agenda...agenda open session board meeting wednesday, june 26, 2019 lambton college events centre,...

AGENDA OPEN SESSION BOARD MEETING

Wednesday, June 26, 2019 Lambton College Events Centre, Sarnia, ON

4:00 pm Directors:

Marg Dragan Anthony Iafrate Bill Gillam Jenny Greensmith

Louis Guimond Brian Knott, Vice-Chair Katherine Mantha Bob McKinley

Wayne Pease Rachael Simon Fred Vanderheide, Treasurer Paul Wiersma, Chair

Ex-Officio Directors: Mike Lapaine Dr. Michel Haddad

Shannon Landry Dr. Andre Rudovics

Participants: Samer Abou-Sweid Julia Oosterman

Laurie Zimmer Kathy Alexander

Paula Reaume-Zimmer

Recorder: Melissa Rondinelli *attached

NO. TOPIC ACTION TIME PRESENTER

1.0 CALL TO ORDER: WELCOME AND OPENING REMARKS 4:00 Paul Wiersma

1.1 Traditional Territory Acknowledgement Paul Wiersma

2.0 AGENDA APPROVAL

2.1 Report on May and June In-Camera Meetings Information Paul Wiersma 2.2 Approval of Agenda Decision

2.3 Declaration of Conflict of Interest Decision

3.0 CONSENT AGENDA

3.1 ITEMS TO BE RECEIVED

3.1.1 Facilities Quarterly Report* Information Fred Vanderheide

3.1.2 Legislative Updates* • Amendments to Public Sector Labour Relations

Transition Act, 1997* • Protecting a Sustainable Public Sector for

Future Generations Act, 2019*

Information Anthony Iafrate

3.1.3 Boar Chair Report* Information Paul Wiersma

3.2 ITEMS FOR APPROVAL

3.2.1 Open Session Board Minutes – May 22, 2019* Decision Paul Wiersma

NO. TOPIC ACTION TIME PRESENTER

3.2.2 Broader Public Sector Accountability Act (BPSAA) Attestation*

Decision Fred Vanderheide

4.0 BOARD DECISIONS/OVERSIGHT/POLICY FORMATION

4.1 Quality Committee Highlights* Information 4:05 Brian Knott

4.2 Quality Committee Performance Scorecard* Discussion/ Decision

4.3 Quality Improvement Plan (QIP) Update* Discussion

4.4 Resource Utilization & Audit Committee (RUAC) Highlights*

Information 4:20 Fred Vanderheide

4.5 Revised 2019-20 Operating Plan* Decision

4.6 RUAC Performance Scorecard* Discussion/ Decision

4.7 Governance and Nominating Committee Highlights*

Information 4:35 Anthony Iafrate

4.8 Board Work Plan 2018-19* Information

4.9 Strategic Plan Progress Report Jan-Dec 2018* Discussion Mike Lapaine

4.10 Charlotte Eleanor Englehart Hospital Capital Improvement Project Update*

Information 4:45 Mike Lapaine

5.0 CHIEF OF PROFESSIONAL STAFF REPORT* Information 4:48 Dr. Michel Haddad

6.0 OPEN FORUM Opportunity for Directors to reflect on how patients, families and community were considered in discussions.

Paul Wiersma

7.0 ADJOURNMENT Next Meeting: September 25, 2019

4:55 Paul Wiersma

Bluewater Health Board of Directors

Open Session Meeting June 26, 2019

Proposed Motions

AGENDA ITEM MOTION

2.2 Agenda to approve the agenda as presented 3.0 Consent Agenda to receive the reports presented and to

approve the following items in the Consent Agenda: 3.2.1 Open Session Board Minutes –

May 22, 2019* 3.2.2 Authorize the Board Chair to

sign the annual Broader Public Sector Accountability Act Attestation

4.2 Quality Committee Performance Scorecard to approve the revised performance monitoring framework for the Quality Committee Performance Scorecard as presented

4.5 Revised Operating Plan 2019-20 to endorse the 2019-20 proposed Operating Plan as presented with the revised plan to be used to update the Hospital Accountability Planning Submission

4.6 Resource Utilization and Audit Committee Performance (RUAC) Scorecard

to approve the revised performance monitoring framework for the RUAC Performance Scorecard as presented

Resource Utilization and Audit Committee Report Prepared by: Facilities Planning & Development Period Ending June 2019 Capital Projects

FPD – RUAC Report – June 2019 Page 1 of 4

Bluewater Health Capital Project List Combined Heat & Power Project (CHP) Project Budget; $4,900,000 Funding Source; Capital Status; In Progress Anticipated Start; Apr.2019 Anticipated Completion; Nov. 2020 Comments;

• Engaged Environmental Consultant • RFP for engineering services in progress anticipated release week of June 17, 2019

Diesel Tank Replacement Project Budget; $600,000 Funding Source; HIRF – 2019/20 Status; In Progress Anticipated Start; Apr.2019 Anticipated Completion; Aug. 2019 Comments;

• Specifications for tender package completed • Pre-environmental scan completed • Tender release week of the 10th

Urology Suite Renovation Project Budget; $650,000 Funding Source; 2018/19 Capital Status; In Progress Anticipated Start; Mar. 2019 Anticipated Completion; June 2019 Comments;

• RFQ package released • Contractor site visits scheduled for February 13 • Project anticipated to be completed by June 15, 2019

Parking Equipment Upgrade Project Budget; $150,000 Funding Source; Capital Status; In Progress Anticipated Start; May 2018 Anticipated Completion; Sept. 2019 Comments;

• Tender package released, closing June 28, 2019 • Replacement of all parking equipment including backend processing system

Resource Utilization and Audit Committee Report Prepared by: Facilities Planning & Development Period Ending June 2019


Project’s Cont’d CEEH Acute Care Bathroom Upgrades Project Budget; $60,000/rm Funding Source; HIRF 2019/20 Status; Planning Anticipated Start; Oct. 2018 Anticipated Completion; Sept. 2019 Comments;

• Creation of AODA compliant private bathrooms • Convert Acute Care rooms to all private with one three bed ward • Detailed specifications being developed for completion of two rooms

Pneumatic Tube Expansion Project Budget; $75,000 Funding Source; 2018/19 Capital Status; Completed Anticipated Start; Jan. 2019 Anticipated Completion; Mar. 2019 Comments;

• Installation in progress • New receiver installed in Surgery A, London Building

Chiller Project Budget; $850,000 Funding Source; HIRF 2018/19 Status; Completed Anticipated Start; Sept. 2017 Anticipated Completion; Mar. 2019 Comments;

• Commisioning September 29 • Installation of new VFD’s are being completed to better control cooling tower motors (Energy

Initiative)

X Block – Roof Replacement Project Budget; $190,000 Funding Source; HIRF 2018/19 (ECP) Status; Completed Anticipated Start; Jan 2019 Anticipated Completion; Mar 2019 Comments

• RFQ released • RFQ awarded to Accent Roofing

CEEH Enabler Project – Electrical Upgrades Phase 1 Project Budget; $190,000 Funding Source; HIRF 2018/19 Status; Completed Anticipated Start; Feb 2019 Anticipated Completion; March 2019 Comments;

• Replacement of end of life and non-serviceable electrical switch gear • Replacement of 12 associated sub-panels • RFQ released and awarded to Clark Haasen Electric

Project Cont’d



CEEH Enabler Project – Sanitary Sewers Project Budget; $150,000 Funding Source; HIRF 2018/19 (ECP) Status; Completed Anticipated Start; Oct. 2018 Anticipated Completion; Mar. 2019 Comments:

• Replacement of internal castiIron piping and new external sewer connections • Exploratory work being conducted to create as built drawings • Review with the Town of Petrolia has occurred around supporting infrastructure • Specification/designs being created to begin replacing pipes under Acute Care Area

HIRF 2019/20 Exceptional Circumstances Submissions (ECP) CEEH Enabler Project – Electrical Upgrades Phase 2 Project Budget; $1,500,000 Funding Source; HIRF ECP 2019/20 Status; In Progress Anticipated Start; Apr. 2019 Anticipated Completion; Mar. 2020 Comments;

• Replacement and relocation of all onsite transformers and electrical services • Replacement/relocation of onsite backup generator • Specifications and tender package in progress • Dependent of ECP approval

CEEH Enabler Project – Mechanical Upgrades Project Budget; $1,700,000 Funding Source; HIRF ECP 2019/20 Status; Planning Anticipated Start; Apr. 2019 Anticipated Completion; Mar. 2020 Comments;

• Conversion of Steam Plant to Hot Water and relocated to new boiler room • Replacement of steam pipe system/install new head end. • Specification and tender package being finalized • Dependent on ECP approval

CEEH Enabler Project – Medical Gases Project Budget; $1,000,000 Funding Source; HIRF ECP 2019/20 Status; Planning Anticipated Start; Apr. 2019 Anticipated Completion; Mar. 2020 Comments;

• Replacement of medical gas piping system throughout the hospital • Relocation of oxygen tank • Specification package being completed • Dependent of ECP approval



Ministry Capital Projects CEEH Redevelopment Project Project Budget; $9,000,000 Funding Source; Ministry Capital Submission Status; Planning Anticipated Start; Sept. 2015 Anticipated Completion; Comments;

• Stage 1 submission submitted to Minitstry/LHIN currently under review

Addictions Centre Project Budget; $8,500,000 Funding Source; Ministry Capital Submission Status; Planning Anticipated Start; Sept. 2015 Anticipated Completion; Comments;

• Project is a Stage 2 of 4, completed the volume/activity validation process • Awaiting to submit the space specifications and site selection report • Master Planning/Programming continues on permanent solution..Awaiting funding

Board Chair Report

I would like to highlight my activities as Chair for the period of May 22, 2019 to June 20, 2019: May 22, 2019 Prepared for and chaired the BWH Board meetings May 25, 2019 Attended the Opening of the Patodia Eye Institute June 3, 2019 Meetings with President and CEO and COPS for Performance

Evaluations June 3, 2019 Attended and Presented at the Professional Staff Association

Annual Meeting June 10, 2019 Meeting with President and CEO for Performance Evaluation June 12, 2019 Prepared for and attended the Nominating Committee meeting June 13, 2019 Attended the BWH Leadership Development Graduation June 17, 2019 Meeting with COPS for Performance Evaluation June 20, 2019 Met with the President and CEO to prepare for the June Board

meetings and discuss hospital and Board business Various dates Communicated with BWH staff and Board members regarding

hospital and Board business

Paul Wiersma

MINUTES

OPEN SESSION BOARD MEETING Wednesday, May 22, 2019

Directors:

Marg Dragan √ Anthony Iafrate √ Bill Gillam √ Jenny Greensmith - R

Louis Guimond √ Brian Knott, Vice-Chair √ Katherine Mantha √ Bob McKinley √

Wayne Pease √ Rachael Simon √ Fred Vanderheide, Treasurer √ Paul Wiersma, Chair √

Ex-Officio Directors:

Mike Lapaine √ Dr. Michel Haddad - R

Shannon Landry √ Dr. Sharon Rutledge √

Dr. Enoch Daniel√

Participants: Samer Abou-Sweid √ Julia Oosterman √

Laurie Zimmer √ Kathy Alexander - R

Paula Reaume-Zimmer √

Recorder: Melissa Rondinelli (*attached in the minute record book)

1.0 BOARD EDUCATION

Cathy Kelly, Vice-President Home and Community Care of the ESC LHIN provided an educational presentation to the Board regarding Home and Community Care in Sarnia-Lambton. She explained the ESC LHIN is legislated to provide a number of services to the community including information, referrals, coordination, purchased home care, etc. Cathy noted patients receive care based on their care needs and goals. She reviewed the Patient Care Model used by the ESC LHIN and explained the most complex patients are assigned care coordinators. Cathy then discussed new innovations being led by the ESC LHIN: • Clinical Care Coordinators - nursing is combined with care coordination to support the

most complex patients • Nursing Clinics - support numerous patients in clinics instead of going to patients’ homes

for interventions such as wound care, intravenous therapy, injections, etc. She noted Sarnia Lambton has the highest utilization of nursing services and the highest rate of IV antibiotic prescription. Next, Cathy reviewed data specific to Sarnia-Lambton and the ESC LHIN region:

• Patients by month – Primary Clinics • Active Patients by Type • Patients and Visits by Service (1 unit = 1 hour of service) • Referrals with High Needs and Admitted – 8771 total referrals - 24% with high

needs • Referrals from BWH – 4,580 overall referrals, 19% high needs patients • Referral Sources for BWH and Other • Wait Times for Referrals from BWH – Cathy noted the ESC LHIN is a leader within

the province for wait times. Cathy was asked if there is data for BWH patients referred for home care before their admission to hospital. She did not have the data available. Cathy then discussed the Intensive Hospital to Home (IHH) Program which provides enhanced services for patients for

Bluewater Health – Open Meeting May 22, 2019 Page 2 ____________________________________________________________________________

30-60 days. The average cost for this program is $177 per day versus $500 per patient day in hospital. This program supports patients that would have otherwise become ALC patients. Cathy reviewed the number of IHH patients from BWH and their discharge dispositions: 46% returned to regular home and community care service levels, and 36% transitioned to long-term care. Cathy was asked the percentage of IHH patients that returned to hospital, which she estimated at 10-12%. She also highlighted an increase in IHH referrals in January and discussed challenges with personal support worker (PSW) resources to support the patients at the time. Cathy discussed strategies to increase PSW service provider capacity and other strategies to increase system capacity such as: family management home care, respite options, expansion of IHH to Community IHH, grow your own PSW initiative, etc. She also briefly discussed other innovations being led by the ESC LHIN including: End to End Supply Chain Management resulting in $1M savings, eShift Virtual Ward, and eRehab.

Mike Lapaine noted there were 1,500 units of care provided in Sarnia Lambton per day and asked how many providers there are in the area. Cathy indicated there are seven local companies including Bayshore, VON, etc. and likely hundreds of care providers working each day. She added there are over 27,000 units of care provided per day across the region. She was also asked how the Community IHH will link back to primary care. She reported the Complex Care Coordinators will manage the program. Paul thanked Cathy for her presentation.

2.0 CALL TO ORDER Paul Wiersma called the meeting to order at 5:38 pm and welcomed the Board and guests. He brought attention to the chocolate bars provided for everyone in recognition of BWH’s achievement of Exemplary Standing from Accreditation Canada.

2.1 Traditional Territory Acknowledgement Paul read the traditional territory acknowledgement.

3.0 AGENDA APPOVAL 3.0 Report on April In-Camera Board Meeting

Paul reported on the items discussed at the April In-Camera Board meeting, which included:

• Professional Staff Credentialing • Critical Incident Reports • Capital Projects and Planning • Ontario Health Teams

Bluewater Health – Open Meeting May 22, 2019 Page 3 ____________________________________________________________________________ 3.1 Approval of Agenda*

Motion duly made, seconded and carried: to approve the agenda as presented. 3.2 Declaration of Conflict of Interest

Paul invited Directors to share any conflicts of interest. No conflicts were declared.

4.0 CONSENT AGENDA 4.1 ITEMS TO BE RECEIVED 4.1.1 Board Chair Report* 4.1.2 Professional Staff Association Report* 4.1.3 Board Meeting Effectiveness Survey Results* 4.1.4 Analysis of Loans and Investments* 4.1.5 Broader Public Sector Executive Compensation Act (BPSECA) Update* 4.2 ITEMS FOR APPROVAL 4.2.1 Open Session Board Minutes – April 24, 2019* 4.2.2 Chief Financial Officer Certificate* 4.2.3 Delegation of Authority – Freedom of Information and Protection of Privacy Act

(FIPPA)* Motion duly made, seconded and carried: to receive the reports presented and to approve the following items in the Consent Agenda: Open Session Board Minutes – April 24, 2019 Chief Financial Officer Certificate Authorize the Board Chair to sign the annual Delegation of Authority under the

Freedom of Information and Protection of Privacy Act.

It was asked who the Chief Privacy Officer (CPO) is at Bluewater Health. Samer Abou-Sweid confirmed Karelyn vanWynen is the acting CPO.

5.0 PRESIDENT AND CEO REPORT* Mike Lapaine presented his report and thanked the Board for its participation in the Accreditation process. He advised the hospital’s success in achieving Exemplary Standing with Accreditation Canada, and the recent ranking from Newsweek as one of the top 50 hospitals in Canada, have been gleaning a lot of positive attention. BWH plans to leverage this attention to continue to build the hospital’s brand. The Board acknowledged the great accomplishment of Exemplary Standing and asked what the process was for addressing the unmet Accreditation standards. Shannon Landry


explained action plans will be developed for each unmet standard, and some already have plans in place. In addition, there is a plan to ensure sustainability of the standards into the future.

6.0 CHIEF OF PROFESSIONAL STAFF (COPS) REPORT* Mike presented the report on Dr. Haddad’s behalf. He then acknowledged Drs. Haddad and Rutledge for their work in bringing attention to, and, addressing physician burnout. Mike was asked to explain OTN, which is the Ontario Telemedicine Network, a videoconferencing platform for patients to connect with physicians and care providers. OTN is being explored for neurology and infectious disease consults.

7.0 BOARD DECISIONS/OVERSIGHT

7.1 Quality Committee Highlights*

Brian Knott presented the Quality Committee Highlights. He noted the Committee received annual program reports from a number of areas: Emergency (ED) and Intensive Care Departments, Ethics and Research, and the Quality and Patient Safety Program. The ED highlighted quality improvement work to improve patient flow within the department with a new three zone system. The Ethics report indicated the Accreditation surveyors were impressed with BWH’s Ethical Framework, and the Committee has expressed an interest in hearing from BWH’s ethicist, Dr. Butcher, again. He also mentioned there was a low number of requests for information made through the Freedom of Information and Protection of Privacy Act, which he attributed to the openness and transparency of the hospital. Brian reported each presenter exemplified passion for BWH and the quality of care and expertise provided at the hospital. Questions about the three zone system in the ED followed. Laurie Zimmer explained patients are triaged and then assigned to the most appropriate zone: Red= high acuity, Yellow= high acuity- non-admitted, may require investigation, and Green= low acuity – ear aches, colds, sprains. She reported the physician and staffing models are designed specific to each zone, and patient flow has improved by utilizing the space the best possible way.

