City of Kingston Council Agenda - Meeting 19-2009 - Report ... · 2007-2012 Status Report Co m m u...

Rideaucrest Home Organizational Development Framework

2007-2012

Status Report

Co m m u n i ty Deve I o p m e n t Services G rou p

City of Kingston I

October 2009

Rideaucrest Home is a special place, with special meaning for many people in our community. From modest beginnings in the 1800’s sewing as a “house of refuge” for the poor, Rideaucrest has become a prominent long-term care facility that is an integral and much loved piece of the social fabric of this community. Rideaucrest is:

e3 First, foremost and truly “home” for 170 residents e 3 Prominent in the lives of the residents’ families and friends e 3 A workplace for over 225 full time and part time employees as well as other visiting

professionals and service providers e:* A passion for the scores of people who give of their time and talents as members of the

A uxiliaryNolun teers e 3 A valued community resource, offering premium meeting facilities, oftice. space, meals on

wheels and resources to hundreds of individuals and scores of community groups e3 An essential partner in the continuum of health long-term care research and long-term

care giving in the community

It is not an easy task trying to be so many things to so many people: creating a supportive, home- like setting for our residents; managing an increasingly complex workplace; actively programming

large, well used community facility; and, being an involved member of the health long-term care Aor . But it is the challenge we gladly accept.

Successive city councils and the taxpayers of Kingston have long recognized the Home’s value and importance to the community by providing strong ongoing financial support to ensure quality resident long-term care, an enjoyable visitor’s experience, and good wages and safe working conditions for employees. In return, the management and staff of Rideaucrest are asked to ensure value for the public money being spent in support of the Home, through effective management, efficient operations and quality resident care.

As city budgets tighten, there is increasing emphasis on finding more cost-effective ways to provide quality long-term care for our residents while providing a re warding work experience for all staff and volunteers. This has been our challenge for the past three years. It is a challenge that is not without its pain or frustrations at times as we look to do more with less and maintain our impressive standard of resident care. It is, however, a challenge that the Rideaucrest team is meeting as we work together to identify opportunities and implement solutions.

I

h d 5 ~ &“*U

- 1 - 1 P a g e

Rideaucrest Home Organizational Development Framework . October. 2009

TABLE OF CONTENTS

introduction .......................................................................................................................................... 3

Chapter 1 . The Ontario Long-term Care System ............................................................................. 4

Chapter 2 . Rideaucrest Home Improvement Plan - The Road Travelled: ................................... 13

Year One Accomplishments: 2007 ................. i .................................................................. 16

Year Two Accomplishments: 2008 ................................................................................... 20

Year Three Accomplishments: 2009 ................................................................................ 26 Chapter 3 . An Organizational DevelOpi?Ient Framework - The Road Ahead ............................. 30

RideauCreSt Organizational Development Framework (2009-2012 1 ............................. 36

List of Figures Figure 1 . Organizational Elements ................................................. ................................ 36

Figure 2 - Elements . of a Talent Organization ................................................................ 37

Figure 3 - Rideaucrest Home Funding Sources ............................................................ 44

Figure 4 - Municipal Subsidy as a % of total Revenunes .............................................. 46

Figure 5 - Funding Source by Year .................................................................................. 4’

Figure 6 - 2009 Budget by expenditure Category ........................................................ 42

Figure 7 - Breakdown by Category of gross Budget Increase .................................... 47

List of Tables Table 1 . Rideaucrest Home Case Mix Index: 2003-2008 ....................................... 23

Table 2 - Comparison of Staffing Levels for Some Area Municipal Homes 38

Table 3 . Gross and Net Budget Compakison 2005-2010 ................................................ 41

Table 4 . Budget to Actual Spending Comparison 2005-2008 ....................................... 41

Table 5 . 2005-2009 Budget by Category ......................................................................... 45

Table 6 . Comparison of Rideaucrest with Area Municipal Homes .............................. 48

. List of Appendices Appendix A . Improvement Plan implementation tracking tool Appendix B . Organizational performance indicators

- 2 - I P a g e

Rideaucrest Home Organizational Development Framework October, 2009

This report outlines the strategic management framework for Rideaucrest Home for the period 2007-2012. The framework is much like a road map to guide public policy, management, financial and operational decision making for the Home. The strategies described in this report are intended to position the organization as an acknowledged well managed, cost-effective provider of excellent quality long-term care services that is fully compliant with provincial regulations, is fulfilling the expectations of city council and meeting the daily needs of residents, their families and staff. This multi-year approach builds on the considerable organizational improvements of the past three years and sets a course for further organizational development over the next three years.

The report is organized in the following chapters:

I. The Ontario Long-term Care System An overview of the long-term care health sector within which Rideaucrest Home operates is provided. To understand Rideaucrest and its ongoing improvement strategy, it is important to have a general awareness of the nature of the broader long-term care sector.

2. Rideaucrest Home Improvement Plan - The Road Travelled The story of Rideaucrest Home and its importance to the social fabric of Kingston serves as the backdrop to recent efforts to bring stability and reliability to the management and operation of the Home.

The circumstances that gave rise to an operational review of the Home in 2006 and the resulting recommendations that set the stage for the development and implementation of an organizational development action plan for Rideaucrest. The management strengthening, policy development and process efficiencies undertaken over the past three years are summarized with special attention paid to efforts to stabilize and improve the financial position of the Home.

3. An Organizational Development Framework - The Road Ahead After three years of putting in place and strengthening the necessary foundational management and operational systems within Rideaucrest, the organizational strategy for the Home will be shifting focus in 2010 towards building a broader organizational road map for the future. While considerable attention will continue to be placed on quality improvement initiatives to operate the Home in a more cost-effective manner, increasingly, the primary focus will be on improving the culture of the workplace.

J

- 3 - I P a g e


Rideaucrest Home is a long-term care facility owned by the City of Kingston and operated in accordance with the legislative and regulatory framework of the Ontario long-term care sector. To understand and appreciate the management strategy for improving the organizational performance of Rideaucrest Home, it is important to understand the nature of the long-term care sector. Public policy decision-making at the municipal level must be compliant with the regulatory framework of the provincial long-term care health system.

Ontario’s long-term care facilities provide care for people who are not able to live independently in their own homes, even with the assistance of community support services and in-home professional care, and who require that 24-hour nursing service be available to meet their nursing and personal care needs. Long-term care facilities provide a range of services to meet the needs of residents, including accommodation, meals, nursing and personal care, as well as a variety of social and recreational activities.

Resident Profile In Ontario, long-term care residents are predominately widowed women (females represent about 73% of the total resident population provincially). Seventy per cent (70%) of all residents are over 80 years old. The average age of admission for residents is 83 years. The most prevalent diagnoses for residents in long-term care are: mental disorders such as Alzheimer‘s disease, dementia or other psychiatric diagnosis, circulatory. diseases and musculoskeletal disabilities such as arthritis. Approximately 60% of residents require specific plans of care to manage varying degrees of incontinence. Most residents require considerable supervision and assistance with activities of daily living such as dressing, bathing, going to the bathroom, eating and getting out of bed. The typical resident receives 10-12 different kinds of medication every day. Approximately 30% of residents require some form of specialty treatment ordered by a physician and carried out by nursing staff, ranging from topical medications, creams and ointments to catheters, ostomies, oxygen and other medical interventions.

Legislation Long-term care facilities are governed by provincial legislation, regulations and related administrative guidelines and directives established and enforced by the Ministry of Health and Long-term Care. Historically, provincially funded and regulated long-term care facilities have fallen into three categories: nursing homes, municipal homes for the aged and charitable homes for the aged, with each being governed by its own separate legislation.

Nursing Homes are licensed by the Ministry of Health and Long-term Care and are operated either by non-profit organizations (approximately 10%) or private for profit corporations (90% of all nursing homes). The licensee of a nursing home is accountable for the accommodation, care, programs and services provided by that long-term care facility. Examples locally of privately owned and operated nursing homes include Helen Henderson Centre and Trillium Care Centre.

Municipal and Charitable Homes for the Aged are managed under non-profit governance structures. Rideaucrest is a municipal home, as is Frontenac County’s Fairmount Home, the John Parrott Centre in Lennox and Addington County, and St. Lawrence Lodge in the United Counties of Leeds and Grenville. A local example of a charitable home is Providence Manor.

-

- 4 - I P a g e


A new Long-term Care Act received Royal Assent on June 4, 2007 and is the cornerstone of the Ontario government’s strategy to improve and strengthen care for residents in long-term care homes. The Act cannot be proclaimed into force until all of the regulations required to opertionalize the Act are finalized (this is ongoing). When proclaimed into force, ,this Act will replace the three existing pieces of legislation governing long-term care homes: Nursing Homes Act, Homes for the Aged and Rest Homes Act, and Charitable Institutions Act.

With the enactment of the new legislation, expected in 2010, all long-term care facilities will be covered by the same legislation and will be required to provide services in keeping with the same provincial standards.

Municipal Obligation According to legislation, all municipalities must establish and maintain a long-term care facility, or enter into an agreement to establish and maintain a facility jointly with other municipalities. Municipalities that are part of a county or regional government system typically fulfill this obligation through the upper level of government. Such is the case of Fairmount Home. Most municipalities operate one long-term care facility. Many of the larger municipalities, however, operate a number of facilities; Toronto for example operates ten such facilities.

Long-term Care Reform in the 1990’s In 1993 the province introduced the system under which long-term care facilities currently operate. Reforms included:

0

a resident needs-based funding system with variable funding to recognize the different care levels which exist in individual long-term care facilities; one process for the charging of resident fees (the amounts for accommodation which residents can be charged are set out in regulations under the three Acts and are the same for all long-term care facilities); eligibility criteria for, admission which apply in the same manner to all long-term care facilities across the province (a province-wide, mandatory long-term care facility placement coordination system came into effect in July 1994 under Bill 101); and

0 a uniform accountability system for all long-term care facilities, including the requirement to sign a Service Agreement in exchange for provincial funds.

As this is being written a new resident needs-based funding system is being introduced across the long-term care sector and is discussed later in this report.

Resident Safeguards All long-term care facilities must comply with provincial standards that are designed to respect, support and promote residents’ rights, in keeping with the Residents’ Bill of Rights which is enshrined in legislation. These standards emphasize resident participation in the planning and evaluation of each care plan, as well as in the planning and evaluation of facility programs and services. The legislation governing long-term care facilities also lists key information that each long-term care facility operator must provide to all residents of the facility. In addition, residents are to be given the opportunity and the support to establish and maintain an organized Residents’ Council.

- 5 - I P a g e


Long-term Care Facility Programs and Services

accordance with residents’ needs and preferences in a manner that promotes and supports residents’ autonomy and involvement in decision making about their own care. It is expected that care and services will be provided in a manner which fully promotes residents’ rights and respects their dignity and privacy.

Long-term care facilities must provide accommodation, care, programs and services ; !

Mandatory Resident Long-term Care, Programs and Services All long-term care facilities are required to provide the following programs and services to meet the needs of residents in accordance with provincial performance standards:

e

e

e

e

e

e

e

e

e

e

nursing and personal care on a 24-hour basis, including care given by or under the supervision of a registered nurse or a registered practical nurse, the administration of medication, and assistance with activities of daily living medical care that is available in the facility - residents may continue to have their personal physician provide care to them in the facility, medical supplies and nursing equipment necessary for the care of residents including the prevention or care of skin disorders, continence care, infection control, and sterile procedures supplies and equipment for personal hygiene and grooming equipment for the common use of all residents, including wheelchairs, geriatric chairs, canes, walkers, toilet aids and other self-help aids for the activities of daily living meal services, including three meals daily, snacks between meals and at bedtime, special and therapeutic diets and dietary supplements and devices enabling residents to feed themselves social programs, recreational programs and physical activities including supplies and equipment necessary for these activities laundry, including machine washing and drying of personal clothing bedding and linen including firm, comfortable mattresses with waterproof covers, pillows, bed linen, wash cloths and towels bedroom furnishings such as beds (where the resident is confined to the bed, a bed with an adjustable head and foot section), adjustable bedrails, bedside tables, and a comfortable easy chair; and the cleaning and upkeep of accommodations

.

