Open Meeting of the Board of Directors - HDGH Us/BOD Open Packages... · 2015-11-27 · OPEN...

Open Meeting of the

Board of Directors

March 25, 2015 Corporate Boardroom

5:00 Meeting

Prayer

Enlighten each one of us as we are called to help and to serve those around us,

May our decisions and actions bring forth justice and healing.

May we embrace those around us with the same tenderness that we ourselves require,

We pray for God’s supportive love, wisdom and peace in all that we do.

Amen

Hôtel-Dieu Grace Healthcare Open Meeting Agenda

March 25, 2015 5:00 Meeting

Item Topic Responsibility Time Action Required Approval Discussion Information

Page

1.0 Call to Order & Opening Prayer B. Chillman 5:00

1.1 Quorum B. Chillman X

1.2 Declaration of Conflict of Interest B. Chillman X

1.3 Agenda B. Chillman X

2.0 Consent Agenda Items* 5:05

2.1 Minutes of the previous open meeting – February 25, 2015 B. Chillman X

2.3 Minutes of the Workplace Excellence Committee Meeting –March 18, 2015 X

2.4 Minutes of the Finance and Audit Committee Meeting – March 13, 2015 X

2.5 Minutes of the Professional Advisory Committee Meeting – March 4, 2015 X

4.0 Business Arising

5.0 Centre of Excellence J. Kaffer/B. Marra 5:10 X

6.0 Executive Leadership Team Report

6.1 Lead Agency Update M. Broga 5:40 X

7.0 QIP L. Lombardo/M. Campigotto 6:10 X

8.0 Board Chair Report B. Chillman 6:20 X

10.0 Sponsor Report F. Bagatto 6:30 X

11.0 Date of Next Meeting April 22, 2015

12.0 Adjournment B. Chillman 6:40

13.0 Dinner Break & Media reporting 6:40-7:10

Tab 2.1

Board of Directors Open Meeting Minutes

Hôtel-Dieu Grace Healthcare OPEN Meeting of the Board of Directors

February 25, 2015 Minutes of the open meeting of the Board of Directors held Wednesday, February 25, 2015, in the Corporate Boardroom. Community Members Present Ex-Officio Members Present S. Cunningham – Chair B. Chillman – vice chair T. Doey J. Kaffer B. Payne R. Truant L. Lombardo R. Pollock M. Horrobin Community Members Absent Ex-Officio Members Absent C. Derbyshire–past chair T. Catherwood Dr. Ranjit F. Bagatto M. Lomazzo Administration: B. Marra N. Crozier S. Grbevski A. Steen M. Campagna D. Dutot M. Benson-Albers M. Campigotto 1. CALL TO ORDER

S. Cunningham called the meeting to order at 5:00pm The Chair asked if there were any conflicts of interest – none declared. The agenda was approved as written. On behalf of the Board of Directors S. Cunningham welcomed Dr. Tamison Doey; she will represent the Professional Advisory Committee as an ex-officio member of the Board of Directors.

2. CONSENT AGENDA ITEMS

It was moved by L. Lombardo and seconded by R. Truant to approve the consent agenda items. CARRIED

3. Business Arising None

4. Integrated Risk Management Program

S. Tompkins provided the Board of Directors information outlining the Integrated Risk Management Program, highlighting the policy statement, objectives, areas of risk for the hospital and the three year risk assessment checklist with HIROC. This program will assist the Board of Directors in fulfilling their oversight responsibilities, advising them of what might threaten the organization’s overall corporate objectives and how to understand the risk culture at HDGH.

The Policy Statement: Hotel-Dieu Grace Healthcare will ensure that integrated risk management (IRM) principles and practices are entrenched in all aspects of its organization philosophy, culture, planning and operations. The organization and Board of Directors will work together to reduce risk by ensuring the appropriate action is taken on known and/or identified “high” or “extreme” risks; ensuring contingency plans are in place while promoting ongoing quality improvement. The Director of Risk Management will develop, implement and maintain the Integrated Risk Management Program.

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February 25, 2015 The 3 year cycle began in the summer of 2014; at that time there were some areas identified as risk by staff. Many times we identify risk everyday as part of our regular work, how we evaluate, process, and get that information to a Risk Summary Profile is the key to mitigating and monitoring. “Integrated” means risk is evaluated at all levels= financial, administration, etc.

Action: S. Tompkins to present the IRM program to each committee. The Plan for 2015-2016 verification & quantification will be completed in next 3 months. A Risk Profile summary should be presented in 3 months to the Board of Directors.

5. BRANDING UPDATE

N. Crozier presented the Board of Directors an update for the current status of the HDGH Branding strategy. She provided an overview of the timeline from September 2014 to date; covering the initial consultations with Holly Ward Communications, presentations given to the Board of Directors in late 2015 and the creation of the Branding Committee January 2015. On February 23, 2015 focus groups were held with staff, patients/family advocates, physicians and the public. The next steps for the Committee are to review the feedback, identify some brand promises and three taglines. A survey will then be sent to all staff and physicians for additional feedback on the final three-five choices. The goal is to have a report presented to the board by April or May.

6. INFLUENZA OUTBREAK DEBRIEF REPORT

A Debriefing was held with the Outbreak Management team and Windsor Public Health, M. Campigotto provided overall highlights of this meeting.

• 14 days total • 5 patients - lab confirmed • 1 staff – lab confirmed • Areas of strength; many factors contributed to the quick resolution of this outbreak but the

largest are: o Early detection/isolation of symptomatic clients o Communications; to the community, staff, media, stakeholders o Tamiflu clinics with in house physician for all staff to access antiviral o Nurse Practitioners assessed patients and provided clinical decisions for Tamiflu

• Areas of improvement; while these where identified they did not affect the outcome o Having preparedness plan for Tamiflu administration to patients and staff o Ongoing “Outbreak” training for staff o Early Flu awareness campaign

7. EXECUTIVE REPORT UPDATES

A new reporting template for the Executive Leadership Team (ELT) was distributed to the Board; this will be used for monthly reports and are tied directly to each ELT member’s priorities. Some of the reports will be provided verbally and periodically there will be actual presentations. Some of the

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February 25, 2015 reported items were discussed such as the “Big Night Gala”, it will be held Friday November 13 instead of in April.

8. BOARD CHAIR REPORT Nothing to report

9. DATE OF NEXT MEETING – MARCH 25, 2015

10. ADJOURNMENT It was moved by B. Payne and seconded by M. Horrobin that the meeting be adjourned at 5:45pm. CARRIED

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Tab 2.3

Workplace Excellence Committee Open Meeting Minutes

Hotel Dieu Grace Healthcare Workplace Excellence Committee

Minutes of the meeting of the Workplace Excellence Committee held Wednesday, March 18, 2015 in the CPH Administration Conference Room #1. Present: T. Catherwood C. Derbyshire M. Winterton A. Templer Regrets: R. Pollock (Chair) J. Kaffer Administration: M. Campagna M. Benson-Albers S. McGeen L. Peterson A. Tuovinen 1. Call to Order and Opening Prayer

• As the Chair advised he was unable to attend the meeting, T. Catherwood agreed to be Acting Chair.

