent on each item was appropriate.Answered: 12 Skipped: 0
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Q8: I felt supported and valued as a member of the Board.Answered: 12 Skipped: 0
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Q9: I was encouraged to discuss and share my opinion openly.Answered: 12 Skipped: 0
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Q10: Disagreements were handled openly, honestly and directly.Answered: 11 Skipped: 1
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Q11: Meeting participants appeared to be prepared for the meeting.Answered: 11 Skipped: 1
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Q12: Follow-up action item responsibilities were clear to all meeting participants.Answered: 12 Skipped: 0
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Q13: The meeting finished in a reasonable amount of time given the agenda content.Answered: 12 Skipped: 0
Comments: • Excellent meeting with great participation by a good variety of members.• Perhaps book tours earlier in order to avoid a late start to the meeting
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Q15: Were you satisfied with your opportunity to participate in the debate?Answered: 12 Skipped: 0
Comments: Board chair provides adequate time for questions on each agenda item
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Q16: Were you satisfied with the manner in which other Board members contributed to the debate?Answered: 11 Skipped: 1
Comments: • Regarding the open forum, Would it be possible for the Chair to offer topic (from time
to time) that might generate some broad discussion - we have a safe space in the in camera setting I feel. Whether we might be so comfortable in the open session might be debated but I do feel that it would be an opportunity for a greater level of engagement as representatives of the broader community.
• All board members share their skill sets well during discussions
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Q17: Was the chair effective in allowing all sides to be heard while bringing the matter to a decision?Answered: 12 Skipped: 0
• Keep us on time
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Q18: Were you satisfied with what the Board accomplished?Answered: 12 Skipped: 0
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Q19: Were you satisfied with the Board's overall performance?Answered: 12 Skipped: 0
Comments:• Board members are able to discuss items openly and honestly
BLUEWATER HEALTH BOARD
12-Sep 27-Sep Oct Nov Dec Jan 22-Feb 28-Feb Mar Apr May June June AttendanceMEMBER AGM %
Dragan, Marg C 1 1 1 1 1 1 1 1 100%Iafrate, Anthony 1 1 1 1 1 1 1 1 1 100%Gillam, Bill 1 1 1 1 1 1 1 1 0 88%Greensmith, Jenny 1 1 1 0 1 1 1 1 1 88%Guimond, Louis 1 1 1 1 0 1 1 1 1 88%Haddad, Dr. M. 1 1 1 0.5 0 C 1 1 1 79%Kohlmeier, Guy 0 1 1 1 0 1 1 1 1 88%Knott, Brian 1 1 1 1 1 1 1 1 1 100%Landry, Shannon C 1 1 1 1 C 1 1 1 100%Lapaine, Mike C 1 1 1 1 C 1 1 1 100%Mantha, Katherine 1 1 1 1 1 1 1 1 1 100%McKinley, Bob 1 1 1 1 1 1 0 1 1 88%Pease, Wayne 1 1 1 1 1 1 1 1 1 100%Vanderheide, Fred 1 1 1 1 1 0 1 1 1 88%Wiersma, Paul 1 1 1 1 1 1 1 1 1 100%PROFESSIONAL STAFF ASSOCIATIONKohli, Kapil 0 0 0 0 0 NA 0 0 0 0%Rutledge, Sharon 1 1 1 1 1 NA 1 1 1 100%Taylor, Nathan 0 1 1 1 1 NA 0 1 0 71%
Bluewater Health Education Record 2017-18Name of Conference/Webcast
Way
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Kath
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OHA On-Line Learning Modules x NA x x x x x x x x x NA NA NA
Understanding Hospitals and the Health Care System x x x x x x x xEssentials Certificate in Board Governance x x x x x x x x x x xAdvanced Certificate in Board Governance/Advanced Board Program for the Health Care Sector x x x x x x x x x
Financial Literacy for Hospital Board Directors x x xConference for Board Finance Committee Members x xSept 2017 - BWH Board Orientation x x x x x x x x xSept 2017 - Governance Forum xSept 2017 - Health Achieve x xSept 2017 - Webinar: What Directors Need to Know - Quality of Care, Privacy and Accountability
x x x
Nov 2017 - Effective Governance for Quality and Patient Safety xNov 2017 - BWH Board Retreat x x x x x x x x x x x x x xNov 2017 - OHA Teleconference - Executive Compensation x xFeb 2018 - Webinar- Are you ready? New Amendments Non-Profit Governance in Ontario
x x x
Feb 2018 - Webinar - What Directors Need to Know: The new H-SAABWH Understanding Indigenous Cultures Workshop x x xBWH Bridges out of Poverty Workshop x x
Note: Conferences in shaded area may have been attended in past years.
MINUTES
OPEN SESSION BOARD MEETING Wednesday, April 25, 2018
Directors:
Marg Dragan, Treasurer √ Anthony Iafrate √ Bill Gillam - R Jenny Greensmith √
Louis Guimond √ Brian Knott √ Dr. Guy Kohlmeier √ Katherine Mantha √
Bob McKinley√ Wayne Pease, Chair √ Fred Vanderheide √ Paul Wiersma, Vice-Chair √
Ex-Officio Directors:
Mike Lapaine √ Dr. Michel Haddad √
Shannon Landry √ Dr. Sharon Rutledge √
Dr. Nathan Taylor – R
Professional Staff, Staff and Guests:
Dr. Kapil Kohli – R Samer Abou-Sweid - R
Laurie Zimmer √ Julia Oosterman √
Paula Reaume-Zimmer √ Kathy Alexander – R
Recorder: Melissa Rondinelli (*attached in the minute record book)
1.0 CALL TO ORDER
Wayne Pease called the meeting to order at 5:20 pm and welcomed the Board and guests. 1.1 Report on February In-Camera Board Meeting
Wayne reported on the items discussed at the March In-Camera Board meetings, which included minutes, credentialing and updates on the CEEH and Withdrawal Management projects.
2.0 AGENDA APPROVAL 2.1 Approval of Agenda* Motion (K. Mantha/B. McKinley): to approve the agenda as presented.
2.2 Declaration of Conflict of Interest Wayne invited Directors to share any conflicts. None were declared.
3.0 CONSENT AGENDA
3.1 ITEMS TO BE RECEIVED – REPORTS 3.1.1 Board Chair* 3.1.2 Professional Staff Association Report*
3.2 ITEMS FOR APPROVAL 3.2.1 Open Session Board Minutes – March 28, 2018* 3.2.2 Whistleblower Service* Motion (K. Mantha/B. Knott) and carried: to approve the Open Session Board Minutes of March 28, 2018; and to approve that management continue to provide the
Bluewater Health – Open Meeting April 25, 2018 Page 2 ____________________________________________________________________________
Whistleblower Service in accordance to Whistleblower Policy (Gov. 3.60) with the same provider. Questions regarding how widely the Whistleblower Service is advertised and whether BWH shares the cost with other hospitals were raised. It was explained there is an annual awareness campaign about the Whistleblower Service. Mike Lapaine added the service is considered best practice and advised BWH does not cost-share with other hospitals for the service.
4.0 PRESIDENT AND CEO REPORT* Mike presented his report. He noted he was asked about BWH’s preparedness for a code orange event and explained the hospital participates in extensive exercises to ready itself for these events. He explained there is an internal process to call in staff, as well as a fan out protocol coordinated by an Emergency Operation Centre within the city. Mike noted there have been two code orange events within the last four years, both of which were quickly downgraded. He added it is easy to mobilize staff as people voluntarily show up to help; however, it is more difficult to ramp down operations. Mike also noted there is a protocol in place to move patients to designated locations in the event an evacuation is required. It was questioned if there are any international protocols given the hospital’s proximity to the USA. Mike explained BWH participates in the Incident Management System, which includes a special communication system with the USA. He also noted BWH is planning to strengthen its Emergency Preparedness Policy with minor changes. Next, Jenny Greensmith congratulated BWH on the exceptional response rate for the Workplace Engagement Survey, noting she was looking forward to receiving the results. She also brought attention to Doctor’s Day and Nursing Week coming up in May to recognize these professionals. Jenny then asked for more information about the Quality Care Review highlighted in the report. It was explained BWH has created an algorithm to illustrate how the hospital assesses incidents to determine if they are due to individual error or a system issue. The exercise was meant to provide reassurance that reporting an incident does not necessarily mean someone did something wrong, and provides opportunity to make changes to improve the system. Lastly, Mike brought attention to the Elevating Patient Experience article. He reported BWH was recognized in the article, as it is one of the highest performers for patient experience data according to the National Research Corporation (NRC). Mike noted BWH introduced
Bluewater Health – Open Meeting April 25, 2018 Page 3 ____________________________________________________________________________
Patient Experience Partners four to five years ago, while other organizations are just beginning to introduce them now.
5.0 BOARD DECISIONS/OVERSIGHT
5.1 Resource Utilization and Audit Committee (RUAC) Highlights* Marg Dragan presented the RUAC Committee Highlights and highlighted the positive 3M audit results, specifically recognizing the collaboration between the physicians and coders. She also noted the Committee discussed funding updates and banking arrangements.
5.2 Financial Statement* Marg presented the Financial Statement for the period ended February 28, 2018. She noted
the forecasted surplus is $1M because of additional funding received (surge, QBP, CCO). Mike mentioned the surplus might be even higher than forecasted. It was questioned what BWH would do with this surplus. Mike explained the hospital would retain the surplus, and the funds would go into working capital. Marg added the surplus would also be helpful if there are any deficits in the year ahead. Anthony Iafrate asked if the Ministry of Health and Long-Term Care (Ministry) would consider the surplus when allocating funding next year. Mike responded it would not.
