board client services, quality & safety committee...

2016 06 13_Board CSQS Committee _DRAFT Agenda_v4

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BOARD CLIENT SERVICES, QUALITY & SAFETY COMMITTEE MEETING

DATE: June 13, 2016

TIME: 9:00 – 11:00am

PLACE: Labelle Boardroom

AGENDA

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9:00-9:05 1.0 Welcome; Declaration of Conflict Melody Isinger √

Core Business

2.0 Approval of Agenda for June 13, 2016 Melody Isinger √

9:05-9:10 3.0 Review and Approval of May 9, 2016 Minutes Melody Isinger √

4.0 Business Arising Melody Isinger √

Consent Agenda – assumed approved unless any member of CSQS wishes to discuss

5.0 Consent Items 5.1 Quarterly Events Report 5.2 Quarterly Complaints Report 5.3 Accreditation Update

Jennifer Proulx

√

Standing Items

9:10–9:30

6.0 Quality Reports 6.1 Adverse Events (Verbal)

6.2 FY 2015-16 Q4 QIP Update 6.3 CCEE Semi-Annual Update

Jennifer Proulx /

Caroline Guimond √

Strategic Discussion

9:30-9:50 7.0 Champlain CCAC Action Plan Update Marc Sougavinski/ Catherine Butler

√

9:50-10:00 8.0 Medical Assistance in Dying (MAID) Update (Verbal) Catherine Butler √

10:00-10:10 9.0 Special Needs Strategy (SNS) Update (Verbal) Catherine Butler √

10:10-10:30 10.0 Semi-Annual People Services and Organizational

Development Update Patrice Connolly √

Joint Meeting with Finance & Audit Committee

10:30-11:00

11.0 Board Scorecard Discussion/Review Deryl Rasquinha /

Catherine Butler √

12.0 Full Management Scorecard (Informational item) Deryl Rasquinha / Catherine Butler

√

CONFIDENTIAL

DRAFT

Minutes – Champlain CCAC Client Services, Quality and Safety Committee – May 9, 2016

Champlain Community Care Access Centre Centre d’accès aux soins communautaires de Champlain

Head Office

4200 Labelle Street Suite 100 Ottawa ON K1J 1J8 Siège social 4200, rue Labelle Bureau 100 Ottawa ON K1J 1J8

Tel/Tél : 613 745 5525 866-994-8124 Fax/Téléc : 613 745 1422

www.champlain.ccac-ont.ca

MINUTES

Client Services, Quality & Safety Committee (CSQS)

Held May 9, 2016

Champlain CCAC Head Office

BOARD COMMITTEE

MEMBERS (CSQS):

Melody Isinger

Denise Alcock

Andrée Durieux-Smith

Abebe Engdasaw

Sherryl Smith

Chair

Ex-officio member

By phone

REGRETS (CSQS):

BOARD COMMITTEE

MEMBERS

(FINANCE):

Maria Barrados

Robert D’Aoust

Sherryl Smith

Chair

By phone

FINANCE REGRETS

STAFF PRESENT

(CSQS):

Marc Sougavinski

Paul Boissonneault

Catherine Butler

Christian Gagnon

Ashley Haugh

Claire Ludwig

Jennifer Proulx

Deryl Rasquinha

Catherine Richard

Jamie Stevens

Chief Executive Officer

Director, Information Systems & CIO

Vice-President, Clinical Care (by phone)

Systems Specialist

Executive Assistant

Director, Program Development & Clinical Care

Director, Quality & Program Evaluation

Vice-President, Performance and Strategy

Manager, Occupational Health and Safety Program

Director, Business Intelligence

FINANCE STAFF

PRESENT FOR JOINT

PORTION OF

MEETING:

Jimena Martinez Acting Corporate Controller

RECORDER: Ashley Haugh Executive Assistant

GUEST(S):

2

Minutes–Champlain CCAC Client Services, Quality & Safety Committee, May 9, 2016

AGENDA ITEM ACTION TO BE TAKEN

1.0 Declaration of Conflict of Interest

There were no declarations of conflict

2.0 Approval of Agenda

It was moved by Abebe Engdasaw, seconded by Andrée Durieux-Smith and agreed

to approve the agenda for the May 9, 2016 meeting.

CARRIED

3.0 Approval of Minutes

It was moved by Andrée Durieux-Smith, seconded by Abebe Engdasaw and agreed

to approve the minutes of the April 11, 2016 meeting.

CARRIED

4.0 Business Arising

There was no business arising.

5.0 Quality Reports 5.1 Adverse Events There were no adverse events to report.

6.0 IMPACT Centre Update and Tour

The Committee received an update and tour of the IMPACT Centre:

People want to remain in their homes as long as possible. Technology is one way to assist patients, caregivers and families meet this goal.