7.2 Quality Committee Performance Scorecard*

Brian presented the scorecard and highlighted BWH’s results with respect to the indicators updated this month:

• Access to Care indicators have all improved • 30- Day Mental Health Readmissions have increased and are being reviewed to

determine if follow up calls are required • Readmission within 30 days for COPD is not reaching the target – the increase is

expected during the winter season


• The Overall Rating of Experience indicator for Inpatient no longer includes Maternal Infant Child (MIC) data effective January 2019, only Medical and Surgical inpatients

• Workplace Violence incidents – A subcommittee has been created to analyze incidents and the code white calls therefore this indicator may increase

Questions about the Overall Rating of Experience and Workplace Violence indicators followed. It was explained the MIC program will continue to monitor this indicator and their specific data was removed from the inpatient data for benchmarking purposes. It was also clarified the hospital will likely collect benchmark data for workplace violence for two years before setting a target, and the indicator may change to become a process measure in the future. Shannon noted this indicator was mandated by Health Quality Ontario, and while achievement of zero workplace violence incidents is unlikely, it is important to note BWH is addressing each incident and ensuring action plans are put in place for patients and staff.

7.3 Resource Utilization & Audit Committee (RUAC) Highlights* Fred Vanderheide presented the RUAC Committee Highlights. He reported the Committee

learned about the hospital’s insurance coverage through the Healthcare Insurance Reciprocal of Canada (HIROC), specifically details about liability limits, premiums, and annual surplus dividends paid to BWH. He also noted an educational session regarding the absenteeism indicator was provided, and the Committee was briefed on the supports in place for employees to help reduce absenteeism, and plans to create a more positive experience through the attendance support program. Fred noted some funding announcements have been made specific to the Mental Health and Addictions Program, and the hospital is awaiting more details before forecasting the bottom line for this fiscal year.

A question was raised about the number of sick days used by staff. Mike explained there is

no set amount of sick days for each employee, and advised BWH has a generous sick plan for staff, provided there is supporting medical documentation. He reported the hospital also has an attendance support program to help manage and support staff. An example of sick time provided in another sector was provided.

7.4 Financial Statements*

Fred presented the financial statement for the period ended March 31, 2019 and reported the hospital will have a modest surplus of $127K this year, versus the budgeted deficit of $921K. He noted this is due to additional surge and Quality Based Procedure (QBP) funding received. Fred also pointed out salary and wages were $1.8M higher than budgeted, the adjusted working capital is at $1M, the current ratio for Hospital


Accountability indicators is better than targeted, and the hospital is in a good financial position overall. There were no questions or comments.

Motion duly made, seconded and carried: to approve the Financial Statement for the period ended March 31, 2019 as presented.

7.5 Resource Utilization and Audit Committee Performance Scorecard*

Fred presented the March scorecard and highlighted the following: • ALC rate meeting target at 14.6%, which is better than the previous month • Absentee Rate – not meeting target of 2.8, but better than the last quarter at 3.12 • Cost per weighted case data has not been updated • % of Capital Budget spent is at 62%

There were no questions or comments. 7.6 Governance and Nominating Committee (G&N) Highlights* Wayne Pease presented the highlights and brought attention to the work completed

regarding Board evaluations. He encouraged attendance at upcoming Ontario Hospital Association Governance Centre of Excellence (OHA GCE) educational events and noted AGM planning is well underway. Wayne also recommended Directors peruse the Broader Public Sector Executive Compensation Act (BPSECA) document included in the consent agenda, and reported more information regarding legislative changes will follow. It was asked if BWH could determine if the OHA GCE has an advanced schedule of educational events to share with the Board.

Action: Melissa Rondinelli to inquire if an advanced schedule of events is available from

the OHA GCE. 7.7 Accreditation Canada Report 2019* Wayne presented the report and encouraged the Board to thank hospital employees for

their great work in achievement of Exemplary Standing (score of 99.6%). It was questioned if the Accreditation process will continue as Ontario Health Teams evolve. Mike suggested it would be several years before any transition occurs and noted Regional Health Authorities are often accredited as a system.

7.8 Bluewater Health Foundation Report*

Paul presented the report on Kathy Alexander’s behalf as she was unable to attend the meeting. There were no questions or comments.

Bluewater Health – Open Meeting May 22, 2019 Page 7 ____________________________________________________________________________ 8.0 OPEN FORUM

Paul noted several Directors attended the OHA GCE’s Advanced Board Governance for Health Care conference and asked for their feedback. It was shared there was a lot of focus on OHTs at the conference. Attendees reviewed the pros and cons of being early OHT adopters, discussed various levels of readiness, different governance models and more. It was recommended Board to Board discussions occur with a focus on trust building, and that analysis of financial and legal risks should take place. It was reported one-third of the group had submitted an OHT application, mostly mid-size hospitals, and not from this area. It was asked whether the Ministry will publish the applications. Mike was unsure and indicated the applications approved by the Ministry will be indicative of what it is looking for. Dr. Daniel shared physician concerns regarding privacy issues with shared patient records within an OHT. It was also noted cyber security was raised at the conference as a huge risk for hospitals. It was pointed out the RUAC has received presentations regarding BWH’s cyber security and mitigation strategies in place. Questions were raised about the impact of the new Patodia Eye Institute on BWH and whether BWH participates in disaster simulations. Mike assured the Board BWH will continue to receive QBP funding for cataract surgeries, while Dr. Patodia will provide other procedures at his new clinic. He noted BWH completes an annual Code Orange (disaster) tabletop exercise and has a policy in place for disasters. The hospital has considered a mock exercise in the future, however, this is a significant undertaking. Discussion regarding active shooter simulation exercises followed. It was noted past mock exercises had a significant impact on staff and there were limitations in how to share the learnings with others not involved. Laurie Zimmer added BWH has connected with Sunnybrook for shared learnings following their recent event as well. Dr. Daniel shared a personal experience with an active shooter situation and indicated information sharing is key in such events.

9.0 IN-CAMERA MEETING AGENDA ITEMS Paul reported the In-Camera meeting agenda topics for May include:

• For decision - Nominating Committee Report • For information

o CEO and Chief of Staff Succession Planning and Performance Evaluation o Board Chair Correspondence o Ontario Health Team Update o Annual Quality and Patient Safety Report o Litigation Claims Report o Risk Management Checklists and Integrated Risk Management Update o Business and Financial Risk Assessment o Annual Review of Insurance Coverage o Pay Equity


o Executive and Director Expense Reporting o 2019-20 Funding Update

10.0 ADJOURNMENT Motion duly made, seconded and carried: to adjourn the meeting at 6:31 pm. ________________________ ____________________________ Paul Wiersma Mike Lapaine Chair Secretary Board of Bluewater Health Board of Bluewater Health

_________________ Melissa Rondinelli Senior Executive Assistant, Recorder

Name of Hospital: Bluewater HealthLHIN: ESC LHINReporting Period: April 1, 2018 to March 31, 2019

SiteConsultant Firm

Name(s)

Name and Title of Consulting Contract

Contract Term (If the contract term has been extended, please include the

original contract term and the amended contract term)

Procurement Value(A) Original value plus

(B) Value of amendments and© Total procurement value

($) / Total Paid

Consultant Selection Process(Open Competitive,

Invitational Competitive, Non-competitive)

If non-competitive, please provide an explanation

Modifications to Agreement (Yes/No)

If Yes, did the procurement documents permit

modifications to the term or value of the agreement?

BWHAdaptive Strategy

Partner

Consultant - Home Care

Strategy Discussion

30-Oct-18 $2,500 Non Competitive No

Hospital Report on Consultant Use

Quality Committee of the Board Highlights

June 17, 2019

Program Report: Rural Health and Medicine* The Committee received a presentation highlighting quality improvements made in Medicine A, Medicine G, CCCOG, Palliative Care and Rural Health. There is a concerted focus on conservable bed days both in Charlotte Eleanor Englehart Hospital (CEEH) and the Medicine A and G Units. The collaborative model of care (CMOC) has been implemented on Medicine A and G, and will soon be implemented in CEEH. Medicine Telemetry is working to standardize a process for cardioversions and care for patients recovering from pacemaker implantation. The Choosing Wisely Campaign is ongoing. , A recreational therapist has been recruited to CCCOG and staff have noted a difference early on. The Palliative Care Unit was able to install a canopy on their patio through donations for patient and family use. Lastly, CEEH is focusing on palliative care, palliative physician consults and palliative education. Based on feedback from the community, CEEH is hoping to build a palliative care room through the redevelopment project Patient Experience Complaints and Compliments Report The Patient Experience Complaints and Compliments report was presented to the Committee. The increase in complaints is attributed to increased methods for submitting complaints, as well as patients and families feeling empowered to provide feedback. The highest areas of concern expressed by patients and families are information and communication provided at discharge and communication during heights of surge. Initiatives such as the use of the Patient Oriented Discharge Summary (PODS) and the Collaborative Model of Care (CMOC) are hoped to positively impact these trends, particularly around communication. Hospital Standardized Mortality Rate The Committee was updated on a recent audit completed to investigate BWH’s HSMR. While the HSMR was above the target, it was discussed that there were no quality issues or concerns, nor were any patterns identified. An education article on HSMR was also provided to the Committee. Health and Wellness Update The Committee received the BWH Health and Wellness update. The report reviewed events and initiatives including the resiliency workshop held in April for Administrative Assistants, ongoing Indigenous Cultural Safety Training, Pride Day, the I am Affected Campaign, and the recently launched Excellence Canada Mental Health in the Workplace survey available for BWH employees to complete. No One Waits (NOW) Initiative The Committee was updated on the current status of the NOW Initiative, as well as the next steps of the NOW. Medical Day Treatment Hub Plans The Committee was apprised of a potential space redevelopment by the Bluewater Health Foundation.

The following items will be coming forward separately for Board discussion: • Revised Operating Plan • Proposed changes to the Quality Committee of the Board scorecard

Submitted by: Brian Knott, Chair

Meets/Exceeds Target FOI Masked due to n size <5

Within 5% of Target Italics n size between 5 - 29

Worse than Target by 5+% * no established target

Data Unavailable ⱡ corporate target

Q1

19/20

Jan

18

Feb

18

Mar

18

Apr

18

May

18

Jun

18

Jul

18

Aug

18

Sep

18

Oct

18

Nov

18

Dec

18

Jan

19

Feb

19

Mar

19

Apr

19 Re

po

rt

Pe

rio

d

YTD

1 SarniaQIP/

P4R

25.8

hrs

<=16

hrs24.6 22.4 18.9 16.8 16.6 18.9 23.4 20.2 29.3 19.4 19.0 6.3 12.9 18.2 16.2 11.1

Jan-

Dec14.6 ◄

2 SarniaSP/

NOW

9.7

hrs ⱡ 2 hrs 11.0 10.0 7.3 6.5 6.3 7.8 9.6 8.2 11.7 6.8 6.5 3.3 5.1 6.5 5.8 4.0

Jan-

Dec5.4 ◄

SarniaHSAA/

P4R

10.5

hrs11.3 10.1 8.4 9.7 8.5 9.9 10.5 8.8 11.1 8.9 9.1 8.0 8.9 9.5 9.0 9.0

Jan-

Dec9.2 ◄

Petrolia 0 4.6 4.2 3.7 4.0 3.9 3.7 3.5 4.0 3.6 3.8 4.3 3.6 4.0 3.6 4.1 4.3Jan -

Dec4.0 ◄

SarniaP4R/

QIP

33.2

hrs

<= 20

hrs30.1 28.4 26.0 21.7 21.7 24.7 29.0 26.6 38.1 24.5 24.9 14.2 20.3 25.5 23.0 18.6

Jan-

Dec21.8 ◄

Petrolia 0.0% 0.0% * 7.8 10.2 7.7 7.8 7.4 6.0 9.6 12.2 10.9 6.3 6.8 7.9 5.0 5.6 7.3 10.3Jan -

Dec7.0 ◄

5 0.0 n/a 0Jan-

Dec2 0

Exceptional Relationships - Expand innovative partnerships and collaborations to improve experiences, services, transitions and community

6 12.9% 14.1% 0.0 0.0Apr-

Mar14.2%

7 18.2% 16.4% 0.0 0.0 0.0Apr-

Mar18.7% ##

ED n/a 52.0% 57.6 56.2 46.7 60.0 49.3 47.4 49.3 52.2 41.1 50.0 56.4 50.8 47.0 48.3 48.6 47.9% ◄

Inpatient

Med/Surg65.6% 67.0% 70.5 62.0 72.1 67.9 80.4 58.2 62.7 64.8 54.2 65.5 69.8 63.8 64.1 63.4 70.8 66.0% ◄

ED 82.5% 85.0% 91.5 79.7 84.7 88.9 81.4 77.6 89.2 76.6 81.5 82.8 91.2 87.9 78.5 75.0 83.8 78.5% ◄

Inpatient

Med/Surg55.1% 58.0% 54.7 47.2 53.3 67.9 80.0 55.8 55.1 50.0 51.0 63.5 61.8 61.7 47.6 55.0 57.1 52.6% ◄

Inspired People - Advance our culture of kindness with an intention to learn, lead, collaborate and celebrate

ED 73.1% 76.3 65.6 62.7 74.5 76.7 74.6 75.7 68.2 70.2 64.4 72.2 72.7 66.2 68.3 54.1 64.2% ◄

All Inpatient 76.0% 72.0 68.4 75.6 87.1 81.2 75.0 80.9 66.7 70.4 80.9 79.2 87.1 76.0 77.6 89.1 80.7% ◄

11 SP 55.7% 55.7%Jan -

Dec51.6% ##

12 QIP n/a * 4 10 6 5 3 5 16 17 15 35 33 41 24Jan -

Dec133 ◄

2

This is preliminary data and subject to change

OMHRS assessments: 30 days or less since last discharge from this facility;

excluding short-stay assessments17.5

10 0

22.6

11.0

20.3

Jan-

Dec

0

This indicator tracks the total number of incidents reported organization wide.

Collecting baseline

Positive score = 9 - 10


Positive score = Yes

Positive score = Completely

Positive score = Yes, definitely


8

QIP

3

4

Ingrain patient safety

9Leaving hospital did patients receive

enough information

51.6Organization promotes staff health/wellness

Overall Incidents of Workplace Violence

12.9

Build sustainable partnerships and collaborations

Readmission within 30 days for COPD

SP

Strengthen Patient and Family-Centred Care

QIP

Overall Rating of Experience

Total High Severity Patient Safety Incidents 21

SP

13.9

18.6

Average Time to Inpatient Bed

Q4 18/19

10Was Patient/Family Treated with

Kindness

11.3

Jan-

Dec

n/aJan-

Dec

30-Day Mental Health Readmission

Focus on the experience of care and caring

Q4 17/18 Q1 18/19 Q3 18/19

Comments

0

YTD Performance

0

0

Ref.

90th Percentile ED Wait Times (Admitted

Patients)

Performance Indicator

Pe

er

Co

mp

ara

tor

BW

H

Ta

rge

t

90th Percentile Time to Inpatient Bed

Quality Committee Performance Scorecard

0

Quality Care - Assure the right care, in the right place, at the right time, by the right provider

0

0

<=8

hrs

Q2 18/19

#

90th Percentile ED Length of Stay for

Complex Patients

Improve access to care

Up

da

ted

n size: 37 n size: 37

n size: 48 n size: 49


Strengthen Patient and Family-Centred Care

Quality Committee Key Performance Indicators


Emergency

Received Enough Information

Emergency



Improve Access to Care

57.1%BWH Target

67.0%

BWH Target

85.0%

BWH Target

58.0%70.8%

48.6%

Overall Rating of Experience Inpatient

Medical/Surgical

Received Enough Information

Inpatient Medical/Surgical

BWH Target

52.0%83.8%


11.010.0

7.36.5 6.3

7.8

9.68.2

11.7

6.8 6.5

3.3

5.16.5

5.8

4.0Bluewater Health Target 2hrs by October 2019

0.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

Jan18

Feb18

Mar18

Apr18

May18

Jun18

Jul18

Aug18

Sep18

Oct18

Nov18

Dec18

Jan19

Feb19

Mar19

Apr19

Q4 17/18 Q1 18/19 Q2 18/19 Q3 18/19 Q4 18/19 Q1 19/20


24.6

22.4

18.9

16.8

16.6

18.9

23.4

20.2

29.3

19.4

19.0

6.3 12.9

18.2

16.2

11.1

Bluewater Health Target <=16 hrs

Peer Comparator 25.8 hrs

0

5

10

15

20

25

30

35

Jan18

Feb18

Mar18

Apr18

May18

Jun18

Jul18

Aug18

Sep18

Oct18

Nov18

Dec18

Jan19

Feb19

Mar19

Apr19

Q4 17/18 Q1 18/19 Q2 18/19 Q3 18/19 Q4 18/19 Q1 19/20


Bluewater Health ED 52.0%Bluewater Health IP Target 67.0%

0

20

40

60

80

100

Jan18

Feb18

Mar18

Apr18

May18

Jun18

Jul18

Aug18

Sep18

Oct18

Nov18

Dec18

Jan19

Feb19

Mar19


ED Inpatient…Bluewater Health ED

Target 85.0%Bluewater Health IP Target

58%

0

10

20

30

40

50

60

70

80

90

100

Jan18

Feb18

Mar18

Apr18

May18

Jun18

Jul18

Aug18

Sep18

Oct18

Nov18

Dec18

Jan19

Feb19

Mar19

Leaving Hospital did Patient Receive Enough Information

ED Inpatient…

Bluewater Health ED Target 73.1%

Bluewater Health IP Target 76.0%

40

4550556065

7075808590

Jan18

Feb18

Mar18

Apr18

May18

Jun18

Jul18

Aug18

Sep18

Oct18

Nov18

Dec18

Jan19

Feb19

Mar19

Was Patient/Family Treated with Kindness

ED All Inpatient

n s

ize:

923

n s

ize:

1032

n s

ize:

826

n s

ize:

1060

Bluewater Health Target 55.7%

0

200

400

600

800

1000

1200

0%

10%

20%

30%

40%

50%

60%

70%

2011 2013 2016 2018

Organization Promotes Staff Health/Wellness

n size Organization Promotes staff health/wellness

1

Bluewater Health Briefing Note

Name of Committee: Board of Directors Date of Meeting: June 26, 2019 Submitted by: Marlene Kerwin Subject: Changes to Scorecard Reporting Format Purpose of Report: Information Input Approval

Situation

Bluewater Health has been investigating opportunities to enhance the QCB Balanced Scorecard. The most significant change investigated has been the threshold for monitoring performance against targets.