• T. Catherwood called the meeting to order at 7:30 a.m. and led the Committee in prayer.

o Congratulations were extended to M. Winterton on his promotion to Corporate Leader – Environmental Protection & Infrastructure Services/City Engineer at the City of Windsor

o Congratulations were extended to A. Templer on his HRPA’s Lifetime Honorary award he received last month.

2. Approval

a) March 18, 2015 Agenda MOTION: To approve the March 18, 2015 agenda as distributed. MOVED: C. Derbyshire SECONDED: M. Winterton

MOTION CARRIED

b) Disclosure of Conflict of Interest • There was no conflict of interest noted.

Open Workplace Excellence Committee – March 18, 2015 Minutes Page 1

3. For Information a) Open and In-Camera Agendas

• A review of the explanatory note regarding open and in-camera meetings was reviewed and discussed.

b) HR Strat Plan Status

• M. Benson-Albers provided an update on the status of the HR Strat plan with the following notations:

o Currently updating and incorporating suggested changes to the plan, which will be presented to the Board at the May meeting.

o The Compensation Strategy and Policy has been completed and is currently awaiting approval.

o Leadership Forum meetings are being restructured with a leadership/ Learning focus.

o A project team has been organized as it relates to the Performance Appraisal System. In addition, an RFP process has been conducted and awarded.

o Recognition and Rewards have been approved consisting of three President Awards aligned with strategic priorities, as well as the J. Kenneth Deane Health Systems Innovator Scholarship, Rookie of the Year Award and Physician of the Year Award. Presentation of awards is scheduled for March 31, 2015.

o Currently transitioning current “Star” program to “KUDOS” program for year round on the spot recognition tied to our values and strategic priorities.

o Succession Planning/Talent Management project currently underway to identify emerging leaders in the organization.

o Position Description/Role Clarity Project currently underway. o This item to be brought back to the committee on a regular basis to

review outcome and updates.

c) Joint Health & Safety Committee • The Joint Health & Safety Committee’s meeting was cancelled this month;

however, inspections were still completed and no concerns were noted. • The ELT have begun performing Executive Walkabouts that have members of

ELT meeting with patients and staff.

d) Metrics/Safety & Wellness Update • Work Related Incidents for January

No lost time incidents to report for February 2015. • NEER Index Rating

Next NEER statement will be received by the end of March 2015. • Workplace Violence

There were 14 incidents of physical aggression filed in February. The issue of aggressive incidents will be a priority focus for the Safety

Officer moving forward. Currently she is reviewing incidents over the past six months to determine if there is any trending we can identify with respect to a specific area, time of day, patient, staff, etc. Any


patterns will determine focus for education/corrective actions moving forward.

A discussion related to security assist took place. • Attendance Support

January reports were distributed and managers have been completing Phase 1 meetings.

Next reports are scheduled to be sent the end of March 2015. A discussion related to sick time took place and it was suggested that

communication to staff advising of detailed information, i.e. over budget as if equivalent to that of 33 FTEs, which is the same as all staff on 2N being off sick the entire year, would be beneficial.

• Wellness Initiatives Nutrition Month (March) was recognized by the Food and Nutrition

Services whereby they organized several activities such as staff education and “healthy eating”.

Some of the features included live chef demonstration of healthy cooking in the cafeteria, nutritional displays with take away materials, and prizes for participation, which included a free staff gym membership and free yoga classes.

e) Bargaining Union Updates

• A review and discussion of the update took place.

f) Accreditation Update • M. Campagna advised the committee that a report out meeting took place last

week and we are cautiously optimistic we are headed in the right direction and will be ready for accreditation.

• A mock accreditation will be conducted next week, which will assist with the preparation for the actual accreditation and in determining areas requiring focus.

• Actual accreditation is scheduled for June 2015.

4. Request to Move to In-Camera Meting

MOTION: For the Committee to move into In-Camera.

MOVED BY: C. Derbyshire SECONDED BY: M. Winterton

MOTION CARRIED


Tab 2.4

Finance and Audit Committee Open Minutes

Hotel-Dieu Grace Hospital Finance and Audit Committee

Open Agenda Minutes of the meeting of the Finance and Audit Committee held March 13, 2015 in the CPH Administration Conference Room 1. Present: M. Horrobin, Chair B. Payne R. Truant (via conf. call)

P. Soulliere Administration: M. Campagna S. Laframboise L. Peterson Regrets: C. Davison

1. Call to Order

• M. Horrobin called the meeting to order at 7:00 a.m., and led the Committee in prayer.

2. For Approval/Recommendation

a) Agenda

MOTION: To approve the March 13, 2015 Open Agenda as distributed.

MOVED BY: B. Payne SECONDED BY: P. Soulliere

MOTION CARRIED b) Disclosure of Conflicts of Interest

No conflict of interest reported.

c) Follow Up From Previous Minutes i. Compliance Certificate – WoodGundy

The Compliance Report from CIBC WoodGundy, which was provided in the agenda package, was reviewed and discussed.

It was determined that this compliance certificate is what the committee is looking for.

WoodGundy will ensure a copy of the Compliance Report will be available on a monthly basis.

A review of our investments will be conducted after three months to review performance.

ii. Conference Management reviewed the budget allotment for Board and Board

Committees and it was determined that one Committee member and one staff member will attend the conference.

Finance & Audit Committee Meeting Minutes – March 13, 2015 – Open meeting 1 | P a g e

After a brief discussion, it was decided that R. Truant would participate on behalf of the Committee. S. Laframboise and M. Campagna will determine who from staff will attend.

L. Peterson will make all necessary arrangements and advise accordingly.

3. For Information

a) Open/In-Camera Agendas • A review of the explanatory note regarding open and in-camera meetings was

reviewed and discussed.

b) Salary Disclosure • A review of the salary disclosure was reviewed and discussed. • It was noted that several individuals made the list due to the following:

There were 54 weeks captured on payroll for 2014. 14 RNs were captured due to these extra weeks as well as overtime. It is anticipated that the list will be smaller next year.

4. Other Business

No other business was brought forward.

MOTION: For the Committee to move into In-Camera.