Optional Services Long-term care facilities may provide other services for a fee as long as the resident agrees in writing to receive these services. Examples of such services include, but are not limited to:

hairdressing and barber services telephone connections and monthly fees, cable television connections and monthly fees tuck shop, newspaper delivery dry cleaning, mending and ironing non-prescription drugs, medication and treatment products, and supplies not available through the Ontario Government Pharmaceutical and Medical Supplies, and uninsured health care services (e.g., specialized foot care, dental care)

-

- 6 - I P a g e

Rideaucrest Home Organizational Development Framework Ocfober, 2009

Accountability Framework - Long-term Care Service Agreement Each year, long-term care facility operators must sign an accountability agreement with the Ministry of Health and Long-term Caje in order to continue operating and receive provincial funds. The agreement includes a budget package and outlines the programs and services that are to be provided by the long-term care facility operator. It also includes provisions relating t9 records, reporting and corrective actions that may be taken by the Province. In 2010 each provider will be entering into a new accountability agreement with the Local Health Integration Network - in our case the South East LHIN. Once the agreement is signed between the two parties, the Province, through the LHIN, provides operating subsidies to the long-term care facility operator based on the provisions and budget set out in the agreement. Staff of the Ministry of Health and Long-term Care is responsible for monitoring service compliance with the agreement.

Non-compliance with the service agreement, legislation and regulations can result in sanctioning by the Ministry and LHIN. Sanctions may include: 1) close scrutiny of operations by the Ministry (this action is referred to as “enforcement” monitoring); 2) the “freezing” of admissions to a long- term care facility; 3) takeover of operations and closure of the facility; and, 4) cancellation of the Service Agreement, thereby canceling provincial funding commitments; such sanctions are applied in only the most serious of circumstances.

Funding of Long-Term Care The province provides a certain amount of funding towards the operation of long-term care facilities. Starting in April 2010, the provincial funding will be administered by the Local Health Integration Networks (LHINs) that have been established by the province to manage and coordinate the health care system on a regional basis.

Long-term care facilities have two main sources of revenue:

1. 2.

Provincial subsidy payment to the facility; and Resident accommodation fees collected directly by the facilities from residents

At their sole and absolute determination, long-term care facility operators may also choose to contribute to the operation of their facilities through other sources of revenue. Examples would include fund-raising and donations. Most municipalities provide some form of operating subsidy to their long-term care facilities; the level of municipal support varies widely across the province.

Resident Needs-Based Funding System Currently long-term care facilities are funded using a resident needs-based funding system. This funding system equitably distributes the funds available within the Province for the long-term care facility program budget based on the comparative needs of residents in individual facilities. Annual funding entitlements for each facility are determined through a resident classification process that is completed in the fall of each year by the Ministry of Health and Long-term Care. Funding adjustments are made on April 1’‘ of each year, and a facility’s entitlement may go up or down, depending on how much the resident mix changes from the previous year.

i

Ontario’s long-term care facility resident classification system identifies the nursing and personal care needs of long-term care facility residents from the documentation in each resident‘s care plan, and in turn uses this information to determine levels of funding for nursing purposes. Each fall, the Ministry recruits registered nurses from the long-term care system to be classifiers for the

- 7 - I P a g e


annual resident classification exercise. Classifiers collect information from the previous three months of resident records and document the care requirements on an established Ministry for, (one form completed for each resident). This data is then .used to’determine the care category ot each resident based on the classification system’s criteria.

The classification system has seven resident care categories ranging from “A” (lightest care) to “G” (heaviest care). Typically, a facility will have a mix of residents in the seven care categories. The actual number of residents in each care category will vary from facility to facility.

The data collected by the Ministry on the care needs of residents is summed up to determine a Case Mix Measure for each facility. The Case Mix Measure is a measure of the actual care requirements of all of the residents in a facility, and is reflected as a numerical value in order to compare one facility to another.

All of the Case Mix Measure values are grouped to come up with a provincial average. The provincial average Case Mix Measure is then used to calculate the Case Mix Index for each long- term care facility through an established formula. The Case Mix Index is also reflected as a numerical value and represents the aggregate nursing and personal care needs of the residents in each facility in relation to the provincial average. The Case Mix Index value is used in the Province’s funding formula to determine the annual funding entitlement which the facility will receive for nursing and personal care services.

A Case Mix Index value of “100” represents the provincial average mix of long-term care facility residents. The Case Mix Index values will differ for each facility because of the variations in th care requirements of residents, and may be above or below the “100” average value. Facilities with lower or higher Case Mix Index values receive proportionately lower or higher funding levels in relation to the average.

Resident Assessment Instrument (MI) Ontario long-term care facilities are transitioning to a new resident assessment system over the next year, known as the Resident Assessment Instrument (RAI). The’ RAI is a set of computerized care management tools. They help health professionals in long-term care to assess and monitor the care needs of their residents. It has been implemented in more than 30 countries including the United States, UK, Germany, Italy, France, Japan and Australia as well as several provinces and territories in Canada.

I ,.

All residents are assessed using a standardized assessment form on admission and regularly thereafter including when there is a significant change in their health status. The information serves as the basis for a number of computer-generated reports. By incorporating many different aspects of a resident such as behaviour, cognitive abilities, daily life activities, exercise, diet and medication, the tool can be used to alert staff of potential risks and problems. Each repod generated by the system is designed to help the care team identify each resident’s needs and capabilities, to monitor their progress and wellbeing and to understand the best way to allocate staff and resources in the home to meet those needs.

Currently there is no one common approach for resident assessment in long-term care. Eac’ home uses its own choice of assessment tools. There is no standardized way for residents to be observed and the different professions in the care team can work to different timelines. With RAI

- 8 - I P a g e


there will be a common assessment tool for every home in the province. The observation period for each part of the assessment is set and there are clearly defined rules - by whom, when, what and how the assessment is undertaken. Each resident is assessed according to th-eir needs. Only if a potential problem is highlighted, or the care team judges it necessary, are further specialized assessments completed.

The current resident classification system focuses on how much care a resident needs, or what the resident cannot do. It focuses on each resident’s nursing and personal care requirements and not on the services provided. It is insensitive to clinical complexity, does not include a common approach to care planning or a measurement of the results. It is a once-a-year snapshot of resident needs. With RAI the focus is more on what the resident can do with the right support. It focuses on the resident’s strength, abilities and preferences. It recognizes the additional elements of care that can improve the resident‘s quality of life and enables measurement of all care activities as often as an assessment is undertaken.

Provincial Subsidy Payment Based on Occupancy Provincial funding to long-term care facilities considers a facility’s occupancy rate. Facilities operating at 97% occupancy or higher on average throughout the year are considered to be at full occupancy. This means that even if the facility has empty beds from time-to-time, if the overall yearly occupancy average is 97% or higher, the facility will be paid as if it were at full capacity throughout the year. If a facility’s occupancy falls below the 97% level, then the facility will be reimbursed based on actual occupancy on a per bed basis. Allowing for empty beds for short periods gives each long-term care facility some flexibility to prepare for and arrange new admissions without losing funding.

Long-term Care Facility Funding Model Provincial funding for long-term care is provided in four separate and distinct “envelopes”:

Nursing and Personal Care Funding in this envelope varies each year, depending on the level of care of residents in each facility for that year. The amount of funding for this envelope is determined by the facility’s Case Mix Index as noted previously. Funds in this envelope are used to pay the nursing and personal care staff salaries and wages (including the director of nursing, registered nurses, registered practical nurses, personal support workers and some defined ward clerk hours), as well as to purchase the supplies and equipment for the nursing department.

Programming and Support Services Funding in this envelope is a fixed per.diem and is the same for all long-term care facilities. The full amount of this envelope is paid by the Province. Funds in this envelope are to be used to cover the costs of services such as recreational programs, therapies and other resident support services. As well funding in this envelope is used to cover the costs of the program and support service staff wages and salaries, as well as the related equipment and supplies. -

Other Accommodation Funds in this envelope cover the costs of services such as administration, dietary and environmental services (laundry, housekeeping, and maintenance), including staff

- 9 - ] P a g e


Nursing and Personal Care Proarammina and SUPPO~~ Services

salaries/wages, equipment and supplies. A separate mandatory amount is set aside for raw, food costs in this envelope. I

$79.46 $7.57

The Province ensures that funds provided in the Nursing and Personal Care envelope and in the Programming and Support Services envelope are spent only for that purpose. Any unspent funds in those two envelopes are recovered by the Province. Facilities are reimbursed for their actual expenses in these envelopes through a reconciliation process applying the 97% occupancy rule. Any surplus funds from the Accommodation envelope can be retained by the operator, with the exception of the “raw food” allowance, which must be spent as required or returned to the Province.

Other Accommodation (includes a mandatory raw food expenditure of $7.31 per resident per day) TOTAL FUNDING

The 2009 per diem rates (per day per resident) paid to long-term care providers by the province are:

$54.90

$141.93

Resident Fee Policy The fee structure for residents of long-term care facilities is the same throughout Ontario and i.. regulated by the Province. All long-term care facilities must administer their resident fee policies in keeping with the amounts and protocols prescribed in legislation. All long-term care facilities must provide Basic accommodation for at least 40% of all of the residents in the facility. The remaining percentage of residents (60% or less) may be offered Preferred (semi-private and private) accommodation depending on the structural design of the facility. The maximum rates for Basic and Preferred accommodation are set by the Ministry.

Each year, there is a resident rate adjustment on July 1st based on the annual increases in federal and provincial entitlements, such as Old Age Security and Guaranteed Income Supplement.

Financial assistance is available to those residents in Basic accommodation who, based on their net disposable income after taxes, cannot afford to pay the full Basic accommodation rate. This assistance is not available to residents in Preferred accommodation. To obtain a Ministry subsidy for accommodation, a resident must go through an application process which requires submission of financial information confirming his or her actual income. Note, this is an income based assessment; it is not based on the value of one’s assets.

Long-term care facilities may-charge Preferred rates of:

up to a maximum of $8.00 per day for semi-private accommodation above the Basic accommodation rate

- 10- IP a g e


up to a maximum of $18.00 per day for private accommodation above the Basic accommodation rate

Structural Design Standards The province sets out mandatory design requirements as well as functional considerations and recommendations to support “best practices” and quality care outcomes. Standards do change from time to time. Rideaucrest Home, for example, was designed and built under different design standards than apply today. The Home was, in fact, over-built at the time, exceeding minimum space requirements by a considerable margin (e.g. resident room size). In some regards, Rideaucrest still exceeds provincial minimum design standards.

Resident Admission Process The fourteen (14) Community Care Access Centres across the province are responsible for managing the access to both long-term care community and facility services in their respective regions. Any persons wishing to apply for admission to a long-term care facility must, by law, apply through the Community Care Access Centre. Facilities are not permitted to admit people who have not met the provincial eligibility criteria as determined by the Placement Coordinator of the Community Care Access Centre. Approval of an application is not possible without a valid Ontario Health Insurance Plan (OHIP) number issued by the Ministry.

Admission to a long-term care facility is limited to persons who are aged 18 years and older. Whereas admission to long-term care facilities generally was restricted at one time to persons older than 65, increasingly in recent years, younger adults who have a variety of health issues requiring residential nursing care are being accepted. This changing face of long-term care presents significant challenges to facility operators who must adjust the services and programs being offered and the staffing skill sets available.

Long-term Care Facility Accountability and Monitoring Program The performance of all long-term care facilities in Ontario are subject to regular review and monitoring by the Ministry of Health and Long-term Care in relation to applicable legislation, the terms and conditions of service agreements, regulations, guidelines, directives and over 400 care standards.

Ministry Compliance Advisors complete a thorough review of each facility’s care, programs and services at least once in a calendar year. If non-compliance is identified in relation to prescribed standards within a particular facility, the Compliance Advisor will leave written findings of non- compliance with the Administrator of the facility along with a request for a plan of corrective action. The Compliance Advisor will deal directly with the long-term care facility Administrator to ensure that remedial measures are completed in a manner that is consistent with the action plan submitted from the facility.