The IMPACT Centre is working with health care technology developers and vendors to test, evaluate and recommend new technologies with patients and caregivers in real-life situations. The IMPACT Centre is set up to resemble a typical apartment with a kitchen, living area, bedroom and bathroom.

The goals of the IMPACT Centre are to: o Enhance patient safety o Enable patients and caregivers o Enable the circle of care o Enhance service quality

There are technologies that support socialization, monitoring, safety, etc. It allows authorized caregivers and members of the circle of care to monitor activities – e.g., sensors to see if the patient has gotten out of bed, opened the front door, opened the fridge, etc.

Want technology that is easy to use out of the box for the patient and the circle of care/families.

3



Staff is working with Bruyère and Carleton University on a potential research project to use data from the use of technology to be able to predict if a patient is at risk of a fall. Funding is required for this project.

Discussion included:

Started looking for vendors by reaching out and issued a Request for Proposal. There are a variety of business models possible to roll out the technologies, that are currently under review

Technologies can enable new practices. Where feasible, these practices will be evaluated in planned pilot sites looking at new models of care and enhanced care coordination

7.0 Employee Health and Wellness Annual Report The Committee reviewed the annual Employee Health and Wellness report:

The Employee Health and Wellness Program consists of: o Occupational Health and Safety Program o Infection Prevention and Control (IPAC) Program o Wellness Program o Mental Health Strategy

Overall, the CCAC is performing well in employee health and wellness. However, there are areas for improvement.

In 2016-2017, quarterly meetings of the six Joint Heath and Safety Committees (JHSC) at the Champlain CCAC will be scheduled in advance to ensure meetings are taking place in all locations. Inspections and follow-ups required will also be closely monitored.

The health and safety of employees and the workplace is important and this will continue to be a priority during this time of health system transformation.

Joint CSQS and Finance and Audit Committees

8.0 Scorecard Review

The Committees discussed the April scorecard (March data); the last scorecard for

the 2015-2016 year:

Overall, the Champlain CCAC has performed well.

Referral volume continues to remain higher than a year ago.

Significant progress has been made on service wait times in the community

over the past year and it is currently around 25 days; from close to 120 days

a year ago. Work continues to meet the provincial target of 21 days (90%

receiving service within 21 day).

The five day wait time for complex PSS continues to improve.

Patient complaint resolution time has generally increased, however, it is due

to the delay in the administrative closure of files not in the resolution of the

actual complaints. Work was done in April to administratively close the

4



complaints and ensure this process is completed in a timely manner in the

future.

A report on absenteeism is being brought to the Board in June.

Ended the year with a deficit of approximately 1.8M, less than 1% of

budget.

The performance agreement completion rate has increased as this is the time

of year when they are being completed.

The Committees discussed the format of the 2016-2017 scorecard:

Overall, the 2016-2017 scorecard is similar to the 2015-2016 scorecard,

however, it has a focus on metrics related to our Action Plan for supporting

complex patients. Any metrics not carried over from the 2015-2016

scorecard are still being monitored internally by staff. If there are significant

changes in any of these indicators it will be reported to the Committee.

Patient capacity is being tracked on the new scorecard, this is also being

communicated to partners on a monthly basis as part of the new Care

Report.

Many of the metrics and targets are determined by the Multi-Sector Service

Accountability Agreement or the Quality Improvement Plan.

It was moved by Melody Isinger, seconded by Robert D’Aoust and agreed to

recommend the Board approve the new scorecard.

CARRIED

The meeting was adjourned by consent.

ACTION: Headings to be

updated (both scorecards),

as discussed.

ACTION: Examine

possibility of year over

year comparisons,

especially for end of year

reporting.

ACTION: Staff will report

back to the Committee if

there are any significant

changes in metrics not

carried over to 2016-2017

scorecard.

CONFIRMED: ________________________________________________ MELODY ISINGER, CHAIR

Champlain CCAC CSQS Committee of the Board, June 13, 2016

Item 5.1– Quarterly Events Report PAGE 1

Submission to the CSQS Committee of the Board

Quarterly Events Report: January 2016-March 2016 (Q4)

June 13, 2016

EVENT REPORTING

Adverse Events: The last Adverse Event occurred on January 3, 2016 (Q4, 15-16). Top 5 Reported Events in CELS: Within CELS, the event categories and definitions include those required internally and by the OACCAC reporting requirements and data collection needs. In Q4, the top five reported events were:

1. Patient Fall - Unwitnessed fall resulting in injury, recommendation to call 911 and/or additional healthcare resources

2. Compliment about Service Provider 3. Quality of Services Provided by SPO- general 4. Quality of Services Provided by SPO- responsiveness 5. Infusion Pump Issues AND Abuse/Threat/ Harassment/ Injury to Staff