MOVED BY: B. Payne SECONDED BY: P. Soulliere

MOTION CARRIED

Finance & Audit Committee Meeting Minutes – March 13, 2015 – Open meeting 2 | P a g e

Professional Advisory Committee Open

Minutes

Tab 2.5

Open Minutes HDGH Professional Advisory Committee

HDGH Administrative Boardroom March 4th, 2015

Present: Dr. T. Doey (Chair) Dr. A. Steen Ms. J. Bennett Dr. M. Broga

Ms. S. Tompkins Dr. L. Cortese Ms. A. Anderson Ms. M. Campigotto Ms. S. Bastable Dr. E. Ranjit

Dr. F. Demarco Dr. N. Liem Dr. M. Steele Ms. A. Brooks Dr. S. Grbevski Mr. B. Marra Ms. M. Campagna Regrets: Dr. S. Namaan Ms. J. Kaffer Dr. S. Ahmad

1. CALL TO ORDER The Chair, Dr. T. Doey called the meeting of the Professional Advisory Committee to order at 1230 hrs.

2. APPROVAL OF THE AGENDA MOTION MOVED by Ms. M. Campigotto and SECONDED by Dr. A. Steen, that the agenda be approved as written. CARRIED

3. DECLARATION OF CONFLICT

No conflicts of interest were declared.

4. REPORT OF THE CEO • No report.

5. REPORT OF THE CHAIR OF THE PAC – Dr. T. Doey Highlights included the following: • Dr. T. Doey stated she has been having discussions with the VP of Medical Affairs; Dr. A.

Steen regarding which roles will be designated to whom. Dr. T. Doey stated that her role is more focused on the rules and regulations and the hospital bylaws while Dr. A. Steen’s role is more focused on the operational aspects.

• Dr. T. Doey stated to members that she is very excited to start her new role as Chair of the PAC. She stated that she has found people that she has met with to demonstrate a very positive attitude and pleased with the organization.

• Dr. T. Doey spoke to members about proper documentation on patient charting which include History and Physical examinations and discharge summaries occurring within the time frame as indicated in the hospital rules and regulations. She also spoke to members

Page 1

about legibility issues on charting and orders. Dr. T. Doey stated the issue of documentation and legibility will be topics at the next Quarterly Staff Meeting that will be held on Friday, March 13th, 2015.

6. REPORT OF THE VPMA – Dr. A. Steen • Dr. A. Steen congratulated Dr. T. Doey on her new position at Chair of the PAC. • Dr. A. Steen stated that the Medical Quality Assurance Meetings are progressing well. There

have only been a few meetings but these meetings have identified some reoccurring issues that need to be addressed.

7. REPORT OF THE CNO – Ms. M. Campigotto • Ms. M. Campigotto updated members that Ms. K. Quinlan has been meeting with the

accreditation teams weekly. Currently she is focused on 3 key area; Complex Continuing Care, Palliative Care and Medication Reconciliation.

• Ms. K. Quinlan continues to meet with all the lead representatives for the Required Operating Practices.

• Ms. M. Campigotto stated she is currently working with the project management office to develop a quality framework.

• The College of Nurses will be coming next week to provide training to the front line nursing staff. Approximately 86-88% of staff is scheduled to attend training. This training will be focused on following proper nursing standards.

• National Safety week will start March 9th. Posters and banners will go up around the facility. • Ms. M. Campigotto stated that hand hygiene rates have gone up in the 90% percentages for

last month. Ms. M. Campigotto stated the increase may have been due to the flu outbreak that occurred.

8. REPORT OF THE CFO – Ms. M. Campagna

• Report deferred to the in camera meeting.

9. REPORT OF THE VICE DEAN HOSPITAL & INTERFACULTY RELATIONS – SCHULICH Dr. M. Steele presented a brief report to the members that highlighted the following topics: • Save the Date for The SouthWestern Academic health Network (SWAHN) “Breaking Break

with SWAHN: Nutrition Research and Innovation Symposium”. The deadline to register is March 10, 2015. Dr. M. Steele was excited to announce that Dr. T. Doey and Dr. S. Ahmad submitted a poster presentation for this event.

• The Windsor Program Awards of Excellence Banquet will take place Thursday, April 16th, 2015.

• Dr. M. Steele spoke about the Mini Fellowships Fund. All members of Schulich faculty are eligible to apply. The deadline for current competition is Monday, March 16th. Ms. A. Brooks will forward the information to members.

• Dr. Julio Martinez-Trujilo has been appointed to the position of Provincial Endowed Academic Chair in Autism.

• The Windsor Star featured an article promoting the Windsor Program students and the Medpals initiative.

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• The Dean’s Gala will take place on Saturday, September 26, 2015 at the London Convention Centre.

• After a year of planning, the Family Medicine program successfully launched the Preventing Crashes course. The program aims to support Family Medicine Residents via simulation and locally developed case scenarios of an acute nature.

• Congratulations to Dr. Wassim Saad who has been selected as one of the recipients to receive the 2015 CAME Certificate of Merit Award.

10. OTHER BUSINESS • There was no other business noted.

11. ADJOURNMENT

The meeting was adjourned at 1245 hours.

Submitted by:

Dr. T. Doey, PAC Chair, Hôtel-Dieu Grace Healthcare

Page 3

Tab 5.0

Centre of Excellence

Defining a Centre of Excellence

March 2015

1

Agenda

1. Background 2. Defining a Centre of Excellence 3. Elements of a Centre of Excellence 4. Accepted Examples 5. Next Steps for HDGH

2

Background

3

• 1980 – Establishment of the Network of Centres of Excellence (Government of Canada, 2015)

• Connecting commercialization and research • Majority of Centres of Excellence in Canada are

tied to universities • Centres of Excellence in Healthcare first

originated in the mid 90’s in the USA • Medicare termed hospitals Centres of Excellence

based on volumes, outcomes and cost efficiencies • Believed to be a provider who specializes in a

particular area can produce better outcomes (Quality Health Care, 2012)

Defining a Centre of Excellence

4

• No clear, universal definition available • “Centre of Excellence” and “Institute” often seen as

interchangeable • Some accepted definitions… • “A tertiary or quaternary health care provider that is

identified as the most expert and cost efficient and produces the best outcomes”(Mosby's Medical Dictionary, 2009)

• “A team of people that promote collaboration and using best practice around a specific focus area to drive customer-valued results” (Agile Element, 2014)

Elements of a Centre of Excellence

5

• No clear standards defining a Centre of Excellence • Often self proclaimed – no official designation • Many are based around a specific areas of focus:

• Cancer • Bariatric Surgery • Cardiology

• For some well defined areas – quality standards exist • Often used in describing a CoE:

• World-class clinical and research expertise • Knowledge mobilization • Superior service and quality • Cutting edge practices


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Examples in Healthcare: • Mount Sinai Hospital

• Women’s and Infant’s Health • Chronic Disease Management • Healthy Aging and Geriatrics • Specialized Cancer Centre • Emergency Services • Research Institute

• West Park Healthcare Centre • Long-term Ventilation CoE

• Ontario Hospital Association • Governance Centre of Excellence


7

Examples in Mental Health:

• Douglas Mental Health University Institute National Centre of Excellence in Mental Health

• Children’s Hospital of Eastern Ontario

(CHEO) Provincial Centre of Excellence for Child and Youth Mental Health


8

Research &

Innovation

Knowledge Transfer & Teaching

Volumes & Patient

Outcomes


9

Volumes and Patient Outcomes:

• High patient volumes • Clinical expertise (AAOS, 2006)

• Proven results

Research and Innovation:

• Evidence based practices (Advisory Board, 2014)

• Leading edge methodologies • Full affiliation with an academic centre (Avery, n.d.)