Further to the annual review, additional reviews of long-term care facility operations are conducted as necessary by Ministry staff, including follow-up visits to confirm and evaluate corrective measures that have been implemented in response to the annual review, investigations of complaints registered by the public about individual long-term care facilities and special visits as appropriate. In-the event of on-going, serious non-compliance where there is concern that resident health, welfare and safety are potentially at risk based on reviews completed by Compliance Advisors, the Ministry may determine that a facility requires closer scrutiny.

.

- 11 -1P a g e


The Provincial Long-term Care Reform Agenda i

In preparing the improvement framework for Rideaucrest, management has been mindful of the evolving provincial long-term care agenda. With the creation of the new Long-term Care Homes Act, 2007, an independent commission headed by Elizabeth Sharkey, was established by the province to provide it with advice that is serving as the basis for ongoing development of regulations under the Act. The report of that commission, known as the Sharkey Report, was released in May 2008. Recommendations of the Sharkey Report strive to ensure that two principal goals are achieved in any future reforms of the long-term care system:

1. To strengthen staff capacity for better care, and 2. To create a strong foundation for quality care and accountability for resident outcomes

- 12- IP a g e

Brief History Rideaucrest Home is a full-service municipal long-term care facility owned and operated by the City of Kingston. The Home dates back to 1820, when the Compassionate Society of Kingston established the first "House of Industry" on Earl Street to provide room and board to people who had fallen on hard times. In 1848 the name, Rideaucrest Home for the Aged, was officially adopted for the now municipally supported service. In 1870 the facility was moved to a house on Montreal Street. The original stone house was demolished in 1966 and a modern 220 bed facility was constructed at 360 Montreal Street. On October 27, 1993, the current facility at 175 Rideau Street was opened and the former site redeveloped.

Residents Male Female

Some Quick Stats (as of August 2009)

170 43

127 Married Averaae Aae on Admission

76 83 vrs

Oldest Younaest

103 yrs 53 vrs

Accommodation Private 10

1 3 I P a g e

Semi-private Basic

91 69

Numh,er-.,of Employees Full Time

21 3 110


The Hay Group Operational Review -the point of departure In 2005, the current Administrator was hired with a mandate to introduce industry-leading management practices and operational efficiencies to Rideaucrest Home, bring stability and predictability to the Home’s budget, and begin the process of transforming the culture of the organization to one that would support and embrace the goal of becoming an acknowledged centre of excellence for long-term care services. The Administrator hired the Hay Group in 2006 to undertake an independent, objective review of the management and operations of the Home as a matter of prudent business practice, so as to better understand the current realities within the Home and to lay the ground work for a plan of action to address the operational deficiencies, cost pressures and budget anomalies that were being experienced at Rideaucrest over a number of preceding years. An operations review was seen as the essential first step in developing a plan aimed at bringing consistency to what should be a stable and predictable operating environment, and for developing strategies to ensure that taxpayers receive good value for their investment in Rideaucrest.

The Hay Group study was designed to serve as an organizational development tool for the Administrator, by identifying those general areas within the management and operation of the Home where improvements could be considered based on comparisons with industry standards or leading practices in the long-term care sector. The Hay Group was. asked to provide recommendations to strengthen performance in the following functional areas:

0 !Governance and management 0 Financial management 0 Overhead costs 0 Operational efficiencies 0 Staff structure and roles 0 Resident programs and services 0 Decision-making and communication processes

On April 17, 2007, Council received the Hay Group report. The key recommendations are summarized below (the full set of recommendations is provided as part of Appendix A):

. There are no significant differences between the care profile of Rideaucrest residents and the residents of other long-term care facilities. It follows then that service levels and staffing ratios within Rideaucrest should be in line with accepted industry leading practices

= There are opportunities for reducing operating costs over the medium to long-term however these may be limited by certain organizational realities such as existing wage rates and benefits, terms of collective agreements, and structural considerations such as the size and complexity of the physical plant -

= Short term restructuring and research costs would need to be incurred in order to realize potential savings

1 4 I P a g e


Management capacity and capabilities needed to be strengthened as a matter of first priority

j

. .

An Action Plan: Seeking Organizational Stability (2007-2009) With Council’s receipt of the Hay Group recommendations in April of 2007, a multi-year action plan for improvement was developed to guide the process of researching, developing and, where appropriate, systematically instituting change initiatives within the Home, over time. The following advice from the Hay Group was. central to the development and roll out of the action plan.

“We wish to emphasize that there is the potential for significant cost savings over the medium and long-term, but not in the short term.. .. There are a number of organizational barriers to achieving the identified savings, including the culture (of the organization) and (the) capabilities of.. .the management team.. .. It is critical that these barriers be addressed before the injtiation of significant restructuring. ”

-The Hay Group 2007

The overall purpose of the Rideaucrest Improvement Plan, for the period 2007-2009, was to bring about changes that would ensure the Home was operated efficiently and effectively within budget parameters set by City Council, the service expectations of the community and in compliance with Provincial, standards of care. Within that overall mandate, the elements of the plan and the priority of focus over the past two years has been to:

1) Strengthen management capacity and the managing framework of the Home; and, 2) Establish stability and confidence in the annual budgeting process, and

With the advice of the Hay Group as our touchstone, a multi-year plan was created with the following primary and secondary themes governing the priorities to be set and the work to be done for each year: -

1 5 I P a g e


I 1 0 7 * 1 Creating management capacity 1 Cost saving initiatives

Strengthening management capacity Improving processes and procedures I2O0* I I

I 1

2009 I Strengthening management capacity I Improving processes and procedures

1 2010 + 1 Improving workplace culture Cost effectiveness/revenue enhancements I I I I

Note * work commenced second half of 2007

The roll-out of the improvement plan over the past two years has been evolutionary rather than revolutionary, in recognition of the need for a careful, methodical and inclusive approach to introducing, managing and sustaining meaningful changes in the organization. The stability of a home-like environment for the residents and families has been and continues to be the paramount consideration in structuring and executing the action plan. Management also has been ever-mindful of the unsettling impact of change on staff, managers and volunteers in the Home.

A summary of how the specific recommendations of the Hay Group Report have been addressed to date is provided as part of Appendix A. The process to date has yielded significant successes, many worthy of note in this report. Numerous other improvements are perhaps less prominent but no less important to the overall objectives of the action plan. The improvements to date in the management practices and operational stability of the Home are significant and encouraging - a strong base for future organizational development work has been put in place.

It needs to be stated at the outset that the primary focus of the improvement strategies to date has been on building management capacity and strengthening operating systems to bring stability, consistency and predictability to the operation of the Home. Without such foundational work, as noted by the Hay Group, creating and sustaining significant operating efficiencies is not possible. Certainly over the past two years the improvement process has identified and implemented a number of ways to reduce net costs or constrain budget increases. These however, have been incidental to the more critical capacity building and process development work undertaken to date. The following discussion supplements the information contained in Appendix A regarding the actions taken over the past two and half years and our ongoing efforts.

Year One Accomplishments: 2007

The improvement plan was initiated in the latter half of 2007 with the primary focus being to create the administrative and financial management capacity needed in the Home to drive and sustain organizational change over the long-term. As noted in the Hay Report, the Home’s

1 6 l P a g e


administration costs, as measured in relation to the number of residents in the home, were below the 25" percentile when compared to other long-term care facilities. That means 75% of the comparator long-term care facilities spent more per resident on administration and management than the City of Kingston.

While laudable in the sense that the city tended to focus its ongoing investment in the Home on front line services and not administrative overhead, the Hay Group advised the city of the need to invest substantially more administrative resources into Rideaucrest in order to properly manage the Home. Ensuring that appropriately skilled management personnel and robust administrative systems were in place was, therefore, the priority for laying the ground work for successfully improving the Home. While it was expected to be challenging, finding and securing the necessary skilled personnel has proved to be far more difficult than anticipated.

The process of creating capacity, recruiting, retaining and training management personnel was, and continues to be, a challenge for a variety of reasons (e.g. organizational readiness, labour market competition for specialized skill sets, and uncompetitive management salaries). So much so. in fact, that as vacancies arose, Rideaucrest operated with less management capacity in 2007 (and throughout most of 2008) than in the preceding years. This placed an inordinate burden on the Administrator and other managers and slowed the initial progress on implementing the elements of the action plan. Despite the initial management challenges, advances made in Year-One included:

Changes in Food Services Management Sodexho, a well regarded food services management firm that provides services to a number of area health care facilities including Fairmount Home and Providence Care, was hired to manage dietary services. The firm has brought the needed expertise, experience and rigor of current management systems and leading practices to food purchasing, inventory and cost control, information management, food preparation, health and safety and labour relations. This alternative to managing a department within the Home was assessed as the most effective,way at the time to bring the level of consistency and controls in the delivery of food services up to meet expectations. We are pleased with the performance and progress made by Sodexho.

Changes in Nursing Management Sweeping changes within the nursing department were called for by the Hay Group to address a host of management and budgetary challenges. An interim director of nursing was put in place to stabilize the management of the department in 2007. The Hay Group recommended a new organizational structure for the department to bring needed stability and oversight. Two additional non-union nurse manager positions were recommended, however only one position was ultimately approved at the time, being mindful of the city's budgetary constraints. From a labour management perspective, hiring only one additional manager, while helpful certainly, was not a sustainable solution given the excessively high staff to manager ratio of 120:l. -

Due to a general shortage of registered nurses in this field and intense competition among health care providers, this new position was only filled in January 2009 - 20 months after it

17 I P a g e


was first recommended (Note: The incumbent recently resigned to pursue a career opportunity in health care and recruitment is once again underway to fill this vacancy).

Financial Expertise and Administrative Capacity The Administrator brought needed rigour to the finances of the Home upon her arrival in 2005. It became obvious quickly however, that operating a large, 170 bed facility in today's increasingly complex and fiscally demanding long-term care health system required additional financial expertise to support the Administrator. The Hay Group corroborated the Administrator's assessment of the Home's capacity and recommended corrective action be taken promptly. A new position of manager of administration/ finance was created therefore provide the necessary capacity and systems to oversee the broad financial interests of the Home. This position was created to bring a new level of dedicated financial expertise to the Home, to assist the Administrator and department heads in budgeting, financial planning, fund raising and numerous other administrative functions.

B

This position oversees the review of all functions within the Business Office at the Home to ensure proper systems are in place to guide everything, from attendance management, accounts receivable/payable, provincial subsidy management, management of resident co- payments, health and safety, donations, and fund raising, The added value of this position to the operation of the Home is significant. Unfortunately, despite a number of attempts to recruit for this position, it did not get filled successfully until the end of 2008. (Notwithstanding the delay in successfully filling the position, the Administrator made significant inroads into the finances of the Home in 2007 and 2008, which resulted in the Home coming in under budget in 2008 to the tune of $300,000).

The corporate Finance Department enhanced its support to Rideaucrest Home when requested by management staff in budget performance monitoring, and review of emerging financial issues. That support, although limited in scope and duration, greatly assisted the Administrator and other managers in addressing financial challenges.

Zero-based Budget Review Unexpected and substantive variances in budget performance in the years leading up to the development of this improvement effort in 2007, particularly in the nursing department, were prominent indicators suggests that immediate corrective action was required. In the fall of 2007, all departmental budgets were rebuilt for the 2008 year from base zero. Working with corporate Finance staff and hired experts in the field of long-term care finances and labour management, the Administrator and her team dismantled and rebuilt the departmental budgets.

Assumptions that had been long embedded in the budget were challenged and in many cases modified, calculations underwent rigorous verification, ' and discrepancies were identified, researched and corrected. As a result, the budgets have a new defensible precision and better reflect the true requirements of the Home and our obligations under legislation and collective agreements. Each successive year, with the assistance of the corporate Financial Analyst, the budgets are refined further to meet changing needs and circumstances.

1 8 I P a g e


Interim Cost Containment Plan Continued A cost containment plan was introduced in the nursing department in 2006 in an attempt to constrain a projected sizeable budget overrun in the nursing department for that year. This involved the strategic reduction in available part time staff hours through reduced vacation and sick time replacements and call-ins. It had the intended effect without offending Ministry staffing or care standards. It must be noted that even with this reduction in part time staffing levels, the nursing department's staff to resident ratio remains among the most favourabte in the sector, as noted by the Hay Group.