Motion (M. Dragan/A. Iafrate) and carried: to approve the Financial Statement for the
period ended February 28, 2018 as presented. 5.3 Resource Utilization and Audit Committee (RUAC) Performance Scorecard*
Marg presented the scorecard and summarized the status of the following indicators updated this month:
• 90th Percentile Emergency Department (ED) Length of Stay (LOS)– negatively impacted by seasonal surge
• ALC Rate %– meets/exceeds target • Absenteeism Rate – performance within 5% of target due to overtime and staff
burnout related to seasonal surge • Cost per Weighted Case
o Acute Inpatient/Day Surgery – off target o Rehab – on target o Continue Care – off target
• Surplus/Deficit – meeting target • Adjusted Working Capital – meeting target with some uptake in spending
5.4 Medical Advisory Committee Highlights*
Dr. Haddad presented the Committee Highlights and brought attention to the quality improvement initiatives listed. He mentioned there are a number of education opportunities coming up for the Professional Staff. Dr. Haddad then discussed BWH’s current recruitment efforts and reported a formal agreement has been made for an
Bluewater Health – Open Meeting April 25, 2018 Page 4 ____________________________________________________________________________
Emergency Department (ED) Residency Program, which he hopes will expand to family practice and palliative care. Jenny questioned the process/requirements for when a psychiatrist leaves their practice. Dr. Haddad explained the psychiatrists is required to determine which patients continue to require psychiatric care and those that can been cared for by their family physician. The patients requiring psychiatric care are then referred to another psychiatrist. He noted some family physicians are not comfortable treating their patients and will refer them back to psychiatry. Paula Reaume-Zimmer added there has been a change in psychiatry practice as well, with psychiatrists seeing the patients, and then handing them back to family physicians. This practice has allowed for a better response to acute mental health demands, and wait times have decreased substantially. She also reported BWH is working closely with the Canadian Mental Health Asscoation and Community Living to ensure complex chronic patients are being seen and any outstanding immediate requests are dealt with. Katherine Mantha then asked why the ED Residency program is for year three, and if there are plans to offer it for years one and two. Dr. Haddad explained the first two years of residency are family practice, with the third year being a specialty. He noted he would like to offer family practice for years one and two in the future. Marg asked how many positions would be offered. Dr. Haddad reported there will be one position. Discussion regarding the benefits and costs of the Residency Program vs. recruitment followed.
5.5 Governance and Nominating Committee Highlights* Brian Knott presented the Committee Highlights. He noted Board members could expect to receive the OHA Board Self-Assessment Tool shortly, which will measure the Board against other hospitals. He also provided a succession planning update noting the Board received applications from 18 exceptional candidates, and the Nominating Committee held interviews the day prior.
5.6 Revised Nominations Process Policy*
Brian reported Accreditation Standards illustrated gaps in BWH’s nominations process. As a result, the policy has been amended to add a process for determining leadership positions. There were also other changes recommended as summarized in the briefing note. Jenny questioned why the requirement to share the position descriptions was removed from the policy. It was explained this step was duplicative and is included in another Board policy.
Motion (B. Knott/A. Iafrate): to approve the revised Board Nominations Process Policy as presented.
Bluewater Health – Open Meeting April 25, 2018 Page 5 ____________________________________________________________________________
Louis Guimond questioned why gender was not included in the policy under Balance within the Board. Brian reported gender is considered during succession planning. Fred Vanderheide suggested although it is not explicit in the policy, it could be inferred.
5.7 Revised Board Evaluation Policy*
Brian reported this policy was due for review as per the Board Policy Review cycle. It was noted there was opportunity to add Chair evaluations; therefore, the policy was revised to include this.
Motion (B. Knott/K. Mantha): to approve the revised Board Evaluation Policy as presented.
5.8 Bluewater Health Foundation Report*
Brian presented the report noting Kathy Alexander is on a leave of absence during the time leading up to election. He then highlighted the upcoming Hoedown for HealthCare and Golf fore Health fundraising events.
6.0 POLICY FORMATION
6.1 Draft Meetings without Management Policy*
Brian noted the idea of holding meetings without management was previously discussed as a Board. He explained it was agreed a policy would be developed for these meetings and presented the draft for consideration. Brian indicated the meetings would take place four times per year with the intent of monitoring how well the Board is operating. Motion (B. Knott/B. McKinley): to adopt the new Meetings without Management Policy as presented. There were no questions or comments made.
7.0 OPEN FORUM Jenny brought attention to the fact there may be discrimination against autistic individuals given the recent tragedy in Toronto. She noted provincial associations are concerned about the stigma that may be directed against these individuals, and are working to provide a joint statement of awareness. Fred noted he and his wife attended the Withdrawal Management event hosted by the BWH Foundation last week. He advised he was impressed by the presentation and it was very informative. Brian reported a friend recently underwent hip surgery and shared glowing remarks about the care he received at BWH and the staff that cared for him. Brian also noted he attended the Bridges Out of Poverty workshop held at BWH, and highly recommended Board
Bluewater Health – Open Meeting April 25, 2018 Page 6 ____________________________________________________________________________
members attend if possible. Jenny advised the Social Service Network is sponsoring the Circles Out of Poverty Program and registration is open to all Community Board members. She indicated she would share the information with the Board and added the program is life changing in terms of the way you view your patients. Paul Wiersma reported Chief Joanne Rogers joined the Nominating Committee for Board interviews this week, and recognized her background brought a different perspective to the process. He also noted there were several indigenous candidates this year.
8.0 IN-CAMERA AGENDA ITEMS Wayne advised the Board will be meeting In-Camera following this meeting to disucss the CEEH and WMS projects, insurance and personnel items.
9.0 ADJOURNMENT Motion (A. Iafrate/J. Greensmtih) and carried: to adjourn the meeting at 6:14 pm. ________________________ ____________________________ Wayne L. Pease Mike Lapaine Chair Secretary Board of Bluewater Health Board of Bluewater Health
Title ROLES AND RESPONSIBILITIES AS AN ELECTED AND EX-OFFICIO DIRECTOR
Issuing Body/ Prepared By
Governance and Nominating Committee
Approved by Board of Directors Number: GOV 5.20 Effective Date Revised Date
O: January 2009 R: June 2012 September 2014 January 2016May 2018
Version 54 File Name: S:\CHIEF EXECUTIVE OFFICER\BOARD AND BOARD COMMITTEES\BOARD BWH\BOARD POLICIES\5.20 - Roles And Responsibilities As An Elected And Ex-Officio Director - Jan 2016.Docx
Controlled document. Any documents appearing in paper form must be used for reference purposes only. The on-line copy on the file server above must be considered the current documentation.
Purpose As part of its responsibility for ensuring Board effectiveness, the Board of Bluewater Health (BWH) will establish, approve and periodically review a description of the Roles and Responsibilities as an Elected and Ex-Officio Director. This description is an important requirement of effective governance as it provides Directors with a clear understanding of what is expected of them and serves as a benchmark against which individual director performance can be assessed.. This policy sets out the Roles and Responsibilities as an Elected and Ex-Officio Director as developed and approved by the Board of BWH. Policy 1.0 Accountability and Fiduciary Duties A Director acts ethically, honestly, in good faith and in the best interests of BWH and in so doing, supports BWH in fulfilling its mission and mandate, and discharging its accountabilities. A Director exercises the care, diligence and skill that a reasonably prudent person would exercise in comparable circumstances. Directors with special skill and knowledge are expected to apply that skill and knowledge to matters that come before the Board. A Director does not represent the specific interests of any constituency. A Director acts and makes decisions that are in the best interest of BWH as a whole. A Director adheres to the vision, mission and values of BWH and complies with the Public Hospitals Act, the Corporations Act, by-laws, applicable laws and regulations and Board policies. A Director adheres to the Principles of Governance and Board Accountabilities policy (GOV- 5.10) 2.0 Exercise of Authority A Director carries out the powers of office only when acting as a voting member during a duly constituted meeting of the Board or one of its committees. A Director respects the
APPROVED DRAFT
ROLES AND RESPONSIBILITIES OF THE BOARD OF DIRECTORS
Number: GOV 5.20 Page 2 of 3
responsibilities delegated by the Board to the President/Chief Executive Officer and Chief of Professional Staff, avoiding interference with their duties but insisting upon accountability to the Board and reporting mechanisms for assessing organizational performance. 3.0 Conflict of Interest A Director does not place him/herself in a position where his/her personal interests conflict with those of BWH. A Director complies with the Conflict of Interest provisions in the by-laws and Board approved policy. 4.0 Team Work A Director works positively, cooperatively and respectfully with others in the performance of his or her duties while exercising independence in decision-making. 5.0 Participation A Director reviews pre-circulated material and comes prepared to Board and committee meetings and educational activities, asks informed questions, and makes a constructive contribution to discussions. A Director considers the need for independent advice to the Board on major corporate actions. 6.0 Formal Dissent A Director reviews the minutes of the previous meeting on receipt and insists that they record any Director’s disclosure of an actual or potential conflict of interest, abstention or dissent. A Director who is absent from a Board meeting is deemed to have supported the decisions taken and policies approved by the Board in his or her absence unless he or she formally records a dissenting view with the Board secretary. 7.0 Board Solidarity The official spokesperson for the Board is the Chair or the Chair’s designate. A Director supports the decisions and policies of the Board in discussions with outsiders, even if the Director holds another view or voiced another view during a Board discussion or was absent from the Board meeting. A Director refers requests for statements on behalf of the Board to the Board Chair. The Board Chair may delegate his/her responsibility for representing and acting as spokesperson for the Board to other Directors, as required. 8.0 Confidentiality A Director respects the confidentiality of in camera Board discussions and information and such other Board discussions as deemed to be confidential by the Board. Directors will respect the confidentiality of any Informal Meetings. 9.0 Time and Commitment A Director is expected to commit the time required to fulfill Board and committee responsibilities. A Director is expected to attend a minimum of 85% of the meetings of the Board and 85% of committee meetings of which he/she is a member. Directors who fail to meet the attendance requirements are subject to review by the Chair and may be asked to step down from the Board. All Directors are expected to serve on the Quality Committee at least once over their first term, and serve on at least two (2) different Board Standing Committees over the course of any subsequent term as a Director. on at least one Board committee each year and on the Quality Committee at least once during a term (exceptions to be approved by the Board). Directors are also expected to represent the Board and BWH in the community and to
Commented [MR1]: Service requirements amended to align with the Nominations Process Policy.
ROLES AND RESPONSIBILITIES OF THE BOARD OF DIRECTORS
Number: GOV 5.20 Page 3 of 3
participate on adhoc commitees and panels or in other forums, when reasonably requested by the Board Chair. 10.0 Competencies A Director actively contributes specific expertise, skills and other attributes that are needed on the Board. 11.0 Education A Director seeks opportunities to be educated and informed about the Board and the key issues at BWH and in the broader health care system through participation in Board and Committee orientation and education programs, maximizing use of information and resources on the Board website, participation in strategic planning processes, Board retreats and other mechanisms, as appropriate. 12.0 Self-Evaluation and Continuous Improvement A Director is committed to a process of continuous self-improvement as a Board member. All Directors participate in processes for the evaluation of the Board and in the Individual Director evaluation and act upon results in a positive and constructive manner. 13.0 Fundraising Activity A Director supports the efforts of the BWH Foundation and Charlotte Eleanor Englehart Hospital Foundation. Monitoring Method and Frequency: 1. Accreditation Canada Survey and report (every three years) 2. Board Evaluation (as per Policy 5.86) 3. Individual Director Evaluation (as per Policy 5.86) 4. Review of the Policy (every three years)
C H A R L O T T E E L E A N O R E N G L E H A R T S I T E | M I T T O N S I T E | N O R M A N S I T E
Delegation of Authority
I, Wayne L. Pease, as Chair of Bluewater Health, hereby delegate all of the powers and
duties of the “Head” under the Freedom of Information and Protection of Privacy Act
(FIPPA) in relation to Bluewater Health to the Chief Privacy Officer (“CPO”) of Bluewater
Health.