02468

101214161820

Jun

-14

Jul-

14

Au

g-1

4

Sep

-14

Oct

-14

No

v-1

4

Dec

-14

Jan

-15

Feb

-15

Mar

-15

Ap

r-1

5

May

-15

Jun

-15

Jul-

15

Au

g-1

5

Sep

-15

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-15

No

v-1

5

Dec

-15

Jan

-16

Feb

-16

Mar

-16

NU

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F EV

ENTS

DATE

CLIENT FALL-UNWITNESSEDJUNE 2014-MARCH 2016

Median= 1



0

5

10

15

20

25

30

Jun

-14

Jul-

14

Au

g-1

4

Sep

-14

Oct

-14

No

v-1

4

Dec

-14

Jan

-15

Feb

-15

Mar

-15

Ap

r-1

5

May

-15

Jun

-15

Jul-

15

Au

g-1

5

Sep

-15

Oct

-15

No

v-1

5

Dec

-15

Jan

-16

Feb

-16

Mar

-16N

UM

BER

OF

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TS

DATE

COMPLIMENT ABOUT SPOJUNE 2014-MARCH 2016

0

5

10

15

20

25

30

35

40

Jun

-14

Jul-

14

Au

g-1

4

Sep

-14

Oct

-14

No

v-1

4

Dec

-14

Jan

-15

Feb

-15

Mar

-15

Ap

r-1

5

May

-15

Jun

-15

Jul-

15

Au

g-1

5

Sep

-15

Oct

-15

No

v-1

5

Dec

-15

Jan

-16

Feb

-16

Mar

-16

NU

MB

ER O

F EV

ENTS

DATE

QUALITY OF SERVICES BY SPO-GENERALJUNE 2014-MARCH 2016

Median= 9

Median= 8



0

10

20

30

40

50

60

70N

UM

BER

OF

EVEN

TS

DATE

QUALITY OF SERVICES BY SPO-RESPONSIVENESSJUNE 2014-MARCH 2016

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101214161820

Jun

-14

Jul-

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Au

g-1

4

Sep

-14

Oct

-14

No

v-1

4

Dec

-14

Jan

-15

Feb

-15

Mar

-15

Ap

r-1

5

May

-15

Jun

-15

Jul-

15

Au

g-1

5

Sep

-15

Oct

-15

No

v-1

5

Dec

-15

Jan

-16

Feb

-16

Mar

-16N

UM

BER

OF

EVEN

TS

DATE

INFUSION PUMP ISSUESJUNE 2014-MARCH 2016

Median= 21

Median= 0



Improvement Activities Patient Fall – Unwitnessed fall resulting in injury, recommendation to call 911 and/or additional healthcare resources Patient Falls are captured in CELS by witnessed falls as well as those that though not witnessed, do have an impact on the patient and require an intervention. Patient falls continue to be addressed by Champlain CCAC and is an indicator on our annual Quality Improvement Plan. Compliment to Service Provider Through continued efforts, the Quality team is able to more accurately capture and categorize events, including events related to positive aspects of care for patients. Quality of Services Provided by Service Provider – General Quality of Service, for both CCAC and SPO staff, is captured through the subcategories: professionalism, responsiveness, time management and cleanliness. Quality of Service- General are those complaints which have an impact on the quality of services provided but do not fall into the identified subcategories. Continued review of these events have helped determine two new categories, specifically, Quality of Service- consistency of care, and Quality of Service- continuity of care. Quality of Services Provided by Service Provider – Responsiveness Quality of Service, for both CCAC and SPO staff, is captured through the subcategories: professionalism, responsiveness, time management and cleanliness. The area of responsiveness, which encompasses complaints regarding the quality of service provided or arranged – related to timeliness and consistency in addressing care needs, requests, inquiries – will be a particular focus for the upcoming year as identified in the

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Jan

-15

Feb

-15

Mar

-15

Ap

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5

May

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Jun

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Jul-

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Au

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5

Sep

-15

Oct

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No

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-15

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-16

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ABUSE/THREAT/HARASSMENT/INJURY TO STAFFJUNE 2014-MARCH 2016

Median= 10



Action Plan and FY 16/17 QIP, and will be the focus of a new SPO Monitoring initiative currently under development. Abuse/Threat/Harassment/ Injury to Staff A workgroup was initiated in FY15/16, with representation from all three Quality subcommittees (Nursing, Personal Support Services and Allied Health), to work on educating CCAC and SPO staff about how to recognize and respect professional boundaries, how to build effective communication skills when working with patients and caregivers, and effective documentation of challenging situations and behaviours. This work will continue into FY 16/17. Infusion Pump Issues Issues related to the use of infusion pumps in the community is a focus area for Accreditation- Home Care Standards and has been identified as a work plan item for the Nursing Quality Subcommittee. As such, data specific to events involving infusion pumps are now captured in CELS. Key issues include supplies and equipment, patient and staff education, referrals and the communication of medical orders. Ellen Alie Manager, Quality, Risk and Patient Experience Sponsoring Executive: Deryl Rasquinha, VP, Performance & Strategy