The containment strategy remains in place today. Management continues to monitor the effectiveness of this strategy in connection with enhanced attendance management practices to ensure impacts on levels of service to our residents and staff workload are within acceptable limits. Staffing levels and work assignments remain a significant issue in the Home, and will be the focus of considerable attention in this change agenda going forward.

Program and Process Efficiencies Created In 2007 management and staff began looking for additional operating efficiencies in a variety of areas within the Home. Major efficiency initiatives undertaken along with other recovery actions included:

Elimination of part-time Accreditation Coordinator function (staff redeployed) Air Handling Equipment Enhancements to reduce operating costs Part Time Policy Development Position Eliminated (staff redeployed) Reviewed and reduced in-home printer use Tightened laundry quotas Developed strategic plan for home Reviewed and revised on-call and call-in protocols

These initiatives either reduced costs or contained cost increases in the operating budget in the order of about $250,000 heading into the 2008 budget cycle.

Job Descriptions Review A review of current bargaining unit job descriptions within the Home was undertaken with the assistance of human resources expertise. In addition, a new performance appraisal tool was developed. Clarity of roles and responsibilities, clarity of employer expectations of employees, and constructive performance feedback processes are essential elements in developing and sustaining an engaged and motivated workforce. Work in this area will continue in future years in an effort to strengthen the workforce and create a culture of engagement within the Home.

Professional Advisory Committee Established A-review of the Home's internal committee structure was undertaken and as a result, the Medical Advisory, Infection Control, and Pharmacy and Therapeutics Committees were

. merged into one forum - the Professional Advisory Committee. This clinical body enhances communication and decision-making and eases the administrative burden required to

-19 IP a g e


support the former committee system. This constituted a significant realignment of administrative energy and resources.

Space Review The Administrator commissioned a review of the Home's space allocation practices and service needs. A multi-year plan was developed to improve space usage in areas such as administration, kitchen, restorative care, and on the nursing terraces. Ontario Safety Association for Community and Health Care

Other Notable Improvements

rn

m

m

m

m

In 2008,

Redeveloped Fire Plan (2 year project) Purchased evacusleds (46) for Wellington Terrace and Crestview - emergency prepared ness Morgan Scott, our supplier for sanitary hygiene cleaning products audited Housekeeping dept and presented Home with Green Certificate in February 12 week project with Alzheimer's Society and H'art Studios to paint murals in Gardenwalk terrace OAMHSS AWARD for Reflections on Caring: a video for families on our Resident Centred Care program Opening of Secret Garden June 2007 Presentation on Culture of Excellence by Lutherwood Services Established a Signage Team to review posters/signs/etc in the Home New front reception area furniture for entrance of main lobby and staff entrance Piloting mailboxes for each terrace for easy access by residents

Year Two Accomplishments: 2008

the first full year of the improvement plan implementation, efforts continued on strengthening the administrative and management fundamentals of the Home': strengthening the management level of the organization through the hiring of key positions; providing management training and educational opportunities, and; ensuring the Home had credible administrative policies and standard operating procedures. It is notable that difficulties in recruitment for management vacancies plagued and slowed the effectiveness and timeliness of many change initiatives through 2008. The following major initiatives were undertaken:

Rideaucrest Strategic Plan A new strategic plan for Rideaucrest was developed to serve as the broad road map for developing the organization over the next few years. It is treated as a "living document" and is intended to be revised and updated to reflect changes in Rideaucrest Home's internal and external environment. The elements of the plan are discussed in Section 3 of this report.

Scheduling Review In conjunction with corporate Human Resources, the Canadian Union of Public Employees (CUPE) and the Ontario Nurses Association (ONA), a review of the staff scheduling practices within the Home was undertaken in an effort to address long-standing labour and

2 0 I P a g e


management concerns regarding fairness, efficiency and effectiveness. Some progress was made in what is an exceedingly complex issue. There is, however, a significant amount of work yet to be done in this area over the coming years as part of this service improvement initiative. All parties are committed to making improvements that not only will enhance the effectiveness and efficiency of the Home, but will provide employees with an improved work environment and quality of life outside of the workplace.

Nursing Leadership Review and Training The Home committed new money and time to assist our nursing leadership team (both unionized and non-union) in honing their considerable skills and expertise to meet the increasingly complex demands in the long-term care field. The initial uptake of this program among staff was disappointing and management is developing strategies to increase participation among the registered nurses and registered practical nurses.

Resident Satisfaction Survey Initiated An annual survey process to gain residents’ feedback on key indicators such as quality of food and care was developed and initiated in 2008. Timely, verifiable feedback from residents and families is required to ensure that the quality of care in the Home remains high and that the scope of services offered remains relevant.

The survey consists of 22 questions, administered in person to residents over a two week period in October of 2008. One quarter of the residents, chosen at random, were interviewed by an independent third party (Rob Wood of 80/20 Info Inc.). Questions ranged from queries about overall satisfaction with life in the Home to specific questions about food, cleanliness, activities and decor. A report analyzing the survey results was released to the public and council in early 2009. Key results include:

J 87% said Rideaucrest is a comfortable place to live J 82% said Rideaucrest staff are friendly and helpful J 81 % are happy with the way they are treated J 79% found the decor attractive J 79% were happy with the medical long-term care received J 70% were happy with the.food

The level of satisfaction among residents is high and management and staff are intent on maintaining or improving on these results. The report provides important insight into areas for improvement, which will form the basis for future improvement work. Our aim is to improve satisfaction with food to at least 80% and maintain an overall satisfaction rating of at least 85%.

Review of Spiritual and Pastoral Long-term care Rideaucrest Home makes available a range of spiritual and pastoral care services to those residents and families that wish to participate. This is a discretionary service funded by the city that distinguishes Rideaucrest from other Homes. A review of this service area was conducted by an independent third party in 2008. The review concluded that the spiritual

2 1 I P a g e


services programming is valued by residents and their families. The consultant’s report was -

presented to Council. -I Attendance Management Employee absenteeism is excessive at Rideaucrest Home. This has been a long-standing issue that has challenged management for many years. Staffing costs (salary, wages and benefits) comprise 82% of the Rideaucrest annual operating budget. As a “24/7” health care facility] the operational implications and financial costs of high absenteeism rates are substantial. Finding ways to reduce absenteeism therefore is an important strategy to reduce costs and bring operational stability to the Home and has been a priority consideration of the Administrator since her arrival in 2005.

In 2008, the rate of absenteeism at Rideaucrest averaged about 19 days per employee. The average for the city corporation was about 6 days. The average for the long-term care sector in Ontario is about 9 days. If the rate of absenteeism at Rideaucrest could be reduced to be more in line with the industry average, significant budgetary savings would be had, along with improved productivity.

Long-standing excessive absenteeism is often a symptom of broader organizational issues and ills. For example, it may be the result of: the sick leave provisions of the collective agreements; insufficient or ineffective management and supervision; ineffective attention to disciplinary actions; a lack of clarity as to corporate expectations for employees; excessive workload; poor health and safety policies, practices and training; bullying or harassment in the workplace; and/or, an embedded workplace culture of acceptance and entitlement.

Managing attendance and reducing absenteeism is the key to financial and operational effectiveness and stability of the Home. Training related to the introduction of a new corporate attendance management and return to work program was initiated at Rideaucrest in late 2008 - a needs apessment was completed, training was provided to management staff and an orientation to the corporate attendance management program was conducted with staff. Full implementation of the program was delayed until 2009 to enable corporate Human Resources to retain the necessary labour management expertise to properly execute and support the plan within the Home. Strengthening our attendance management processes and practices continues] and will be a primary focus of future human resource planning, as described later in this report.

Financial Strategy - Maximizing Provincial Subsidy In 2008, the key piece of the financial strategy for Rideaucrest was to find ways to maximize provincial subsidies and specialized grants available to the Home. We took advantage of provincial funding changes and management was vigilant in seeking funding opportunities. We are pleased with the results to date. We have seen increases across all funding envelopes, particularly in dietary

Particular attention was given envelope, since nursing is the

- services and nursing.

to maximizing the nursing and personal care funding biggest cost centre for the Home and the area with the

22 I P a g e


Year CMI

greatest potential to increase provincial funding. The level of funding in this envelope is tied to the assessed care needs in the Home and the numerical rating assigned to the Home by the Province for this purpose - known as the Case Mix Index (CMI), as described in Section 1 of this report.

2003 2004 2005 2006 2007 2008 96.15 102.00 100.89 99.92 95.12 99.84

Table 1 below shows the annual CMI ratings for the Home since 2003. It is notable that the rating of the Home dropped 6 points from a high of 102.0 in 2004 to a low of 95.12 in 2007. On its face, a reduction in the CMI would lead one to conclude that the care profile of the Home was improving; that residents were less in need of nursing and personal care interventions and services. Yet we know that the residents are entering the Home older, frailer and in increasing need of medical and nursing supports.

Table I - Rideaucrest Home CMI 2003-2008

In its review, the Hay Group observed that the care profile of residents at Rideaucrest does not differ from most other long-term care facilities and on that basis concluded that the CMI for Rideaucresbought to be higher. One would expect the rating, all things being equal, to be around the 100 mark, given the resident care profile of the Home. This led the management team to conclude, after careful review, that our charting and documentation practices were the principal source of this decline in the recorded CMI.

Experience has shown that attention to resident care charting and documentation is the key to an appropriate CMI rating. In 2003, for example, when faced with a similarly low CMI, the Home hired a consultant to work with management and staff to improve charting procedures and practices (common practice among long-term care providers). As a direct result of that effort, the CMI improved by 6 points in 2004. Unfortunately, with staffing and management changes in the intervening years, and increased provincial competition for available funding, the CMI for the Home declined annually thereafter.

Ensuring that Rideaucrest is doing everything in its power to maximize provincial nursing care subsidy is critical to the financial health of the organization. Each additional point on the CMI translates into about $45,000 of provincial subsidy to cover nursing and personal care costs. In the absence of a sufficient level of provincial nursing and personal care subsidy, the city must either reduce staffing costs to reflect available funding or increase the city’s contribution to the operation of the Home. Continuing to add more staffing resources was not an option, given the city’s budgetary strain. To that end, management hired a specialist in this field to work with staff to improve charting and reporting practices and protocols.

2 3 I P a g e


For the modest outlay of $18,000 for consulting assistance, management and staff were successful in increasing the CMI by 4.72 points, which will yield a net increase in provincial subsidy of over $200,000 beginning in 2009. Not to repeat the experience of 2004, procedures and training have been put in place to ensure that we sustain the necessary level of rigor in our charting practices to maximize available funding and provide the best resident care possible.

Improving Communications Timely, accurate information is the life blood of any high functioning organization. The Administrator continued to implement new or improved reporting and communication mechanisms in 2008 to provide residents, families, staff and members of council with information necessary to understand what is happening in the Home and be able to make decisions accordingly. Since 2005 the Administrator has implemented periodic newsletters to the Rideaucrest community, administrator communiques to update parties on ongoing activities and issues in the Home, regular reporting to the Commissioner on operational issues, departmental town hall meetings with staff, regular all staff meetings, weekly updates to Council, providing computer access and training to all staff, one-on-one conversations with parties and an open door management policy have all contributed to a significant increase in communications and information flow within the Home and to interested parties outside the Home. It is appreciated that communications strategies must continually be reviewed and renewed. The Administrator and her team are committed to seeking improved

. ways of keeping all interested parties informed.

Management Training A variety of enhanced management training opportunities were made available during 2008 and will continue to be offered going forward in an effort to strengthen the management capacity in the Home. The training is focused on the issues being faced by managers and supervisors in the Home, such as labour management, attendance management, health and safety, leadership, communications, customer service, etc.