If the CPO is not reasonably available, then the CPO’s powers and duties shall be
delegated to the Vice-President Operations of Bluewater Health until the CPO is
reasonably available.
Date: ________________________ ____________________ Wayne L. Pease
Chair, Board of Directors
89 Norman Street Sarnia Ontario N7T 6S3 Administration Office T 519 464-4400 F 519 464-4407 www.bluewaterhealth.ca
Indigenous Patient Navigator Erie St. Clair LHIN and Bluewater Health have partnered to support an Indigenous Patient Navigator who will assist Indigenous patients, caregivers, and their families in better navigating the healthcare system. The aim of this position is to improve patient pathways and transition points within the hospital, and hospital to community care. The Indigenous Patient Navigator will assist in bridging the service gaps between Indigenous communities and healthcare providers by facilitating linkages with primary care and acute care, chronic disease management and mental health and addiction services, among others. The overall goal of this position is to assist clients to move easily through the healthcare system in a culturally safe and relevant manner. This support will be provided through case management/system navigation and connections to education/promotion, as well as promotion/access to culturally appropriate health care services, and quality improvement processes. The role is will be/is being filled by Nikki George, who is a member of the Kettle and Stony Point First Nation and has 20 years of experience in health and wellness community program planning and development with both urban and rural Indigenous populations. She has her Bachelors of Science Nutrition from Western University and a Masters of Health Studies from Athabasca University. We thank the Indigenous Health Planning Committee for its support and guidance in selecting the candidate. New Best Practice Service Offered A Peripherally Inserted Central Catheter (PICC) is a central venous access line inserted in the arm and used for long-term administration of medications such as chemotherapy or certain antibiotics that may be very damaging to the veins. Bluewater Health previously had only limited ability to provide this service and as a result patients traveled to London, Windsor and Chatham for this procedure. In order to provide best practice care, Bluewater Health expanded this service with the acquisition of two new machines for ultrasound-guided insertion – one for each hospital. Physicians began offering the service to inpatients in March on a rotating call basis. The hospital launched a nurse-led outpatient clinic for PICC lines the week of May 14. It operates Tuesdays and Thursdays, from 7:00 am to 3:00 pm. It is estimated this will result in 400 PICC line insertions each year.
Report to the Board from President & CEO Mike Lapaine
May 2018
Surgical Program Marketing A plan is being implemented to increase local patient requests and physician referrals for surgeries at Bluewater Health. The March 10 issue of HeartBeat and March issue of Pulse (both available in The Sarnia Observer) featured information about our local surgeons and surgical offerings. Further plans include speaking opportunities at local service clubs, information in the new physician newsletter Medical Matters, and an information campaign in traditional and social media.
Service and Excellence Honoured Bluewater Health staff, professional staff and volunteers were celebrated at Bluewater Health’s Annual Recognition Ceremony, including long service award recipients, retirees and Bridging Excellence Awards finalists and recipients. In total 318 staff, professional staff and volunteers were recognized for a service anniversary from five to 60 years (in five year increments), and the careers of 54 retirees were honoured. This year, three individuals were recognized for 40 years of service (Debbie Freeman, CEEH Administration; Barb Johnson, Rehabilitation; and Anne Reid, Telemetry Medicine unit); one for 50 (Dr. Frank Riedl) and one for 60 (volunteer Jean Paisley). Bluewater Health’s Bridging Excellence Awards recipients were also announced as part of the recognition event. The recipients of the 8th annual Bridging Excellence Awards are: • Values: Dan Edwards (volunteer) and Carlo Olivotto, Senior Biomedical Technologist (staff); • Vision: the Community Paramedic Program Team; and • Mission: Deb Croteau, Director, Diagnostic Services.
Fundraising Hoedown for Healthcare was held May 11, supporting Rural Health. A summary is included in the Foundation report. Three upcoming events are planned by Bluewater Health Foundation: • June 7 – Annual Golf Fore Health tournament, supporting the CT scanner • July 13 – Do It for Sarnia Block Party located in the Suncor Agora band shell at Centennial Park • October 11 (tentatively) – Gala, supporting Mammography unit at Bluewater Health
Resource Utilization and Audit Committee (RUAC)
May 10, 2018 Highlights
Facilities Quarterly Report The Committee received an update regarding the status of the 17-18 approved capital projects; HIRF (Health Infrastructure Renewal Funding) and HEEP (Hospital Energy Efficiency Program) projects underway at BWH including the CEEH Redevelopment Capital project. BWH has submitted its 2018-19 HIRF application to the Ministry for approval and the 2018-19 HEEP application will be submitted in June. Human Resources Quarterly Report The Committee received an update on the status of the union negotiations; pay equity; recruitment; and, Bill 148 - Employment Standards Act. The Committee was informed BWH continues to monitor absenteeism. The first phase of the staff scheduling software is almost complete and Phase 2 will be rolled out in the fall. Management Assessment Business/Financial Risk Report The Committee received an update on the management assessment and financial risks facing the hospital as of March 31, 2018 and the steps taken to mitigate any potential impact(s). Analysis of the Loans and Investments The Committee received an update on the status of the bank loans and Englehart estate investments. In addition, the following will be coming forward separately for Board approval: - Monthly Financial Statement - 2018-19 – Capital Budget - 2018-19 – Revised Operating Plan - Chief Financial Officer Certificate Submitted by: Marg Dragan Chair, Resource Utilization and Audit Committee
Statement of Revenue and ExpenseDRAFT surplus/(deficit) as at March 31, 2018(000's)
Deferred Building Grants 8,854 9,060 206 2%Building Amortization (10,405) (10,475) (71) 1%Interest on L/T Liabilities (168) (111) 56 -34%
Operating Surplus/(Deficit) $ (1,546) 567 2,142
Notes to DRAFT Financial StatementsMarch 31, 2018 Year-End Actual
Note 1
Note 2
Annual Budget Year-End Actual
$ 2,200,000 $ 2,697,279
$ 4,001,349 $ 3,555,075
$ 203,570 $ 203,203
$ 261,515
$ 6,404,919 $ 6,717,072
Note 3
Note 4
Note 5
Note 6
Note 7
Note 8
Note 9
Note 10
Note 11
Note 12
Note 13
Bluewater Health has a preliminary operating surplus of $2M for the 17/18 fiscal year which is higher than the February forecasted surplus of $1M. The improved performance is attributed to a funding injection from the LHIN to support the surge of patient activity that began in late December as well as a funding injection for QBPs that the hospital was performing above its initial allotment.
LHIN Revenue is $1.79M better than budget for year-end. This positive variance is primarily one-time funding for opening additional beds for surge capacity as well as additional QBP funding for hip and knee replacements that the hospital was performing. In addition, the hospital was notified in March that the Ministry would not be recovering funds related to prior year activity. This funding was recognized in the current month. The remaining positive variance is a result of funding for physicians for which there is an offsetting Medical Staff Remuneration expense.
Bluewater Health does OHIP billings for various physician groups. There is an offsetting Med Staff Remuneration expense for these billings. The YTD negative variance is primarily Nuclear Med and ECG.
Patient Revenue - Other is a combination of WSIB Revenue, Revenue from Other Provinces, Revenue from Non-Residents, and Revenue paid directly by Patients. The positive variance of $483K is comprised of Revenue from WSIB ($27K), Other Provinces ($308K), Non-Residents ($92K), and Self Pay Revenue ($56K).
Bluewater Health receives CCO funding for Oncology Drugs, QBPs, and the Ontario Breast Screening Program. Bluewater Health is not forecasting achieving all QBP funding for Cancer Surgeries and the Oncology program. There is also an overage in our drug expense related to CCO funded drugs. The hospital received the final reconciliation for 16/17 CCO QBP Funds and Cancer Surgery Agreement (CSA) funds. The hospital achieved more funding from 16/17 than what had been recognized in that fiscal year.
Net Marketed Services Surplus/(Deficit) is the net income earned on the hospital's non-core business. This includes the retail pharmacy and building rental income. The majority of this variance is a result of the retail pharmacy. There were some initial one time expenses related to the expansion of the retail pharmacy which impacted the surplus for 17/18.
Supplies and Expenses are over budget $668K at the end of the year. This negative variance is mainly due to software maintenance contracts, lab supplies, housekeeping supplies, and physician recruitment costs.
Room Differential revenue is better than budget by $182K. The majority of this positive variance is from the Rehab unit.
Utilities ended the year at $977K under budget. The budget for 17/18 was increased to align with the 16/17 actual utility expense with an anticipated increase in utilities. The current year spending is $400k less than prior year.
Salaries & benefits are over budget $487K at the end of the year. The hospital experienced a surge in patient activity that began late December. This increased activity put additional pressures on staffing resulting in the negative variance. The hospital received bed surge funding which mitigates this overage.
Med/Surg supplies are over budget by $413K at year-end. The negative variance is primarily attributed to the Operating Room which is performing additional QBP hip & knee replacements for which the hospital received additional funding. There is also a large variance in the ER which is attributed to the surge volumes.
The hospital receives an annual management fee as part of our investment with Lambton ProResp. The management fee received was higher than budgeted for the year.
Amortization expense is under budget by $372K at year-end. Not all approved capital items were purchased by the end of the fiscal year which supports this positive variance.
Drug Expense is over budget by $679K at year-end. The majority of this variance ($460K) pertains to the Oncology program and is aligned with the variance in CCO drug funding from Note 2 above. The remaining negative variance pertains to the Rehab, Acute Medicine, and Telemetry units.
DRAFT Balance SheetAs at March 31, 2018Comparison to March 31, 2017(000's)
Note: Current ratio excludes CEEH Site Investments
Adjusted Working Capital is calculated using the definition of the Working Capital Funding Initiative
Mar-18 Mar-17
2017/18 2016/17Actual Actual
1
Bluewater Health Briefing Note
Name of Committee: Board of Directors Date of Meeting: May 23, 2018 Submitted by: Marlene KerwinSubject: 2018-19 - Capital Budget Purpose of Report: Information Input Approval
Situation
Bluewater Health’s 2018-19 Capital Budget is due for review and recommendation to the Board of Directors for approval.