Background

The current QCB Balanced Scorecard monitors performance at a 5% threshold from target. This is a historical threshold that was put in place when scorecards were first developed at Bluewater Health. This threshold limits the ability to monitor meaningful progress against past performance. The hospital researched literature on performance monitoring and looked at scorecards from other hospitals and LHINs to support a revised performance monitoring framework.

Analysis/Considerations

The attached document outlines the metrics on the performance scorecard and the new colour coding for the indicator status to allow the organization to better identify meaningful progress. A revised scorecard is also attached.

Recommendation

The Board approves the revised performance monitoring framework for the

QCB scorecard as presented.

a

x

Performance Scorecard

1. All indicators are aligned with Bluewater Health’s Kaleidoscope of Care.

2. Targets are based on last year’s performance.

3. The data is presented monthly/quarterly as the most recent completed month/quarter. The

rationale is to provide historical information and always have one year of data for comparison to

the current results, also described as a 12-month rolling reporting period.

4. Peer data is added to demonstrate relative performance to our peer hospitals.

5. All indicators have a trend line on the scorecard. Trending represents the 12-month rolling

reporting period.

6. An arrow indicates the desired trending for each indicator on the scorecard.

7. There is a definition sheet for readers to understand the background and rationale behind each

indicator.

Indicator Status

The indicator status compares the result against its baseline and target. The baseline is developed

during the target setting process once a year and is a measurement of last year’s performance for a

specific timeframe.

Red = Performance not meeting baseline

Yellow = Meeting baseline but still not meeting target

Green = Meeting or exceeding target

Grey = Data Unavailable. In instances of blank cells, it indicates reliance on internal/external agency

(coded data from Bluewater Health’s Health Records department or MOHLTC/ Canadian Institute of

Health Information – CIHI) to produce the most current results. In such cases, the data will remain blank

for alignment purposes, and only the most current data available will be presented.

References Wang, X., & Dickins, T. (2017, May). Canadian Health Information Management Association Professional Practice

Brief: Balanced Scorecard (Issue Brief No. PPB-0043.17). Retrieved from:

https://www.echima.ca/uploaded/pdf/emails/0043.17_Balanced%20Scorecard.pdf


FOI

Italics

*

ⱡ

JAN

18

FEB

18

MAR

18

APR

18

MAY

18

JUN

18

JUL

18

AUG

18

SEP

18

OCT

18

NOV

18

DEC

18

JAN

19

FEB

19

MAR

19

APR

19Report

PeriodYTD

1 SarniaQIP/

P4R

25.8

hrs

20.2

hrs.

<=16

hrs24.6 22.4 18.9 16.8 16.6 18.9 23.4 20.2 29.3 19.4 19.0 6.3 12.9 18.2 16.2 11.1

Jan-

Dec14.6 ◄

2 SarniaSP/

NOW

9.7

hrs

7.9

hrs. ⱡ 2 hrs 11.0 10.0 7.3 6.5 6.3 7.8 9.6 8.2 11.7 6.8 6.5 3.3 5.1 6.5 5.8 4.0

Jan-

Dec5.4 ◄

SarniaHSAA/

P4R

10.5

hrs

9.2

hrs.

<=8

hrs11.3 10.1 8.4 9.7 8.5 9.9 10.5 8.8 11.1 8.9 9.1 8.0 8.9 9.5 9.0 9.0

Jan-

Dec9.2 ◄

Petrolia 03.9

hrs.

<=8

hrs4.6 4.2 3.7 4.0 3.9 3.7 3.5 4.0 3.6 3.8 4.3 3.6 4.0 3.6 4.1 4.3

Jan -

Dec4.0 ◄

SarniaP4R/

QIP

33.2

hrs

26

hrs.

<= 20

hrs30.1 28.4 26.0 21.7 21.7 24.7 29.0 26.6 38.1 24.5 24.9 14.2 20.3 25.5 23.0 18.6

Jan-

Dec21.8 ◄

Petrolia 0 07.8

hrs.* 7.8 10.2 7.7 7.8 7.4 6.0 9.6 12.2 10.9 6.3 6.8 7.9 5.0 5.6 7.3 10.3

Jan -

Dec7.0 ◄

5 n/a 4 0Jan-

Dec2 0

6 QIP 12.9% 12.1% 12.1% 0Apr-

Mar14.2%

0

7 QIP 18.2% 18.5% 16.4%Apr-

Mar18.7% 0

ED SP n/a 51.1% 52.0% 57.6 56.2 46.7 60.0 49.3 47.4 49.3 52.2 41.1 50.0 56.4 50.8 47.0 48.3 48.6Jan-

Dec47.9% ◄

Inpatient

Med/SurgSP 65.6% 65.9% 67.0% 70.5 62.0 72.1 67.9 80.4 58.2 62.7 64.8 54.2 65.5 69.8 63.8 64.1 63.4 70.8

Jan

Dec66.0% ◄

ED SP 82.5% 83.5% 85.0% 91.5 79.7 84.7 88.9 81.4 77.6 89.2 76.6 81.5 82.8 91.2 87.9 78.5 75.0 83.8Jan-

Dec78.5% ◄

Inpatient

Med/SurgQIP 55.1% 56.7% 58.0% 54.7 47.2 53.3 67.9 80.0 55.8 55.1 50.0 51.0 63.5 61.8 61.7 47.6 55.0 57.1

Jan-

Dec52.6% ◄

ED SP n/a 71.7% 73.1% 76.3 65.6 62.7 74.5 76.7 74.6 75.7 68.2 70.2 64.4 72.2 72.7 66.2 68.3 54.1Jan-

Dec64.2% ◄

All Inpatient SP n/a 74.7% 76.0% 72.0 68.4 75.6 87.1 81.2 75.0 80.9 66.7 70.4 80.9 79.2 87.1 76.0 77.6 89.1Jan-

Dec80.7% ◄

11 SP 55.7% 51.6% 55.7%Jan -

Dec

12 QIP n/a 81 * 4 10 6 5 3 5 16 17 15 35 33 41 24Jan -

Dec133 ◄

51.6


2

20.3

Organization promotes staff health/wellness

11.3


0

CommentsTrending

QUALITY CARE - ASSURE THE RIGHT CARE, IN THE RIGHT PLACE, AT THE RIGHT TIME, BY THE RIGHT PROVIDER

EXCEPTIONAL RELATIONSHIPS - EXPAND INNOVATIVE PARTNERSHIPS AND COLLABORATIONS TO IMPROVE EXPERIENCES, SERVICES, TRANSITIONS AND COMMUNITY HEALTH

OMHRS assessments: 30 days or less since last

discharge from this facility; excluding short-stay

assessments

This is preliminary data and subject to change

Was patient/family treated with kindness


Leaving hospital did patients receive

enough information



INSPIRED PEOPLE - ADVANCE OUR CULTURE OF KINDNESS WITH AN INTENTION TO LEARN, LEAD, COLLABORATE AND CELEBRATE

8

9

10

BUILD SUSTAINABLE PARTNERSHIPS AND COLLABORATIONS

INGRAIN PATIENT SAFETY

3

4

0 1




Complex Patients

90th Percentile ED Wait Times

(Admitted Patients)

1 2

YTD

Performance

UP

DA

TED

Masked due to n size <5

n size between 5 - 29

no established target

corporate target

Q4 17/18 Q1 18/19 Q2 18/19 Q3 18/19 Q4 18/19

DRAFT Quality Committee Performance Scorecard

REF

.

Q1

19/20

Meets/Exceeds Target

Meeting baseline but not meeting target

Performance not meeting baseline

Data Unavailable

Key Performance Indicators

Pee

r

Co

mp

arat

or

De

sire

d

Tre

nd

ing

TargetBaseline

STRENGTHEN PATIENT AND FAMILY-CENTRED CARE

Readmission with 30 days for COPD

11.0 17.5

18.6 12.9 22.6

30-Day Mental Health Readmission

#

IMPROVE ACCESS TO CARE

Total High Severity Patient Safety Incidents

(Level 4 - 5)

13.9

0

0

FOCUS ON THE EXPERIENCE OF CARE AND CARING


Positive score = Yes

Positive score = Completely

0

DRAFT

Leaving hospital did patients receive enough information (Inpatient)

TARGET 58.0%

Q4, Q1, Q2

CURRENT PERFORMANCE

52.6% YTD (Open data- includes Jan and Feb-

Inpatient Med/Surg only as per QIP)

PEER COMPARATOR

53.7%

QIP CHANGE INITIATIVES

• Collaborative standardized discharge strategy to improve the information shared with patients

• Patient Oriented Discharge Summary (PODS) • Patient Experience and Chief Nursing Executive

Patient Rounding Project • Integrated Discharge and Health Links Role

Open Data Results for Inpatient Med/Surg only: Jan-50% Feb-59.4% Mar- 57.1%

CHANGE INITIATIVES

• PODS for generic population (Chronic Obstructive Pulmonary Disease/Congestive Heart Failure (COPD/CHF) update June- documents still being vetted by stakeholders

• Medicine patients-planning for June for initiation with the CMOC plan • Patient feedback - Update this process has started, awaiting results • Patient rounding PDSA in process

OPPORTUNITIES FOR IMPROVEMENT

• PODS to be brought to Health Quality Partners for review and discussion. • Identify strategies to have this a visible document for patients and families • PDSA for rounding to determine how to measure effectiveness and assessment of current

process

0%

20%

40%

60%

80%

100%

Feb17

Mar17

Apr17

May17

Jun17

Jul17

Aug17

Sep17

Oct17

Nov17

Dec17

Jan18

Feb18

Mar18

Apr18

May18

Jun18

Jul18

Aug18

Sep18

Oct18

Nov18

Dec18

Jan19

Feb19

Mar19

Q4 16/17 Q1 17/18 Q2 17/18 Q3 17/18 Q4 17/18 Q1 18/19 Q2 18/19 Q3 18/19 Q4 18/19

Perc

ent o

f Pos

itive

Res

pons

es

Improve Information on Discharge

Peer Comparator BWH Target BWH Performance

Readmission rates within 30 days Chronic Obstructive Pulmonary Disease (COPD) TARGET

16.4% Q4, Q1, Q2

CURRENT PERFORMANCE

N/A (Q4 data not verified)

PEER COMPARATOR

18.2%


• Collaborative QIP action plan for community stakeholders and partners

• Improve effectiveness and communication across transitions • Coordinated, consistent and appropriate access for patients • Referral to appropriate pulmonary rehabilitation program • Health care provider to receive timely information • Access to care provider

CHANGE INITIATIVES

• New referral form for pulmonary rehabilitation being piloted • Increase in referrals to pulmonary rehab at family health teams and community

health centers. • Meeting in June with HQP will provide update on new referral process Challenges Patients that are admitted or return with pneumonia and have a diagnosis of COPD are classified as readmissions for COPD within coding guidelines.


• Consistent utilization of referral forms across the region • Enhanced data collection from community partners • Review data for each readmission to ensure it aligns with the

definition from health records

0%

5%

10%

15%

20%

25%

Q3 16/17 Q4 16/17 Q1 17/18 Q2 17/18 Q3 17/18 Q4 17/18 Q1 18/19 Q2 18/19 Q3 18/19

COPD Readmission


Readmission rates within 30 days for patients with mental illness or an addiction

TARGET 12.1%

Q4,Q1,Q2

CURRENT PERFORMANCE

N/A (Q4 data not verified)

PEER COMPARATOR

12.9% QIP CHANGE INITIATIVES

• Improve collaborative treatment planning and handover with community partners

• Utilize Residential Withdrawal Management (RWM) Beds • Improve access to urgent outpatient psychiatric

appointments to avoid admissions Information about Q3 •Q3 is not on our QIP but showed an increase of readmissions-17.5% •There were 30 readmissions to MHIP in Q3- this included 26 patients. Four of the patients readmitted had 2 readmissions in this quarter

CHANGE INITIATIVES

• Standing appointments for outpatient support has created a more timely appointment.

• OTN opportunities have been expanded to provide support for the Indigenous population with three successful appointments completed in collaboration with the Southwest Ontario Aboriginal Health Access Centre


• Proposed CMHA expanded model of service for evening and weekend hours to increase access to community MH resources

• Proposed MHEART- Mental Health Emergency Response Team- CMHA worker in community for follow up with various strands ( i.e. wellness check by police)

Peer Comparator, 12.9%

BWH Target, 12.1%

0%

5%

10%

15%

20%

25%

Q4 16/17 Q1 17/18 Q2 17/18 Q3 17/18 Q4 17/18 Q1 18/19 Q2 18/19 Q3 18/19

30 Day Mental Health Readmission


90th Percentile Time to Inpatient Bed TARGET 16 hrs.

Q4, Q1,Q2, Q3

CURRENT PERFORMANCE (YTD)

14.6 (YTD)

PEER COMPARATOR

25.8


• Collaborative planning team for improved bed management and time to inpatient bed through the No One Waits (NOW) collaborative hospital initiative

• Concerted effort on cultural changes within the organization for improved access for our patients

April 2019- 11.1%

CHANGE INITIATIVES

P1- CMOC Implemented on Rehab- Plan to implement on Medicine in June/July P2- All value stream maps are completed. SBAR form developed in draft. Admission process built into meditech. Generic PODS completed and being vetted by stakeholders including community partners. P3- Monthly stakeholder meeting. Family Health Team meetings for discharge information and template for discharge documentation. OPPORTUNITIES FOR IMPROVEMENT

• Leadership Retreat to communicate Six Change Ideas • Generic PODS- implementation in Medicine- ?June • Admission Documentation- implementation ?July • Admission and Discharge standardized communication letters- finalize • Discharge physician template pilot group to be determined.

0

5

10

15

20

25

30

35

Hour

s

Decrease Time to Inpatient Bed

Ontario High Volume Community Hospitals BWH Target BWH Performance

Overall Incidents of Workplace Violence TARGET

Collecting Baseline Q4,Q1,Q2,Q3

CURRENT PERFORMANCE

133 (YTD)

PEER COMPARATOR

n/a


• Education and training for workplace violence prevention for staff working in high-risk environments

• Improve awareness of workplace violence by providing quarterly reports and recommendations to improve

• Continual focus on building a reporting culture

CHANGE INITIATIVES

• Training being completed for two more NVCI trainers so that all classes will be covered.

• Jan- May-31 staff trained in Non Violent Crisis Intervention • Practice Alert is being created to educate on the correct form to be used. Plan to

send out in June. • When files are closed, incident is reviewed as to whether corrective measures are

adequately put in place prior to file being closed.

OPPORTUNITIES FOR IMPROVEMENT • Code White forms to be evaluated to include whether an RL6 was completed, this

will then enable the team to review ones that were not reported for appropriateness.

• A report is being investigated to alert the team when multiple incidents have occurred with the same patient to ensure an investigation is completed.

• Increase the number of people trained in NVCI and GPA in high risk identified areas

05

1015202530354045

Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 Apr-19

Num

ber o

f Wor

kpla

ce V

iole

nce

Inci

dent

s


Resource Utilization and Audit Committee (RUAC)

June 13, 2019 Highlights

Erie St. Clair (ESC) Security Maturity Dashboard The Committee received the revised ESC’s 2019-20 Security Maturity Dashboard reflecting the future state with future investments in follow-up to TransForm’s Cyber Security presentation in March. RUAC Contributions to the 2016-21 Board Goals The Committee received a chart outlining its accomplishments for supporting the Board’s goals for the 2016-21 strategic plan. The chart outlines RUAC’s contributions to improving front-line connectivity, Board education; strategic support on resource optimization and leveraging strategic community relationships for the 2018-19 meeting year. NOW (No One Waits) Quarterly Update The Committee received a presentation on the NOW initiative highlighting the Quarter 1 results for the Time to Inpatient Bed Change Management Target Setting. BWH was trending six hours last year and this year the hospital is trending at four hours. The Committee received an overview of the work underway to reach the goal of two hours; the standard work that has been taken for transferring a patient from the ED; the work underway by the admission and transfer working group; stakeholder engagement; and, the accountability framework escalation and testing the process. In addition, the following items will be coming forward separately for Board approval/discussion:

- Auditor’s Report and 2018-19 Financial Statement - Appointment of the Audit Firm - Facilities Quarterly Report - Broader Public Sector Accountability Act (BPSAA) Compliance – Consultant

Use/Allowable-Perquisites - Balanced Scorecard

Submitted by: Fred Vanderheide Chair, Resource Utilization and Audit Committee

1


Name of Committee: Board of Directors Date of Meeting: June 26, 2019 Submitted by: Marlene Kerwin Subject: Revised 2019-20 Operating Plan Purpose of Report: Information Input Approval

Situation The hospital has received 2019-20 funding confirmation and as such a revised Operating Plan for 2019-20 with this new information requires Board approval. Background In the fall of 2018, the Finance Department developed budget envelopes for each department to identify efficiencies and savings to offset inflationary increases (averaging 1.6% of the overall budget). The projected revenue assumed no increase to global funding as none had been announced to date by the Ministry. Program Directors worked with their physician leaders and front-line managers to review their programs and identify efficiencies and cost saving opportunities. Analysis/Considerations Bluewater Health submitted a preliminary Expenditure Plan to the Resource Utilization and Audit Committee (RUAC) in February 2019 showing a planned deficit of approximately $2.6 million for the 2019-20 fiscal year. The preliminary Expenditure Plan did not incorporate final funding information related to global funding, quality-based procedure funding, etc. (Appendix B). These adjustments and other revisions such as the inclusion of Pay 4 Results funding and matching expenses, have now been incorporated and the hospital is proposing a revised 2019-20 Operating Plan with a deficit of approximately $1.3 million. The revised operating plan is attached in Appendix A. The summary of changes is outlined in the below table:

x

2

Preliminary Operating Deficit $(2,626,816) New Ministry Funding (per letter dated March 29/18) $1,383,073 Additional CCO QBP Funding $424,500 Removal of OHIP/Med Staff % Clawback $249,300 Other Net Revisions to Operating Plan based on 18/19 Actual Results (734,560) Revised Operating Deficit for 2019/20

$(1,304,503)

A revised Hospital Accountability Planning Submission (HAPS) document will be submitted to match the Board approved revised Operating Plan. Recommendation The Board endorse the 2019-20 proposed operating plan as presented and that this revised plan be used to update the Hospital Accountability Planning Submission.