10

Knowledge Transfer and Teaching:

• Advancing industry knowledge in core service area through education and training (AAOS, 2006)

• Academic placements and structured teaching opportunities (Advisory Board, 2014)

11

Next Steps for HDGH

To establish HDGH as a Centre of Excellence:

• Develop creation and performance standards to confer credibility

• Define purpose, benefits to patients & system • Develop criteria for establishing the CoE • Identify indicators and benchmarks in all three

areas (Volumes/Outcomes, Research, Knowledge) • Assess current state and plans to address gaps

12

Next Steps for HDGH

This will require the following: • Determine which core service area is most

appropriate to focus on (mental health, rehabilitation, complex continuing care, palliative care, children and youth mental health)

• Determine what investments need to be made (i.e. investing and growing institutional research to validate best practice)

• Make a commitment to focus on and invest in the establishment of a CoE – this will not happen overnight!

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A vision for an HDGH Centre of Excellence in Mental Health

Coming April 2015

Tab 6.0

Executive Leadership Team Report

6 m6 6 Month - Executive Leadership Report to the Board of Directors

Wednesday, March 25, 2015 (open meeting)

1. Accreditation is quickly approaching and we are looking forward to the experience of our first survey

as a stand-alone non-acute hospital. We have recruited a coordinator to support the clinical teams with achievement in the Required Organizational Practices (ROPs) and service standards. We have established a threshold target of 95% compliance with the requirements to ensure criteria are met. We are pleased that in our last report out to the CEO, all of the teams reported that they are well positioned to meet this target. A comprehensive communication plan is in place to provide staff with appropriate awareness and training in preparation for the survey. (i.e. banners, newsletters, intranet for posting of questions, kick off interview, jeopardy event, and virtual avatar for weekly messages.) The collection of supporting evidence to substantiate our assessment of compliance continues to be gathered and the Mock Survey sessions have been scheduled for March 24, & 25 with additional sessions in May to assist in preparation for accreditation in June.

2. As of March 10th, the executive team has begun our weekly Patient & Staff Walkabouts. The initial roll-out to complex/rehab is already generating great information on our patient care processes; specifically our admission process and how care goals are established. After successful implementation on the palliative unit in CCC, we are pleased to be rolling out the “This is me” document that assists in personalizing patient care.

3. Children’s Mental Health Programs are currently accredited through the Canadian Centre for

Accreditation; this is a 4 year accreditation certification. Pre-site documentation must be submitted in June and on-site evaluations will occur in September 2015. We are working in parallel with the corporate accreditation process and the work is currently progressing on time.

4. As part of HDGH’s lead role in the implementation of the Rehabilitative Care Alliance

restorative/rehabilitative framework, meaningful changes in philosophy, practice and process within the clinical areas of CCC and rehab are key enablers to success. To support these changes, there has been increased involvement of our Physiatrist physician partners within the CCC clinical environment to support professional education and guide patient plans of care. The goals of these changes include improvement of patients’ functional ability, shorter lengths of stay, supporting patients’ goals of discharge home and delivery of quality care.

5. In partnership with the ESC LHIN and our regional rehab/CCC partners at BWH and CKHA, we are

participating in a regional rehab/CCC bed mapping project. The purpose of this project will be to virtually assign patients currently within our rehab/CCC programs to one of the new bedded restorative care programs defined by the Rehabilitative Care Alliance- those programs being rehabilitation, activation/restoration, and short term medically complex and long term medically complex. Using the information generated from this project, both our organization and our ESC LHIN partners can better determine the current volumes and needs of these populations, thus better informing resource planning and funding/program opportunities.

PATIENTS


Wednesday, March 25, 2015 (open meeting)

1. We have been working on developing an extensive public relations campaign to educate the general public and our community at large about Hôtel-Dieu Grace Healthcare’s new role post hospital realignment of services. To that end;

i. We have gone live with a HDGH Twitter Account and have remained very active with other social media platforms such as Facebook and YouTube;

ii. We have begun planning and rolling out our broader Social Media Strategy as we meet with each member of ELT to discuss privacy settings for individual social media accounts;

iii. We have developed a consistent corporate look and feel for all internal and external materials (i.e. ELT memos; You Spoke, We Listened; & the Path to 2018 document). This has also included a corporate wide refreshing/creating program brochures in preparation for our upcoming Accreditation;

iv. We have provided extensive media training to all members of our ELT and organizational leaders;

v. In collaboration with our Director of Strategy and the ELT, we have worked to develop the Path to 2018 Document identifying the organizational priorities going forward;

vi. We contracted Suede Productions for the creation and launch of the HDGH Corporate Video which has been very well received and was played during a recent taping of Face to Face

2. There has been a great deal of work undertaken with our Project Management Office (PMO) which has

a direct correlation on partnerships, research and overall program delivery. Over the past six months, the PMO has;

i. Developed and implemented the PMO framework; ii. Completed the Development of a Master Project List

iii. Project management templates have been developed and tested with a number of groups; iv. Strategic PMO - Portfolio mapping of priorities, registered projects and deliverables has begun;

Projects currently requiring active PMO support include:

i. MCYS Lead Agency – (Project management consultation and hands on support) ii. Rehab Expansion – (Project management consultation, liaison between capital and operational

plans (not involved in operating dollar request)) iii. Referral Triage – (Project management consultation and project leadership) iv. Long Term Mechanical Vent Strategy – (Project management consultation) v. Musculoskeletal Injury Prevention - (Project management consultation)

IDENTITY


Wednesday, March 25, 2015 (open meeting) 3. We are working towards becoming a premier location of choice for our community volunteers, student

volunteers and academic placements. We have grown our program from 100 volunteers and very limited placements to over 260 with at least 55 additional individuals going through the required recruitment process. We have increased our placements by speaking to the managers and working out arrangements of what the volunteers can do to provide the greatest impact and also derive a high quality and rewarding volunteer experience. We will continue to grow and enhance our volunteer program based on demand and the opportunity for appropriate placements.