Background
The Capital Budgeting Process begins in October for the following fiscal year and is completed by March. Directors/Managers prepare submissions for their capital requests which are reviewed and approved by their respective Vice-President, before being considered by an internal Capital Budget Committee.
The Capital Budget Committee is composed of representatives from Finance, Bio-Medical, Transform (IT and Purchasing), Clinical & Clinical Support Directors, the Foundation, and a Patient Experience Partner. The Committee meets to discuss each capital submission and to determine the capital items that should be recommended to Executive Council and ultimately to the Board of Directors for approval.
Analysis
Much of the capital that was purchased as part of the new building project is reaching end of life. As such, Bluewater Health is seeing an increase in capital requests. The Facilities Department has also been conducting meetings with individual programs to determine their strategic needs in the development of a five-year capital plan. This in-depth planning, coupled with the aging medical equipment, brought forward an increase in capital requests for the year. The total capital requests for the 2018-19 fiscal year were $18.1 million. This includes $441,000 of projects for which there will be offsetting HIRF (Hospital Infrastructure Renewal Funding) funding. The Foundation will also provide capital funding of approximately $1.9 million for the 2018-19 fiscal year.
After much scrutiny and analysis, the Committee is recommending the approval of $7,484,283 in total capital expenditures for 2018-19. Included in this total is $500,000 for contingency items as well as $450,000 towards new ultrasound machines that will be purchased at the start of the 2019-20 fiscal year. The much needed ultrasound machines will be purchased over 2018-19 and 2019-20 using a single competitive procurement process.
x
2
The Capital Budget Committee has categorized and prioritized the capital requests submitted using a ranking system, and has recommended the 2018-19 Capital Budget provided below:
Description Amount Mammography Equipment $900,000 Ultrasound Machines $900,000 Urology Suite $650,000 Digital Radiography CEEH Site $270,000 New Investment (Pharmacy Automation, Bariatric Equip, etc.) $690,991 IT Hardware $235,000 Replacement of Medical Equipment (Beds, Monitors, etc.) $2,578,275 Replacement of Non-Medical Equipment $268,500 Building Renovations $50,000 Chillers (HIRF Recommended Project) $441,517 Contingency $500,000 Total Recommended Capital Budget for the 2018/19 Fiscal Year
$7,484,283
Executive Council has also reviewed and endorsed the recommended 2018-19 Capital Budget.
Recommendation The Resource Utilization and Audit Committee recommends the Board approval the 2018-19 Capital Budget as presented.
1
Bluewater Health Briefing Note
Name of Committee: Board of DirectorsDate of Meeting: May 23, 2018Submitted by: Marlene Kerwin Subject: Revised 2018-19 - Operating Plan Purpose of Report: Information Input Approval
Situation
Bluewater Health submitted a preliminary Expenditure Plan to the Resource Utilization and Audit Committee in January 2018. At that time, Ministry funding was not confirmed and the hospital was unable to determine the impact of Bill 148 on hospital operations. The hospital has since received 2018-19 funding information as well as more information regarding the impact of Bill 148. As such, a revised Operating Plan for 2018-19 with this new information requires Board approval.
Background
The preliminary Expenditure Plan brought forward to the Committee showed Bluewater Health with a planned deficit of approximately $2.8 million for the 2018-19 fiscal year. This preliminary deficit did not incorporate any additional expenses pertaining to Bill 148. The Expenditure Plan did not incorporate final funding information.
These adjustments and other minor revisions have now been incorporated and the hospital is proposing a revised 2018-19 Operating Plan with a deficit of approximately $921,000.
Analysis/Considerations
The revised Operating Plan is attached in Appendix A. The summary of changes is outlined in the below table:
Preliminary Operating Deficit $(2,767,163) Net New Ministry Funding $2,722,361 Anticipated Reduction of CCO Funding (Cancer Surgery QBPs) $(332,000) Anticipated Increase in Expense related to Bill 148 $(700,000) Other Net Revisions to Operating Plan based on 2017-18 Actual Results $156,056
Revised Operating Deficit for 2018-19 $(920,746)
Recommendation
The Resource Utilization and Audit Committee recommends the 2018-19 Operating Plan to the Board for approval.
17/18 Annual Budget 17/18 Year-End 18/19 Preliminary Expenditure Plan
Revised 18/19 Expenditure Plan
Projected Variance from
17/18 YE Actual
1
Bluewater Health Briefing Note
Name of Committee: Board of Directors Date of Meeting: May 23, 2018 Submitted by: Paula Reaume-Zimmer Subject: Community Accountability Planning Submission (CAPS) Purpose of Report: Information Input Approval
Situation CAPS reporting applies to Fund 2 programs of the Mental Health and Addictions Services, which includes: Assertive Community Treatment (ACT), Substance Abuse, Withdrawal Management Services and Residential Withdrawal Management Services, Psychiatric Assessment Nurse (PAN), and Community Treatment Order Coordinator (CTO).
BWH was required to post a draft CAPS by May 11, 2018 for the ESC LHIN to review. At this time, BWH has not received any further request for edits. The CAPS now requires BWH Board approval to proceed to the ESC LHIN June Board meeting.
Background For the past four months, BWH has been participating in a Fund 2 CAPS review along with partners in ESC LHIN. This review has included a program by program review and comparison amongst peer programs throughout the LHIN. The completed CAPS is a result of these efforts.
Analysis Key changes to 2018-19 CAPS compared to previous year’s submissions:
• Administrative salaries were included in unique programs i.e. ACT, Substance Abuse.This is now consolidated into the administrative budget.
• Residential Withdrawal Management Services (RWMS) has been added to the budget.Since the RWMS Program has only been in operation for two and a half months of the 2017-18 fiscal year, it is difficult to forecast. The assumptions used for WMS activity is an occupancy of 71% (five of seven beds) with an average length of stay of approximately four days. A full year of operations will allow for a more accurate annual forecast.
Recommendation The Board of Directors approves the CAPS as presented.
Note: Program 3029/CMHP1 includes ACT, Crisis Intervention, Community Treatment Order,Child & Youth Mental Health ,BSO, Eating Disorders & sessional feesProgram 3029/CMHP1 Medical Remuneration includes $45,490 paid out to Chatham KentProgram 3074 / SAP includes Addictions,Community Withdrawal Management and Withdrawal Management ResidentialProgram 8301/PG includes Problem GamblingProgram 3029/POMS represents Psychiatric Outpatient Salaries
Program 3029/POMSAnnual Operating Budget
18/19 Program 3029/CMHP 1 Program 3074/SAP Program 8301/PG
Cost per Weighted Case (Actual YTD)ER Outpatient (12% of overall activity)
Q1/Q2 17/18
10.1
8.1
9.3
9.6
9.0
9.7
8.0
8.9
9.8
9.4
10.0
8.8
11.2
9.6
8.4
4.1
3.9
4.3
4.4
3.9
4.0
4.1
4.7
4.0
5.0
3.7
3.8
4.6
4.2
3.7
0
2
4
6
8
10
12
Jan17
Feb 17
Mar 17
Apr17
May17
Jun17
Jul17
Aug17
Sep17
Oct17
Nov17
Dec17
Jan18
Feb18
Mar18
90th Percentile ED Length of Stay for Complex Patients
Sarnia Petrolia Peer Comparator BWH Target
27.2
19.9
24.9
26.5
23.9
27.6
16.6
20.9
25.1
27.0
28.2
25.7
29.9
27.9
26.0
7.5
7.7
7.3
7.2 7.9 8.8
7.3
6.9 8.4
13.8
10.1
7.0 7.8 10.2
7.7
BWH Target
Peer Comparator
05
101520253035
Jan17
Feb 17
Mar 17
Apr17
May17
Jun17
Jul17
Aug17
Sep17
Oct17
Nov17
Dec17
Jan18
Feb18
Mar18
90th Percentile ED Wait Times (Admitted Patients)
Sarnia Petrolia
Bluewater Health Target
0.00
0.50
1.00
1.50
2.00
2.50
3.00
3.50
4.00
Q4 16/17 Q1 17/18 Q2 17/18 Q3 17/18 Q4 17/18
Absenteeism Rate - (avg # 7.5hr sick days) All Staff
1
Medical Advisory Committee (MAC) Highlights May 16, 2018
Quality Improvement Initiatives MAC:
• Approved recommendations from the Pharmacy and Therapeutics Committee, the Infection and Prevention Control Committee and the Order Sets Committee
• Approved an Ethics Framework Policy and the Terms of Reference for the Ethics & Research Committee
• Received an update and approved changes to the QPEC scorecard indicators for 2018/19
• Shared progress updates on departmental Program Quality Indicators • Received an update on the patient flow initiative • Discussed the PICC line services being offered at Bluewater Health • Discussed ways palliative care consults can be made available to all patients
who could benefit • Received a budget update
Physician Education, Development and Engagement
• Members were encouraged to enroll in Physician Leadership Institute courses • Members received an update on the results of the NRC Health Physician Survey • Discussed ways to support physician wellness and health initiatives • Discussed upcoming events:
o Professional Staff Association Annual Meeting – June 4, 2018 o Bluewater Health Annual General Meeting – June 27, 2018 o Summer Social Event at Dr. Haddad’s house – June 28, 2018 o Physician Family BBQ – July 29, 2018 o Physician Leadership Institute Course to be provided in the fall – topic to
be determined Recruitment/Succession Planning
• Discussed departmental succession planning for leadership positions • Encouraged members to apply for Professional Staff Association executive
positions • A new Internist and Hospitalist have recently signed on and recruitment efforts
continue for emergency, neurology, plastic surgery and hospitalist positions. • Learned that the Ministry of Health and Long-Term Care and the LHIN have
shown support for the geriatrician business case that was submitted.