Champlain CCAC Board CSQS Committee, June 13, 2016

Item 5.2–Quarterly Complaints Report PAGE 1


Quarterly Complaints and Compliments Report:

January 2016-March 2016 (Q4)

June 13, 2016

COMPLAINT AND COMPLIMENT REPORTING

Complaint categories: There are six complaint categories captured in CELS 2.0. Compliments provided to both CCAC and SPO staff are also reported:

Amount of services: Complaint regarding the CCAC’s decision about the amount of any particular service included in the plan of service

Eligibility for services: Complaint regarding the CCAC’s decision regarding eligibility for service

Exclusion of Services: Complaint regarding the CCAC’s decision to exclude a particular service from the plan of service

Quality of services: Complaint regarding the quality of service provided or arranged

Termination of services: Complaint regarding the decision to terminate service

Violation of rights: Complaint about violation of patient rights: Client Bill of Rights (LTC Act) or the Human Rights Act.

Compliments about CCAC: Expression of appreciation, praise, or commendation of a CCAC staff member.

Compliments about SPO: Expression of appreciation, praise, or commendation of a Service Provider staff member.

Compliment about Health Care Team: Champlain CCAC category; expression of appreciation, praise, or commendation of both CCAC and SPO staff.

Each of the complaint categories are continuously reviewed and broken down into subcategories to better capture the actual area of concern.

Complaints and Compliments Reported in CELS

Total Number Reported

(FY 2014/15)

Number Reported Q4 (FY 2015/16)

Number Reported Year

to Date (FY 2015/16)

Average Days to Resolution (FY 2014/15)

Average Days to Resolution

Q4 (FY 2015/16)

Average Days to Resolution

Year to Date (FY 2015/2016)

Complaints

584 115 724 36.83 37.6 30.41

Compliments

205 33 169 N/A N/A N/A



Total Number of Complaints Reported in CELS (By Month):

Total Number of Complaints and Compliments Reported in CELS (By Theme)

Note: There are no reports under Violation of Rights.