4. With the creation of a dedicated Student Coordinator, we have also enjoyed tremendous success in

this area. To date, we have 218 students registered at HDGH and as we did with the volunteers, we have also increased the diversity of the placements. We have students in the Mental Health Clinic providing Music Therapy, numerous nursing students across the campus, Occupational Therapy, Paramedic, Pharmacy, Physiotherapy, Psychology, Recreational Therapy, Social Work, Speech Pathology, VIP, High school Co-op, Dietary, EA and Withdrawal management. We increased the placement options by meeting the managers of each area and discussing their needs and how they can support the students in their learning.

5. Recently, we were approached by the two longstanding Volunteer Auxiliaries. Based on the very

positive and comfortable working relationship that they have developed with our Manager, they decided to merge the two Auxiliaries into one and effective March 2015, they are known as the Hotel-Dieu Grace Healthcare Auxiliary. We have made all the necessary administrative changes for paperwork, banking information, and accounting.

1. The Rewards and Recognition Awards have been determined and approved and there will be 4 Presidents Awards aligned with the strategic priorities (Patients, People, Identity and Safety), a J. Kenneth Deane Health Systems Innovator Scholarship, a Rookie of the Year Award and a Physician of the Year Award. They will be presented at the Annual Service and Retirement Recognition Event scheduled for March 31, 2015. The President’s Health and Safety Award will be determined and awarded during Health and Safety week in May, 2015. There has been an outstanding response with over 40 nominations received for the available awards. An inaugural meeting to discuss transition from the STAR Recognition Program to the KUDOS Recognition program is scheduled for early April.

PEOPLE

Lead Agency Update

Tab 6.1

Executive Leadership Report to the Board of Directors

Wednesday, March 25, 2015

The two deliverables expected by the Ministry of Children & Youth Services for the fiscal year 2014/15included the development of a Core Services Mental Health Plan for Children and Youth and a Community Mental Health Plan for Children and Youth.. With the help of these Plans, children and youth and families will be aided in getting the mental health services in their community that are accessible, responsive, and based on the experiences of the children and youth and families that need help.

The Core Services Mental Health Plan is to ensure that core services are delivered by the community-based child and youth mental health sector in the Windsor-Essex community. The Plan was developed collaboratively by the Core Services Providers as identified by the Ministry (Children First, Maryvale Adolescent and Family Services, and Family Respite Services). The plan was then shared with families and youth through community engagement sessions which were facilitated by the Centre for Excellence for Children & Youth Mental Health. There were two family engagement sessions and one for youth engagement. The feedback from both engagement sessions was included in the Plan. The Core Services Plan is ready for submission to the Ministry on March 31, 2015.

The intent of the Community Mental Health Plan for Children and Youth is to ensure that the community-based sector works together with health care providers, school and other organizations so young people and their families receive the support they need. This Plan was developed in collaboration with community partners from Education, Child Welfare, Developmental Services, the Municipality, Early Years services, the Children’s Treatment Centre, Youth Justice, United Way providers, Canadian Mental Health Association, Community Health Centre, CCAC, Youth Addictions, and youth residences. The Plan reflects the current state of the inter-sectorial services for children and youth with mental health issues and their families. This Plan was shared during the family and youth engagement sessions for input. The next steps will be determining the pathways into Core Services and exit plans back to the community for children and youth who completed their mental health interventions. This plan is read for submission to the Ministry on March 31, 2015.

The primary lesson learned during this process was the importance of engagement with all relevant stakeholders, including the Core Child & Youth Mental Health Providers, the inter-sectorial community partners, families, and youth. The input and dialogue during these engagement sessions were invaluable in shaping awareness and buy-in of Moving on Mental Health and in developing a collective approach to priorities.

Moving on Mental Health An Update March 2015

Agenda 1. Background 2. Deliverables 3. Project Plan – Phase One 4. Project Status 5. Next Steps

Background

Background - Why focus on system change?

Transforming the experience of children and youth, with mental health problems and their families, so that regardless of where they live in Ontario they will know:

• What mental health services are available in their communities; and

• How to access mental health services and supports that meet their needs

Background

In November 2012, Ontario released “Moving on Mental Health” as part of a comprehensive mental health and addictions strategy. This initiative recognizes that child and youth mental health services have not been organized as a system and that with the recognition of the importance of mental health, MCYS felt it imperative to strengthen the community-based system for delivering mental health services and to bring cross sectorial partners together locally to benefit children, youth and families.

Background

In order to achieve these goals, MCYS will:

• Create and support pathways to care • Define Core Services and processes • Establish lead agencies in every Ontario community

that will be responsible for the planning and delivery of child & youth mental health services

• Develop a transparent, equitable funding model • Put in place appropriate/regulatory/accountability

tools

LEAD AGENCIES

PATHWAYS TO CARE

CORE SERVICES AND KEY

PROCESSES ACCOUNTABILITY

FUNDING

MOVING ON MENTAL HEALTH

DRAFT SERVICE FRAMEWORK

Background

2006

2012

2013

2011

Background

Moving on Mental Health

• 16 Lead Agencies have been named and are collaborating to provide a consistent approach to planning and implementation

• Additional 18 Lead Agencies to be named • Expected to take until 2015-2016 to fully

implement • Key to success:

• Engagement of all service providers • Engagement of children, youth and families

Deliverables

Core Service Plan Mapping • Due to MCYS March 31st, 2015 • Individual meetings with core service providers • Group meeting with core services provides to map current state

(including access points and care pathways) • Engaging youth and families to ensure we got it right

Community Plan • Due to MCYS March 31st, 2015 • Group meeting with non-core service providers and community

providers to map complete local system current state (including access points and care pathways)

• Engaging youth and families to ensure we got it right

Project Plan (High-level)

CORE Services Plan – Highlights

• Nov. 2014 • Individual engagement meetings with CORE leads

• Dec. 2014 • Engagement meeting with CORE leads and Centre for

Excellence • CORE services template sent to leads for populating • Templates compiled and mapping document developed

• Jan. 2015 • Large group meeting to review CORE services plan

(combined submissions) and mapping document • Documents revised with feedback


Community Mental Health Plan – Highlights • Nov. 2014

• Presented Moving on Mental Health Strategy and project plan to Child & Youth Planning Committee

• Dec. 2014 • Community services template sent to leads for

populating • Jan. 2015

• Templates compiled and mapping document developed • Large group meeting to present and review completed

template and mapping document • Documents revised with feedback


Family and Youth Engagement Centre of Excellence for Child & Youth Mental Health, parent representatives and iAM youth representatives engaged to determine best approach

March 3-20, 2015 • Online and paper survey • Designed for engagement with those currently accessing

child & youth mental health services in Windsor Essex

March 11, 2015 • Youth focus group • Two family focus groups • “What is your experience? Did we get it right?”