2019/20 Operating PlanBluewater Health

Revenue $

Ministry of Health Revenue 147,384,038 151,034,616 147,546,096 149,861,488 (1,173,128) CCO Revenue 6,881,533 8,330,522 7,266,166 7,890,666 (439,856) Paymaster Funding 1,242,954 1,322,005 1,286,847 1,293,495 (28,510) OHIP Revenue 12,682,222 13,116,282 13,381,593 13,775,293 659,011 Patient Revenue - Other 1,604,200 1,477,025 1,410,900 1,410,900 (66,125) Room differential 2,876,000 2,486,263 2,469,000 2,469,000 (17,263) CC Co-payment 410,000 515,156 434,000 434,000 (81,156) Recoveries 2,822,762 3,640,586 2,617,176 2,617,176 (1,023,410) Parking Revenue 1,020,000 992,733 997,000 997,000 4,267 Other Revenue 188,500 330,032 236,029 236,029 (94,003) Deferred Equipment Grants 2,426,580 2,407,371 2,664,474 2,664,474 257,103 Interest and Donations 60,000 168,441 100,000 100,000 (68,441)

Total Revenue $ 179,598,789 185,821,032 180,409,281 183,749,521 (2,071,511)

Expenses $

Salaries and Wages 89,849,893 91,707,302 90,761,236 92,066,902 359,600 Medical Staff Remuneration 20,301,200 20,489,614 20,675,226 20,819,626 330,012 Employee Benefits 24,183,290 24,562,393 24,874,078 24,911,171 348,778 Employee Future Benefits 320,000 429,431 300,000 300,000 (129,431) Utilities, Buildings & Grounds 4,474,270 4,416,914 4,194,270 4,194,270 (222,644) Equipment Expense 6,528,705 7,045,013 6,443,817 6,693,817 (351,196) Supplies and Expenses 11,982,656 12,694,343 11,686,771 11,645,322 (1,049,021) Contracted Out Services 3,662,263 3,770,958 3,667,063 3,747,613 (23,345) Medical/Surgical Supplies 8,587,940 9,049,224 8,487,504 8,687,504 (361,720) Drug Expense 5,480,229 6,698,375 5,828,291 6,228,291 (470,084) Interest Expense 167,593 213,601 311,793 311,793 98,192 Amortization 5,343,964 4,828,082 6,186,122 5,842,473 1,014,391

Total Expenses $ 180,882,003 185,905,250 183,416,171 185,448,782 (456,468)

Hospital Operating Surplus/(Deficit) $ (1,283,214) (84,218) (3,006,890) (1,699,261) (1,615,043)

Net Marketed Services Surplus/(Deficit) 362,460 210,712 380,074 390,396 179,684

Net Other Votes Surplus/(Deficit) - - - 4,362 4,362

Ministry Operating Surplus/(Deficit) $ (920,754) 126,494 (2,626,816) (1,304,503) (1,430,997)

Appendix A

18/19 Annual Budget 18/19 Year-End Actual 19/20 Preliminary Operating Plan

19/20 REVISED Operating Plan

Variance from 18/19 YE Actual

1


Name of Committee: Resource Utilization and Audit Committee Date of Meeting: February 14, 2019 Submitted by: Samer Abou-Sweid Subject: 2019-20 Operating Plan Purpose of Report: Information Input Approval

Situation Bluewater Health (BWH) management is presenting an Expenditure Plan for the 2019/20 fiscal year for Board approval (Appendix A). In absence of complete information about the Ministry of Health and Long-Term Care funding allocation for the coming fiscal year, which historically had not been received before April 1st, the Expenditure Plan has been completed based on all available information. The expenditure portion of the budget needs to be approved and submitted by March 31 in order to manage hospital operations pending funding confirmation. This approach is consistent with past practice and across Ontario hospitals. Background In the fall of 2018, the Finance Department developed budget envelopes for each department to identify efficiencies and savings to offset inflationary increases (averaging 1.6% of the overall budget). The projected revenue assumed no increase to global funding as none had been announced to date by the Ministry. Program Directors worked with their physician leaders and front-line managers to review their programs and identify efficiencies and cost saving opportunities. Analysis Based on submitted program budgets, anticipated pressures in the upcoming fiscal year, and available funding information (absent any additional funding), the hospital is projecting a $2.6M deficit for 2019/20 fiscal year. This position at this time of year is similar to past years, as outlined below: 2016/17:

BWH submitted a Projected Expenditure Plan in January/February showing a $2.5M deficit BWH was expecting additional funding which was announced in the spring and included a

funding formula reset/correction of $2M for the current year and a promised additional $2M for the following year. The budget was then revised to a $300K surplus

BWH ended the year with a $0.9M surplus 2017/18:

BWH submitted a Projected Expenditure Plan in January/February showing a $1.3M deficit BWH was expecting additional funding which was announced in the spring but did not include

the second year funding formula reset/correction of $2M. The budget was then revised to a $100K surplus

BWH ended the year with a $2.1M surplus

X

2

2018/19: BWH submitted a Projected Expenditure Plan in January/February showing a $2.8M deficit BWH was expecting additional funding which was announced in the spring. The budget was

then revised to a $900K deficit As of the date of this briefing note, the hospital is forecasting a deficit of just over $300K, but

actively aiming to balance by yearend and taking the necessary measures to do so. Upon reviewing the proposed opportunities, only those which did not result in reduced services, risks to quality of care or staff layoffs were approved. Inflationary pressures amounted to $2.2M and additional quality and care delivery improvement pressures of $1.2M were added. Some of the improvements included:

additions of Occupational and Recreational Therapy for Mental Health and Complex Continuing Care Cognitive Units;

medication reconciliation improvement; Ambulatory Clinic services; Physician Assistant and Hospitalist roles; clinical coding and flow improvement; and Indigenous Navigator role.

Although BWH’s projected deficit for 2019/20 is similar to past year’s, the hope of receiving additional funding in spring is lower this year. While the Ontario Hospital Association (OHA) has advocated with the Ministry for a 3.45% increase to the overall hospital envelope (1.6% inflation, 2.25% growth and targeted funding, -.4% repeal of Bill 148), based on Ministry communication thus far, there is little confidence of this materializing. The hospital, however, remains hopeful and continues to advocate with the ESC LHIN and Ministry for additional funding. Utilizing the hospital’s ethical framework and considering long-term sustainability of hospital operations, the risk of submitting a deficit expenditure plan was weighed against other risks, including: 1) The risk of reducing clinical services on patients: BWH is the only provider of acute services in

the region and all services were deemed critical, especially given the rising demands of the aging patient population. Some opportunities for improving patient flow and transitioning patients to home and long-term care were identified and need to be actioned with engagement from hospital staff/physicians and commitment from ESC LHIN Home and Community Care and partner organizations.

2) The impact of layoffs on staff morale: past approaches to staff layoffs did not deliver the promised sustainable savings in the past, but rather negatively impacted the hospital culture which needed few years to rebuild.

3) Ability to meet capital investment needs: BWH is projecting a similar investment to past years, but could consider reducing expenditures this year at the risk of increasing future pressures.

Recommendation Based on the above analysis, it is recommended that BWH submit the Expenditure Plan as presented (Appendix A) with a $2.6M deficit while continuing to work with the ESC LHIN, the OHA and the Ministry on additional global funding allocation and actively improving bed utilization to improve flow and achieve efficiencies. RUAC proposed Motion: Whereas management presented the 2019/20 Operating Plan, and whereas the hospital is still awaiting final confirmation of the 2019/20 funding details from the Ministry, and whereas management is looking for approval of the expenditure portion of the budget prior to the new fiscal year in order to manage hospital operations pending funding confirmation, the RUAC recommends the Board approve the 2019/20 Operating Plan outlined in the expenditure portion of the budget as presented.

Meets/Exceeds Target FOI Masked due to n size <5

Within 5% of Target Italics n size between 5 - 29

Worse than Target by 5+% * no established target

Data Unavailable ⱡ corporate target

Q1

19/20

Jan

18

Feb

18

Mar

18

Apr

18

May

18

Jun

18

Jul

18

Aug

18

Sep

18

Oct

18

Nov

18

Dec

18

Jan

19

Feb

19

Mar

19

Apr

19 Re

po

rt

Pe

rio

d

YTD

1 SarniaQIP/

P4R

25.8

hrs

<=16

hrs24.6 22.4 18.9 16.8 16.6 18.9 23.4 20.2 29.3 19.4 19.0 6.3 12.9 18.2 16.2 11.1

Jan-

Dec14.6 ◄

2 SarniaSP/

NOW

9.7

hrs ⱡ 2 hrs 11.0 10.0 7.3 6.5 6.3 7.8 9.6 8.2 11.7 6.8 6.5 3.3 5.1 6.5 5.8 4.0

Jan-

Dec5.4 ◄

SarniaHSAA/

P4R

10.5

hrs11.3 10.1 8.4 9.7 8.5 9.9 10.5 8.8 11.1 8.9 9.1 8.0 8.9 9.5 9.0 9.0

Jan-

Dec9.2 ◄

Petrolia 0 4.6 4.2 3.7 4.0 3.9 3.7 3.5 4.0 3.6 3.8 4.3 3.6 4.0 3.6 4.1 4.3Jan -

Dec4.0 ◄

SarniaP4R/

QIP

33.2

hrs

<= 20

hrs30.1 28.4 26.0 21.7 21.7 24.7 29.0 26.6 38.1 24.5 24.9 14.2 20.3 25.5 23.0 18.6

Jan-

Dec21.8 ◄

Petrolia 0.0% 0.0% * 7.8 10.2 7.7 7.8 7.4 6.0 9.6 12.2 10.9 6.3 6.8 7.9 5.0 5.6 7.3 10.3Jan -

Dec7.0 ◄


5 HSAA 12.7% 17.2% 17.2 15.7 16.0 14.1 14.2 11.7 16.6 17.4 17.0 18.2 16.3 18.7 17.0 14.5 13.4Apr -

Mar15.8% ◄

Inspired People - Advance our culture of kindness with an intention to learn, lead, collaborate and celebrate

6 0.00 2.80 2.80Jan -

Dec 0.00##

7 SP $5,431 $5,800Apr -

Mar$5,988 0

8 0 $5,814 $5,849 0.0 0.0 0.0Apr -

Mar$6,237 0

9 0 $14,121 $10,823 0.0 0.0 0.0Apr -

Mar$14,404 0

10 0 $637 $620Apr -

Mar$663 0

11 0 $330 $319 $302 $304 $338 $338 $313 $310 $313 $313 $319 $322 $319 $317 $321 $321 $326 $402Apr-

Mar$402 ◄

12 0 n/a $0 -$426 $134 $143 -$44 -$90 -$131 -$188 -$245 $57 $29 $89 $187 $78 $476 $847 $175Apr -

Mar$175 ◄

13 HSAA n/a -$921 $1,218 $1,711 $2,094 -$80 -$172 -$334 -$243 -$122 -$122 -$562 -$715 -$597 -$654 -$663 $127 -$642Apr -

Mar-$642 ◄

14 HSAA n/a $0 $3,780 $5,357 $2,373 $2,887 $2,523 $2,687 $2,333 $2,025 $2,117 $1,726 $1,268 $2,239 $2,490 $2,982 $1,048 $0Apr -

Mar$0 $0

15 0 n/a 100% 40 71 79 0 0 0 2 2 3 30 45 47 54 56 62 1Apr -

Mar1% ◄

March results are preliminary and subject to change

2.83

$14,404

3.40

Our overall expenses for this indicator have incresed by $146K compared to Q3

17/18 and our weighted cases have decreased by 133 cases for the same period.

$14,335Our overall expenses for this indicator have increased by $320K compared to Q3

17/18 and our weighted cases have decreased by 143 cases for the same period

Our overall expenses for this indicator have increased by $2.87M compared to Q3

17/18 and our weighted cases are up by 247 for the same period

$6,237$6,154

3.12

$0

Previous target 3.10. Target 2019 CY - 2.80.

% Capital Budget Spent Actual YTD

Mental Health Inpatient Cost per Patient Day

Ensure continuous investment in strategic infrastructure

Rehab Inpatient

(4% of overall activity)

Cost per Weighted

Case (Actual YTD):

QBP Financial Exposure (Potential lost revenue related to

QBP achievement) Actual YTD in 000s

Surplus/(Deficit) Actual YTD in 000s

Continuing Care Cost per Weighted Patient Day

Absenteeism Rate- (avg # 7.5hr sick days)-All Staff

Adjusted Working Capital Actual YTD in 000s

$0

Our overall expenses for this indicator have decreased by $283K compared to Q2

17/18. The weighted patient days have decreased by 1,144 weighted days for

the same period

0

$0

$0

$0

3

4

$5,849ED Outpatient


Acute Inpatient & Day Surgery (53%

of overall activity)$5,988

3.42

$663$620

$10,823

2.85

Demonstrate accountability and efficiency


Outstanding Performance - Optimize roles, resources, revenues, technology and innovation

$5,799 $5,881

ALC Rate -All Inpatient Services

(Sarnia and Petrolia)


Q4 18/19


Q4 17/18 Q1 18/19 Q3 18/19

Comments

0

YTD Performance

0

0

Ref.


(Admitted Patients)

Performance Indicator

Pe

er

Co

mp

ara

tor

BW

H

Ta

rge

t


Resource Utilization & Audit Committee Performance Scorecard

0


0

0

<=8

hrs

Q2 18/19

$0

#


Complex Patients


Up

da

ted

Resource Utilization & Audit Committee Key Performance Indicators




Improve Access to Care



Outstanding Performance - Optimize roles, resources, revenues, technology and innovation

11.010.0

7.36.5 6.3

7.8

9.68.2

11.7

6.8 6.5

3.3

5.16.5

5.8

4.0Bluewater Health Target 2hrs by October 2019

0.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

Jan18

Feb18

Mar18

Apr18

May18

Jun18

Jul18

Aug18

Sep18

Oct18

Nov18

Dec18

Jan19

Feb19

Mar19

Apr19

Q4 17/18 Q1 18/19 Q2 18/19 Q3 18/19 Q4 18/19 Q1 19/20


24.6

22.4

18.9

16.8

16.6

18.9

23.4

20.2

29.3

19.4

19.0

6.3 12.9

18.2

16.2

11.1

Bluewater Health Target <=16 hrs

Peer Comparator 25.8 hrs

0

5

10

15

20

25

30

35

Jan18

Feb18

Mar18

Apr18

May18

Jun18

Jul18

Aug18

Sep18

Oct18

Nov18

Dec18

Jan19

Feb19

Mar19

Apr19

Q4 17/18 Q1 18/19 Q2 18/19 Q3 18/19 Q4 18/19 Q1 19/20


Bluewater Health Target 17.2% Provincial Target 12.7%

02004006008001,0001,2001,4001,6001,8002,000

0.0

5.0

10.0

15.0

20.0

25.0

30.0

Jan18

Feb18

Mar18

Apr18

May18

Jun18

Jul18

Aug18

Sep18

Oct18

Nov18

Dec18

Jan19

Feb19

Mar19 A

LC D

ays

All

Inpatient

Serv

ices

ALC R

ate

ALC Rate - All Inpatient Services (Sarnia and Petrolia)

ALC Rate Patient Days

$5,799

$5,881

$5,988

$5,700 $5,750 $5,800 $5,850 $5,900 $5,950 $6,000 $6,050

Q4 17/18

Q1 18/19

Q3 18/19

Cost per Weighted Case (Actual YTD)Acute Inpatient & Day Surgery (53% of overall activity)

$3,7

80

$5,3

57

$2,3

73

$2,8

87

$2,5

23

$2,6

87

$2,3

33

$2,0

25

$2,1

17

$1,7

26

$1,2

68

$2,2

39

$2,4

90

$2,9

82

$1,0

48

$0

$1,000

$2,000

$3,000

$4,000

$5,000

$6,000

Jan 1

8

Feb 1

8

Mar

18

Apr

18

May

18

Jun 1

8

Jul 18

Aug 1

8

Sep 1

8

Oct

18

Nov 1

8

Dec

18

Jan 1

9

Feb 1

9

Mar

19

Adjusted Working Capital YTD in 000s

-10

0

10

20

30

40

50

60

70

80

90

100

Jan18

Feb18

Mar18

Apr18

May18

Jun18

Jul18

Aug18

Sep18

Oct18

Nov18

Dec18

Jan19

Feb19

Mar19

Apr19

% Capital Budget Spent Actual YTD

$5,849

$6,154

$6,237

$5,600$5,700$5,800$5,900$6,000$6,100$6,200$6,300

Q4 17/18

Q1 18/19

Q3 18/19

Cost per Weighted Case ED Outpatient (12% of overall activity)

Q1 & Q2 18/19Q1 & Q2 18/19

1


Name of Committee: Board of Directors Date of Meeting: June 26, 2019 Submitted by: Marlene Kerwin Subject: Changes to Scorecard Reporting Format Purpose of Report: Information Input Approval

Situation

Bluewater Health has been investigating opportunities to enhance the RUAC Balanced Scorecard. The most significant change investigated has been the threshold for monitoring performance against targets.