Performance Indicators and Standards Quality and service performance is multidimensional and difficult to measure. Indicators, while not a direct measure of quality, can quantify the occurrence of an event or outcome and help raise meaningful questions about the care and service provided, especially during a time of organizational redesign such as is the case at Rideaucrest. The Administrator introduced a management system of performance measurement and continuous quality improvement upon her arrival and has been making strides year over year to embed performance management thinking into the culture of the organization consistent with accepted leading practices in the health care system. Developing and reporting on key indicators of performance is ongoing. Significant work has been done to date and a significant amount will be required in future as the province moves to institute new performance accountability measures within the long-term care sector. It is encouraging that Rideaucrest has been "ahead of the wave" in this regard. In section 3 of this report there is a

24 I P a g e


discussion on performance management and Appendix B provides a summary of some of the performance indicators and benchmarks being used to monitor and evaluate our ongoing performance.

As noted in the background section of this report, the Ministry of Health and Long-term Care requires all long-term care facility operators to comply with 460 standards and criteria governing resident care and other programs and services. The listing is too extensive to include in this report, however it is available for review in the office of the Administrator or Commissioner.

Life Cycle Asset Management Introduced As part of the city’s asset management program a comprehensive life cycle management plan for the capital assets at Rideaucrest is being developed. The intent is to ensure that a proper maintenance and replacement program together with a complete multi-year financing plan is put in place for all capital assets and building systems. This issue becomes increasingly important as the capital assets of the Home approach the end of their design life and require repair or replacement. Examples include: mechanical, electrical, structural systems, etc.

At present about $300,000 is allocated to the capital needs of the Home annually from the operating budget. This typically only meets the annual capital requirements of the Home. Not enough money is being set aside presently to fund the capital refurbishment or replacement needs of the Home. Work continues with our colleagues in other city departments to create an asset management plan that will then serve to guide capital investment planning. As a tentative first step, recognizing the plan is not yet in place, the annual contribution from the operating budget to the capital reserve was increased by $50,000 beginning in 2009. Further reports on this will be coming to council in the future.

Policies and Procedures Review In 2008 the Administrator initiated an extensive and systematic review and update of policies and operating procedures and practices across the Home. Notable work undertaken in 2008 included:

e Occupational health policies and procedures revised Infection control policies and procedures revised Health and safety strategies introduced

e Home-wide risk analysis and reporting introduced New nursing management model completed and approved

25 I P a g e


Year Three Accomplishments: 2009

Over the course of 2009 management and staff have continued to strengthen policies, processes and procedures across many areas of the Home. Developing and sustaining adequate management capacity remains an ongoing challenge. By year end, it is expected that most major management and operational processes and procedures will have been reviewed and refreshed or well on the way to the desired level of completion, effectiveness, efficiency and stability. Notable initiatives undertaken to date this year include:

Governance Completion of Policy and Procedure Manual development for each department within the home, notably:

0

0

0

0

0

0

0

0

New housekeeping and laundry policies and procedures manual New maintenance policies and procedures created Revised dietary policies and procedures New Restorative Care policies and procedures initiated New Life Enrichment policies and procedures created New Volunteer policies and procedures being created New nursing policies and procedures being developed New Infection control policies and procedures developed

= Working with peer providers and our sector association to develop and obtain performance benchmarking data Developing accountability agreement with Local Health Integration Network

= Created annual report and DVD of 2008

Financial Management Each year improvements have been made to promote more efficient and effective use of resources, to engender greater transparency and accountability through better reporting and monitoring of financial performance, and to sustain efficiency savings. In 2008/2009, with the support of corporate Finance staff, key strengthening initiatives have included:

Year-long implementation of new provincial Resident Assessment Instrument, which will form basis for new provincial funding model Special grant opportunities yielded about $100,000 for the creation of two new nursing positions in the Home, as well as taking advantage of special high intensity needs funding Budget analysis and cost reduction scenarios developed Enhancing systems of internal control and accountability

= Improving reporting systems to promote regular monitoring and discussion of budgets = Providing group and individual training on the use of-financial systems and reporting tools

Making managers ‘risk-aware, through formal risk workshop initiatives. Documenting threats to the achievement of departmental and overall objectives, considering the impact and likelihood of these risks. Developing actions plans to prioritize resources accordingly

2 6 l P a g e


m Developing performance management indicators to better inform management of areas where attention should be focused and to challenge poor financial performance when it happens

* New policies and procedures developed and implemented

-1

Operational efficiencies Implementation of continuous quality improvement strategy and processes Home-wide Redeveloped the coffee/gift shop to enhance revenue generation and customer satisfaction Permanently converted Conference Room A to house enhanced restorative care program

m All dietary staff certified in food handling = All life enrichment staff certified in food handling = Staff scheduling changes made to improve care/services to residents and for service

improvements; further discussion with unions underway Staff satisfaction surveys initiated (annual schedule) - life enrichment, housekeeping and laundry completed this year Safety engineered needles policy/procedure and program implemented

Staff structure and roles = Hired and oriented new Manager Nursing Services

Hired and oriented new Resident Care Coordinator (registered nurse) = Developing a nurse recruitment strategy with corporate Human Resources department = Converted part time Nurse Practitioner position to full time status to leverage 50%

provincial funding and improve effectiveness of resident care Completed clinical and operational review of nursing department - implementation strategy being developed for roll-out in 201 0 As recommended by the Hay Group, a human resources manager was hired and oriented to the Home. This corporate resource is dedicated to Rideaucrest to assist with labour management issues over the next few years Revised orientation program to include mandatory training for all staff Realigned nursing management structure to meet labour management demands; created additional nurse management position, which was the original recommendation of the Hay Group. The recruitment processes are underway in the fourth quarter.

Resident programs and services Home-wide review of Power of Attorney policies and processes initiated and well underway, to bring greater accountability to our processes

m Reinvigorated the Family Council, and working to develop leadership within the council Reviewed concerns about residents’ weights - dietary action plan developed

= Created a Resident Orientation Guide (a first for the Home) *-Created a virtual tour of the Home on city website to assist families and individuals

making resident placement decisions Annual resident satisfaction survey conducted

2 7 I P a g e


Resident Safety Plan under review - . Extensive landscaping and outdoor feature enhancements for staff and residents completed in partnership with AuxiliaryNolunteers Purchased garden furniture (benches; chairs and tables and pergolas (2) for residents

9 Plans to purchase new dining room furniture for all 4 terraces pending council approval of vendor with 2009 and 2010 capital budget plus some donation dollars

Decision-making and communication processes Participation in long-term care telemedicine project with province underway

9 Emergency procedures revised Pandemic plan being revised along with business continuity considerations . Infection control measures strengthened Home-wide roll-out of ethics training for all staff

= Developed Home-wide strategy to enhance health and .safety policies, procedures and practices through Joint Health and Safety Committee Developing an Education Plan for management and staff

= Developed a “Good Catch policy and program (re: workplace safety “near misses”) . Staff in-services re: bullying in the workplace and team building conducted Home-wide = Developed and implementing Human Resource Plan for the Home, including attendance

management strategy 9 Gentle Persuasive Techniques initiative rolled-out Home-wide

Strengthened joint health and safety committee process Drafted Code of Conduct for Visitors as well as staff . Prepared bullying in the workplace survey tool-survey awaiting results

Risk Management Managing risk of all types - financial, operational, managerial, environmental, etc - is the key to improving the operational stability, the effectiveness and efficiency of any organization. In partnership with our corporate Financial Analyst, corporate HR and the joint health and safety committee, management has developed a comprehensive risk management strategy and implementation plan for Rideaucrest Home. This is a significant piece of work for the Home and the corporation and positions the Home well to address issues proactively and in a collegial manner with all stakeholders.

Rideaucrest also has reviewed and enhanced its occupational health and safety standard operating procedure. An independent program audit by the Ontario Safety Association for Community and Health Care lauded the strength of our program:

2 8 I P a g e


~~ ~

“Notwithstanding the fact that the lost time injury frequency is above the average for long-term care homes, the organization does appear to be well positioned with respect to health and safety. Activities at the home are very positive and the health and safety program is well developed. In fact, the organization is mature enough that consideration should be given to exploring opportunities for more sophisticated health and safety management system that supports a positive culture of health and safety. The culture of the home is one that supports the notion of due diligence. Much of the necessary and important data and record keeping that the organization currently performs supports a culture of due diligence.

At Rideaucrest it was noted that objectives have been established for health and safety, as outlined in the ”Health and Safety Strategies” document of 2008/2009. This document represents an excellent example of an organizational action plan for health and safety improvement. Building and sustaining a culture of safety oat a workplace should be considered a continuous activity. It is not a simple process and will require constant and consistent attention over a long period of time, offen many years.

The current “Risk Summary”report for reporting on safety objectives and indicators to the City department responsible for the home is a positive feature of the organization, and is well constructed. The ”Health and Safety Strategies, 2009/2009 document prepared at Rideaucrest to guide health and safety is an excellent document in its own right, and represents a thorough plan of action toward improving health and safety. These types of documents are a visible reflection of portions of the Plan-Do-Check-Act cycle at work.

Since the organization has already implemented a number of key features of health and safety management system it may be an opportune time to review some of the formal guidelines that exist related to health and safety management systems and start modeling future health and safety initiatives on these tools. An important feature of health and safety management systems is the further develop a safety culture at the organization. Considerable effort has been made in the past year to see policies and procedures manuals reviewed, revised and updated.

- Ontario Safety Association for Community and Health Care September 2009

2010 - A Watershed Year The fourth quarter of 2009 marks a significant watershed in the ongoing drive to bring operational strength and cost effectiveness to Rideaucrest Home. With much of the foundational work completed or well on the way to completion (notwithstanding our ongoing nursing recruitment and retention challenges), more attention will now begin to turn towards broader organizational and human development issues that will better position the Home to meet the challenges of the future. But even as the focus of attention begins to shift, significant work must and will continue on a number of operational matters, primarily around revenue development (rental of non-resident space, parking revenues, fund-raising strategies, resident co-payment review, and space alterations to gain efficiencies), finding further net savings through operational efficiencies, and strengthening our’management team.

2 9 I P a g e


Change has a considerable psychological impact on the human mind. To the fearful it is threatening because it means that things may get worse. To the hopeful it is encouraging because things may get better. To the confident it is inspiring because the challenge exisfs to make things better,

King Whitney, Jr.

An Organiza tional Development Approach As we work towards bringing Rideaucrest Home to a more acceptable and sustainable level of operating efficiency and effectiveness over the next three to five years, we have adopted an approach called an integrated organizational development framework. Organizational Development (OD) refers to a planned program of change that focuses on permanently improving the effectiveness of the organization, its processes, and in particular its people. An OD approach takes the long view to improving performance; it avoids the temptation of the “quick fix” and it discourages the singular focus on one element of change in isolation from the others.

To be sustained over the long-term, change must be meaningful to and be accepted by those people who are affected by the change. To be meaningful and accepted] the change process must be a respectful dialogue between interested parties; a dialogue that is allowed to evolve, providing all stakeholders with the opportunity to be part of the process and to influence the outcomes of that process. This takes time, careful planning] patient and sensitive management, attention to ongoing and frequent communications aimed at engaging staff and other stakeholders, and an acceptance that change can at times be confusing, exhilarating] frustrating, rewarding, unwieldy, often slow and sometimes shockingly fast.

The Strategic Framework It is important for the development strategy at Rideaucrest Home to be consistent with and rooted in the strategic framework that has been adopted by the City Corporation to guide its overall corporate development. Elements of the corporate strategic framework that are guiding the Rideaucrest development plan include:

Corporate Strategic Plan The City of Kingston is striving to become Canada’s most sustainable community, and has adopted a “four pillar” model for weaving the principles and practices of susfainability into every decision-making process within the city corporation and the broader community. If we are to become an organization that strives to meet the needs of present generations without compromising the ability of future generations to meet their needs,

3 0 J P a g e


then every decision made must have regard for the economic, environmental, cultural and social ramifications over the short and long-terms.

In keeping with the overall objectives of sustainability, the city corporation has adopted a strategic plan to guide its corporate decision-making over the next three years. The plan has been shaped by a community vision, the priorities of city council, our corporate mission, vision and values, and by municipal strategies and initiatives.