Project Status Deliverable #1 - CORE Service Plan

0yr 1yr 2yr 3yr 4yr 5yr 6yr 7yr 8yr 9yr 10yr 11yr 12yr 13yr 14yr 15yr 16yr 17yr 18yr

Targeted Prevention

HDGH RCC - Triple P Target = 700

Children First – Community Triple P Target = 100

Children First – Parenting through Separation and Divorce & KEYS Target = n/a

Maryvale – Triple P Target = 400

Brief Services Total Target = 630

HDGH RCC – Walk-In Clinic Target = 500

HDGH RCC – Brief Treatment Target = n/a

Children First – Three Counselling Sessions Target = 50

Maryvale – Crisis Appointments Target = 80

Counselling and Therapy

Total Target = 1220

HDGH –RCC Specialized Treatment Services Target = 500

Children First – Clinical Intervention Services Target = 200

Children First – In Home Family Support Services Target = 120

Maryvale – Counselling Outpatient & Day Treatment Target = 520

Family/Caregiver Capacity Building and Support Target = 300

Family Respite Services – In Home, Centre and Community Based Respite Target = 170

Maryvale – After School Programs Target = 10

Specialized Consultation and Assessment

Total = 886

HDGH RCC – Psychology and Psychiatry Consultation and Assessment

Target = 600

Children First – Psychological Assessment and Consultation Target = 150

Maryvale – Neuropsych, Speech, Learning Strengths/Challenges

Target = 136

CORE Services Template and Services Map* – 100% Completed

Project Status Deliverable #2 - Community Mental Health Plan

MCYS Template and Services Map* – 100% Completed

0yr 1yr 2yr 3yr 4yr 5yr 6yr 7yr 8yr 9yr 10yr 11yr 12yr 13yr 14yr 15yr 16yr 17yr 18yr

Targeted Prevention Total Target = 1200

HDGH RCC - Triple P Target = 700

Children First – Community Triple P Target = 100

Children First – Parenting through Separation and Divorce & KEYS Target = n/a

Maryvale – Triple P Target = 400

Essex County Diversion Program Rebound Life Choices Program

Essex County Diversion Program Beyond Bullying Program

Essex County Diversion Program Teen Intervene Program Essex County Diversion Program Substance Abuse Program New Beginnings Outpatient Therapeutic Supports (Youth from WEDSB)

City of Windsor Ontario Early Years Centres (OEYCs)

Windsor Essex Catholic District School Board Mental Health Lead, Getting Along Digitally, Friends for Life, B-RAD, WITS, LAB

Windsor Essex Children's Aid Society Family Well Being Program

Brief Services Total Target = 630

HDGH RCC – Walk-In Clinic Target = 500

HDGH RCC – Brief Treatment Target = n/a

Children First – Three Counselling Sessions Target = 50

Maryvale – Crisis Appointments Target = 80

Essex County Diversion Program L.O.S.S. Program Essex County Diversion Program M.E.S.S.A.G.E. / R.E.S.P.E.CT. Program

Canadian Mental Health Association - Windsor Essex Griefworks (Children's Bereavement)

Next Steps • Completed documents to be submitted by March 31st • MCYS has not yet determined Phase Two deliverables • We continue to move forward with our planning…

Service Provider Program CORE Service Continuum Do you make

referrals to a CORE service

providers?

If yes, please list CORE providers.

If so, is there a protocol?

Promotion Universal Prevention

Early Intervention

Pre

vent

ion

Serv

ices

HDGH RCC Triple P Yes

Children First Community Triple P Yes

Parenting through Separation and Divorce & KEYS Yes

Maryvale Triple P Yes

Essex County Diversion program

Rebound Life Choices Program No

Beyond Bullying Program No Teen Intervene Program No

Substance Abuse Program No

New Beginnings Attendance Centre (Youth on probation) No

Outpatient Therapeutic Supports (Youth from WEDSB) No

City of Windsor Ontario Early Years Centres No

WECDSB Mental Health Lead, Getting Along

Digitally, Friends for Life, B-RAD, WITS, LAB

No

WECAS Family Well Being Program No

Questions

2015/16 Quality Improvement Plan for Ontario Hospitals"Improvement Targets and Initiatives"

Hotel-Dieu Grace Healthcare 1543 Prince Road

AIM Measure Change

Quality Dimension Objective Measure/Indicator

Unit /

Population Source / Period

Organization

Id

Current

performance Target Target justification

Executive

Champion Lead Discussion Planned improvement initiatives (Change Ideas) Methods Process measures Goal for change ideas Comments

Sonja

Grbevski

John Norton

/Rose

GrantRennie

1) Review process for OP therapy booking , including process

for multiple bookings for therapy

2) Monitor wait time data by three areas ( Speech,

Occupational Therapy & Physiotherapy

3) Review programming requirements and OP flow initiatives

to support access to outpatient therapy and provide

recommendations to senior leadership.

1) Create a team to review OP booking

requirements , processes and map out

department booking flow

2) Monitor wait time data monthly through

the OP unit based Quality team, including

avg wait time and % meeting targets

1) % of appts booked prior to discharge

2) Avg wait time & % meeting target for

OP therapy ( three OP disciplines and also

specific case mix groupings : i.e. neuro,

stroke , # hip )

3) % stroke patients booked within 72

hours of discharge (QBP best practice)

1) 30% appt booked

prior to discharge

2) Improve avg wait

time by Q3

3) Track data related to

stroke patients seen

within 72 hours (

establish baseline and

target)

Marie

Campagna

Sherri

Laframboise/

Alison

Anderson

1) Measure & Monitor costs & clinical indicators

2) Sharing and education to programs of financial and clinical

data that supports costs and funding to organization

1) Continue to monitor departmental

budgets monthly at on-off budget meetings

or through processes established with budget

reps/department managers and establish

process for monthly which continues to

include variance reporting by

managers/directors

2) Implement a CORE group that will focus on

cost savings and operational supply cost

savings

3) Establish a data quality framework that is

integrated with the program based unit

councils and program structure

1) 100% variance reports submitted by

due date for financial on/off budget

meeting reviews

2) LOS information shared at 100% of

quarterly Utilization /Quality /Physician

Advisory Committee meetings

3)Share HSFR information and education

at various meetings for adequate

dissemination to leadership and staff

4) Share data quality information and

education to program staff

5) Core savings in the amount of

$400,000.