Background

The current RUAC Balanced Scorecard monitors performance at a 5% threshold from target. This is a historical threshold that was put in place when scorecards were first developed at Bluewater Health. This threshold limits the ability to monitor meaningful progress against past performance. The hospital researched literature on performance monitoring and looked at scorecards from other hospitals and LHINs to support a revised performance monitoring framework.

Analysis/Considerations

The attached document outlines the metrics on the performance scorecard and the new colour coding for the indicator status to allow the organization to better identify meaningful progress. A revised scorecard is also attached.

Recommendation

To approve the revised performance monitoring framework for the RUAC scorecard

as presented.

a

x

Performance Scorecard

1. All indicators are aligned with Bluewater Health’s Kaleidoscope of Care.

2. Targets are based on last year’s performance.

3. The data is presented monthly/quarterly as the most recent completed month/quarter. The

rationale is to provide historical information and always have one year of data for comparison to

the current results, also described as a 12-month rolling reporting period.

4. Peer data is added to demonstrate relative performance to our peer hospitals.

5. All indicators have a trend line on the scorecard. Trending represents the 12-month rolling

reporting period.

6. An arrow indicates the desired trending for each indicator on the scorecard.

7. There is a definition sheet for readers to understand the background and rationale behind each

indicator.

Indicator Status

The indicator status compares the result against its baseline and target. The baseline is developed

during the target setting process once a year and is a measurement of last year’s performance for a

specific timeframe.

Red = Performance not meeting baseline

Yellow = Meeting baseline but still not meeting target

Green = Meeting or exceeding target

Grey = Data Unavailable. In instances of blank cells, it indicates reliance on internal/external agency

(coded data from Bluewater Health’s Health Records department or MOHLTC/ Canadian Institute of

Health Information – CIHI) to produce the most current results. In such cases, the data will remain blank

for alignment purposes, and only the most current data available will be presented.

References Wang, X., & Dickins, T. (2017, May). Canadian Health Information Management Association Professional Practice

Brief: Balanced Scorecard (Issue Brief No. PPB-0043.17). Retrieved from:



FOI

Italics

*

ⱡ

JAN

18

FEB

18

MAR

18

APR

18

MAY

18

JUN

18

JUL

18

AUG

18

SEP

18

OCT

18

NOV

18

DEC

18

JAN

19

FEB

19

MAR

19

APR

19Report

PeriodYTD

1 SarniaQIP/

P4R

25.8

hrs

20.2

hrs.

<=16

hrs24.6 22.4 18.9 16.8 16.6 18.9 23.4 20.2 29.3 19.4 19.0 6.3 12.9 18.2 16.2 11.1

Jan-

Dec14.6 ◄

2 SarniaSP/

NOW

9.7

hrs

7.9

hrs. ⱡ 2 hrs 11.0 10.0 7.3 6.5 6.3 7.8 9.6 8.2 11.7 6.8 6.5 3.3 5.1 6.5 5.8 4.0

Jan-

Dec5.4 ◄

SarniaHSAA/

P4R

10.5

hrs

9.2

hrs.

<=8

hrs11.3 10.1 8.4 9.7 8.5 9.9 10.5 8.8 11.1 8.9 9.1 8.0 8.9 9.5 9.0 9.0

Jan-

Dec9.2 ◄

Petrolia 03.9

hrs.

<=8

hrs4.6 4.2 3.7 4.0 3.9 3.7 3.5 4.0 3.6 3.8 4.3 3.6 4.0 3.6 4.1 4.3

Jan -

Dec4.0 ◄

SarniaP4R/

QIP

33.2

hrs

26

hrs.

<= 20

hrs30.1 28.4 26.0 21.7 21.7 24.7 29.0 26.6 38.1 24.5 24.9 14.2 20.3 25.5 23.0 18.6

Jan-

Dec21.8 ◄

Petrolia 0 07.8

hrs.* 7.8 10.2 7.7 7.8 7.4 6.0 9.6 12.2 10.9 6.3 6.8 7.9 5.0 5.6 7.3 10.3

Jan -

Dec7.0 ◄

5 HSAA 12.7% 16.2% 16.2% 17.2 15.7 16.0 14.1 14.2 11.7 16.6 17.4 17.0 18.2 16.3 18.7 17.0 14.5 13.4Apr -

Mar15.8% ◄

6 SP 2.8 3.4 2.8Jan -

Dec0

0

7 SP $5,431 $5,799 $5,800Apr -

Mar$5,988

0

8 $5,814 $5,849 $5,849Apr -

Mar$6,237

0

9 $14,121 $10,823 $10,823Apr -

Mar$14,404

0

10 $637 $620 $620 0Apr -

Mar$663

0

11 $330 $317 $314 $302 $304 $338 $338 $313 $310 $313 $313 $319 $322 $319 $317 $321 $321 $326 $402Apr-

Mar$402 ◄

12 n/a $143 $0 -$426 $134 $143 -$44 -$90 -$131 -$188 -$245 $57 $29 $89 $187 $78 $476 $847 $175Apr -

Mar$175 ◄

13 HSAA n/a $2,094 -$2,627 $1,218 $1,711 $2,094 -$80 -$172 -$334 -$243 -$122 -$122 -$562 -$715 -$597 -$654 -$663 $127 -$642Apr -

Mar-$642 ◄

14 HSAA n/a $2,373 $0 $3,780 $5,357 $2,373 $2,887 $2,523 $2,687 $2,333 $2,025 $2,117 $1,726 $1,268 $2,239 $2,490 $2,982 $1,048 $783Apr -

Mar$783 ◄

15 n/a 47% 100% 40 71 79 0 0 0 2 2 3 30 45 47 54 56 62 1Apr -

Mar1% ◄

March results are preliminary and subject to change

Cost per

Weighted Case

(Actual YTD)

Absenteeism Rate - (avg # 7.5 hr. sick days) All Staff 3.122.85

Adjusted Working Capital Actual YTS in 000s

DEMONSTRATE ACCOUNTABILITY AND EFFICIENCY

ENSURE CONTINUOUS INVESTMENT IN STRATEGIC INFRASTRUCTURE

$6,154$5,849 $6,237

$14,335 $14,404$10,823

$663$620

0

% of Capital Budget Spent Actual YTD 0

QBP Financial Exposure (Potential lost revenue related to

QBP achievement) Actual YTD in 000s

ALC Rate - All Inpatient Services

(Sarnia and Petrolia)

Continuing Care Cost per Patient Day

$5,988$5,881$5,799


Surplus/(Deficit) Actual YTD in 000s

Acute Inpatient & Day Surgery (53% of

overall activity)

ED Outpatient


Rehab Inpatient


3.42

OUTSTANDING PERFORMANCE

0

CommentsTrending

QUALITY CARE - ASSURE THE RIGHT CARE, IN THE RIGHT PLACE, AT THE RIGHT TIME, BY THE RIGHT PROVIDER

EXCEPTIONAL RELATIONSHIPS - EXPAND INNOVATIVE PARTNERSHIPS AND COLLABORATIONS TO IMPROVE EXPERIENCES, SERVICES, TRANSITIONS AND COMMUNITY HEALTH

INSPIRED PEOPLE - ADVANCE OUR CULTURE OF KINDNESS WITH AN INTENTION TO LEARN, LEAD, COLLABORATE AND CELEBRATE

3

4

#

BUILD SUSTAINABLE PARTNERSHIPS AND COLLABORATIONS




Complex Patients


(Admitted Patients)

YTD

Performance

UP

DA

TED

Masked due to n size <5

n size between 5 - 29

no established target

corporate target

Q4 17/18 Q1 18/19 Q2 18/19 Q3 18/19 Q4 18/19

DRAFT Resource Utilization & Audit Committee Performance Scorecard

REF

.

Q1

19/20


Meeting baseline but not meeting target

Performance not meeting baseline

Data Unavailable

Key Performance Indicators

Pee

r

Co

mp

arat

or

De

sire

d

Tre

nd

ing

TargetBaseline

IMPROVE ACCESS TO CARE

0

0

2.83 3.40

FOCUS ON THE EXPERIENCE OF CARE AND CARING

1

Governance and Nominating Committee Highlights

June 12, 2019

Board Evaluation The Committee discussed upcoming Board evaluations: Self-Assessment, Peer, Board Chair and Exit surveys. All members are encouraged to participate. The results will be reviewed in the fall. Annual General Meeting (AGM) The Committee discussed the format of the June Board meetings which will take place on June 26, 2019 as follows:

• In-Camera - 3:00 pm • Open Session - 4:00 pm • Annual General Meeting - 5:00 pm • Post AGM Meeting immediately following AGM

Invitations have been distributed and the hospital is expecting a good turnout. Board Goals The Committee reviewed the activities the Quality and Resource Utilization & Audit Committee reported in contribution to achieving the Board’s Goals. A high level overview of the Board’s goals and progress will be shared via the Board Chair’s Annual Report, and a detailed summary will be reviewed with members at the next Board Retreat. Board Education/Orientation/Team Building All Board members are encouraged to attend upcoming OHA GCE sessions. Please click here to learn more. Please also RSVP to the Summer Social Event hosted by Dr. Haddad (June 27, 2019) if you have not already done so. Legislative Updates The Committee briefly discussed proposed legislative changes as outlined in the consent agenda. More information will follow. Board Liaison Update The CEO reported he attended the BWH Foundation AGM and there is an upcoming meeting with the Advisory Panels. It was mentioned the Board continues to require a representative for the CEEH Foundation Board. Please contact Paul Wiersma for more information if you are interested. In addition, the following items will be coming forward separately for Board approval/discussion:

• Board Work Plan 2018-19 • Strategic Plan Progress Report

Submitted by: Anthony Iafrate

https://www.oha.com/learning/governance-centre-of-excellence#1

1

No. Work Plan Item Committee Responsible

Alignment Policy/Strategic Plan/Legislation

Board Agenda Category (P=Public)

Sept

embe

r

Oct

ober

Nov

embe

r

Dece

mbe

r

Janu

ary

Febr

uary

Mar

ch

April

May

June

Status (CompleteIn ProgressDeferred)

Comments

1.1 Monitor Strategic Plan annually G&N A-2/E-3 Discussion (P) x x x Complete1.2 Monitor strategic goals and quality/resource objectives via

Balanced Scorecards and provide oversight for remediation/improvement plans

RUAC ECFAASP

A-3/E-3

Discussion (P) x x x x x x x x x Complete

1.2a Monitor strategic goals and quality/resource objectives via Balanced Scorecards and provide oversight for remediation/improvement plans

Quality ECFAASP

A-3/E-3

Discussion (P) x x x x x x x x Complete

1.3 Review/approve/monitor Quality Improvement Plan (QIP) Quality C-1/E-3ECFAA

Decision (P) x x x x x Complete

1.4 Establish annual performance indicators and targets Quality/RUAC ECFAASP

Decision (P) x x x Complete

2.1 Complete CEO/CoPS performance evaluation and approve goals/objectives

Exec B-3 In-Camera x x x x x Complete

2.2 Establish annual CEO/CoPS performance expectations Exec B-3 In-Camera x Complete2.3 Determine annual CEO/CoPS compensation Exec B-3 In-Camera x Complete2.4 Ensure CEO/CoPS establish an appropriate succession plan for

BWH leaders and Professional StaffExec B-1/E-3 Minutes x x Complete

2.5 Review/approve annual HR and Physician HR plans RUAC E-3 Decision (P) x x Complete 2.6 Review/approve executive performance-based compensation Exec B-3

ECFAAIn-Camera x Complete

2.7 Review/approve salary recommendation for non-union compensation

RUAC B-3ECFAA

In-Camera x Complete

2.8 Review/approve Medical Director and other medical leadership appointments as required

MAC E-3 In-Camera x x x x x x x x x x Complete

3.1 Monitor Quality and Patient Safety program annually Quality C-1/C-8SP

In-Camera x Complete

3.2 Monitor accreditation activities and respond as required (timing aligned with accreditation cycle)

Quality/G&N C-1/E-3/E-10 Discussion x x x x x x x x Complete

3.3 Review Critical Incident Aggregated Data reports (Excellent Care for All Act legislation: at least twice annually)

Quality C-1ECFAA

In-Camera x x Complete

3.4 Monitor litigation claims and Risk Assessment Checklist Quality C-2/E-10 In-Camera x x Complete

3.5 Monitor ethical framework outcomes and related policies (minimum annually)

Quality C-4 In-Camera x Complete

3.6 Monitor research being undertaken within the organization (minimum annually)

Quality C-3 Minutes x Complete

BLUEWATER HEALTH WORK PLAN 2018-19

1.0 Establishing Strategic Direction

2.0 Providing for Excellence Management

3.0 Ensuring Program Quality and Effectiveness

2




Sept

embe

r

Oct

ober

Nov

embe

r

Dece

mbe

r

Janu

ary

Febr

uary

Mar

ch

April

May

June


Comments


3.7 Monitor pandemic plan and emergency preparedness (i.e. Disaster plan and other related activities) - annually

Quality C-1/C-8 Minutes x Complete

3.8 Monitor Quality Improvement Initiatives (through monthly program tours or didactic presentations) - education articles will be linked to program

Quality E-10 ECFAA

Minutes x x x x x x x x Complete

3.9 Review recommendations from MAC on any systemic/recurring issues related to quality of care provided by professional staff as required (standing agenda item)

Quality/MAC C-1PHA

In-Camera x x x x x x x x x Complete

3.10 Receive minutes from the Quality and Patient Experience Committee

Quality E-10 IV Minutes x x x x x x x x x Complete

3.11 Monitor patient experience results via Concerns/Compliments reports and 4 principles of PFCC

Quality C-2/C-5ECFAA

SP

Minutes x x x x Complete May report deferred to June.

3.12 Provide update on Workplace Violence (also incorporated into 2018_19 QIP & scorecard) - twice annually

Quality ECFAA Minutes x x Complete

3.13 Monitor staff, professional staff and volunteer engagement survey results

Quality ECFAASP

Minutes x Complete

3.14 No One Waits (N.O.W.) Initiative update - quarterly Quality/RUAC SP Minutes x x x x x Complete January meeting cancelled. May update moved to June.

3.15 Review/approve Professional Staff appointments, reappointments, privileges as required

MAC PHA In-Camera x x x x x x x x x x Complete

3.16 Review fairness/effectiveness of credentialing process annually MAC In-Camera x Complete

3.17 Receive reports from the CEO in relation to the 3rd party whistleblower service

RUAC C-7 Minutes x x Complete

3.18 Monitor Integrated Risk Management (IRM) annually - include best practices' 3 corporate priorities

Quality C-2SP

Minutes x x Complete

3.19 Hospital Standardized Mortality Rate report - twice annually Quality SP Minutes x x Complete

3.20 Health and Wellness Update Quality SP Minutes x x Complete 3.21 Receive Quality of Care Information Protection Act (QCIPA) &

Quality Care Review Recommendations in aggregate twice per year (used to be combined within the Quality & Patient Safety Program report)

Quality ECFAAE-10 IV

x x Complete

3.22 Receive annual Occupational Health and Safety Program Report RUAC OH&SA / HPPAC-8

Consent R (P) x Complete

3




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3.23 Receive an update on environmental stewardship outcomes annually

RUAC C-9 Consent R (P) x Complete

3.24 Receive annual report on AODA accountabilities, progress and compliance

RUAC AODAE-3


4.1 Monitor financial performance via monthly financial statements RUAC D-1/D-2 Discussion (P) x x x x x x x x x x Complete January meeting cancelled.

4.2 Review/approve annual operating plan RUAC C-1/D-1 Decision (P) x x x x x Complete Operating Plan approved Feb 27, 2019. Final budget reviewed June 2019.

4.2a Review/approve annual operating plan Quality C-1/D-1 Decision (P) x Complete4.3 Review/approve Hospital Accountability Planning Submission

(HAPS)RUAC D-1/D-2 Decision (P) x

(draft HAPS)

x x(Final HAPS)

x Complete HAPS approved Feb 27, 2019 .