Corporate Sustainability Statement The Corporation of the City of Kingston will provide goods, services and infrastructure in a manner that values, protects and enhances the quality of life and place for our citizens while ensuring that we do not impede the ability of future generations to prosper. The city is committed to conducting its business in a manner that:

1) Is affordable for tax payers and purchasers of services while not allowing future generations to be burdened by debts or deficits that they cannot afford to bear or from which they derive no benefit

2) Values, protects and enhances our natural assets 3) Supports citizens’ access to services and opportunity needed to live healthy and

productive lives with freedom, dignity and security 4) Values diversity

The Organizational Development Framework for Rideaucrest Home will strive to align operational goals, objectives and activities within the Home with the strategic direction of the city corporation.

Rideaucrest Strategic Plan . Rideaucrest Home developed a strategic plan is the spring of 2008. This is meant to be a “living document” that evolves as needs and circumstances change. In April 2009 a cross section of management and staff, including representatives from corporate human resources, met to begin working towards an integrated change management strategy to guide the Home over the coming years. The first step in moving foward at a strategic level is to assess the present and look forward with an eye to emerging issues and trends. The following organizational strengths, challenges, opportunities and threats were identified in the strategic plan and validated again in 2009 as part of this development process:

Current State of Organization

Strengths: Seasoned, dedicated staff and volunteers Quality care Municipal resource base Salaries and benefits Site and physical facilities Lo cat ion History and tradition in the community

3 1 I P a g e


a

Challenges: Staffing levels and workload 3 Internal communication Need for teamwork, interdisciplinary approach Morale issues Residual negative publicity from budget and organizational review

Future State of Organization

Opportunities: Expanded partnerships More family engagement Increased profile and outreach Research and academic links New revenue sources Potential for site development

Threats: Competition with other corporate priorities Consumer demands Increasing regulatory and compliance requirements Increasing resident care needs Nursing shortages Staff burnout Unknown impact of the LHlNs

Organizational development efforts going foward will build on our strengths, address our challenges, capitalize on opportunities and be mindful of known or anticipated threats to success. The strategic plan sets out the following:

Our Mission The management and staff of Rideaucrest Home are committed to enriching the lives of people who require the long-term support of a safe and caring community in which all voices are valued and personhood and dignity are respected.

Our Vision To be recognized as a centre that balances a quest for excellence and innovation with the goal of supporting people to live mbaningful lives.

Our Values

Respect & Dignity

Each person is a whole and unique human being with rich individual life experiences, dignity and worth.

32 I P a g e


m Knowing each resident is fundamental to providing care with respect and dignity . A fundamental human need exists for opportunities to continue meaningful connections and to form new relationships

m Each person has the potential to lead a meaningful life Each resident should be supported to lead the delivery of her or his own care by making informed choices in the context of individual values

Compassion - Compassion comes from caring relationships that are based on trust, understanding and sensitivity Compassion requires an approach that consciously seeks the resident’s perspective about what matters Compassion prevails when we listen to the voice of each person, respect what they say is important and then act on what is important

Excellence

Excellence is best achieved through partnership with members of our own community (residents, families, volunteers and employees) and with members of our broader community including learning institutions, social and health care agencies, community groups, and the city corporation Seeking excellence means that committed people reach beyond what was ever thought possible Excellence is fostered by a culture that values openness to change, innovation, communication, networking and life-long learning Excellence in care must be viewed through the eyes of the resident and family

. =

. Accountability

m Rideaucrest Home, which is in a position of trust as a public service offered by the City of Kingston, must have the foresight to respond to the changing needs of the broader community it serves We are accountable to provide a safe, respectful and healthy environment for all residents, families,. volunteers, students and employees. We are accountable to enrich and develop our greatest asset, that of human resources, through learning and leadership opportunities It is our responsibility to foster a culture that recognizes contributions to compassionate, excellent, dignified and respectful care Rideaucrest Home is accountable for fiscal responsibiiity in service planning and implementation.

m

.

33 I P a g e


-B Strategic Goals The organizational goals for Rideaucrest, as set out in the strategic plan are: -3

Resident Care and Services

Provide resident-centred coordinated care for all aspects of resident life

Utilize current and best available evidence for the development of policies and practices To foster an abilities-focused environment for residents, families and staff Increase academic linkages for research and education to advance quality of care

I Focus on resident safety

Successful implementation of the care and services goals will result in Rideaucrest being a Home that consistently delivers personalized, safe and progressive care that facilitates meaningful lives for residents and their families.

Organizational Development Foster an environment of trust, communication, respect, self- confidence and innovation that builds teamwork, solution seeking and a commitment to resident care Train, develop and recognize staff to meet standards and legislative requirements, promote growth, achieve goals and acknowledge achievements Grow, develop and support the Rideaucrest volunteer base Improve recruitment and retention by continually educating and promoting Rideaucrest as a long-term care employer of choice Promote a culture of health, safety and well-being Achievement of these goals will establish Rideaucrest Home as a dynamic and positive long-term care facility with a responsive interdisciplinary team of well skilled staff and volunteers that work cohesively to provide quality care with a focus on resident safety

Outreach and Profile

= Identify the needs of the long-term care population in our service area and target services to meet those needs

= Enhance community relations through media relations and community events Collaborate and partner with other long-term care facilities, agencies, health care providers and academic institutions to enhance services, achieve joint goals and fulfill and share our vision

34 I P a g e


Achievement of these goals will lead to Rideaucrest being recognized as an innovative forerunner in care and service provision to its target population

Resources

= Increase donor base Achieve efficiencies

= Promote “green” policies and practices that are environmentally sustainable Ensure the optimal utilization of staff and volunteer skills and contributions .

= Optimize space utilization m Enhance physical environment for staff and residents

Achievement of these goals will elevate Rideaucrest as a recognized leader in efficiency and resource utilization.

The Provincial Reform Agenda - The Sharkey Report As noted in Section 1 of this report, the province is introducing sweeping reforms to the long- term care sector. The emphasis of the reform is on quality of resident care. In 2007 the province commissioned an independent review of staffing and care standards across the sector in response to longstanding complaints about inconsistent and insufficient staffing and care standards in long-term care in general. The province is using the recommendations of the Sharkey Report as the basis for new regulations being drafted under the new Long-term Care Homes Act.

2

Sharkey recommended that the Ministry of Health and Long-term Care strengthen the accountability of long-term care homes for the provision of quality care by linking resources to resident outcomes through the measurement of quality of care and resident and staff satisfaction. Establishing standardized province-wide tools and processes that regularly measure and enable public reporting has been recommended in the following areas:

. = Resident and family satisfaction = Staff satisfaction and engagement

Resident quality of care outcomes based on quality indicators (such as functional status, continence, falls, wounds, pain, nausea, dyspnea)

The organizational work that has been done at Rideaucrest Home since the Hay Group report was received is consistent with and supportive of the thrust of the new provincial change agenda; in fact, many of the actions we have taken in recent years and are planning to take over the coming years are considered leading practices in the long-term care sector and are expected to be mandated in new provincial regulation over the next year or so. Moving forward, we must be mindful of and respond to the province’s health care reform agenda.

.

3 5 I P a g e


Rideaucrest Organizational Development Framework (2009-201 2)

The overall goal of our organizational development strategy for the next three years is stated below:

Rideaucrest Home will be acknowledged by 2013 as an effectively managed, efficiently operated municipal long-term care facility; an

employer of choice that provides quality resident-focused care.

To achieve this desired future state, corporate and departmental decision-making processes (strategic, managerial and operational) that affect the Home must balance and integrate three key organizational considerations, namely: resident care; human resources and public accountability (see Figure I ). Broad strategies to address each element are described below.

Figure 1- Organizational Elements

The Rideaucrest Home’s development strategy for the next three years is rooted in the corporation’s drive to become a “Talent Organization”. Talented, motivated, engaged employees are critical to corporate performance and success. A positive employee relations culture is created by leadership providing accountability, resources, information and support to employees (see Figure 2).

-

36 I P a g e


Figure 2 - Elements of a Talent Organization

Performance

Health & Safety Compentencies Client Services

The human resource strategy over the next three years involves the following general theme areas:

1. Enhancing positive communication systems, culture, and accountability (role & process clarity)

2. Strengthening Human Resources practices, processes and capacity 3. Strengthening management and employee/union relations 4. Improving workplace health, safety and wellness .

With the assistance and guidance of the corporate human resources/organizational department, specific annual human resource work plans with milestones and clear accountabilities will be developed to help focus and manage this improvement initiative, evolving as needs and circumstances change.

Staffing Plan and Evaluation Process: Particular attention will be paid over the next three years to ensuring that staffing resources in the Home are appropriately aligned to efficiently and effectively:

J Serve the care needs of the residents in the Home J Fulfill the service and budgetary expectations of council, and J Comply with provincial regulation and direction.

3 7 l P a g e


Sherwood Manor 107 Beds

Table 2 provides a comparison of staffing at Rideaucrest with selected municipal homes in the area.

Full Part Time Time

RN 1 9 3

RPN 7 8

Table 2: Comparison of Staffing Levels for Some Area Municipal Homes

F T 10

47

48

71 58

49 50 41

35

53 63 44

I HOME I NURSIN(

90

53

52

29 42

51 50 59

65

47 37 56

HOUSEKEEPING LAUNDRY MAINTENANCE

2 5 29 71 0 2 0 100 1 0 100 0

I I I

Fairmount I RN 1 5

PSW

I I PSW I 33 I 34

2

19 21

I I

DIETARY

HOUSEKEEPING

I I I Rideaucrest I RN I 10 11 25 31 69

12 12 50 50

1 I I I

LAUNDRY MAINTENANCE

2 0 100 0 2 1 67 33

SUPPORT STAFF Percentage

DIETARY

SUPPORT STAFF D *..-- >I DIETARY

I I 2Casua1 I 1 I I I I

DIETARY I 7

DIETARY 113 115 146 154 I I I I I

HOUSEKEEPING I 13 I 14

Presently, each facility in the province determines the level and type of staffing that it provides to its residents based on the assessed needs of each resident and available resources, subject of course to collective agreements and provincial standards. It is our intention to review the staffing plans for Rideaucrest to ensure:

Continued management capacity strengthening = The allocation of staff resources to “hands on” resident care and individualized care

based on resident needs = The assessment and provision of indiiiidualized care needs based on a team approach

that involves the various health and support professionals that provide care and facilitate programs

38 J P a g e


= Consistent provision of staff learning and development opportunities, including on the job

= Strengthening of leadership capacity at all levels in the organization = Successful recruitment and retention of registered nurses

Greater staffing efficiencies while maintaining staff safety and resident satisfaction = Integration as may be appropriate with the regional planning objectives of the Local

Health Integration Network

. - mentorship and coaching time f

It is anticipated that over the next year or two the province will establish standards and expectations for staffing arising from the recommendations of the Sharkey Report noted earlier. One of the key areas of policy development at the provincial level for application locally is in creating a standardized system for evaluating and validating the impact of staffing increases on resident outcomes, quality of long-term care and quality of life.

As noted in the Hay Group report, the staffing levels at Rideaucrest across most service and program categories well exceed existing provincial requirements and long-established norms within the municipal and charitable long-term care home sector. These established standards and norms along with any new standards arising from the implementation of the Sharkey report will serve as the benchmarks by which we assess the staffing needs of the Home over the next three years and align those needs with our financial constraints. This is discussed further in the Public Accountability Strategy section of this report.

The Recruitment Challenge Across the health care system there is a chronic shortage of registered nurses, at both the clinical and administrative/management levels. This is particularly the case within long-term care. Competition for this specialized skill set is intense among service provider organizations and is increasing exponentially. The city corporation realizes this critical and ongoing staffing need at Rideaucrest. The Human Resources/Organizational Development team is working with the Rideaucrest management and our collective bargaining agents to develop and execute a nursing recruitment and retention strategy. This is critical to the operational stability of the Home and the ongoing comfort and safety of the residents. Wages and benefits, working conditions, work load, organizational culture, corporate supports, professional development and. quality of life in the community are all factors that must be aligned to attract and retain quality individuals. Addressing these issues in a proactive and integrated fashion, as we are doing within this integrated improvement strategy, is the key to recruitment success.

therefore, must be at the forefront of any decision-making involving Rideaucrest and must be the prime consideration of any organizational development strategy for the Home. The province sets a wide range of resident care, service and program standards with which the Home must comply. In addition, the provincial reform agenda as noted - is driving new approaches to care and care planning.