Submitted by: Mike Haddad, MD, Chief of Professional Staff
Quality Committee of the Board Highlights May 14, 2018
Program Report: Rural Health and Inpatient Medicine, Director Bob DeRaad, CEEH Nurse Practitioner Marcel Blais
Successes: reconfiguration of number of beds for Medicine A and G; introduction of the Nurse Practitioner role at CEEH; Medication Reconciliation at admission on all units at both sites is in the 90 to 100% range
Challenge: Sarnia site continues to see a high number of falls; Petrolia site is seeing a significant increase in patients requiring Palliative Care
Next Steps: Sarnia site will continue to work on strategies for falls reduction this includes continuing with the five year plan of switching out regular hospital beds for alarmed beds – currently, in year three; Petrolia site will continue with providing Palliative Care training for staff and planned renovations to create at least one dedicated room for Palliative Patients and their families
Workplace Violence Update, Director Quality & Patient Experience and Interprofessional Practice, Dave Remy a review of what workplace violence is took place BWH policies that support prevention of violence will be available in one central location education is being developed and will be customized based upon risk level a slogan ‘No Excuse for Abuse’ was chosen by the Committee and signage will be throughout both
sites in June reporting is being developed with a focus on ease of use for staff ED Quality Revisit Program Report, Nadine Neve, Manager of Emergency Services a regular review of ED return visits occurs to determine opportunities for improvement (particularly
for individuals who have returned within 72 hours) January to April 2018 - 40 audits have been completed at Sarnia site and 15 audits at Petrolia site;
zero sentinel events have occurred a number of successes have been achieved as well as themes noted and next steps identified (see
presentation for details); challenges include: illegible hand writing on patient charts, missing chart information and orientation of new grads
Personal Health Information Protection Act (PHIPA), Freedom of Information and protection of Privacy Act (FIPPA) Compliance Report, Karelyn van Wynen, Manager Health Records, Patient Registration and Interim Privacy Officer, shared the 2017 IPC Year End Statistical Report for the Information & Privacy Commissioner of Ontario. Monitor Ethical Framework outcomes and related policies Shannon Landry shared the new Ethics policy developed and approved by the Ethics and Research Committee. The policy provides the background, vision, philosophy, decision making approach, ethical framework and an SBAR worksheet that walks individuals through a series of questions from an ethical perspective. The policy has been reviewed and approved by the Quality and Patient Experience Committee. It will be going to the Medical Advisory Council and then will be brought to the Board. This preparation is key for accreditation in 2019. Submitted by: Paul Wiersma
YTD is Top Box Responses for all sectors, Q3 reporting period n=1650.0%
Bluewater Health Quality Committee
Performance Scorecard
77.5
SPApr -
Mar
Build sustainable partnerships and collaborations
QIP/
HSAA/
P4R
30-Day Mental Health Readmission
Focus on the experience of care and caring
Difficult to speak up if perceive a problem
with patient care
Medication Reconciliation at Discharge
Q4 16/17
490th Percentile ED Length of
Stay for Complex Patients
9
Performance Indicator Ref.
Ingrain patient safety
Improve access to care
#
Pe
er
Co
mp
ara
tor
BW
H
Ta
rge
t
Total High Severity Patient Safety Incidents
Overall Rating of Experience
60.1
11
Readmission within 30 days for COPD
Was Patient/Family Treated
with Kindness
Is a Culture of Kindness Promoted at BWH
Supervisor helps access training and
development
8
Leaving hospital did patients
receive enough information
QIP
Up
da
ted
Comments
0
Q3 17/18 Q4 17/18
5
YTD Performance
41.9
Q2 17/18
43.0
2
49.4
Quality Care - Assure the right care, in the right place, at the right time, by the right provider
19.2
ALC Rate % -All Inpatient Services
(Sarnia and Petrolia)
13.0
18.8
QIP
64.2 0.00
Strengthen Patient and Family-Centred Care
10.1
hrs
Q1 17/18
73.168.2
15.4 19.2
69.1
0 0
<=8
hrs
Apr -
Mar
Apr -
Mar
Jan-
Dec
12.0 8.4
21.6
May 2018 with March data
n size: 44 n size: 44
n size: 54 n size: 53
Overall Rating of Experience
Emergency Department
BWH Target
49.1%BWH Target
61.6%
BWH Target
49.1%
Overall Rating of Experience
Inpatient Units
BWH Target
75.9%
52.3%
68.5%
Received Enough
Information Inpatient
BWH Target
81.0%
77.3%
21.0%
June data unavailable
province-wide due to daily
bed census summary
methodology changes
Exceptional Relationships - Expand innovative partnerships and collaborations to improve experiences, services, transitions and community
Build sustainable partnerships and collaborations
Strengthen Patient and Family-Centered Care
Quality Committee Key Performance Indicators
Inspired People - Advance our culture of kindness with an intention to learn, lead, collaborate and celebrate
Focus on the experience of care and caring
Target
49.6%
Quality Care - Assure the right care, in the right place, at the right time, by the right provider
Ingrain patient safety
Difficult to speak up if perceive a
problem with Patient Care
YTD n size: 432
Received Enough
Information Emergency
Improve access to care
Is a Culture of Kindness Promoted at Bluewater Health
Target:
N/A
YTD n size: 432
97 97 9795 97 97 97 96 96 98 98 97 97 97 97
60
70
80
90
100
JAN
17
FEB
17
MAR
17
APR
17
MAY
17
JUN
17
JUL
17
AUG
17
SEP
17
OCT
17
NOV
17
DEC
17
JAN
18
FEB
18
MAR
18
Medication Reconciliation at Discharge
0
5
2
0
0
0 1 2 3 4 5 6
Q4 16/17
Q1 17/18
Q2 17/18
Q3 17/18
Q4 17/18
Total High Severity Incidents
18.4
17.2
18.5
16.7
17.8
0.0
21.5
17.2
17.7
18.6
14.8
15.7
16.9
15.7
0.0
5.0
10.0
15.0
20.0
25.0
Jan17
Feb 17
Mar 17
Apr17
May17
Jun17
Jul17
Aug17
Sep17
Oct17
Nov17
Dec17
Jan18
Feb18
ALC Rate % - All Inpatient Services (Sarnia & Petrolia)
ALC Rate Provincial Target BWH Target
0.0
20.0
40.0
60.0
80.0
100.0
Jan17
Feb 17
Mar 17
Apr17
May17
Jun17
Jul17
Aug17
Sep17
Oct17
Nov17
Dec17
Jan18
Feb18
Overall Rating of Experience
ED Inpatient ED Target IP Target
0.0
20.0
40.0
60.0
80.0
100.0
Jan17
Feb 17
Mar 17
Apr17
May17
Jun17
Jul17
Aug17
Sep17
Oct17
Nov17
Dec17
Jan18
Feb18
Leaving Hospital did Patients Receive Enough Information
ED Inpatient BWH ED Target BWH IP Target
68.9
66.7
69.5
66.7
62.9
57.7
73.0
70.4
71.2
55.8
68.4
69.8
81.8
59.1
75.9
73.4
88.3
81.4
81.8
71.4
81.7
85.7
82.1
84.0
73.9
81.4
67.8
65.5
0.0
20.0
40.0
60.0
80.0
100.0
Jan17
Feb 17
Mar 17
Apr17
May17
Jun17
Jul17
Aug17
Sep17
Oct17
Nov17
Dec17
Jan18
Feb18
Was Patient/Family Treated with Kindness
ED Inpatient BWH ED Target BWH IP Target
74.3%
46.9%
10.1
8.1
9.3
9.6
9.0
9.7
8.0
8.9
9.8
9.4
10.0
8.8
10.7
9.6
4.1
3.9
4.3
4.4
3.9
4.0
4.1
4.7
4.0
5.0
3.7
3.8
4.6
4.2
0
2
4
6
8
10
12
Jan17
Feb 17
Mar 17
Apr17
May17
Jun17
Jul17
Aug17
Sep17
Oct17
Nov17
Dec17
Jan18
Feb18
90th Percentile ED Length of Stay for Complex Patients
Sarnia Petrolia Peer Comparator BWH Target
The Foundation held its first Partnership Celebration on March 26 to recognize contributions from local businesses, corporations, service groups and third party event committees. Approximately 80 people attended the event at the St. Clair Corporate Centre for hors d’oeuvres and cocktails provided by Grind Catering and had the opportunity to mingle and network with board members, senior leaders, and other supporters. This event provided a great opportunity to provide information about hospital initiatives and future sponsorship opportunities in an informal atmosphere. Thank you to the senior leaders and board members who attended, and the Donor Stewardship and Planned Giving Committee who organized the event.
Also coordinated by the Donor Stewardship and Planned Giving Committee was our semi-annual Speaker’s Series on April 18 which focused on Withdrawal Management. Presentations were made by Paula Reaume-Zimmer, Integrated Vice-President, Mental Health & Addictions, and Josh Klaver, Community Withdrawal Management Worker. There was also a meet and greet with some of the executive leadership team and an opportunity for each of them to speak for a few minutes about their role with the organization. There was a good turnout and lots of good questions posed by the audience.
Congratulations to Foundation board member Dan Edwards who won a Bluewater Health Bridging Excellence Award for his volunteerism and commitment to mental health both at the hospital and in the Sarnia-Lambton community. Members of the Foundation team were so very proud to attend with Dan and see him recognized for all of his efforts!
The PAIRS trivia challenge took place on April 27 and was a sold out event again this year. $30,000 in proceeds will be shared between Bluewater Health Foundation and St. Joseph’s Hospice for palliative care in the community.
The annual Memorial Wall Service was held on May 2 for families of loved ones whom memorial donations were made in honour of in 2017. These services are very well attended every year and families continue to provide feedback to us about how pleased they are that we honour their loved ones in such a way.
The Hoedown for Healthcare raised over $7,000 for rural health on May 11. The committee, made up of CEEH Foundation board members, Petrolia community members, and Bluewater Health Foundation staff, worked very hard to sell tickets and execute this event. A huge thank you to the Petrolia Lions, who were a tremendous help with set up, coordinating the food, working the bar and clean up.
A mail appeal went out in early May to donors and those who have visited the Mammography Department in the last year. This appeal features a patient story, a description of the need for our current equipment to be upgraded, and information about the innovative features of the new mammography equipment that will be purchased. In its first two weeks, the appeal has raised over $3,000 in generous donations from the community!