0102030405060708090

100A

pr-

14

May

-14

Jun

-14

Jul-

14

Au

g-1

4

Sep

-14

Oct

-14

No

v-1

4

Dec

-14

Jan

-15

Feb

-15

Mar

-15

Ap

r-1

5

May

-15

Jun

-15

Jul-

15

Au

g-1

5

Sep

-15

Oct

-15

No

v-1

5

Dec

-15

Jan

-16

Feb

-16

Mar

-16

NU

MB

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OM

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INTS

DATE

NUMBER OF COMPLAINTS BY MONTHAPRIL 2014-MARCH 2016

value UCL LCL Median

050

100150200250300350400450500550600

NU

MB

ER O

F C

OM

PLA

INTS

AN

D

CO

MP

LIM

ENTS

THEME

NUMBER OF COMPLAINTS AND COMPLIMENTS BY THEMEAPRIL 2014-MARCH 2016

Median= 51



0123456789

10

Jan

-14

Feb

-14

Mar

-14

Ap

r-1

4

May

-14

Jun

-14

Jul-

14

Au

g-1

4

Sep

-14

Oct

-14

No

v-1

4

Dec

-14

Jan

-15

Feb

-15

Mar

-15

Ap

r-1

5

May

-15

Jun

-15

Jul-

15

Au

g-1

5

Sep

-15

Oct

-15

No

v-1

5

Dec

-15

Jan

-16

Feb

-16

Mar

-16

NU

MB

ER O

F C

OM

PLA

INTS

DATE

AMOUNT OF SERVICEJANUARY 2014-MARCH 2016

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Jan

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Feb

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Mar

-14

Ap

r-1

4

May

-14

Jun

-14

Jul-

14

Au

g-1

4

Sep

-14

Oct

-14

No

v-1

4

Dec

-14

Jan

-15

Feb

-15

Mar

-15

Ap

r-1

5

May

-15

Jun

-15

Jul-

15

Au

g-1

5

Sep

-15

Oct

-15

No

v-1

5

Dec

-15

Jan

-16

Feb

-16

Mar

-16

NU

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OM

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INTS

DATE

ELIGIBILITY FOR SERVICESJANUARY 2014-MARCH 2016

Median=2

Median=3



0

1

2

3

4

5

Jan

-14

Feb

-14

Mar

-14

Ap

r-1

4

May

-14

Jun

-14

Jul-

14

Au

g-1

4

Sep

-14

Oct

-14

No

v-1

4

Dec

-14

Jan

-15

Feb

-15

Mar

-15

Ap

r-1

5

May

-15

Jun

-15

Jul-

15

Au

g-1

5

Sep

-15

Oct

-15

No

v-1

5

Dec

-15

Jan

-16

Feb

-16

Mar

-16

NU

MB

ER O

F C

OM

PLA

INTS

DATE

EXCLUSION OF SERVICESJANUARY 2014-MARCH 2016

0102030405060708090

100

Jan

-14

Feb

-14

Mar

-14

Ap

r-1

4

May

-14

Jun

-14

Jul-

14

Au

g-1

4

Sep

-14

Oct

-14

No

v-1

4

Dec

-14

Jan

-15

Feb

-15

Mar

-15

Ap

r-1

5

May

-15

Jun

-15

Jul-

15

Au

g-1

5

Sep

-15

Oct

-15

No

v-1

5

Dec

-15

Jan

-16

Feb

-16

Mar

-16

NU

MB

ER O

F C

OM

PLA

INTS

DATE

QUALITY OF SERVICES BY SERVICE PROVIDERJANUARY 2014-MARCH 2016

Median=0

Median=37



0

5

10

15

20

25

Jan

-14

Feb

-14

Mar

-14

Ap

r-1

4

May

-14

Jun

-14

Jul-

14

Au

g-1

4

Sep

-14

Oct

-14

No

v-1

4

Dec

-14

Jan

-15

Feb

-15

Mar

-15

Ap

r-1

5

May

-15

Jun

-15

Jul-

15

Au

g-1

5

Sep

-15

Oct

-15

No

v-1

5

Dec

-15

Jan

-16

Feb

-16

Mar

-16

NU

MB

ER O

F C

OM

PLA

INTS

DATE

QUALITY OF SERVICES BY CCACJANUARY 2014-MARCH 2016

0

1

2

3

4

5

6

Jan

-14

Feb

-14

Mar

-14

Ap

r-1

4

May

-14

Jun

-14

Jul-

14

Au

g-1

4

Sep

-14

Oct

-14

No

v-1

4

Dec

-14

Jan

-15

Feb

-15

Mar

-15

Ap

r-1

5

May

-15

Jun

-15

Jul-

15

Au

g-1

5

Sep

-15

Oct

-15

No

v-1

5

Dec

-15

Jan

-16

Feb

-16

Mar

-16

NU

MB

ER O

F C

OM

PLA

INTS

DATE

QUALITY OF SERVICE BY HEALTH CARE TEAMJANUARY 2014-MARCH 2016

Median=4

Median=0



Days to Resolution for Complaints Reported in CELS

0

2

4

6

8

10

12

14

Jan

-14

Feb

-14

Mar

-14

Ap

r-1

4

May

-14

Jun

-14

Jul-

14

Au

g-1

4

Sep

-14

Oct

-14

No

v-1

4

Dec

-14

Jan

-15

Feb

-15

Mar

-15

Ap

r-1

5

May

-15

Jun

-15

Jul-

15

Au

g-1

5

Sep

-15

Oct

-15

No

v-1

5

Dec

-15

Jan

-16

Feb

-16

Mar

-16

NU

MB

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OM

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INTS

DATE

TERMINATION OF SERVICESJANUARY 2014-MARCH 2016

-20

0

20

40

60

80

100

120

140

Ap

r-1

4

May

-14

Jun

-14

Jul-

14

Au

g-1

4

Sep

-14

Oct

-14

No

v-1

4

Dec

-14

Jan

-15

Feb

-15

Mar

-15

Ap

r-1

5

May

-15

Jun

-15

Jul-

15

Au

g-1

5

Sep

-15

Oct

-15

No

v-1

5

Dec

-15

Jan

-16

Feb

-16

Mar

-16

NU

MB

ER O

F D

AY

S

DATE

COMPLAINTS: DAYS TO RESOLUTION APRIL 2014-MARCH 2016

value UCL LCL Median

Median= 26

Median=1

Champlain CCAC Board CSQS Committee – June 13, 2016

Item 5.3 – Accreditation Update PAGE 1


Accreditation Update

June 13, 2016

INFORMATION ITEM

The purpose of this briefing note is to provide the Board CSQS Committee with an update on the status of accreditation.