4.4 Review/approve/monitor capital expenditure plan RUAC D-1/D-2 Decision (P) x x x x x x x x x Complete4.5 Review/approve Hospital Service Accountability Agreement (H-

SAA)RUAC D-1/D-2 Decision (P) x x Complete H-SAA approved

Mar 27, 2019 4.6 Review/approve Community Accountability Planning

Submission (CAPS) and Multi-Sectoral Accountability Agreement (M-SAA)

RUAC D-1/D-2 Decision (P) x(draft CAPS)

x(Final CAPS)

x x Complete CAPS approved Feb 27, 2019 - MSAA approved Mar 27, 2019

4.7 Review/approve Chief Financial Officer Report - ensuring legislative requirements at met

RUAC C-2/D-2/D-3/E-3/E-10

Consent A (P) x x x x Complete

4.8 Monitor business/financial risk management RUAC C-2/D-2/D-3/E-3/E-10

Consent A (P) x x x x Complete

4.9 Review/receive quarterly report on investments and loans RUAC D-3/D-4/E-10 Consent R (P) x x x x Complete

4.10 Review/monitor physician bank loans annually RUAC D-3/D-4/E-10 In-Camera x x Complete4.11 Review/receive Human Resources Report quarterly RUAC E-10 Consent R (P) x x x x x Complete4.12 Review/receive Facilities Report quarterly RUAC D-1/E-10 Consent R (P) x x x x x Complete Deferred to June. 4.13 Review/receive insurance annually RUAC D-3 Minutes x x Complete4.14 Review/approve banking arrangements/resolutions RUAC D-3 Consent R (P) x x x Complete4.15 Review/approve audit activities as required

(post-audit/management letter, management's response and action plan, audit plan, financial statements, firm/compensation)

RUAC E-3/E-10 Consent R x x x Complete

4.16 Review/approve Executive and Director expenses RUAC BPSAAD-6/E-2/E-18

Consent R x x Complete

4.17 Review/approve Public Sector Salary Disclosure Attestation RUAC PSSDAE-2


4.0 Ensuring Financial Viability

4




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4.18 Review/approve BPSECA Attestation - annual executive compensation

RUAC BPSECAD-1

Consent A (P) x x NA - Waiting on ESC LHIN Response

4.19 Review/approve BPSAA Attestation - consultant use, perquisites, lobbyist rules, etc.

RUAC BPSAAD-6/E-18/E-2

Consent A (P) x Complete

4.20 Provide update on HIS or any other significant technology investments as needed

RUAC SPD-1

Minutes x x x x x x x x Complete

4.21 Provide update on cyber security annually RUAC C-2 Discussion (P) x x Complete January meeting cancelled

4.22 Monitor/approve decisions related to property matters as required

RUAC D-1 In-Camera x x x x x x x x x x Complete January meeting cancelled

4.23 Monitor status of the development of the 5-Year Plan - services, facilities, capital equipment, and technology

RUAC E-3SP

Minutes x x x x Complete

5.1 Develop/approve annual work plan All/Quality separate

E-15 Decision (P) x x Complete

5.1a Develop/approve annual work plan Quality E-15 Decision (P) x Complete5.2 Review/revise/approve Terms of Reference All/Quality

separateE-10 Decision (P) x Complete

5.2a Review/revise/approve Terms of Reference Quality E-10 Decision (P) x Complete5.3 Develop/approve/monitor Board Goals G&N/All E-15/E-19 Decision (P) x x x x Complete5.4 Complete Board/Director/NDCM/Committee/Meeting

evaluations as required and address opportunities identified by results

G&N/All/Quality Separate

E-11/E-12/E-13/E-14/E-19

Consent R (P) x x x x x Complete

5.4a Complete Board Committee Meeting evaluation as required and address opportunities identified by results

Quality E-10/E-11/E-12/E-13/E-15/E-18

Consent R (P) x x Complete

5.5 Strengthen Board Orientation/Education/Team Building G&N/All/Quality Separate

E-9SP

Discussion (P) x x x x x x x x x x Complete

5.5a Quality Committee Education Article Review - article to be linked to program who is scheduled for tour or didactic presentation item 3.8

Quality E-9SP

Discussion (P) x x x x x x x x Complete

5.6 Complete Board succession planning, recruitment and nomination process

G&N E-8/E-9 Minutes x x x x x x Complete March meeting cancelled.

5.7 Review Board/NDCM member meeting attendance and education record

G&N E-19 Discussion (P) x Complete

5.8 Review/revise/approve Board policies as required All E-1 Consent R (P) x x x x Complete5.9 Plan for Annual General Meeting G&N E-10 Minutes x x x x x x x Complete March meeting

cancelled.5.10 Review/receive annual FIPPA/PHIPPA compliance report and

complete FIPPA Delegation of AuthorityQuality C-6

FIPPAPHIPPA

Consent A (P) x Complete

5.0 Ensuring Board Effectiveness

5




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5.11 Review/approve Corporate By-Law amendments as required G&N E-1 Decision (P) x Complete

5.12 Complete Board meetings without Management. Board E-17 Discussion x x x Complete 5.13 Consider Generative Discussion items for Board meetings. G&N E-9 In-Camera x x x x x x x x x x Complete March meeting

cancelled.5.14 Participate in Accreditation Activities. G&N All Board Policies Discussion x x x x x x x x Complete March meeting

cancelled.

6.1 Review/receive Global Communication and Community Engagement Plan

G&N E-2/E-3/F-1 Information (P) x Complete

6.2 Review/receive reports from CEO/Board liaison representatives re: stakeholder relationships as necessary i.e.. Governance Advisory/Foundation Boards/CAP/RHAP

G&N E-2/E-3/F-1/F-2SP

Information (P) x x x x Complete

6.0 Fostering Relationships

CompletedIn ProgressDeferred

G&NQuality RUACMACBoard

PROGRESS REPORT: JANUARY – DECEMBER 2018


Within 5% of Target

Worse than Target by 5=%

Goal Initiative Indicator PerformanceJune 2016

PerformanceMay 2017

PerformanceMar 2018

Target Year 2 Jan - Dec 2018

PerformanceYear 2

Jan - Dec 2018

Target Year 3 - 2019

Ingrain patient safety Implement a Quality and Patient Safety Plan It is difficult to speak up if I perceive a problem with patient care - Pulse Survey 2016/17Staff speak up about negative effects - Employee Engagement Survey (EES) May 2018

Collecting Baseline Data

Jan - Mar 2017 41.9%

Apr 17 - Mar 1846.9%

49.60% EES 2018 - 56.1% TBD

Improve access to care Improve Emergency Department wait times 90th percentile ED wait times (admitted patients)

22 hours Sarnia - 24.6 CEEH - 6.8

Jan - Dec 2017 Sarnia - 24.9

CEEH - 8

Sarnia - <=20 hours Jan - Dec 2018 Sarnia - 26 CEEH - 7.8

Sarnia - <=20 hours

Build sustainable partnerships & collaborations

Provide a seamless patient journey across the continuum of care

Alternate level of care (ALC) rate 27.40% 21.40% Apr 17 - Mar 1815.00%

17.20% Jan - Dec 2018 16.2%

16.20%

Apr 17 - Mar 18 ED - 49.7%

50.60% Jan - Dec 2018 ED - 51.1%

ED - 52%

Apr 17 - Mar 18 Inpt. 68.6%

72% Jan - Dec 2018Inpt. - 66.3%

Inpt. 67.0%

Supervisor helps access training and development

63.30% Dec 201666.3%

Apr 17 to Mar 1869.4%

NA EES 2018 Training & Development Theme -

70%

NA

NEW INDICATOR- The organization promotes staff health and wellness.

49.40% 51.6% NA EES 201851.6%

55.7%

Apr 17 to Mar 18ED - 66.8%

ED - 68.6% ED - 71.9% ED - 73.7%

Apr 17 to Mar 18Inpt - 78.2%

Inpatient - 81% Inpt. 66.8% Inpt. - 76%

BWH: Is a culture of kindness promoted at BWH?

Employees -61.9% Prof Staff -56.1%

Volunteers -80.1%

Dec 2016Employees -58.9% Prof Staff -56.1%

Volunteers -88.6%

Apr 17 - Mar 18 Employees - 69.9%Prof Staff - 69.1%

Employees -67.9% Prof Staff -62.1%

Volunteers -86.1%

EES 2018Employees - 69.9%

Prof - 69.1%

Employees - 71.9%Prof Staff - 71.1%


Increase awareness and understanding of resource decisions

Cost per weighted case 2015/16 Q3 $5,537 2016/17 Q3$5,669

Apr 17 - Mar 18$5,788

$5,800 $5,988 $5,800


Implement a sustainable plan for services, facilities, capital equipment and technology

Status of plan - Yr 1 No plan Under development Plan Updated Plan Updated Plan Updated Plan Updated

Outstanding PerformanceOptimize roles, resources, revenues, technology and innovation


Patient: Treated with kindness Q2 2016/1766.7%

Apr - Sept 201676.8%

Strengthen our culture of kindness

Enhance an environment of continuous learning

Promote individual, team and professional development

Collecting Baseline Data

Quality CareAssure the right care, in the right place, at the right time, by the right provider

Exceptional RelationshipsExpand innovative partnerships and collaborations to improve experiences, services, transitions and community health

Inspired PeopleAdvance our culture of kindness with an intention to learn, lead, collaborate and celebrate

Strengthen Patient & Family-Centred Care

Ingrain the four principles of Patient & Family-Centred Care

Overall rating of experience Q2 2016/1771.10 %

Strategic Plan: Kaleidoscope of Care 2016-2021

Successes Successfully prepared for Accreditation 2019 (Exemplary Standing) Embedded “just culture” decision tree into patient safety incident management process Completed monthly hospital-wide Morbidity and Mortality patient case reviews and

semi-annual department reviews Quality and Patient Safety Plan updated Improved dissemination of learnings from patient safety incidents

o Closing the Loop Newsletter o Near Miss Reports

Achieved Laboratory Accreditation with exceptional results Expanded influenza vaccination campaign Developed mitigation strategies and focused work for risks identified through the

Integrated Risk Management System and Risk Assessment Checklists o Completed Workplace Violence Prevention Risk Assessments o Embedded Good Catch Program and Red Rule Policy into patient safety culture

Key Priorities for 2019 Continued focus to minimize risks identified through Integrated Risk Management

System Continued corporate focus on “just culture” Quarterly monitoring of Accreditation Canada Required Organizational Processes to

ensure continuous quality improvement

Goal Initiative Indicator

Ingrain patient safety

Implement a Quality and Patient Safety

Plan

It is difficult to speak up if I perceive a problem with patient care

At or better than target. Continue to monitor.

Within 5% of target. Monitor and take action as appropriate.

Below target by more than 5%. Take action and monitor progress.

It is difficult to speak up if I perceive a problem with patient care/Staff speak up about negative effects

Strategic Goal: Ingrain Patient Safety

56%

0%

10%

20%

30%

40%

50%

60%

Q3 16/17 Q4 16/17 Q1 17/18 Q2 17/18 Q3 17/18 Q4 17/18 Q1 18/19 Q2 18/19 Q3 18/19 Q4 18/19

Difficult to Speak up/Staff speak up about negative effects Bluewater Health Target

Preferred Trending

Our Status

Our Status

Our Status

Strategic Plan Progress Report 2018

Successes Launched No One Waits (NOW) Initiative

1. Match Capacity and Demand o Design models of care delivery to match patient care needs and maintain staffing

levels to meet demand o Align beds and services to match demand and manage variations (Right Beds,

Right Service) 2. Process Efficiencies

o Improve Admission, Transfer and Discharge Processes o Reduce Conservable Bed Days o Physician Initiatives to Improve Efficiency and Flow

Introduced BWH Outpatient Psychiatry Clinics to improve access to psychiatric consultations and collaborative-shared care with primary care providers, with an objective to improve knowledge transfer and increase early detection and intervention for mental health care

Recruited new specialists: internist, respirologist, endocrinologist, OB/GYN, urologist, rheumatologist, and hospitalist

Achieved exceptional wait time results for numerous priority indicators (CT, MRI, Hip/Knee/Cancer Surgeries, lab tests, etc.)

Key Priorities for 2019 NOW Initiative Support Canadian Mental Health Association proposal for Community Mental Health

model that operates extended evening hours and 7 days a week Establish a collaborative Mental Health program, providing a youth-centric mental

health and addictions service in the community, along with key partners (health and social services)

Enhance Primary Care integration Continue to work with partners on innovative models to provide local sub-specialty care

i.e. chronic pain management, geriatric care, etc.

Improve access to care Improve Emergency

Department (ED) wait times

90th percentile length of stay for admitted patients



Above or below target by more than 5% depending on preferred trending. Take action and monitor progress.

No established target.

Updated: April 2019 Bluewater Health

90th Percentile Emergency Department (ED) Length of Stay (LOS) for Admitted Patients

Strategic Goal: Improve access to care Alignment: PUC; QCB; QPEC; RUAC

Bluewater Health, Sarnia Results

Charlotte Eleanor Englehart Hospital of Bluewater Health, Petrolia Results

Bluewater Health, Sarnia Target

Ontario High-Volume Community Hospital Results

0

5

10

15

20

25

30

35

40

45

Apr16

May16

Jun16

Jul16

Aug16

Sep16

Oct16

Nov16

Dec16

Jan17

Feb17

Mar17

Apr17

May17

Jun17

Jul17

Aug17

Sep17

Oct17

Nov17

Dec17

Jan18

Feb18

Mar18

Apr18

May18

Jun18

Jul18

Aug18

Sep18

Oct18

Nov18

Dec18

Jan19

Feb19

Mar19

Q1 16/17 Q2 16/17 Q3 16/17 Q4 16/17 Q1 17/18 Q2 17/18 Q3 17/18 Q4 17/18 Q1 18/19 Q2 18/19 Q3 18/19 Q4 18/19

ED L

OS

(ho

urs

)

Pre

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Tre

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SarniaStatus


Successes Updated five-year capital plan Implementation and ongoing roll out of the interRAI Standardized Mental Health and

Addictions screening and assessment Opened interim Residential Withdrawal Management Services beds and successfully

operated services for one full year Collaborated to complete Stage 1 Parts A and B of the CEEH Redevelopment Project for

submission to the ESC LHIN and Ministry of Health and Long-Term Care Expanded Outpatient Pharmacy services to the Assertive Community Treatment team Transitioned Workplace Violence reporting to the RL6 system Successfully introduced Hip and Knee Replacement Bundled Care Model and

participated in Voluntary Bundled Care Expansion for Shoulder and Reverse Arthroplasties

Introduced Pharmacist Discharge Facilitator role Created an on-site Obstetric Gynecology Clinic Updated laboratory/radiography equipment to reduce turnaround time, improve quality

of care, and increase patient, staff and physician satisfaction Key Priorities for 2019 Align beds and services to match demand and manage variation i.e. Short Stay

Transition Unit, Surge beds, etc. Continued capital planning for permanent Residential Withdrawal Management Services

and the CEEH Capital Redevelopment Project Ongoing participation in the Regional Hospital Information System (HIS) project Implementation of the WellLink (blockchain technology) to support a longitudinal

mental health record shared between BWH, CMHA LK and St Clair Child and Youth Establishment of a Musculoskeletal Hip and Knee Rapid Access Centre Implementation of the Regional PACS project Planning for Medical Day Treatment Hub Launch of new intranet for staff, Professional Staff and volunteers



Implement a sustainable plan for services, facilities, capital equipment and technology

Status of plan


Successes Increased volume of hip and knee replacement surgeries Expanded the Clinical Resource Team to broader the number of individuals and

disciplines to work in multiple areas Continued participation in Choosing Wisely initiatives: opioid prescribing, de-

prescribing, Diagnostic Imaging – education re appropriate test (CT/MRI/Ultrasound), code status

Aligned Program scorecards with strategic priorities, NOW, and Bundled Payments Optimized Material Handler Cart Introduced Clinical Documentation Improvement Specialist Improved overall Emergency Department Length of Stay (ED LOS) and Time to Inpatient

Bed during seasonal surge with proactive planning aligned with NOW Initiative Increase of weighted cases

Key Priorities for 2019 Continue to expand the Clinical Resource Team Reduce Conservable Bed Days

o Improve Discharge Bullet Rounds o Focus on Estimated Date of Discharge

Report enhancements using ESM to send out electronic reports to manager Ongoing retrospective charts audits to ensure appropriate/maximum weighted case

component of Cost per Weighted Case, including implementation of 3M Computer Assisted Coding Software

Human resources focus: optimize staffing levels, review/revise the Attendance Support Program, implement the next phase of StaffRight scheduling system, provide staff with remote access to scheduling information

Goal Initiative Indicator Demonstrate accountability and efficiency

Increase awareness and understanding of resource decisions Cost per weighted case






Acute Cost per Weighted Case: Acute Inpatient & Day Surgery (53% of overall activity)

Strategic Goal: Demonstrate accountability and efficiency Alignment: PUC; RUAC

Bluewater Health Target

Peer Comparator $5,431

$5,000

$5,200

$5,400

$5,600

$5,800

$6,000

$6,200

$6,400

$6,600

$6,800

$7,000

Q1 16/17 Q2 16/17 Q3 16/17 Q4 16/17 Q1 17/18 Q2 17/18 Q3 17/18 Q4 17/18 Q1 18/19 Q2 18/19 Q3 18/19

Co

st p

er W

eigh

ted

Cas

e

Our Status

Pre

ferr

ed

Tre

nd

ing


Successes Achieved exceptional Employee Engagement Survey Results

o Response rate of 74.2% vs. Ontario average of 52.8% o 70.5% score for overall engagement of BWH Employees, an increase of 5% from

the previous survey o 74.8% are proud to tell others they are part of BWH o 76.3% positively rate BWH as a place to work o BWH promotes a culture of kindness score increased to 69.9%

Developed Action Plans relative to Employee Engagement Results Culture of Kindness Employee Council (CKEC), composed of representatives from various

program areas, continued its focus on strengthening the culture of kindness across BWH Increased positive patient and family feedback in several hospital areas

Key Priorities for 2019 Stabilize workforce demands Understand reasons behind turnover and focus on retention efforts Implement strategies to reduce orientation and training costs Continue patient rounding with Patient Experience Partners and Chief Nursing Executive Spread the Collaborative Model of Care Continue efforts by the CKEC to strengthen our culture of kindness



Strengthen our culture of kindness

Patient: Treated with kindness

BWH: Is a culture of kindness promoted at BWH?