Respectfully submitted,
Adelle StewardsonMarketing & Fund Development Coordinator
Executive Director Report May 2018
1
Governance and Nominating Committee Highlights
May 9, 2018
Accreditation Update The Committee reviewed the Self-Assessment Report from Accreditation Canada and the action plan created to address any gaps. Work is underway to ensure compliance prior to Accreditation. Board education regarding the Accreditation process will begin in the fall to align with orientation and onboarding. Board Evaluation The Committee reviewed the OHA GCE Governance Practices and Policies Checklist and recommended the document be distributed to Board Directors with the Board Self-Assessment Tool Survey, to educate them prior to completing the survey. Policy improvement opportunities identified through the checklist will be considered. The Committee also reviewed the positive Board Meeting Effectiveness results from the April Board meeting, discussed Board attendance and education records, made a recommendation to revise the scale for the Board Committee and Individual Director Surveys, and reviewed the various Board survey tools and optimal timing for the surveys. Board Education/Orientation/Team Building A draft template to assist members with reporting to the Board following an education session was reviewed and approved by the Committee. It was suggested members be required to report to the Board/Committee following any education session, and the Board Development and Education Policy be amended to include this requirement. A recommendation was also made to combine this policy with the Board Orientation policy. In regards to the Board education schedule, it was noted the Board tour planned for May has been cancelled since the Board meeting will be held in Petrolia, and the Surgery Program report to the Quality Committee has been cancelled due to staff availability. Annual General Meeting (AGM) The timing and venue for the AGM was discussed. The In-Camera meeting will begin at 3:00 pm, followed by the Open Session at 4:00 pm and the AGM at 5:00 pm. The meeting will also include the Board’s first Indigenous Territory Acknowledgement. There was also discussion about the annual Board Chair and CEO reports. The Board Chair report will include an overview of the Board Goals and progress made to date, and the CEO Report/Strategic Plan Progress Report will include an overview of BWH’s annual collaborations vs. the stand-alone report of collaborations completed last year. Board Policies The Committee recommended the appointment requirements in the Roles and Responsibilities of an Elected and Ex-Officio Director Policy be revised to align with the Nominations Process policy. Additional Board policy revisions will follow as the Board prepares for Accreditation. Submitted by: Brian Knott
Resource Utilization & Audit Committee Indicator Definitions and Graphs
Performance Indicator
Quality Care – Assure the right care, in the right place, at the right time, by the right provider
Improve access to care
1 90th Percentile ED Length of Stay for Complex Patients Sarnia
Petrolia
2 90th Percentile ED Length of Stay (Admitted Patients) Sarnia
Petrolia
Exceptional Relationships – Expand innovative partnerships and collaborations to improve experiences, services, transitions and community health
Outstanding Performance – Optimize roles, resources, revenues, technology and innovation
Demonstrate accountability and efficiency
5 Cost per Weighted Case: Acute Inpatient & Day Surgery (53% of overall activity) Actual YTD
6 Cost per Weighted Case: ED Outpatient (12% of overall activity) Actual YTD
7 Cost per Weighted Case: Rehab Inpatient (4% of overall activity) Actual YTD
8 Continuing Care Cost per Patient Day Actual YTD
9 Mental Health Cost per Patient Day Actual YTD
10 QBP Financial Exposure (Potential lost revenue related to QBP achievement) Actual YTD
11 Surplus/(Deficit) in 000s Actual YTD
Ensure continuous investment in strategic infrastructure
12 Adjusted Working Capital (in 000s) Actual YTD
13 % of Capital Budget Spent Actual YTD
Revised: March 2018 Next Update: June 2018 Page 2 of 14
Indicator Name: 90th Percentile Emergency Department (ED) Length of Stay (LOS) for Complex Patients
Alignment: Quality and Patient Experience Committee (QPEC)/Quality Committee of the Board (QCB)/Performance & Utilization Committee (PUC)/Resource Utilization & Audit Committee (RUAC)
Strategic Goal: Improve access to care
Definition: The total ED length of stay where 9 out of 10 complex patients completed their visits. ED Length of Stay defined as the time from triage or registration, whichever comes first, to the time the patient leaves the ED.
Rationale:
Additional Specifications:
Peer Comparator: Ontario high-volume community hospitals, Sarnia Site only
Definition: ED length of stay for admitted visits is defined as the time from triage or registration, whichever comes first, to the time the patient leaves the ED to an inpatient bed. It is measured in hours. The 90th percentile is the maximum length of time in which 9 of 10 of admitted patients have completed their ED visit and have been moved to an inpatient unit. A small number is desirable.
Rationale: Time is crucial to the effectiveness and outcome of patient care, especially for emergency patients. In conjunction with other indicators, this can be used to monitor the total length of time admitted patients spend in the ED in an effort to improve the efficiency and, ultimately, the outcome of patient care. This measure remains one of Bluewater Health’s top priorities in our Quality Improvement Plan (QIP) and Strategic Plan.
Additional Specifications:
Inclusions:
1. Admitted unscheduled emergency visits 2. ED visits with a valid and known registration date/time or triage date/time
and a valid and known date/time the patient left the ED
Exclusions:
1. Scheduled emergency visits 2. Non-admitted unscheduled emergency visits 3. Visits with both unknown/invalid registration and triage date/time OR with
unknown/invalid patient left ED date/time
Peer Comparator: Ontario high-volume community hospitals, Sarnia Site only
Revised: March 2018 Next Update: June 2018 Page 4 of 14
Indicator Name: Alternate Level of Care (ALC) Rate %-All Inpatient Services
Alignment: Quality and Patient Experience Committee (QPEC), Quality Committee of the Board (QCB), Performance & Utilization Committee (PUC), Resource Utilization & Audit Committee (RUAC)
Strategic Goal: Build sustainable partnerships and collaborations
Definition: The rate at which patients who have been designated ALC occupy inpatient beds.
Rationale: Ensuring that each patient receives the appropriate level of care at all times during their healthcare journey is a priority at Bluewater Health. Our goal is for Emily to receive the right care, given at the right time, in the right place, always. The ALC rate represents an opportunity for inpatients to be transitioned to the next level of care, where their care needs and the services provided are better matched. Multiple factors can influence ALC rate, including overall hospital occupancy, and availability of resources both internal and external to the hospital.
Additional Specifications:
ALC Rate = Total number of ALC Days in a given period
Total number of inpatient days in the same time period ×100%
Revised: March 2018 Next Update: June 2018 Page 6 of 14
Indicator Name: Acute Cost per Weighted Case
Alignment: Resource Utilization and Audit Committee (RUAC)/Performance Utilization Committee (PUC)
Strategic Goal: Demonstrate accountability and efficiency
Definition: Acute Cost per Weighted Case is an indicator that measures the cost associated with caring for a standard acute patient. It is calculated as total acute inpatient and newborn expenses (both direct and indirect) divided by acute inpatient weighted cases. The direct costs are the expenses incurred in the departments providing service to our acute patients (e.g., Medicine, Surgery, and Obstetrics). The indirect costs are an allocation of Administration and Support expenses (e.g., Housekeeping, Lab, Pharmacy, etc.). A weighted case is a case with an assigned Resource Intensity Weight (RIW).
Rationale: This is an important indicator as it tracks how an organization is utilizing its resources. It combines the financial spending with the activity that drives the spending. By focusing on weighted cases, comparability is enhanced as differences in acuity, severity and complexity of cases are taken into consideration.
Additional Specifications:
Peer Comparator: No established peer comparator data
Cost per Weighted Case: Acute Inpatient & Day Surgery (53% of overall activity)
Pre
ferr
ed
Tre
nd
ing
Our StatusOur Status
Revised: March 2018 Next Update: June 2018 Page 6 of 14
Indicator Name: Emergency Department (ED) Outpatient Cost per Weighted Case
Alignment: Resource Utilization and Audit Committee (RUAC)/Performance Utilization Committee (PUC)
Strategic Goal: Demonstrate accountability and efficiency
Definition: ED Outpatient Cost per Weighted Case is an indicator that measures the cost associated with caring for a standard Emergency department patient. It is calculated as total emergency department expenses (both direct and indirect) divided by ED outpatient weighted cases. The direct costs are the expenses incurred in the departments providing service to our ED patients (both Sarnia & Petrolia sites). The indirect costs are an allocation of Administration and Support expenses (e.g., Housekeeping, Lab, Pharmacy, etc). A weighted case is a case with an assigned Resource Intensity Weight (RIW).
Rationale: This is an important indicator as it tracks how an organization is utilizing its resources. It combines the financial spending with the activity that drives the spending. By focusing on weighted cases, comparability is enhanced as differences in acuity, severity and complexity of cases are taken into consideration.
Additional Specifications:
Peer Comparator: No established peer comparator data
Cost per Weighted Case: ER Outpatient (12% of overall activity)
Pre
ferr
ed
Tre
nd
ing
Our Status
Our Status
Revised: March 2018 Next Update: June 2018 Page 8 of 14
Indicator Name: Rehab Cost per Weighted Case
Alignment: Resource Utilization and Audit Committee (RUAC)/Performance Utilization Committee (PUC)
Strategic Goal: Demonstrate accountability and efficiency
Definition: Rehab Inpatient Cost per Weighted Case is an indicator that measures the costs associated with caring for a standard rehab patient. It is calculated as total inpatient rehab expenses (both direct and indirect) divided by rehab weighted cases. The direct costs are the expenses incurred in the departments providing service to our rehab inpatients. The indirect costs are an allocation of Administration and Support expenses (e.g., Housekeeping, Lab, Pharmacy, etc.). A rehab weighted case is a case assigned a relative weight using the rehabilitation patient grouper (RPG).
Rationale: This is an important indicator as it tracks how an organization is utilizing its resources. It combines the financial spending with the activity that drives the spending. By focusing on weighted patient days, comparability is enhanced as differences in acuity, severity and complexity of cases are taken into consideration.
Additional Specifications:
Peer Comparator: No established peer comparator data
Cost per Weighted Case: Rehab Inpatient(4% of overall activity)
Pre
ferr
ed
Tre
nd
ing
Our Status
Our StatusOur Status
Revised: March 2018 Next Update: June 2018 Page 9 of 14
Indicator Name: Continuing Care Cost per Weighted Patient Day
Alignment: Resource Utilization and Audit Committee (RUAC)/Performance Utilization Committee (PUC)
Strategic Goal: Demonstrate accountability and efficiency
Definition: Continuing Care Inpatient Cost per Weighted Patient Day is an indicator that measures the costs of providing inpatient care to complex continuing care patients, and is stated on a weighted patient day basis. It is calculated as total inpatient continuing care expenses (both direct and indirect) divided by total RUG weighted patient days (RWPDs). The direct costs are the expenses incurred in the departments providing service to our continuing care inpatients. The indirect costs are an allocation of Administration and Support expenses (e.g., Housekeeping, Lab, Pharmacy, etc.). RWPDs are patient days weighted using an appropriate cost weight (CMI). The CMI is a cost weight reflecting the relative resource use of an individual within a specific RUG group compared with the overall average resource use for all Ontario complex continuing care residents.
Rationale: This is an important indicator as it tracks how an organization is utilizing its resources. It combines the financial spending with the activity that drives the spending. By focusing on weighted patient days, comparability is enhanced as differences in acuity, severity and complexity of cases are taken into consideration.