BACKGROUND/ISSUE

In March 2015, the Champlain CCAC began preparing for its next accreditation on-site survey visit scheduled for early December 2016. As a part of this process, self-assessments were completed in April and May 2015 and an action plan for improvement was developed in the following areas: • Governance; • Leadership; • Infection Prevention and Control; • Medication Management; • Case Management; • Mental Health and Addictions; and • Home Care. Following the release of the white paper, “Patients First - A Proposal to Strengthen Patient-Centred Health Care in Ontario”, the Board discussed the issue of accreditation in late 2015. It was decided then that Champlain CCAC should continue preparing for the site visit in December 2016, but that the Board should revisit the discussion in the spring 2016 to validate the appropriateness of the decision. In March 2016, the Board revisited its decision to proceed with accreditation in 2016. While more clarity was hoped for regarding the transformation of home and community care by spring 2016, there still remained many unknowns on the magnitude and timing of the change. As a result, it was decided that the Champlain CCAC would formally submit a request to Accreditation Canada to postpone its site visit for 12 months. It was further agreed that the organization would continue with work on Required Organizational Practices (ROPs) and High Priority areas and that the accreditation standards should be leveraged where applicable in the design and implementation of processes to support the “Champlain CCAC Action Plan: Maintaining Increasingly High Needs/Complex Patients at Home.”



STATUS OF ACCREDITATION

In April 2016, Accreditation Canada granted the Champlain CCAC’s request to postpone the site visit. New dates have now been confirmed and the site visit has been set for December 11-14, 2017. Based on an extensive review of the action plan for improvement and the Champlain CCAC’s strategic priorities for 2016/2017, the following table provides a summary of the current areas of focus for accreditation for this fiscal year and an update on progress to date. Table 1: Proposed Accreditation Work Activity for the Fiscal Year 2016/17

Standards Set Current Areas of Focus Progress to Date

Leadership Prospective Analysis (ROP)

Disclosure of Events (ROP)

Event Reporting and Feedback (ROP)

Workplace Violence (ROP)

Staff engagement (Requirement)

Prospective analysis (Transition to Rapid Response Nursing (RRN) from Hospital) for 2015 has been completed. Current emphasis placed on progressing with areas for improvement. Event Reporting: Care Coordinator, Manager, and SPI Reports have been streamlined. The CCAC continues to develop new ways to share data on events as well as how this information is used for improvement. Processes have been refined to close the loop between staff reporting and outcome of the event.

Infection Prevention and Control (IPAC)

Continue as planned Work has continued to progress on the action plan for improvement. Policy revisions nearing completion. Revisions to IPAC scorecard complete. Current work underway on Hand Hygiene Audits.

Medication Management

Continue as planned

Medication Reconciliation (ROP)

Work has progressed as planned. Revised policies and procedures are nearing completion. Medication reconciliation has been added to the Board Scorecard for 16/17. The indicator has also been built into team operational reports. A refresher will take place in the fall of 2016.

Case Management

All ROPs/Patient and Family Centred Care standards to align with action plan pilots

Continue with pediatric development work

Priorities for action have been built into the Champlain CCAC Action Plan (See Action Plan for more detail). Pediatric development work currently underway.

Home Care All ROPs Accreditation work related to infusion pumps has been included in the 2016/17 Nursing quality work plan. Policies and procedures have been reviewed,



updated, and implemented for medication reconciliation.

Mental Health & Addictions

Continue as planned Action plan for improvement progressing as planned. Current area of focus: student experience and medication reconciliation.

Governance On hold Progress on hold. Work plan to be revisited late fall 2016.

NEXT STEPS

Progress on addressing identified areas for improvement will continue to be monitored over the summer. A more fulsome review of accreditation status and next steps will take place mid to late fall 2016 (once more detailed and specific information is obtained regarding the transformation of home and community care). An update on progress will be brought forward to the CSQS Committee in the fall 2016. Paula Greco Senior Lead Program Evaluation Sponsoring Executive: Deryl Rasquinha, VP, Performance and Strategy

CASC de Champlain CCAC

FY 15-16 Quality Improvement Plan (QIP) –

Q4 Update

Client Services, Quality and Safety CommitteeJune 13, 2016

Jennifer Proulx – Director, Quality & Program EvaluationEllen Alie, Manager, Quality, Risk and Patient Experience


Reduce % of adult long-stay home care patients who record a fall on their follow-up RAI-HC assessment

TARGET ≤36.0% HQO DATA: Q3 14/15 - Q2 15/16= 39.3%

SAFETY

Improvement Activity Target Status

Collaboration with Ottawa Public Health, Primary Care and Community Partners to address fall prevention and support exercise programs with PSWs in the community

All SPOs implement by

March 31 2016

Delayed due totimelines for e-

module completion; will be implemented

in 2016-2017.