Updated: April 2019 Bluewater Health Page | 54

Was Patient/Family Treated with Kindness

Strategic Goal: Focus on the experience of care and caring Alignment: QCB; QPEC

Emergency Results

Emergency Target 68.6%

Inpatient Results

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Apr16

May16

Jun16

Jul16

Aug16

Sep16

Oct16

Nov16

Dec16

Jan17

Feb17

Mar17

Apr17

May17

Jun17

Jul17

Aug16

Sep16

Oct17

Nov17

Dec17

Jan18

Feb18

Mar18

Apr18

May18

Jun18

Jul18

Aug18

Sep18

Oct18

Nov18

Dec18

Q1 16/17 Q2 16/17 Q3 16/17 Q4 16/17 Q1 17/18 Q2 17/18 Q3 17/18 Q4 17/18 Q1 18/19 Q2 18/19 Q3 18/19

Perc

ent o

f Pos

itive

Res

pons

es

Preferred Trending

EDStatus

Inpatient Status

Inpatient Target 81%



Below target by more than 5%. Take action and monitor progress.

Is a Culture of Kindness Promoted at Bluewater Health?

Strategic Goal: Focus on the Experience of Care and Caring Alignment: QCB

0

10

20

30

40

50

60

70

80

90

Q1 16/17 Q2 16/17 Q3 16/17 Q4 16/17 Q1 17/18 Q2 17/18 Q3 17/18 Q4 17/18 Q1 18/19 Q2 18/19 Q3 18/19 Q4 18-19

Employees - Culture of Kindness Promoted Physicians - Culture of Kindess Promoted

Bluewater Health Employee Target Bluewater Health Physician Target

Preferred Trending

Our Status

Our Status

Our Status


Successes Improved Employee Engagement score related to question: Organization promotes

health and wellness Continued work of Well-Being Advisory Team and restructured Healthy Living Team Provided educational opportunities to support well-being, self-care and resilience Offered Compassion Fatigue sessions with 10 employees now certified as Compassion

Fatigue Educators Established Critical Incident Stress Management Team to support employees and teams Developed Code Lavender Established Professional Staff Association Wellness Committee and extended EAP

Counselling services to Active/Associate Professional Staff Implemented the LEADS Framework from LEADS Canada as the capabilities for Leaders Continued to offer formal management and leadership development programs and

provide department specific training and education to ensure best practice organization-wide

Launched Touring Town Halls led by President and CEO to share knowledge and engage with staff, Professional Staff and volunteers

Partnered with Western University’s Schulich School of Medicine to become an approved site for the training of a family medicine resident specializing in emergency medicine

Key Priorities for 2019 Formalize Wellbeing Strategy and participate in Excellence Canada’s framework for

Mental Health in the workplace Continued focus to support BWH employees and teams in trauma exposed areas Continued collaboration with educational institutions such as Western University’s

Schulich School of Medicine, the University of Windsor, and Lambton College regarding workforce planning, educational needs and training opportunities

Introduce 360 Feedback through LEADS Canada to support leadership development


Promote individual, team and professional development

Enhance an environment of continuous learning

The organization promotes health and wellness






Organization Promotes Staff Health/Wellness

Strategic Goal: Focus on the experience of care and caring Alignment: QCB

n s

ize:

92

3

n s

ize:

10

32

n s

ize:

82

6

n s

ize:

10

60

Bluewater Health Results

Employee Community Average & Bluewater Health Target 55.7%

0

200

400

600

800

1000

1200

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2011 2013 2016 2018

n size

% o

f P

osi

tive

Res

po

nse

s

Pre

ferre

d Tre

nd

ing

Our Status


Successes Strengthened relationships through the Lambton Health Quality Partners collaborative,

which is foundational for the transition to Ontario Health Teams Developed Admission Avoidance strategy to transition patients back to community with

service plan for patients that do not require acute care services Implemented Mobilization of Vulnerable Elders (MOVE) to promote early mobilization

practices for vulnerable seniors admitted to hospitals Increased collaboration with Long Term Care (LTC) Homes - new transition meetings for

patients, and LTC home trials for patients with behaviors More expedient sharing of information between hospital and primary care providers to

support transitions back to the community (fax and electronic transmission vs. paper mailings)

Established integrated management model between BWH Mental Health and Canadian Mental Health Association (CMHA), where managers meet on a monthly basis to leverage relationships to strengthen collaborative practices, improving transition of care to and from hospital

Implemented best practices outlined in ALC framework Key Priorities for 2019 Ontario Health Team development Adopt ALC Leading Practices Continued work to streamline admission, transfer and discharge processes

o Improved flow of information between BWH and Primary Care Providers o Improved coordination between Mental Health and Addiction Services to

Community o Improved communication of discharge date to patient/family and earlier

discharge planning to avoid ALC designation & ALC days o Transition medically fragile patients residing in hospital to community

Develop a process for ESC LHIN coverage for Palliative Medicine patients being discharged to home or Hospice



Provide a seamless patient journey across the continuum of care

Alternate level of care (ALC) rate






Alternate Level of Care (ALC) Rate – All Inpatient Services

Strategic Goal: Build sustainable partnerships and collaborations Alignment: PUC; RUAC

Buewater Health ALC Rate

Provincial ALC Target 12.7%

ALC Days All Inpatient Services

0

200

400

600

800

1000

1200

1400

1600

1800

2000

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

Apr16

May16

Jun16

Jul16

Aug16

Sep16

Oct16

Nov16

Dec16

Jan17

Feb17

Mar17

Apr17

May17

Jun17

Jul17

Aug17

Sep17

Oct17

Nov17

Dec17

Jan18

Feb18

Mar18

Apr18

May18

Jun18

Jul18

Aug18

Sep18

Oct18

Nov18

Dec18

Q1 16/17 Q2 16/17 Q3 16/17 Q4 16/17 Q1 17/18 Q2 17/18 Q3 17/18 Q4 17/18 Q1 18/19 Q2 18/19 Q3 18/19

ALC Day s Inpatient ServicesAL

C Ra

te

Pref

erre

d Tr

endi

ngOur

Status


Successes Introduced Indigenous Patient Navigator role and developed Bluewater Health

Indigenous Partnership Committee Created integrated position with the Lambton County Lake Huron Health Link Completed bedside rounding with Patient Experience Specialist and Chief Nursing

Executive for patient experience feedback Engaged Patient Experience Partners (PEP’s), patients and their families to complete

patient surveys in the ICU and ED using electronic devices with increased real time completion rate

Revised/created Quality Based Procedures education materials for patients Implemented Patient Orientation Discharge Summaries (PODS) on Inpatient

Rehabilitation Unit Provided cultural sensitivity training for staff Developed new services/processes to improve quality of care, reduce delays and

provide local care for patients such as: o Palliative care services at CEEH site o Electroconvulsive Therapy Program o Transesophageal Echocardiography Program o Peripherally inserted central line (PICC) Clinic o Oncology two day model

Key Priorities for 2019 Develop a generic PODS and spread to all areas of the hospital Continued growth of CMOC to improve the patient experience Continued involvement of PEPs in quality improvements initiatives Continued improvement to patient handouts, forms, signage and website content Participate in an Memorandum of Understanding for a Mental Health Engagement and

Response Team (MHEART) that includes a community team with police services (Sarnia and OPP) and CMHA with protocols that include BWH participation


Strengthen Patient & Family-Centred Care (PFCC)

Ingrain the four principles of Patient & Family-Centred Care

Overall rating of experience







Strategic Goal: Strengthen Patient and Family-Centered Care Alignment: QCB; QPEC

Emergency Results

Inpatient Results

0%

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40%

50%

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90%

Apr16

May16

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Q1 16/17 Q2 16/17 Q3 16/17 Q4 16/17 Q1 17/18 Q2 17/18 Q3 17/18 Q4 17/18 Q1 18/19 Q2 18/19 Q3 18/19

Perc

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Preferred Trending

ED Status

Inpatient Status


CHALLENGES Cultural Fear of “speaking up” Influenza vaccination rates Consistent practices/processes with Estimated Date of Discharge (EDD),

admission/discharge practices, and ALC designation Aligning discharge strategies with patient and family centered care Complexity of transformational culture change in a 24/7 - 365 environment Inspiring staff during surge periods or when staffing resources are stretched Workplace violence

Human Resources Limited physician coverage i.e. rehab or psychiatric support on CCOG unit Increased overtime and sick time costs Human Resources – increased turnover, succession planning, retention, and

recruitment of specialized roles High orientation and training needs Skill mix balance between experienced and “new to the profession” staff Conserving knowledge with ongoing staff retirements, relocation to other units and

novice staff Generational differences

Communications Inconsistent messaging to patients/families around transition planning (Home First)

when dealing with myriad community agencies Lack of understanding among inter-disciplinary team members about ALC status and

what it means to the patients’ plan of care Knowledge translation following professional development opportunities

Political Uncertainty within sector with transition to Ontario Health Teams Managing public expectations on capital development projects Dealing with end of life on equipment and substandard inpatient facilities at CEEH

Community Mental Health & Addictions demand on the Emergency Department and patient flow Community resources i.e. home care, affordable housing, access to Long-Term Care

beds, capacity for patients with behavioural issues, demand for outpatient community-based services

Other Timeliness and subjectivity of data obtained through patient experience surveys to drive

changes at the point of care Lack of community digital infrastructure

180 Riverview Drive Chatham, ON N7M 5Z8 Tel: 519 351-5677 • Fax: 519 351-9672 Toll Free: 1 866 231-5446 www.eriestclairlhin.on.ca

Via email June 13, 2019 Kevin Grossi Senior Consultant Health Capital Investment Branch Ministry of Health and Long-Term Care 1075 Bay Street, 2nd Floor Toronto ON M5S 2B1 Dear Mr. Grossi: Re: Bluewater Health Rural Health Capital Improvement Project - Charlotte Eleanor Englehart

Hospital – Erie St. Clair Local Health Integration Network Endorsement of Stage 1 Submission The Erie St. Clair Local Health Integration Network (ESC LHIN) has completed an internal staff review of the Bluewater Health’s Rural Health Capital Improvement Project - Charlotte Eleanor Englehart Hospital (CEEH), Stage 1 Submission. Following this review, the ESC LHIN is pleased to endorse the Programs and Services identified in Part A of the Stage 1 Submission. The ESC LHIN continues to endorse this project. Please also find attached the ESC LHIN revisions to the Ministry of Health and Long-Term Care’s comments on the submission. All of the LHIN’s questions have been resolved to our satisfaction. Once again, we are pleased to offer our support to this project. Sincerely, Ralph Ganter Chief Executive Officer EL/jf Attach. Stage 1 - BWH CEEH Rural Capital Improvement Project – May 17, 2019 cc: Mike Lapaine, President and Chief Executive Officer of Bluewater Health

Laurie Zimmer, Vice-President, Operations, Bluewater Health Caen Suni, Vice President, Integrated Delivery Systems, ESC LHIN

Pete Crvenkovski, Vice President, Performance Accountability & Finance, ESC LHIN Jennifer Mackey, Director Sub-Region Lambton, ESC LHIN Erin Link, Manager Capital Planning, & Acting Director Sub-Region Essex, ESC LHIN

Chief of Professional Staff Report to the Board

June 2019

At the Medical Advisory Committee meeting held on June 19, 2019, the following items were discussed: Quality Improvement Initiatives

• Approved recommendations from the Pharmacy & Therapeutics Committee, Infection Prevention & Control Committee and Order Sets Committee

• Approved revisions to the Most Responsible Practitioner (MRP) Policy • Approved Criteria for Physicians applying to work in the High Acuity area of

Bluewater Health – Sarnia Emergency Department • The MAC was asked to complete the MAC self-assessment survey • Received updates on:

o Patient Order Sets Committee o Ontario Stroke Report card, and BWH’s performance, including strategies

for improvement o New Professional Staff intranet portal o No One Waits (N.O.W.) Initiative o Mechanism to discuss medical utilization – revised MAC scorecard o Admissions from ED for open beds o NP or PA supervision of Clinical Practice o Mask fit testing o Departments encouraged to complete OHA physician well-being,

organizational culture & engagement survey o Discussions with community partners regarding Lambton County as an

Ontario Health Team

Physician Education, Development and Engagement • Chose ‘Managing people effectively’ for next PLI course • Quarterly Chief of Staff Hospital-wide M&M Rounds will begin soon • Encouraged physicians to fill Professional Staff Association Executive positions • Physician Recognition Awards nominations will be sent out over the summer –

encouraged to nominate colleagues for Peer Recognition, Outstanding Contribution to the Hospital, Outstanding Physician of the Year awards

• Discussed recent and upcoming events: o At the Professional Staff Association Annual meeting on June 5, Dr. Andre

Rudovics became the new PSA President, the VP, Sarnia position will be filled by Dr. Dhiraj Dhanjani starting in the fall and efforts are still being made to fill the VP, Petrolia and Secretary/Treasurer positions

o MAC/Board/EC Summer Social event – June 27, 2019 at 5:00 p.m. at Dr. Haddad’s house

o PSA Summer Family BBQ – July 14, 2019 at 12:00 p.m. at Canatara Park o Physician Appreciation Evening – October 3, 2019 at Huron Oaks

Professional Staff By-Laws • Accepted the By-Laws Committee’s proposed amendment to the Professional

Staff By-laws to allow for PSA Executive nominations from the floor at the PSA annual meeting, if there are no nominations prior to the annual meeting

• as per the Professional Staff By-Laws, it will be posted for a period of at least 30 days to allow for comment before a recommendation to the Board

Recruitment/Succession Planning • The MAC discussed subspecialty coverage ideas, collaboration with Western

University and future medical residency plans • Still waiting on geriatrician funding decision from the Ministry • Plastic surgeon from London will provide clinic in AC and have OR time at BWH • Working with the Western Team to recruit a Rehab Medicine specialist • Jointly advertising for two ENTs with Schulich School of Medicine and LHSC • Starting OTN consults for Neurology • Recruitment efforts continue for many needed specialists: ENTs, Plastic Surgery,

Anaesthesiologists, Neurologists, Emergency physicians and Psychiatrists (adult and child)

Submitted by: Mike Haddad, MD, MSc, FRCSC, Chief of Professional Staff

Performance Indicator Definitions and Graphs

Quality Care – Assure the right care, in the right place, at the right time, by the right provider


1 90th Percentile Time to Inpatient Bed

2 Average Time to Inpatient Bed

3 90th Percentile Emergency Department (ED) Length of Stay for Complex Patients Sarnia

Petrolia

4 90th Percentile Emergency Department (ED) Wait Times for Admitted Patients Sarnia

Petrolia

Exceptional Relationships – Expand innovative partnerships and collaborations to improve experiences, services, transitions and community health


5 Alternate Level of Care (ALC) Rate -All Inpatient Services (Sarnia and Petrolia)

Inspired People – Advance our culture of kindness with an intention to learn, lead, collaborate and celebrate


6 Absenteeism Rate- (avg. # 7.5hr sick days)-All Staff

Outstanding Performance – Optimize roles, resources, revenues, technology and innovation


7 Cost per weighted case: Acute Inpatient & Day Surgery (53% of overall activity)

8 Cost per weighted case: Emergency Department Outpatient (12% of overall activity)

9 Cost per weighted case: Rehab Inpatient (4% of overall activity)

10 Continuing Care Cost per Weighted Patient Day

11 Mental Health Inpatient Cost per Patient Day

12 Quality Based Procedures (QBP) Financial Exposure (Potential lost revenue related to QBP achievement) Actual YTD in 000s

13 Surplus/(Deficit) Actual YTD in 000s


14 Adjusted Working Capital Actual YTD in 000s

15 Percent of Capital Budget Spent Actual YTD


Indicator Name: 90th Percentile Time to Inpatient Bed

Alignment: Performance and Utilization Committee (PUC); Quality Committee of the Board (QCB); Resource Utilization and Audit Committee (RUAC)

Strategic Goal: Improve access to care

Definition: This indicator measures the time interval between the decision to admit date/time as determined by the main service provider and the date/time the patient left the Emergency Department (ED) for admission to an inpatient bed or Operating Room (OR). The 90th percentile of this indicator represents the maximum amount of time 9 out of 10 patients spend in an ED waiting for an inpatient bed. Most patients spend less time, while one out of ten patients will spend more time.

Peer Comparator: Ontario High Volume Community Hospital Results, Sarnia only

Strategies

Collaborative initiative to improve the flow and access for patients on all transitions of care including, admission, transfer, and discharge.

Collaborative hospital project/initiative to improve the time for all care transitions which will impact the time to inpatient bed for admitted ED patients by creating improved access, this includes inpatient unit-to-unit transfers. Targets 3 main initiatives: staffing/bed allocations, admission/discharge practice and Alternate Level of Care (ALC).

Health Quality Partner Community group work and ALC community work.







Strategic Goal: Improve access to care Alignment: PUC; QCB; RUAC

Bluewater Health Target 16 hrs.


0

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15

20

25

30

35

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Q1 17/18 Q2 17/18 Q3 17/18 Q4 17/18 Q1 18/19 Q2 18/19 Q3 18/19 Q4 18/19

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Indicator Name: Average Time to Inpatient Bed

Alignment: Performance and Utilization Committee (PUC); Quality Committee of the Board (QCB); Quality and Patient Experience Committee (QPEC); Resource Utilization and Audit Committee (RUAC)


Definition: This indicator measures the time interval between the decision to admit date/time as determined by the main service provider and the date/time the patient left the Emergency Department (ED) for admission to an inpatient bed or Operating Room (OR).

Additional Specifications: Average: Total time to inpatient bed hours

Total number of admitted ED visits

Peer Comparator: Ontario High-Volume Community Hospital Results, Sarnia only

Strategies

Collaborative initiative to improve the flow and access for patients on all transitions of care including, admission, transfer, and discharge.

Collaborative hospital project/initiative to improve the time for all care transitions which will impact the time to inpatient bed for admitted ED patients by creating improved access, this includes inpatient unit-to-unit transfers. Targets 3 main initiatives: staffing/bed allocations, admission/discharge practice and Alternate Level of Care (ALC).

Health Quality Partner Community group work and ALC community work.