Additional Specifications:
This indicator is also referred to as Cost per RUG weighted patient day (RWPD) where RUG stands for Resource Utilization Group.
Peer Comparator: No established peer comparator data
Revised: March 2018 Next Update: June 2018 Page 10 of 14
Indicator Name: Mental Health Inpatient Cost per Patient Day
Alignment: Resource Utilization and Audit Committee (RUAC)/Performance Utilization Committee (PUC)
Strategic Goal: Demonstrate accountability and efficiency
Definition: Mental Health Inpatient Cost per Patient Day is an indicator that measures the cost associated with caring for a Mental Health inpatient. It is calculated as total inpatient mental health departmental expenses divided by total inpatient mental health patient days.
Revised: March 2018 Next Update: June 2018 Page 11 of 14
Indicator Name: Quality Based Procedure (QBP) Financial Exposure (Potential lost revenue related to QBP achievement)
Alignment: Resource Utilization and Audit Committee (RUAC)/Performance Utilization Committee (PUC)
Strategic Goal: Demonstrate accountability and efficiency
Definition: Represents the potential lost revenue associated with under achievement of QBP funded volumes for both Ministry funded and CCO funded quality based procedures.
Rationale: The intent is that the hospital will achieve all anticipated volumes and not have to return any QBP funding to the Ministry and/or CCO.
Additional Specifications:
Peer Comparator: No established peer comparator data
QBP Financial Exposure (Potential lost revenue related to QBP achievement)
Pre
ferre
d T
ren
din
g
Our Status
Our StatusOur StatusOur StatusOur Status
Revised: March 2018 Next Update: June 2018 Page 12 of 14
Indicator Name: Surplus/(Deficit) in 000s
Alignment: Resource Utilization and Audit Committee (RUAC)/Performance Utilization Committee (PUC)
Strategic Goal: Demonstrate accountability and efficiency
Definition: The amount of operating revenue in excess of operating expense from regular hospital operations. This amount excludes building amortization, building deferred grants/donations and interest on long-term liabilities.
Rationale: The hospital compares its actual results to the Board approved budget. The hospital plans for a surplus each year.
Revised: March 2018 Next Update: June 2018 Page 13 of 14
Indicator Name: Adjusted Working Capital (in 000s)
Alignment: Resource Utilization and Audit Committee (RUAC)/Performance Utilization Committee (PUC)
Strategic Goal: Ensure continuous investment in strategic infrastructure
Definition: Adjusted Working Capital is calculated as the hospital’s total current assets less current liabilities from its balance sheet. This definition is then adjusted per Ministry direction to exclude current liabilities such as vacation accrual, etc. and to exclude any externally restricted current assets/liabilities.
Rationale: Adjusted working capital is a critical indicator to evaluate the hospital’s financial outlook. A strong working capital position indicates a readiness for potential capital investment.
Revised: March 2018 Next Update: June 2018 Page 14 of 14
Indicator Name: Percentage of Capital Budget Spent
Alignment: Resource Utilization and Audit Committee (RUAC)/Performance Utilization Committee (PUC)
Strategic Goal: Ensure continuous investment in strategic infrastructure
Definition: Capital purchases made during the time period as a percentage of the overall capital budget for that period. The overall budget includes a budget for contingency items. If capital items are carried over from a previous year, the capital budget associated with those carry over items will also be included in the denominator for this indicator.
Rationale:
Additional Specifications:
Peer Comparator: No established peer comparator data
9 Leaving hospital did Patient receive enough information
Inspired People – Advance our culture of kindness with an intention to learn, lead, collaborate and celebrate
Focus on the experience of care and caring
10 Supervisor helps access training and development
11 Was Patient/Family Treated with Kindness
12 Is a Culture of Kindness Promoted at Bluewater Health
Employees
Professional Staff
Volunteer
Revised: March 2018 Next Update: June 2018 Page 2 of 13
Indicator Name: Medication Reconciliation at Discharge
Alignment: Quality and Patient Experience Committee (QPEC)/Quality Committee of the Board (QCB)
Strategic Goal: Ingrain patient safety
Definition: Total percentage of patients for whom Discharge Medication Reconciliation was finalized as a proportion of the total number of patients discharged from the hospital.
Rationale: Hospital discharge is a critical interface of care where patients are at a high risk of medication discrepancies as they transition out of the hospital. The goal of discharge medication reconciliation is to reconcile the medications the patient is taking prior to admission and those initiated in hospital, with the medications they should be taking post-discharge to ensure all changes are intentional and that discrepancies are resolved prior to discharge. This should result in avoidance of therapeutic duplications, omissions, unnecessary medications and confusion.
Additional Specifications:
Exclusions: 1. Mothers delivered and Newborns, including Newborn Repatriations 2. Patients with Meditech Discharge Dispositions:
I. Expired II. Triaged/Reg'd/Left Against Medical Advice (AMA)
III. Site to Site (CEEH to Sarnia or vice versa) IV. Signed Medical Release V. Transfer
VI. Transfer to another Acute Care Facility VII. Transfer to an Ambulatory Care Clinic
Peer Comparator: No peer comparator data available
Revised: March 2018 Next Update: June 2018 Page 3 of 13
Indicator Name: It is difficult to speak up if perceive a problem with patient care
Alignment: Quality and Patient Experience Committee (QPEC)/Quality Committee of the Board (QCB)
Strategic Goal: Ingrain Patient Safety
Definition: This is a custom employee survey question that asks employees to respond to the statement “in this unit it is difficult to speak up if I perceive a problem with patient care”. The top box responses request respondents to “strongly disagree” and “disagree” with the proposed statement. A higher percentage of employees disagreeing or strongly disagreeing with this statement is preferred.
Rationale: “It is difficult to speak up if I perceive a problem with patient care” is a measure that comes from a reliable and valid survey through patient safety research. To ensure we can track and measure this indicator we will assess a baseline and target by sending staff surveys thorough a Survey Monkey process. This indicator is a measure indicative of patient safety culture throughout the organization and will identify how safe the inter-professional team feels to report patient safety incidents. The development, dissemination, education and implementation of a Quality and Patient Safety Plan will enable a culture of safety by enhancing knowledge transfer of the importance of reporting patient safety incidents to improve quality and safety of the patients we serve.
Additional Specifications:
This indicator was released in December 2016. Responses to this question are collected routinely in a Strategic Engagement survey.
Target for 17/18: 49.6%
Bluewater Health Target 49.6%
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Difficult to Speak up if Perceive a Problem with Patient Care
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Revised: March 2018 Next Update: June 2018 Page 4 of 13
Indicator Name: Total High Severity Patient Safety Incidents
Alignment: Quality and Patient Experience Committee (QPEC)/Quality Committee of the Board (QCB)
Strategic Goal: Ingrain patient safety
Definition: This measure tracks the total number of patient safety incidents categorized as Level 4 or Level 5. An example of a Level 4 patient safety incident is a fall in which the patient falls and sustains a fractured hip requiring surgical repair.
Rationale: A patient safety incident is an event or circumstance that could have resulted, or did result, in unnecessary harm to a patient. Bluewater Health FY17/18 Target for Total High Severity Patient Safety Incidents is set 0, “as zero patient harm is an indisputable goal that must be a priority for all stakeholders. It is the right thing to do for patients and families.” (Cochrane et. al. 2017, p.66) In compliance with the Public Hospital’s Act, there is an obligation of hospitals to report critical incidents to the Quality Committee of the Board.
Additional Specifications:
On September 6, 2017, Bluewater Health implemented a new incident reporting system RL6. With the implementation of the new incident reporting software the severity levels have been amended to reflect the updated guidelines set by the Ontario Hospital Association (OHA). Level 4 - Patient outcome is symptomatic, requiring life-saving intervention or
major surgical/medical intervention, shortening life expectancy or causing major permanent or long-term harm or loss of function.
Level 5 - On balance of probabilities, death was caused or brought forward in the short-term by the incident.
Peer Comparator: No peer comparator data available
Revised: March 2018 Next Update: June 2018 Page 5 of 13
Indicator Name: 90th Percentile Emergency Department (ED) Length of Stay (LOS) for Complex Patients
Alignment: Quality and Patient Experience Committee (QPEC)/Quality Committee of the Board (QCB)/Performance & Utilization Committee (PUC)/Resource Utilization & Audit Committee (RUAC)
Strategic Goal: Improve access to care
Definition: The total ED length of stay where 9 out of 10 complex patients completed their visits. ED Length of Stay defined as the time from triage or registration, whichever comes first, to the time the patient leaves the ED.
Rationale:
Additional Specifications:
Peer Comparator: Ontario high-volume community hospitals, Sarnia Site only
Revised: March 2018 Next Update: June 2018 Page 6 of 13
Indicator Name: Alternate Level of Care (ALC) Rate %-All Inpatient Services
Alignment: Quality and Patient Experience Committee (QPEC), Quality Committee of the Board (QCB), Performance & Utilization Committee (PUC), Resource Utilization & Audit Committee (RUAC)
Strategic Goal: Build sustainable partnerships and collaborations
Definition: The rate at which patients who have been designated ALC occupy inpatient beds.
Rationale: Ensuring that each patient receives the appropriate level of care at all times during their healthcare journey is a priority at Bluewater Health. Our goal is for Emily to receive the right care, given at the right time, in the right place, always. The ALC rate represents an opportunity for inpatients to be transitioned to the next level of care, where their care needs and the services provided are better matched. Multiple factors can influence ALC rate, including overall hospital occupancy, and availability of resources both internal and external to the hospital.
Additional Specifications:
ALC Rate = Total number of ALC Days in a given period
Total number of inpatient days in the same time period ×100%
ALC Rate % -All Inpatient Services (Sarnia and Petrolia)
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Revised: March 2018 Next Update: June 2018 Page 7 of 13
Indicator Name: 30 Day Mental Health Readmission
Alignment: Quality and Patient Experience Committee (QPEC)/Quality Committee of the Board (QCB)
Strategic Goal: Build sustainable partnerships and collaborations
Definition: The percentage of Ontario Mental Health Reporting System (OMHRS) full admissions that were discharged 30 days ago or less from this facility.
Rationale:
Additional Specifications:
Peer Comparator: No peer comparator data available
Revised: March 2018 Next Update: June 2018 Page 8 of 13
Indicator Name: Readmission within 30 days for Chronic Obstructive Pulmonary Disease (COPD)
Alignment: Quality and Patient Experience Committee (QPEC)/ Quality Committee of the Board (QCB)
Strategic Goal: Build sustainable partnerships and collaborations
Definition: The measuring unit of this indicator is an admission for COPD, as defined for the quality based procedure (QBP). Results are expressed as crude 30-day non-elective readmission rate among patients admitted to Ontario acute care facilities.