Implement training and education with Clinical Teams and SPOs re: Falls awareness with patients

Improvementon CCEE

Safety KPI

Most recent data from NRC: Q1-Q2 FY

15/16=75.5%; improvement over FY 14/15 score of 73.5%


ACCESS

Increase the % of complex patients who received their first personal support service with in 5 days of the service authorization dateTARGET ≥95% CCAC DATA: Q4 FY 15/16= 78.6%HQO DATA: Q3 14/15 - Q2 15/16= 73.8%

Increase the % of patients who received their first nursing visit within 5 days of the service authorization TARGET ≥95% CCAC DATA= Q4 FY 15/16= 93.6%HQO DATA: Q3 14/15 - Q2 15/16= 93.6%


Collaboration to develop processes for 24 hours discharge notification

% of new referrals with 24 hour notice of

hospitaldischarge

Replaced with eNotification pilot

(Kemptville District Hospital & Arnprior Hospital)

Implement Neighborhood Care 100% of SPOsOn hold; under

review

Review process of time to SPO/Internalprovider offer to first service date

Identify improvement opportunities

Improvement of service

authorization date completion rates;

Waitlist releases for PSS/Therapies



**Additional Action:Reinforce first visit date field in CHRIS

Improvement in Access metrics access for PSW

and Nursing

Complete & Ongoing

**Additional Action:Use “Client on Hold” feature in CHRIS more effectively

Improvement in Access metrics access for PSW

and Nursing

Complete & Ongoing

Increase the % of complex patients who received their first personal support service with in 5 days of the service authorization dateTARGET ≥95% CCAC DATA: Q4 FY 15/16= 78.6%HQO DATA: Q3 14/15 - Q2 15/16= 73.8%

Increase the % of patients who received their first nursing visit within 5 days of the service authorization TARGET ≥95% CCAC DATA= Q4 FY 15/16= 93.6%HQO DATA: Q3 14/15 - Q2 15/16= 93.6%

ACCESS


Reduce % of home care patients with an unplanned, less-urgent ED visit within the first 30 days of discharge from hospital. TARGET ≤7.0% HQO DATA: Q2 14/15 - Q1 15/16=7.0 %

Reduce % of home care patients who experienced an unplanned readmission to hospital within 30 days of discharge from hospital. TARGET ≤ 18.2% HQO DATA: Q2 14/15 - Q1 15/16= 18.8%


Collaboration with TOHIdentify improvement

opportunitiesNo longer

active

Implement Community Health Evaluation completed using Paramedicine Services (CHECUPS) with Renfrew County Paramedics

Establish baselineperformance

Pilot phase completed;

Evaluation of pilot completed

March 2016

EFFECTIVENESS



**Continuation: Rapid Response Nurse Program

Continuation from 14-15 QIP

Prospective Analysis at QCH completed, improvement work

underway.

** New Project:Integrated Discharge Planning Model

10% decrease in readmissions and ED visits at TOH

Pilot completed; TOH evaluation of project

underway

Reduce % of home care patients with an unplanned, less-urgent ED visit within the first 30 days of discharge from hospital. TARGET ≤7.0% HQO DATA: Q2 14/15 - Q1 15/16=7.0 %

Reduce % of home care patients who experienced an unplanned readmission to hospital within 30 days of discharge from hospital. TARGET ≤ 18.2% HQO DATA: Q2 14/15 - Q1 15/16= 18.8%

EFFECTIVENESS


Percentage of patients who have reassessment on time, per population standards of care.

TARGET ≥ 80% Q3 FY 15-16: 86.7%


Increase the percentage of completed in-home assessments as per guidelines of care

80%Target met;

sustain improvements

7

EFFECTIVENESS


PATIENT-CENTRED


Implement AIDET (Acknowledge, Introduce, Duration, Explanation, Thank You)

All CCAC and SPO Staff

CCAC TAs trained; Training of SPO staff

under review

Define Care Plan FlexibilityDefine; Educate Staff

and SPOs

On Hold pending patient experience

plan

Implement Client Check-In across all Congregate Care Teams

100% of CongregateCare Teams engaged

in client check ins

Pilot complete; implementation in

development

Patient Caregiver Council engagement in specific workplan activities

Council activelyconsulted on 2 key

organizational initiatives

Complete

Increase the % Positive Response to KPI 1 “Overall Experience” on the client experience survey.

TARGET ≥94% CCAC DATA: Q4 15-16: 91.2%HQO DATA: FY 14-15: 92.8% Q1 5-16 = 92%



Trial IVR Technology as a means of obtaining real-time patient satisfaction data

Develop and trial survey

Complete

Reduce average number of calendar days to resolve patient complaints

20 daysFY 15/16= 30.41

days

Reduce the occurrence of missed careDetermine baseline missed care rate

Focus of prospective analysis changed to focus on the Rapid Response Nurse

**New Initiative:Automated Provider Reports

Improve communication

between CCAC and Service Provider Organizations

In progress; Allied Health to be

completed in 2016-17

Patient Centred Appointments 85%Not addressed this

fiscal year

Increase the % Positive Response to KPI 1 “Overall Experience on the client experience survey.