1) 100% of change idea

processes in place

September 2015

Sonja

Grbevski

Andrea

Drummond/

Kendra

Truant

Ideal score is

>1

Improve FIM efficiency scores and ensure timely and accurate

capture of admission and discharge FIM

1) Review and implement improvement

process for timely capture of Admission FIM

score.

2) Review RPG's & RCG's & target high

volume case mix groups where there is

greatest efficiency opportunity.

3) Ensure that staff that are responsible for

FIM scoring have received appropriate

certification and education

1) % of Admission FIM's completed in 72

hours - as well review 48-72 hour (

currently - 70% -February .

2) % designated FIM scoring staff have

received annual certification and

education

100%completed within

72 hours by March

2016 100%

eligible staff have

completed FIM

certification /education

Integration Reduce wait

times and

facilitate early

access for

admission to

post acute rehab

services

Days between date

ready and admission

date - % transferred

within 2 days .

Hours / Rehab NRS / Q3 14-15 42% ( Q3) -

Avg Wait time

is 4.8 days

60% Continued

improvement of

transition time once

patients are ready to

be transferred to sub

acute care from acute

care. Currently 42%

of patients are

transferred within 2

days of readiness -

would like to improve

this by end of fiscal

year to 60%

Marie

Campagna

Alison

Anderson/

Shelley Cole

Improve timely access to inpatient rehabilitation services

through partnership with acute care site.

1) Implement 9am discharge time on unit to

increase admission flow: Currently 7.1% of

patients are discharged by 9am.

2)Monitor discharge and admission flow :

Monitor monthly # admissions, discharges ,

patient days , Avg LOS and BTR ( bed

turnover rate ) . Break down by # hip /stroke

and discuss at Weekly Huddle meetings

within the program , as well as Intake

meetings.

3) Continue to increase transparency of wait

list – shared within internal and external

partners

4) Predictive work on discharges & sharing

with acute care utilization team

5) Pathway compliance from acute care –

monitoring that patients are ready to

transfer on Day 5 ( pathway compliance )

1) Overall discharge time compliance by

9am : % discharged by 9am & 11am

2) Monitor Avg Wait time for transfers

from acute ( currently 4.8 days )

1)To improve discharge

by 9am compliance to

25% discharged and

100% prior to 11am

2) to improve average

wait time to 48 hours (

2 days )

Improve

organizational

financial health

Effectiveness 0 The target is YTD

budget . Current

status - YTD Budget is

$227,000 - the YTD

actual is ( 1,423,000) .

The % will be

reported for purpose

of QIP and the dollar

amount provided

monthly to support

understanding of the

magnitude of actual (

$'s)

FIM efficiency

Indicator : Discharge

FIM - Admission FIM

/ LOS

Ratio (No

unit) / Rehab

NRS / YTD 14-15 927* 0.94 1.1 Peer comparison

Total Margin

(consolidated): % by

which total

corporate

(consolidated)

revenues exceed or

fall short of total

corporate

(consolidated)

expense, excluding

the impact of facility

amortization, in a

given year.

% / N/a OHRS, MOH / Q3

FY 2014/15

(cumulative from

April 1, 2014 to

December 31,

2014)

927* -2.5

30% based on the target

groups and

anticipated

improvement by Q3

Improve access

to outpatient

rehabilitation

therapy

Access Wait time for OP

rehab services -

referral to OP

admission - %

meeting target (

discharge to OP

initial appt )

Rehab Q4 - 14-15 927 0 %( meeting

targets )

AIM Measure Change


Unit /


Organization

Id

Current


Executive



groups and

anticipated

improvement by Q3

Improve access

to outpatient

rehabilitation

therapy


rehab services -

referral to OP

admission - %

meeting target (

discharge to OP

initial appt )

Rehab Q4 - 14-15 927 0 %( meeting

targets ) Marg

Campigotto

Joanne

Desjardins/Al

ison

Anderson

Improve engagement of patients to design and deliver

healthcare and create partnerships in the hospital setting

1) Establish a Patient Centered Care Advisory

Committee by June 2015 2) Review

CCC results bi-annually and establish a

Patient Experience working plan that focuses

on creating partnerships with patients ( i.e.

communication , participation in rounding ,

culture of compassion and service )

3) Review survey questions and survey

process

4) Implement Executive Walk around with

Patient ‘s and collection of key patient

experience indicators related to transition

and experience - implement pilot in March

2015 -implement final model by July 2015

1) % of identified HDGH committees that

have a patient/family representative

2) % of executive walkabout 's completed

to plan

1) 100% of committees

(identified by Patient

Care Advisory Council)

that have a

patient/family member

included 2) 100%

executive walkabouts

completed to plan

Marg

Campigotto

Joanne

Desjardins/Al

ison

Anderson

Improve engagement of patients to design and deliver

healthcare and create partnerships in the hospital setting

1) Establish a Patient Centered Care Advisory

Committee by June 2015

2 ) Ensure there is a patient or family

member on HDGH committees identified by

Patient Centered Care Committee

3) Implement Executive Walk around with

Patient ‘s and collection of key patient

experience indicators related to transition

and experience - implement pilot in March

2015 -implement final model by July 2015

1) % of identified HDGH committees that

have a patient/family representative

2) % of executive walkabout 's completed

to plan

1) 100% of committees

identified(d by Patient

Care Advisory Council)

that have a

patient/family member

included

2) 90% executive

walkabouts completed

to plan

Sonja

Grbevski

John Norton/

Susan

Bastable

40%

approved at

Quality

Committee

Embed medication reconciliation into the normal processes of

patient care

1) Form a multidisciplinary team to

coordinate a work plan and the

implementation of medication reconciliation

across organization and smaller teams at the

patient care unit level to conduct tests of

change

Implement test of change in Rehab by Q3

and Complex Continuing Care by Q4

Test changes

completed in Rehab

and CCC by March 31,

2016

Note: The

current %

completed

may be higher

due to nursing

completing

these

currently on

patients from

home that are

not tracked -

consistent

and accurate

tracking will

be part of the

work done by

this group

Safety 40% Accreditation Canada

requires

implementation

across all programs

by 2018. We are

required to report

ALL patients for QIP .

Based on Q3 -

Currently, SMH is at

100% , Rehab is at

19% and Complex is

at 9% . Our target is

based on 100%

completed on SMH

and Rehab by end of

fiscal 15-16 and

approximately 30-45

additional per month

Increase

proportion of

patients

receiving

medication

reconciliation

upon admission

Medication

reconciliation at

admission: The total

number of patients

with medications

reconciled as a

proportion of the

total number of

patients admitted to

the hospital.