Rationale: Readmission rates are considered a marker of poor hospital performance. High rates may indicate inadequate care, inadequate follow up, and inadequate preparation for discharge or poor doctor to doctor communication at the time of discharge. Reducing readmission rates benefit the patient through a higher quality of care and the hospital through cost containment.
Additional Specifications:
Peer Comparator: Crude calculation of 30 day readmission for COPD in the Erie St Clair LHIN Hospitals for Fiscal Year 16/17 – 18.2%
Revised: March 2018 Next Update: June 2018 Page 9 of 13
Indicator Name: Overall Rating of Experience
Alignment: Quality and Patient Experience Committee (QPEC)/Quality Committee of the Board (QCB)
Strategic Goal: Strengthen Patient and Family-Centered Care
Definition: Overall Rating of Experience: Inpatient (IP) and Emergency Department (ED), patients are asked to rate their hospital experience on a scale from 0 to 10, with 0 being I had very poor experience and 10 being I had a very good experience.
Rationale: Patient experience measurement is an industry best practice and hospitals are required to survey patients at least once every fiscal year, according to Ontario’s Excellent Care for All Act (ECFAA), 2010. “We create exemplary healthcare experiences with patients and families every time”, is the mission of Bluewater Health. These questions reflect how well the hospital is achieving its overall mission. The patient experience is what we strive to excel at. Measurement of patient experience is important because it provides an opportunity to improve care, enhance strategic decision making, meet patients’ expectations, effectively manage and monitor healthcare performance, and document benchmarks for the organization.
Additional Specifications:
Scores are calculated using the following measure recommended by the National Research Corporation Canada (NRCC): Positive - Positive measure type is calculated by counting “Positive” response (i.e., 9-10 or Yes, Definitely or Always) and dividing by the total number of responses.
Inclusion Criteria: - Patients who have received active treatment at Bluewater Health
- 18 years or older at the time of admission - Alive at the time of discharge
Exclusion Criteria: - Patients who have notified Bluewater Health they wish to be excluded from
the mailing list - Patients who are stillborn or deceased while in the hospital - Patients with no fixed address
- Psychiatric patients (unless being specifically surveyed using the Mental Health inpatient or outpatient survey tool)
- Patients who present with evidence of sexual assault or with sensitive issues (e.g., miscarriage)
Peer Comparator: The Ontario Hospital Association Patient Reported Performance Management (OHA PRPM) benchmark includes OHA member hospitals. The Ontario Inpatient (IP) Community Hospital (Hosp) Average compares hospitals of the same size within the province. Peer comparators are updated quarterly.
Inpatient OHA-PRPM – 68.2% Ontario IP Community Hosp Average – 65.0%
Emergency Department (ED) There is no peer comparator as this is a Bluewater Health custom question for the Emergency Department Patient Experience of Care Survey (EDPEC)
Revised: March 2018 Next Update: June 2018 Page 10 of 13
Indicator Name: Leaving hospital did patients receive enough information
Alignment: Quality and Patient Experience Committee (QPEC)/Quality Committee of the Board (QCB)
Strategic Goal: Strengthen Patient and Family-Centered Care
Definition: As Emily leaves the hospital, this indicator asks the question of whether Emily perceives that she received the information she needed from Bluewater Health Staff and Physicians before leaving our care. This question is asked of both inpatients and emergency department patients. Inpatient Question: Did you receive enough information from hospital staff about what to do if you were worried about your condition or treatment after you left the hospital? Not at all/ Partly/ Quite a bit/ Completely Emergency Department Patient Question: Before you left the emergency department, did you understand what symptoms or health problems to look out for when you left the emergency department? Yes/No
Rationale: Patient experience measurement is an industry best practice and hospitals are required to survey patients at least once every fiscal year, according to Ontario’s Excellent Care for All Act (ECFAA), 2010.
Additional Specifications:
Scores are calculated using the following measure recommended by the National Research Corporation Canada (NRCC): Positive - Positive measure type is calculated by counting “Positive” response (i.e., 9-10 or Yes, Definitely or Always) and dividing by the total number of responses.
Inclusion Criteria: - Patients who have received active treatment at Bluewater Health
- 18 years or older at the time of admission - Alive at the time of discharge
- Exclusion Criteria: - Patients who have notified Bluewater Health they wish to be excluded from
the mailing list - Patients who are stillborn or deceased while in the hospital
- Patients with no fixed address - Psychiatric patients (unless being specifically surveyed using the Mental
Health inpatient or outpatient survey tool) - Patients who present with evidence of sexual assault or with sensitive
issues (e.g., miscarriage)
Peer Comparator: The Ontario Hospital Association Patient Reported Performance Management (OHA PRPM) benchmark includes OHA member hospitals. The Ontario Inpatient (IP) Community Hospital (Hosp) Average and the Ontario ED Community Hosp Average is a comparator of hospitals of the same size. Peer comparators are updated quarterly. Inpatient OHA PRMP – 57.5% Ontario IP Community Hosp Average – 54.3% ED OHA PRMP – 84.2% Ontario ED Community Hosp Average – 82.5%
Revised: March 2018 Next Update: June 2018 Page 11 of 13
Indicator Name: Supervisor helps access training and development
Alignment: Quality and Patient Experience Committee (QPEC)/Quality Committee of the Board (QCB)
Strategic Goal: Focus on the experience of care and caring
Definition: This is a custom employee survey question that will ask “My Supervisor helps me to access training and development?” The top box responses request respondents to “Agree” and “Strongly Agree” with the proposed statement. A higher percentage of employees agreeing or strongly agreeing with this statement is preferred.
Rationale: Ensuring that each patient receives the best care possible begins with exceptional care providers. Bluewater Health is committed to strengthening the skills and education of our employees. This commitment to education promotes inspired people who will advance our culture of kindness with an intention to learn, lead, collaborate and celebrate. Evidence suggests that investment in employee training and development leads to employees feeling more valued and willing and able to invest in their work. Employee training and development supports efficiencies and standardized procedures, risk reduction, patient safety and quality of patient care. Research links high levels of employee engagement with increased patient satisfaction when an organization focuses on processes and people. This reflects on the organization’s ability to provide opportunities for personal development to stay up to date with latest techniques and technologies and recognize employees for acquiring additional skills and knowledge sets.
Additional Specifications:
This indicator was released in December 2016. Responses to this question are collected routinely in a Strategic Engagement survey.
Target for 2017/2018:
67.3%
Bluewater Health Target 67.3%
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Revised: March 2018 Next Update: June 2018 Page 12 of 13
Indicator Name: Was Patient/Family Treated with Kindness
Alignment: Quality and Patient Experience Committee (QPEC)/Quality Committee of the Board (QCB)
Strategic Goal: Focus on the experience of care and caring
Definition: This is a new, custom question for Bluewater Health’s patient experience surveys which are mailed to a random selection of patients after they are discharged. Our aim is that the culture of kindness at Bluewater Health will be increasingly felt by our patients and families over time. This question asks Emily to reflect and respond to the statement “Were you and your family treated with kindness by employees, volunteers and physicians at Bluewater Health?” Responses available for this question are as follows: No/ Yes, somewhat/ Yes, mostly/ Yes definitely
Rationale: Exemplary healthcare experiences begin with kindness. We understand that patients expect courtesy, respect and dignity, beginning with an expression and attitude of kindness and caring. We understand that having highly skilled and competent staff isn’t enough. Ensuring that you and your family are treated with kindness is a key focus of Bluewater Health’s commitment to Patient & Family-Centered Care. Patient experience measurement is an industry best practice and hospitals are required to survey patients at least once every fiscal year, according to Ontario’s Excellent Care for All Act (ECFAA), 2010.
Additional Specifications:
Scores are calculated using the following measure recommended by the National Research Corporation Canada (NRCC): Positive - Positive measure type is calculated by counting “Positive” response (i.e., 9-10 or Yes, Definitely or Always) and dividing by the total number of responses. Inclusion Criteria: - Patients who have received active treatment at Bluewater Health
Exclusion Criteria: - Patients who have notified Bluewater Health they wish to be excluded from
the mailing list - Patients who are stillborn or deceased while in the hospital - Patients with no fixed address
- Psychiatric patients (unless being specifically surveyed using the Mental Health inpatient or outpatient survey tool)
- Patients who present with evidence of sexual assault or with sensitive issues (e.g., miscarriage)
Peer Comparator: This is a Bluewater Health custom question and no peer comparator data is available. NRC Health establishes benchmarks/peer comparators based on the following requirements:
- Made up of one year of data - Questions must be used by at least five facilities
Must have at least 1000 responses for the question
Revised: March 2018 Next Update: June 2018 Page 13 of 13
Indicator Name: Is a Culture of Kindness Promoted at Bluewater Health Alignment: Quality and Patient Experience Committee (QPEC)/Quality Committee of the Board
(QCB)
Strategic Goal: Focus on the experience of care and caring
Definition: This is a custom survey question that will ask “Is a culture of kindness promoted at BWH?” Top Box responses from Employees, Professional Staff and Volunteers are displayed. The top box responses request respondents to “Agree” and “Strongly Agree” with the proposed statement. A higher percentage of employees agreeing or strongly agreeing with this statement is preferred.
Rationale: Bluewater health is committed to strengthening our culture of kindness while we deliver Quality Care to Emily. Creating a kindness culture in the workplace reduces stress, fosters relationships, increases psychological wellness and health and leads to increased engagement, energy and resiliency at work. Evidence suggests that high engagement influences human resource goals of increased retention and recruitment, high job performance and lower absenteeism. Research links high levels of employee engagement with increased patient satisfaction when an organization focuses on processes and people. Caring for people creates a workforce with physical energy, mental focus and the emotional drive necessary to provide exemplary care to Emily every day. The culture of kindness has been measured in the “joy” people bring to work; it is palpable throughout the organization and referred to as measuring “humanity”.
Additional Specifications:
This indicator was released in December 2016. Responses to this question are collected routinely in a Strategic Engagement survey.
Target for 2017/2018:
Employees – 65.9% Professional Staff - 60.1% Volunteers - 84.1%
Employee Target 65.9%
Prof. Staff Target 60.1%
Volunteer Target 84.1%
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Is a Culture of Kindness Promoted at Bluewater Health