Bluewater Health Target 2 hrs. by October 2019


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2

4

6

8

10

12

14

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Q1 17/18 Q2 17/18 Q3 17/18 Q4 17/18 Q1 18/19 Q2 18/19 Q3 18/19 Q4 18/19

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Indicator Name: 90th Percentile Emergency Department (ED) Length of Stay (LOS) for Complex Patients

Alignment: Quality Committee of the Board (QCB); Resource Utilization and Audit Committee (RUAC)


Definition: The total ED length of stay where 9 out of 10 complex patients completed their visits. ED Length of Stay is defined as the time from triage or registration, whichever comes first, to the time the patient leaves the ED.

Additional Specifications: Patients are determined complex based on visit disposition and the Canadian Triage and Acuity Scales (CTAS) level.

Peer Comparator: Ontario High-Volume Community Hospital Results, Sarnia Site only

Strategies

Collaborative NOW project to improve the flow and access for patients on all transitions of care. Rapid Assessment Zone (RAZ) will improve access to care for patients not requiring stretchers, assist in throughput and hope to mitigate ED overcrowding.

ED Redesign to zones and implementing Rapid Assessment Zone (RAZ) to improve Physician Initial Assessment (PIA), Ambulance Offload and overall decrease of ED LOS for CTAS 1, 2, and 3.

Paramedic program to reduce ED visits of high users in the community.






90th Percentile Emergency Department (ED) Length of Stay (LOS) Complex Patients

Strategic Goal: Improve access to care Alignment: QCB; RUAC





0

2

4

6

8

10

12

Apr16

May16

Jun16

Jul16

Aug16

Sep16

Oct16

Nov16

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Jan17

Feb17

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Apr17

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Sep17

Oct17

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Dec17

Jan18

Feb18

Mar18

Apr18

May18

Jun18

Jul18

Aug18

Sep18

Oct18

Nov18

Dec18

Jan19

Feb19

Mar19

Q1 16/17 Q2 16/17 Q3 16/17 Q4 16/17 Q1 17/18 Q2 17/18 Q3 17/18 Q4 17/18 Q1 18/19 Q2 18/19 Q3 18/19 Q4 18/19

ED L

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SarniaStatus

Petrolia Status


Indicator Name: 90th Percentile Emergency Department (ED) Length of Stay (LOS) for Admitted Patients

Alignment: Performance and Utilization Committee (PUC); Quality Committee of the Board (QCB); Quality and Patient Experience Committee (QPEC); Resource Utilization and Audit Committee (RUAC)


Definition: Measurement of ED length of stay for admitted visits is in hours. ED length of stay is the time from triage or registration, whichever comes first, to the time the patient leaves the ED to an inpatient bed. The 90th percentile is the maximum length of time in which 9 of 10 of admitted patients have completed their ED visit and have moved to an inpatient unit. A smaller number is desirable.

Rationale: Time is crucial to the effectiveness and outcome of patient care, especially for emergency patients. In conjunction with other indicators, this can be used to monitor the total length of time admitted patients spend in the ED to improve the efficiency and, ultimately, the outcome of patient care. This measure remains one of Bluewater Health’s top priorities in our Quality Improvement Plan (QIP) and Strategic Plan.

Peer Comparator: Ontario High-Volume Community Hospitals, Sarnia Site only

Strategies

Regional Withdrawal Management Department, Intensive home services support.

ED Redesign to improve work flow strategy. Updated surge triggers to open stretchers when in red zone. Choosing Wisely initiatives. Clinical Decision Unit (CDU) utilization.

Collaborative QIP for readmission rates for Chronic Obstructive Pulmonary Disease (COPD) population, Home and Community Care increased level of service in ED during surge times.






90th Percentile Emergency Department (ED) Length of Stay (LOS) for Admitted Patients




Bluewater Health, Sarnia Target


0

5

10

15

20

25

30

35

40

45

Apr16

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Jul16

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Q1 16/17 Q2 16/17 Q3 16/17 Q4 16/17 Q1 17/18 Q2 17/18 Q3 17/18 Q4 17/18 Q1 18/19 Q2 18/19 Q3 18/19 Q4 18/19

ED L

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SarniaStatus


Indicator Name: Alternate Level of Care (ALC) Rate – All Inpatient Services

Alignment: Performance and Utilization Committee (PUC); Resource Utilization and Audit

Committee (RUAC)

Strategic Goal: Build sustainable partnerships and collaborations

Definition: The proportion of inpatient days in acute and Post-Acute care settings that are spent

designated ALC in a specific period.

Rationale: Ensuring that each patient receives the appropriate level of care at all times during their

healthcare journey is a priority at Bluewater Health. Our goal is for Emily to receive the

right care, given at the right time, in the right place, always. The ALC rate represents an

opportunity for inpatients to transition to the next level of care, where their care needs

and the services provided are better matched. Multiple factors can influence ALC rate,

including overall hospital occupancy, and availability of resources both internal and

external the hospital.

Additional Specifications: ALC Rate = Total number of ALC days in a given period

Total number of inpatient days in the same period X 100%

Peer Comparator: Provincial ALC target 12.7%

Strategies

ALC Avoidance Framework Leading Practices - All alternatives explored (geriatric pathway, increasing resourcesin ED, ALC toolkit). Estimated Date of Discharge (EDD Practices, Oculys Reporting, Discharge Strategies).Education for Home First (Staff and Physicians). Cross-sector symposium and community collaboration forcommon goal, Staytrack system, Manager of care transitions role, Community Partnerships.

Bluewater Health - working on admission avoidance strategies, Geriatric Emergency Management (GEM) NursePractitioner (NP) in ED, Assessment Urgency Algorithm scoring on all patients over the age of 75.

Community collaboration






Alternate Level of Care (ALC) Rate – All Inpatient Services

Strategic Goal: Build sustainable partnerships and collaborations Alignment: PUC; RUAC

Buewater Health ALC Rate

Bluewater Health ALC Target 17.2%

Provincial ALC Target 12.7%

ALC Days All Inpatient Services

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2000

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Apr16

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Dec17

Jan18

Feb18

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Sep18

Oct18

Nov18

Dec18

Jan19

Feb19

Mar19

Q1 16/17 Q2 16/17 Q3 16/17 Q4 16/17 Q1 17/18 Q2 17/18 Q3 17/18 Q4 17/18 Q1 18/19 Q2 18/19 Q3 18/19 Q418/19

ALC

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Indicator Name: Absenteeism Rate – (Avg. # 7.5 hr. Sick Days) All Staff

Alignment: Performance and Utilization Committee (PUC); Resource Utilization and Audit Committee (RUAC)

Strategic Goal: Focus on the experience of care and caring

Definition: Paid sick hours divided by 7.5 hrs. (for a normal shift), divided by the number of full time and permanent part time eligible employees.

Rationale: A lower absenteeism rate is preferred. Lower absenteeism is aligned with overall employee wellness.

Peer Comparator: Ontario Hospital Association Average 2.8






Absenteeism Rate – (Avg. # 7.5 hr. Sick Days) All Staff

Strategic Goal: Focus on the experience of care and caring Alignment: PUC; RUAC


0

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5

Q1 16/17 Q2 16/17 Q3 16/17 Q4 16/17 Q1 17/18 Q2 17/18 Q3 17/18 Q4 17/18 Q1 18/19 Q2 18/19 Q3 18/19 Q4 18/19

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Indicator Name: Acute Cost per Weighted Case


Strategic Goal: Demonstrate accountability and efficiency

Definition: Acute Cost per Weighted Case is an indicator that measures the cost associated with caring for a standard acute patient. It is calculated as total acute inpatient and newborn expenses (both direct and indirect) divided by acute inpatient weighted cases. The direct costs are the expenses incurred in the departments providing service to our acute patients (e.g., Medicine, Surgery, and Obstetrics). The indirect costs are an allocation of Administration and Support expenses (e.g., Housekeeping, Lab, Pharmacy, etc.). A weighted case is a case with an assigned Resource Intensity Weight (RIW).

Rationale: This indicator is important as it tracks how an organization is utilizing its resources. It combines financial spending with the activity that drives the spending. By focusing on weighted cases, comparability is enhanced as differences in acuity, severity, and complexity of cases are taken into consideration.

Peer Comparator: Peer comparator is determined based on similar volume of weighted activity.






Acute Cost per Weighted Case: Acute Inpatient & Day Surgery (53% of overall activity)




$5,000

$5,200

$5,400

$5,600

$5,800

$6,000

$6,200

$6,400

$6,600

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$7,000

Q1 16/17 Q2 16/17 Q3 16/17 Q4 16/17 Q1 17/18 Q2 17/18 Q3 17/18 Q4 17/18 Q1 18/19 Q2 18/19 Q3 18/19

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Indicator Name: Emergency Department (ED) Outpatient Cost per Weighted Case



Definition: ED Outpatient Cost per Weighted Case is an indicator that measures the cost associated with caring for a standard ED patient. It is calculated as total ED expenses (both direct and indirect) divided by ED outpatient weighted cases. The direct costs are the expenses incurred in the departments providing service to our ED patients (both Sarnia & Petrolia sites). The indirect costs are an allocation of Administration and Support expenses (e.g., Housekeeping, Lab, Pharmacy, etc.). A weighted case is a case with an assigned Resource Intensity Weight (RIW).

Rationale: This indicator is important as it tracks how an organization is utilizing its resources. It combines financial spending with the activity that drives the spending. By focusing on weighted cases, comparability is enhanced as differences in acuity, severity, and complexity of cases are taken into consideration.







Emergency Department (ED) Outpatient Cost per Weighted Case (12% of overall activity)




$5,000

$5,200

$5,400

$5,600

$5,800

$6,000

$6,200

$6,400

$6,600

$6,800

$7,000

Q1 16/17 Q2 16/17 Q3 16/17 Q4 16/17 Q1 17/18 Q2 17/18 Q3 17/18 Q4 17/18 Q1 18/19 Q2 18/19 Q3 18/19

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Indicator Name: Rehab-Inpatient Cost per Weighted Case



Definition: Rehab-Inpatient Cost per Weighted Case is an indicator that measures the costs associated with caring for a standard rehab patient. It is calculated as total inpatient rehab expenses (both direct and indirect) divided by rehab weighted cases. The direct costs are the expenses incurred in the departments providing service to our rehab inpatients. The indirect costs are an allocation of Administration and Support expenses (e.g., Housekeeping, Lab, Pharmacy, etc.). A rehab weighted case is a case assigned a relative weight using the rehabilitation patient grouper (RPG).

Rationale: This indicator is important as it tracks how an organization is utilizing its resources. It combines financial spending with the activity that drives the spending. By focusing on weighted patient days, comparability is enhanced as differences in acuity, severity, and complexity of cases are taken into consideration.







Rehab Inpatient Cost per Weighted Case (4% of overall activity)




$9,000

$9,500

$10,000

$10,500

$11,000

$11,500

$12,000

$12,500

$13,000

$13,500

$14,000

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$15,000

Q1 16/17 Q2 16/17 Q3 16/17 Q4 16/17 Q1 17/18 Q2 17/18 Q3 17/18 Q4 17/18 Q1 18/19 Q2 18/19 Q3 18/19

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Indicator Name: Continuing Care Cost per Weighted Patient Day



Definition: Continuing Care Inpatient Cost per Weighted Patient Day is an indicator that measures

the costs of providing inpatient care to complex continuing care patients, and is stated

on a weighted patient day basis. It is calculated as total inpatient continuing care

expenses (both direct and indirect) divided by total resource utilization group weighted

patient days (RWPDs). The direct costs are the expenses incurred in the departments

providing service to our continuing care inpatients. The indirect costs are an allocation

of Administration and Support expenses (e.g., Housekeeping, Lab, Pharmacy, etc.).

RWPDs are patient days weighted using an appropriate cost weight (CMI). The CMI is a

cost weight reflecting the relative resource use of an individual within a specific RUG

group compared with the overall average resource use for all Ontario complex

continuing care residents.

Rationale: This indicator is essential as it tracks how an organization is utilizing its resources. It combines financial spending with the activity that drives the spending. By focusing on weighted patient days, comparability is enhanced as differences in acuity, severity, and complexity of cases are taken into consideration.

Additional Specifications: This indicator is also referred to as Cost per RUG weighted patient day (RWPD) where RUG stands for Resource Utilization Group.







Continuing Care Cost per Weighted Patient Day


Peer Comparator $637


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Indicator Name: Mental Health Inpatient Cost per Patient Day



Definition: Mental Health Inpatient Cost per Patient Day is an indicator that measures the cost associated with caring for a Mental Health inpatient. It is calculated as total inpatient mental health departmental expenses divided by total inpatient mental health patient days.

Peer Comparator: HIT Tool HSIMI year-end 25th percentile 2017/2018.









Peer Comparator $330

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Indicator Name: Quality Based Procedure (QBP) Financial Exposure (Potential lost revenue related to QBP achievement)


Committee (RUAC)


Definition: This indicator represents the potential lost revenue associated with under achievement

of QBP funded volumes for both Ministry funded and Cancer Care Ontario (CCO) funded

quality based procedures.

Rationale: The intent is that the hospital will achieve all anticipated volumes and not have to

return any QBP funding to the Ministry and/or CCO.

Peer Comparator: No established peer comparator data






Quality Based Procedure (QBP) Financial Exposure (Potential lost revenue related to QBP achievement)



-$800,000

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Jul17

Aug17

Sep17

Oct17

Nov17

Dec17

Jan18

Feb18

Mar18

Apr18

May18

Jun18

Jul18

Aug18

Sep18

Oct18

Nov18

Dec18

Q1 16/17 Q2 16/17 Q3 16/17 Q4 16/17 Q1 17/18 Q2 17/18 Q3 17/18 Q4 17/18 Q1 18/19 Q2 18/19 Q3 18/19

Rev

enu

e

Pre

ferre

d Tre

nd

ing

Our

Status


Indicator Name: Surplus/ (Deficit) in 000s


Committee (RUAC)


Definition: The amount of operating revenue in excess of operating expense from regular hospital

operations. This amount excludes building amortization, building deferred

grants/donations and interest on long-term liabilities.

Rationale: The hospital compares its actual results to the Board approved budget. The hospital

plans for a surplus each year.

Peer Comparator: No peer comparator data available






Surplus/(Deficit) in 000s



-$1,500

-$1,000

-$500

$0

$500

$1,000

$1,500

$2,000

$2,500

Apr16

May16

Jun16

Jul16

Aug16

Sep16

Oct16

Nov16

Dec16

Jan17

Feb17

Mar17

Apr17

May17

Jun17

Jul17

Aug17

Sep17

Oct17

Nov17

Dec17

Jan18

Feb18

Mar18

Apr18

May18

Jun18

Jul18

Aug18

Sep18

Oct18

Nov18

Dec18

Q1 16/17 Q2 16/17 Q3 16/17 Q4 16/17 Q1 17/18 Q2 17/18 Q3 17/18 Q4 17/18 Q1 18/19 Q2 18/19 Q3 18/19

Surp

lus/

(Def

icit

) in

00

0s


Indicator Name: Adjusted Working Capital (in 000s)


Strategic Goal: Ensure continuous investment in strategic infrastructure

Definition: Adjusted Working Capital is calculated as the hospital’s total current assets less current liabilities from its balance sheet. This definition is then adjusted per Ministry direction to exclude current liabilities such as vacation accrual, etc. and to exclude any externally restricted current assets/liabilities.

Rationale: Adjusted working capital is a critical indicator to evaluate the hospital’s financial outlook. A strong working capital position indicates a readiness for potential capital investment.

Peer Comparator: No peer comparator data available






Adjusted Working Capital (in 000s)

Strategic Goal: Ensure continuous investment in strategic infrastructure Alignment: PUC; RUAC

-$1,000

$0

$1,000

$2,000

$3,000

$4,000

$5,000

$6,000

Apr16

May16

Jun16

Jul16

Aug16

Sep16

Oct16

Nov16

Dec16

Jan17

Feb17

Mar17

Apr17

May17

Jun17

Jul17

Aug17

Sep17

Oct17

Nov17

Dec17

Jan18

Feb18

Mar18

Apr18

May18

Jun18

Jul18

Aug18

Sep18

Oct18

Nov18

Dec18

Q1 16/17 Q2 16/17 Q3 16/17 Q4 16/17 Q1 17/18 Q2 17/18 Q3 17/18 Q4 17/18 Q1 18/19 Q2 18/19 Q3 18/19

Wo

rkin

g C

apit

al in

00

0s

Pre

ferre

d Tre

nd

ing

Our

Status


Indicator Name: Percentage of Capital Budget Spent


Strategic Goal: Ensure continuous investment in strategic infrastructure

Definition: Capital purchases made during the time period as a percentage of the overall capital budget for that period. The overall budget includes a budget for contingency items. If capital items are carried over from a previous year, the capital budget associated with those carry over items will also be included in the denominator for this indicator.

Peer Comparator: No established peer comparator data






Percentage of Capital Budget Spent

Strategic Goal: Ensure continuous investment in strategic infrastructure Alignment: PUC; RUAC

-10%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Apr16

May16

Jun16

Jul16

Aug16

Sep16

Oct16

Nov16

Dec16

Jan17

Feb17

Mar17

Apr17

May17

Jun17

Jul17

Aug17

Sep17

Oct17

Nov17

Dec17

Jan18

Feb18

Mar18

Apr18

May18

Jun18

Jul18

Aug18

Sep18

Oct18

Nov18

Dec18

Jan19

Feb19

Mar19

Q1 16/17 Q2 16/17 Q3 16/17 Q4 16/17 Q1 17/18 Q2 17/18 Q3 17/18 Q4 17/18 Q1 18/19 Q2 18/19 Q3 18/19 Q4 18/19

Per

cen

tage

of

Cap

ital

Bu

dge

t Sp

ent

Pre

ferre

d Tre

nd

ing

agenda...agenda open session board meeting wednesday, june 26, 2019 lambton college events centre,...

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