% / All

patients

Hospital collected

data / most

recent quarter

available

927* 23%

( * note: this

is % currently

completed by

a pharmacist)

95 Continue to Strive for

a very high rating of

care and services

Improve patient

satisfaction

Patient-centred

Overall, How would

you rate the care and

services you received

at the hospital( NRC -

Rehab )

% / Rehab NRC Picker / YTD 927* 90.10%

927* 97.10% 95 (current

performanc

e was a blip

in 1 mth

data)

Continue to strive for

very high satisfaction

results . Note : Fair is

included ( if remove

Fair - 85%)

Overall, How would

you rate the care and

services you received

at the hospital (

Internal - Complex

Continuing Care )

% / Complex

continuing

care residents

Internal Survey /

Q3 - 14/15

AIM Measure Change


Unit /


Organization

Id

Current


Executive



groups and

anticipated

improvement by Q3

Improve access

to outpatient

rehabilitation

therapy


rehab services -

referral to OP

admission - %

meeting target (

discharge to OP

initial appt )

Rehab Q4 - 14-15 927 0 %( meeting

targets ) Marg

Campigotto

and Dr.

Andrea Steen

Sarah Picco 1)We will be continuing to offer the “Just Clean Your Hands”

education to all staff as an education opportunity which gives a

more in depth understanding of the importance of HH and the

4 Moments

2) We continue to release the HH E-Learn annually as a

refresher as well s creating an E-Learn that will go out annually

related to flu season 3) We are

in the middle of creating educational tools/pamphlets for

families related to MRSA, VRE and CDIFF

4) The Client Family Role in Safety Brochure touches on the

importance of HH and discusses how to decrease the spread of

germs/infection which will be distributed to every patient on

admission 5)

We will be focusing on the Allied Health group and Outpatient

areas throughout this year related to HH compliance and

proper PPE use and auditing these groups more frequently

6) Annual PPE training (donning and doffing)

7) Striving to keep our overall HH compliance above 90%

1) eLearning compliance across organization

2) monitor hand hygiene compliance by

discipline and monitor through the QIT and

MQA committees and weekly unit

discussion/huddles ( or what are we calling

the weekly safety huddles )

1) 100% annually eLearning compliance

2) 100% compliance on discussion at QIT

and unit level safety huddles of Hand

Hygiene data 3)

complete hand hygiene audits ( need

target # of audits to be completed per

month from infection control

1) 100% eLearning

compliance

2) HH Data discussed at

100% Quality

Improvement

meetings ( including

MQA/PAC for

physicians)

3) Meeting monthly

target for # audits

completed for hand

hygiene

Marg

Campigotto

and Dr. Frank

Demarco

Sarah Picco 1)We will be continuing to offer the “Just Clean Your Hands”

education to all staff as an education opportunity which gives a

more in depth understanding of the importance of HH and the

4 Moments

2) We continue to release the HH E-Learn annually as a

refresher as well s creating an E-Learn that will go out annually

related to flu season

3) We are in the middle of creating educational

tools/pamphlets for families related to MRSA, VRE and CDIFF

4) The Client Family Role in Safety Brochure touches on the

importance of HH and discusses how to decrease the spread of

germs/infection which will be distributed to every patient on

admission 5) We

will be focusing on the Allied Health group and Outpatient

areas throughout this year related to HH compliance and

proper PPE use and auditing these groups more frequently

6) Annual PPE training (donning and doffing)

7) Striving to keep our overall HH compliance above 90%

1) eLearning compliance across organization

2) Monitor hand hygiene compliance by

discipline and monitor through the QIT and

MQA committees and weekly unit

discussion/huddles ( or what are we calling

the weekly safety huddles )

1) eLearning compliance across

organization

2) Monitor hand hygiene compliance by

discipline and monitor through the QIT

and MQA committees and weekly unit

discussion/huddles ( or what are we

calling the weekly safety huddles )

3) Complete hand hygiene audits ( need

target of # of audits to be completed per

month from Infection Control )

1) 100% eLearning

compliance

2) HH Data discussed at

100% Quality

Improvement

meetings ( including

MQA/PAC for

physicians)

3) Meeting monthly

target for # audits

completed for hand

hygiene

95% Continue to strive for

high compliance .

New audit process

and tool is now in

place and focused

education program .

Reduce hospital

acquired

infection rates

Safety

% Hand Hygiene

Compliance Before

Patient Contact (

includes CCC, Rehab

and SMH)

% / All

patients

audit tool

/Mariner / YTD 14-

15

927* 52%

CDI rate per 1,000

patient days:

Number of patients

newly diagnosed

with hospital-

acquired CDI, divided

by the number of

patient days in that

month, multiplied by

1,000 - Average for

Jan-Dec. 2014,

consistent with

HQO's Patient Safety

public reporting

website.

Rate per

1,000 patient

days / All

patients

Publicly Reported,

MOH / Jan 1,

2014 - Dec 31,

2014

927* 0.17 0.14 The provincial

average is .30 . A

target of .14 would

equal 3 cases per

quarter . We are

currently tracking to

.16 for YE - we will

meet .14 if we only

have one case this

quarter

QIP

Tab 7.0

Tab 10.0

Sponsor Report

CHI REPORT TO THE BOARD

Recently, the Alliance of Catholic Bishops of Ontario invited the four sponsors

who own and sponsor Catholic facilities to provide an update on health care within our

province. Dr. Robert Stewart and I represented CHI. This meeting was chaired_by

Tho**, Cardinal Collins and over 20 bishops were present including our own Bishop

Fabbro. A detailed presentation was made followed by extensive discussion. The topics

of this presentation included: 1. ' Footprint' of Catholic healthcare in Ontario' 2.

Evolution of catholic healtheare. 3. who we are [as sponsors] and how we work

together. 4. Opportgnities and risks. 5. Discussion. The themes that quickly emerged was

hiv we work in parhrership with others and how we care for the most needy and

marginalized.

We were also invited to attend a reception followed by dinner which was attended

by the Minister of Health and Long Term Care, Dr. Eric Hoskins. During the reception,

the Minister had a one on one conversation with almost everyone in the room. During my

conversation with him, the Minister was interested in understanding the role of the

Catholic sponsors and how they support the mission, values and legacy of Catholic

healthcare, tn his comments before dioo"., the Minister shared his experiences caring for

the people of Africa and how this experience motivated him to enter politics. It is clear to

me that he is not a career politician and is motivated by helping people especially the

poor and marginalized. H; referred to us as 'great partners' and used the term parhrership

a number of times. Clearly all in the room were impressed with his commentso which he

gave without notes. His sense of compassion and service really came through.

At our table there were a number of Bishops including Bishop Fabbro. We took

the initiative to explain the great work being done by HDGH, especially the Transitional

Stability Centre. Both Bishop Fabbro and Dr. Robert Stewart expressed great interest in

attending the official opening provided they are invited and given sufficient notice.

Frank BagattoMarch 16,2015

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