The key themes of our resident care strategy are:

3 9 I P a g e


1. Ensuring that the Home-wide resident-centred restorative model of care, in which independence and autonomy are promoted in a home-like setting, is embraced by all employees and volunteers

2. Ensuring clinical practices are current and rigorous

3. Ensuring staffing levels skills are sufficient to meet the care needs of our residents ,

Rideaucrest Home continues to provide quality resident care. There are many initiatives underway to improve our care practices, many cited in the accomplishment section of this report. This report however does not discuss the clinical aspects of resident care as this area is regulated and compliance is actively monitored by the province.

The longer-term financial health of Rideaucrest Home and our ongoing efforts to improve its financial position are a prominent focus of the ongoing organizational development work within the Home. Rideaucrest is a $15 million operation with a net draw on the tax base of the city of about $5.5 million annually; a sizable piece of the corporate pie. In light of this and the ongoing corporate direction to lessen the burden on the local municipal tax base, it is essential to explore ways in which Rideaucrest can contribute to the corporate financial objectives without compromising the health and wellbeing of our residents and employees.

The operational review of Rideaucrest conducted by the Hay Group concluded that there are opportunities over the long- term to achieve operating savings in the Home. That conclusion has served as the driving force behind the development of the financial strategy for the Home over the coming years.

The overriding goal of the financial strategy for Rideaucrest is to reduce, to the extent possible, the municipal contribution to operating Rideaucrest Home, without jeopardizing resident care and while meeting or exceeding all provincial long-term care performance and accountability standards

I I

Specific financial objectives are:

Providing value for money (efficient and effective operations) . Developing a sustainable business model backed by key indicators and sound business systems

= Creating a positive and improving financial position that includes effective budget processes and appropriate level of municipal financial contribution

Although not the primary focus of our improvement initiatives over the past two years, significant steps have been taken to date to reduce costs or at the very least contain cost escalations to at

4 0 I P a g e


Budget

Gross Costs Net Costs

$ million

or below inflation in those areas where we have control or influence. This is demonstrated in the following data and discussion.

2005 2006 2007 2008 2009 201 0 (projected)

14.6 14.5 13.8 14.4 15.2 15.5 5.7 4.9 4.9 5.4 5.6 5.7

Operating Budget Analysis Table 3 below provides a comparison of gross and net budgeted expenditures for Rideaucrest Home from 2005 to 201 0 (projected). The data illustrates two key conclusions:

. $ millions Actual Budget Actual Budget Actual BudgetActual Budget , Total 14.7 14.6 15.4 14.5 14.2 13.8 14.3 14.4

1. The net budget amount represents the municipal contribution. The approved budget amounts show a significant stability year to year, with only a 6% increase in approved gross budgets over this period of time. This is significant given that cumulative inflation over this time was about 10%; and,

Municipal Contribution

2. The annual municipal contribution to the Rideaucrest budget in real dollars has remained relatively unchanged over the past five years.

5.3 5.7 5.7 4.9 5.2 4.9 4.9 5.4

On balance, management and staff have been successful in slowing the growth of the Rideaucrest budget to less than the growth in the rate of inflation over the past five years. In doing so, strategies to reduce expenditures and increase revenues have also been successful in reducing or constraining the relative reliance on the municipal tax base as a source of ongoing funding, primarily towards provincial funding.

To provide context, it is useful to examine actual spending patterns in relation to what has been budgeted each year. Referring to Table 4 below, the actual level of spending at Rideaucrest has declined by about $400,000 from 2005 to 2008. Over that period, annual municipal spending was reduced by $300,000. This demonstrates that as new revenues are found and expenditures reduced, the city’s contribution is being reduced accordingly. This is a significant departure from previous practices whereby annual surpluses within the Home were reinvested into the level of service being offered, which led in part to the upward growth of the Home’s budget in the late ‘90’s and early 2000’s.

Table 4 - Budget to Actual Spending Comparison 2005-2008

I Budnet I2005 I2006 I2007 12008 1

4 1 I P a g e


Reducing Reliance on Municipal Contribution Reducing the city’s financial contribution to the Home will involve a number of strategies aimed at increasing other sources of revenue wherever possible and systematically reducing. expenditures through the adoption of efficiencies. We will be striving to reduce the municipal contribution both in real dollars and as a percentage of total revenues.

Figure 3 below illustrates the relative proportion of each funding source for Rideaucrest Home. Caution must be exercised in examining the potential savings of this strategy. While it is solely at council’s discretion to contribute to the operations of the Home, it must be appreciated that the municipal contribution to Rideaucrest has been embedded in the operating framework of the Home since the mid-1800s. It is substantial and supports the wage rates and favourable staffing ratios enjoyed by the Home compared to many other facilities. That is not to say we should not look for ways to reduce the Home’s dependence on the municipal contribution, it does mean however that weaning the Home from this substantial source of revenue will be challenging and expectations of quick success must be tempered.

Figure 3

Rideaucrest Home Funding Sources

Other

L Provincial 41% I

psidents

In 2005 the city’s contribution to the operating costs of Rideaucrest was almost 6M or almost 40%’ well above any comparators in Ontario according to the Hay Group report. Since 2005, steps have been taken to reduce the municipal contribution significantly to about 37% at the end of 2008.

Over the course of the next three to five years we will be endeavouring to reduce the municipal contribution’s relative share of total through a variety of revenue enhancement and expenditure reduction strategies, which will bring Rideaucrest to a more favourable position compared to other long-term care facilities in the Province. Our objective is to reduce the municipal contribution to around 30% of total revenues by 201 3.

4 2 I P a g e


Figure 4 below, illustrates the success of our strategy to date in reducing the reliance on the municipal contribution as a percentage of the operating budget for Rideaucrest from 2005 to 2009, and projects our objective to reduce it and sustain it at a level approaching 30% by 2013.

Figure 4: Municipal Contribution as Percentage of Total Revenues

Municipal Subsidy as % of total budget 41%

39%

37%

35%

33%

31%

29%

27%

25%

2005 2006 2007 2008 2009 2010 2011 2012 2013

Figure 5 below provides a comparison of revenue streams for the Home from 2005 to 2011 (projected). This shows the steady increase in reliance on provincial subsidies and a decline in the reliance on the municipal contribution and resident co-payments. We will continue to explore and take advantage of opportunities to continue this successful strategy in future years.

43 I P a g e


Figure 5: Funding Source by Year

Funding Source by Year

2011 predicted

2010 predicted

2009 budget

2008 actual

2007 actual

2006 actual

2005 actual

0% 5% 10% 15% 20% 25% 30% 35% 40% 45%

1 pr::Eed 1 2005 actual 1 2006 actual I 2007 actual 1 2008 actual 12009 budget

I w Other 6% 6% 2% 1% I 2% 2%

W Resident 21% 20% 22% 1 23% 21% I 21%

I I

I Municipal 35% 37% 36% 34% 36% j 35%

w~rovincial l 38% I 37% I 40% :I 42% 1 41% 1 42%

2011 predicted

2%

34%

22%

42%

Reducing Labour Costs Table 5 below provides a comparison of budget categories for the years 2005-2009. The Hay Group cited labour costs as one of the primary areas where Rideaucrest Home exceeds the long-term care sector norm by an appreciable amount (due to staffing levels and wage rates), and concluded that if there are substantial savings to be had within the operation of the Home, then this was the category on which city strategies ought to focus over the long-term.

4 4 I P a g e


89,160

Table 5: 2005-2009 Budget by Category

83,000 87,000 107,200 i I 87,000

1 Medical Supplies

1,835,136

I 456,607 f Utilities I

1,227,876 1,379,001 1,461,641

1 Resident Supplies

l ~ - - - ~ - ~ ~ - -

2006 1 . 2007 I 2008 i 2009 I

92,820 115,000 118,500 118,500

421,835 366,685 434,400 443,088

I 472,500 I 540f600 I 516,400 I 479,437

*The 2006 numbers are restated as per 2007 budget template totals to remove debenture principal and interest lines.

Over 82% of the Home’s operating expenditures (2009 budget) are attributed to labour costs (salaries, wages, benefits). The remaining 12% is split between non-labour items such as maintenance, utility costs, food, supplies and other operating costs (Figure 6). It is also noteworthy to point out that 85% of the approved operating budget increase for the Home between 2008 and 2009 was due to escalations in salaries, wages and employee group benefits (see Figure 7).

45 I P a g e


Figure 6

Rideaucrest Home 2009 Budget by Expenditure Category

Res ;idel

Building Maintenance

1%

.salaries wages and benefits

building maintenance

%II Food

rn Medical Supplies

Utilities

resident supplies

13 other

46 I P a g e


Figure 7

Rideaucrest Home Breakdown by Category of Gross Budget Increase

2008 to 2009

Resident Other. 11% Supplies,'O%

Medical \ Supplies, 3%-

Food, 1%-

Building Maintenance, 0%

S ,alaries Bene

Wages and !fits, 85%

With 82% of the budget tied to staffing, it is not reasonable to expect the operating costs of the Home to be reduced appreciable without there being a significant reduction in staffing costs. As has been cited previously Rideaucrest has appreciably higher staffing levels and wage rates than comparable long-term care facilities and even some hospitals.

The staffing levels and wage rates and benefits enjoyed at Rideaucrest are made possible by the sizeable municipal contribution to the operating budget. The wage rates and benefits have been secured through collective bargaining between the city and the Ontario Nurses Association (ONA) and the Canadian Union of Public Employees (CUPE) over many years. The ratio of staff to residents at Rideaucrest is the envy of many of our comparator facility operators that operate at a lesser cost per resident per day. Table 6 below provides a comparison of Rideaucrest with some municipal homes in the area.

47 I P a g e


LTC Facility

A

B C D

Table 6 Comparison of Rideaucrest with some other long-term care facilities in region

No. Municipal Subsidy Subsidy/ No. Staff7 Ratio of Full of Subsidy per ResidentlDay of resident Timemart

Beds Resident staff Time Staff (unionized)

(4) (1) (2) (3) 253 $1,735,000 $7,000 $19 273 1.08 94/163 1:17 110 $1,610,000 $15,000 $41 119 1.08 36/75 1:20 256 $1,050,000 $4,000 $11 259 1.01 81/164 1:20 224 $2,212,000 $10,000 $27 228 1.02 93/119 1:13

76/90 1:20 72/63 1:09 11.8/99 1:08

-

-

-

Note: 1. Includes all full-time and part-time staff - management and unionized 2. Not full-time equivalencies 3. Figures rounded 4. Formula: Municipal subsidy/# of residents/ 366 days

It is noteworthy that a very recently completed survey of Ontario municipal homes by the Ontario Association of Not-for-Profit Homes and Social Services (OANHSS) indicates that the average municipal contribution to facilities the size to Rideaucrest (43 facilities surveyed with 101 - 200 beds) is $1.6 million, which translates into an average per diem of about $28. The maximum per diem among the surveyed group (Rideaucrest not included) is $84. Staff has just received this survey report and will be examining it in greater detail in the coming weeks.

Finding appropriate and accepted financial strategies within our control that balance resident care, public accountability and human resource considerations is the challenge that lies ahead. We are focusing therefore on managing our human resources more effectively and efficiently.

48 I P a g e


Managing Absenteeism One of the key areas being pursued immediately is attendance management. As noted earlier in this report, a significant portion of the labour budget covers unscheduled staff absences from the workplace (over time, sick time, etc). This is the focus of ongoing work with our colleagues in the corporate Human Resources Department, the unions and our employees. It forms one of the principal objectives of the human resources strategy for the Home in the short to medium term and ties closely with our financial objectives.

Reducing unscheduled absences to an acceptable level would ease pressures on the current operating budget considerably. To do that requires the integrated approach being pursued through this framework. It will take considerable time to see appreciable results. Moving forward, we have established annual goals for the reduction of absenteeism. Whereas the average sick time per employee currently is 19 days, it is our hope to reduce that level systematically over the next three to five years through attendance management and other culture improvement strategies, to a level that is more in line with the industry norm, currently 10-12 days. Specific targets are set annually and the budget set accordingly. This is an area of considerable risk within our budgeting assumptions if we are unsuccessful in reducing absenteeism significantly.

Staffing Considerations To achieve significant reductions in the operating costs of the Home, reducing labour costs is unavoidable. Based on the information provided by the Hay Group in its review of the Home and supplementary analysis undertaken by the Administrator we are confident in stating that budgeted labour expenses could be reduced by upwards of $1.5 million and the Home would still comply with all provincial and collective agreement requirements. By reducing the municipal contribution to $4.0 million over time, all other things being equal, the subsidy/resident/day (per diem) as cited on Table 6 would fall from $90 to about $67, which would still be in the upper range of comparable homes.

Ways to achieve such a reduction could include: reducing absenteeism to at or below the industry average; reducing staffing levels closer to industry norms; altering the mix of job classes providing resident care; adjusting the scope of practice between job classes to what is more reflective of comparable municipal homes, and adjusting work routines to find efficiencies without losing effectiveness.

There are risks to such a strategy that will need to be fully explored and understood before proceeding in this-direction. Strategies to manage the risks would need to be developed that are mindful of the impacts such change may have on levels of service currently provided in the Home and on staff morale and productivity. Staging the implementation of a reduction strategy over a number of years through such methods as attendance management, staff attrition (not filling certain positions that become vacant), retirement incentives, reclassification of positions, and as a last resort only if unavoidable - layoffs, would be the recommended way to-proceed if it is council's wish to explore these opportunities.

49 I P a g e


It would be our intent to develop a multi-year plan in consultation with our labour partners and others that would detail precisely how such a reduction strategy would unfold over a staged implementation period of up to five years. We would propose to undertake the necessary planning and consultation through the early part of 201 0 with implementation

, commencing in 2011. This would allow appropriate time to develop a precise plan, assess risks and service implications, engage the affected parties meaningfully, seek council% approval to proceed, re-design positions and work processes, and communicate broadly with affected parties, prior to implementation in 201 1.

~

1

It must also be pointed out that a reduction plan of this nature will have short term costs associated with its preparation and implementation.

Reducing Non-Labour Costs Referring back to Table 5, it is clear from the data that Rideaucrest management and staff have been highly successful in holding the line on or constraining budget increases within the non-labour categories. Finding efficiencies in non-labour areas offers some opportunities to reduce costs further or at least continue to constrain the rate by which the costs in these areas are expected to increase over time. Increased attention to asset management practices and incorporating “green” technologies into future equipment and supply purchases is expected to have a meaningful budgetary payback in reduced energy costs, as well as longer term ecological benefits. The city corporation has initiated an asset management program that includes Rideaucrest Home. .As the program is developed and upfront costs and cost savings are identified, an asset management plan specific to the Home will be developed and the 10 year capital projections and capital reserve continuity model for the Home will be revised and presented to Council for consideration. This work is expected to be completed in 201 0.

Reducing the spoilage of food and reducing waste through better management practices is also expected to improve operational efficiencies within our dietary services.

Fund Raising In 2010 and future years we will be turning our attention to how we may be able to enhance alternative sources of revenue. Fund raising and donations for example, offer appreciable revenue generation opportunities, if the experiences of other long-term care facilities are an indication. The Home has never had an organized fundraising capacity, relying solely on passive receipt of donations from families and friends. The responsibilities of the new manager of administration and finance position include fundraising as a future performance expectation. Experiences at other facilities suggest there is significant potential to be realized through a professionally developed and executed fundraising program.

Other Revenue Opportunities There are other revenue generating possibilities to be considered such as increasing the number of residents paying Preferred accommodation rates, additional fees for services now offered at no charge, increased parking charges, increased room rentals, increased space leasing, etc. Each of these areas poses challenges that may limit revenue

50 I P a g e


potential, and in the overall scheme of things it is not anticipated that there will be sign.ificant growth potential from these alternative sources; however we are committed to exploring all possibilities. Once we have assessed the potential in these areas we .will establish an annual revenue target to guide our implementation strategies.

Accounting and Risk Practices Over the next three years, the following accounting and risk management initiatives will be undertaken to improve overall operational effectiveness, efficiencies and public accountability:

The implementation of documented internal controls and policies to ensure value for money is uppermost in procurement decisions

= Improving control over spending and ensuring that expenditure budgets are not breached without prior authorization

= Re-structuring accounting and reporting methods where necessary to aid better comparisons with other Homes and to better demonstrate departmental performance with regards to cost of service versus provincial funding calculated for its provision (e.g. nursing provincial versus cost to deliver nursing services) Completing value for money exercises for large volume/value expenditure items (e.g. laundry services) to ensure that the best price is continually obtained and that service levels demonstrate good value Preparing operating budgets that meet or beat corporate budgetary target expectations (e.g. the 2% expected CPI rate for 2010), thereby absorbing wage increases in excess of this through revenue maximization and expenditure reduction Maintaining regular team meetings and budget reviews and reinforcing management accountabilities and responsibilities (e.g. through performance management programs) with regard to cost control, financial performance and meeting targets (e.g. budget limits and internally set municipal subsidy targets) . Completing and maintaining risk registers

= Enhancing costing and forecasting tools and embedding financial impact analysis within decision making

= New accountability requirements with the LHlN may require Rideaucrest and the corporation to adjust our accounting and reporting structures to comply with LHlN reporting and compliance requirements

Performance Measurement To know whether the improvement strategies are having the intended impacts on the organization it is critical to establish a system of measurements. There is no singular measure of value, so a number of proxy measures will be used to gauge the success of the recovery plan. Long-term care facilities such as Rideaucrest are required by the province to maintain a number of clinical, risk, program and service quality indicators; these we continue to compile and report to the province as required, but do not include in this report. In addition, we are or intend to monitor the following:

-

Y 51 I P a g e


= Resident and Family Satisfaction = Staff Engagemenu satisfaction

Industry Benchmarks = Health and Safety Indicators

Budget Performance Indicators Appendix B provides a summary of the key non-clinical indicators being used to date. There are a number of efficiency and effectiveness indicators under development at this time that will be implemented once we are confident in the availability and reliability of the necessary comparative data. As was noted by the Hay Group, there is a lack of good data with which to compare long-term care organizations.

. ‘Z

1

Surveys Opinion surveys provide management with invaluable insights that can influence management and operational decision-making within the Home significantly. Three survey programs have been initiated to capture the impressions, thoughts and suggestions of residents, families and staff. The results are reported annually and form part of the information used by management and staff to improve the services and programs in the Home and the workplace environment. This is an important component of the improvement strategy for the Home.

Other Measures and Benchmarks The Hay Group report indicated that much work was required to develop meaningful and accurate benchmarks by which to compare a variety of functions within Rideaucrest with comparable long-term care, facilities. Work is underway to develop such measurements with respect to hourly rates, staff mix and staffing levels. These measures will be introduced as part of this evolving development framework over the next two years. Examples of indicators to be developed, include: raw food costs per resident day; dietary costs (non-food) per resident day; housekeeping costs per resident day and per gross floor area; laundry and linen costs per resident day; building and property costs per resident day and per’gross area; nursing care per resident day and worked hours per resident day.

The Local Health Integration Network (LHIN), as part of its emerging role in planning and integrating health services in the region, is developing a series of performance indicators that will be applied to the long-term care sector through the accountability agreements it will be negotiating with each provider. Measuring performance against these indicators will form a prominent role in the province’s future planning and management oversight of this sector. Indicators are being developed in the following “domains”: fiscal health; organization health; High Quality Health Services; Compliance Status; and, System Integration.

The long-term care sector association to which the city belongs, (Ontario Association of

across its extensive membership base. The aim is to create a broad comparative data base from which member organizations can draw. Rideaucrest is an active member of this organization and its staff is eagerly participating in the data collection project.

- Not-for-Profit Homes and Social Services) is undertaking a data collection exercise

5 2 I P a g e


Governance When the new Long-term Care Home Act and related regulations come into force and effect, it will be mandatory for all municipal homes to have a committee of management to oversee the operations of the home. Current legislation is permissive in this regard. Prior to 1998 the former City of Kingston maintained a committee of management. This was disbanded upon amalgamation and operational oversight was delegated to the responsible Commissioner with reference on significant policy matters to the standing committee system of the day pursuant to council policy (currently the Arts, Recreation and Community Policies Committee). In light of the provincial legislation, staff will be presenting council with recommendations on the establishment and appointment of a committee of management in due course.

Sustaining the Improvement Framework Managing and operating a “24/7” health care facility of the scope and complexity of Rideaucrest demands full the attention and energy of the Administrator and her team. Infusing asignificant improvement agenda, such as we have been pursuing since the Hay Group report, is also a demanding task that merits full attention and energy. Such an ambitious undertaking has been likened to attempting to change a flat tire on a moving vehicle without being able to pull over.

In spite of the daily challenges, the Administrator and her team have made great strides over the past two and half years in bringing greater efficiencies and effective processes to the management and operation of the Home, staying on point - examining processes, identifying Japs, laying the groundwork for future actions, and introducing changes - big and small. This success is acknowledged and celebrated; however, it must also be recognized that the accomplishments to, date have not come without a toll, both personal and organizational. It is unrealistic to expect the Administrator and her team to continue shouldering the full burden of both tasks. Without additional resourcing and supports, the improvement strategy will not be sustainable at its current pace or scope.

Ensuring adequate resources are applied to the change initiative is critically important as we focus on addressing the challenging complexities of organizational culture, particularly if we are going to engage in a significant reduction in labour costs. This effort will require a level of energy, dedicated attention and expertise that neither the Administrator and her team nor our corporate human resources group able to provide. As the Hay Group noted in its review, to make the changes that have been recommended will require the short term infusion of money and resources in order to attain longer-term benefits.

In the context of preparing for the 2010 budget deliberations, we will be working with the corporate Director of Human Resources/Organizational Development as part of the human resource strategy noted previously in this report, to determine the appropriate level of support required to continue with and succeed at this important initiative.

53 I P a g e

o t 0 - cv ,I z e a

r 0 e 2 v) 3 m -w

3j

6 2

a, .L

r r U O I I I I I I I

N

o\ 0 0 N

m 0 0

m 0 0 cu 8

03 0 0 N d U

o\ 0 0 hl

0” m

d

I -0 5 .- t I m

z 0 cu m a

m

. 3

d

3 N

Y

b CD 0 0 0 0 cu (v d d 0 U

I I

5 r

I -0 a, c a, v)

Q

c

2?

W a3 0 0 0 0 cu cu c3 @3

U 0

-t

c .-

m 0 0 N * 0

I N

0 0 N

7 3 0 N N U

d U

I

r i U

lo N

U U

I

co 0 0 cu EJ

I

lo 3

cn 0 0 cu -f U

0"

E f

m $4

W P W c,

U,

W

-I- L s: 8 a

00 0 0 (v m U

z 0 cv cu U

W 0 0 cu c3 U

b 0 0 cv d U

b 0 0 (N m 0

a3 0 0 (v m U

c m

r 3 I5

'3 D '3

Appendix 'B'

I 0

ID 3 7

0 S

b - I.

S n 9)

U ID

I.

- 7

3 z 9) S r) ID

m cn (x,

C D

0

-0

% 0 (;;; 9) S N 9) E. 0 S 9)

-. I

-

U

I\: Y p:

s c 03 8

cc s N s?

2 -L

cn 0 0

U ID C rD

'0 0

cc oc P

(c (c

8 -. -

S e n 9)

.I.

7 v,

e3 0 0 0 0 0

3

2

ID S

In rc

co

P g s?

co

P

e3 4 cn 0 0 0

- .. N 0 0 \I

0 CI N

rb

z D

-L

0

0 8

--L

0 s 3 0 0 0 0 0

ppendix ‘B’

jpendix ‘B’

Date post:	19-Jul-2020
Category:	Documents
Upload:	others
View:	0 times
Download:	0 times

City of Kingston Council Agenda - Meeting 19-2009 - Report ... · 2007-2012 Status Report Co m m u...

Documents