TARGET ≥94% CCAC DATA: Q4 15-16:91.2%HQO DATA: FY 14-15: 92.8% Q1 5-16 = 92%

PATIENT-CENTRED

CASC de Champlain CCACCASC de Champlain CCAC

Client and Caregiver Experience Evaluation (CCEE)

FY 2015-16 Results and Action Plan Focus Areas

Client Services, Quality and Safety Committee

June 13, 2016

Jennifer Proulx – Director, Quality & Program Evaluation

Caroline Guimond – Patient Experience & Risk Specialist


• Provincial tool used by all 14 CCACs

• Available in English and French

• Conducted over the phone with patients or their designated caregivers

• 47 Questions and 9 Key Performance Indicators

• Statistically relevant data across:

• Regions

• Service Providers

• Service Type (nursing, social work (SW), occupational therapy (OT), physiotherapy (PT))

• Clinical Care Teams

• Approximately 2200 completed surveys per year

Background

2

CASC de Champlain CCACCASC de Champlain CCAC 3

Scope


KPI 1 - OverallExperience

KPI 2 - ClientCentred Care

KPI 3 - ClientCentred CareAppointments

KPI 4 - Qualityof Care

KPI 5 - BuildingRelationships

and Trust

KPI 6 - Linkingto otherservices

KPI 7 -Willingness toRecommend

KPI 8 -Expectations

of QualityKPI 9 - Safety

Champlain CCAC 91.4 86.6 91.5 93.8 91.0 79.2 97.1 59.5 75.1

Provincial CCAC 91.6 88.4 90.8 93.5 91.7 77.0 96.6 59.2 76.3

50.0

55.0

60.0

65.0

70.0

75.0

80.0

85.0

90.0

95.0

100.0

Champlain vs the Province FY 2015-16 Q1-Q2

KPI Comparison

4


46.7%

36.4%41.4% 39.3%

46.1% 45.7%40.2% 38.7%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

Nursing PSS PT OT Nutrition SLP SW Placement

Excellent Very Good Good Fair Poor

Overall Satisfaction by Service, by Response (FY 2015-16 Q1-Q3)

5


Year of Survey FY 12-13 FY 13-14 FY 14-15 FY 15-16

KPI 1 - Overall Experience 93.2 92.8 92.5 91.5

KPI 2 – Client-Centred Care 89.5 88.6 88.4 86.1

KPI 3 – Client-Centred Care Appointments 92.4 92.4 91.7 91.5

KPI 4 - Quality of Care 93.9 93.1 92.2 93.4

KPI 5 - Building Relationships and Trust 92.1 91.6 92.5 91.1

KPI 6 - Linking to other services 49.7 74.1 77.6 77.9

KPI 7 - Willingness to Recommend 96.5 97.0 96.8 96.7

KPI 8 - Expectations of Quality 61.6 61.8 60.1 59.0

KPI 9 - Safety 74.4 73.5 75.3 75.1

Key Performance Indicators Year over Year

6


Year of Survey FY 12-13 FY 13-14 FY 14-15 FY 15-16

Nursing 96.5 96.2 93.6 92.7

PSS 92.8 91.6 92.2 92.6

PT 94.2 93.4 93.9 91.1

OT 91.5 92.2 91.7 89.4

Nutrition 95.3 95.2 95.8 92.2

SLP 92.3 95.4 97.0 91.5

SW 87.1 94.1 89.0 86.8

Placement -- 91.3 87.8 88.7

Overall Services Year over Year

7


Priority Matrix – Apr. to Sept. 2015

8


Patient Experience Action Plan: Areas of Focus

Alignment with FY 2016-17 QIP:

• KPI 1: Overall experience – % Positive

• KPI 2: Patient-centred appointments – On Demand pilot project

• KPI 6: Integrated care and support of transitions – Onboarding of complex patients pilot project

• Establish VOICES baseline performance

9


Patient Experience Action Plan: Areas of Focus

• KPI 9: Safety – based on our improvement work from 2014-15, the province has adopted 2 new questions:

• Q23: You are satisfied with the support received from [care coordinator] to address safety concerns at home.

• Q31: You are satisfied with the support received from this agency to address safety concerns at home.

• Monitor highest correlated CCEE item to Overall Experience and identify related improvement opportunity

10


New Survey Offerings

NRC is offering additional modules:

• Clinic survey

• VOICES survey for caregivers of palliative patients

• Hospital discharge survey (for Rapid Response Nurse (RRN) patients and hospital to home)

• Mental Health and Addiction Nurse (MHAN) survey (under development)

11


Clinic Survey:

• Interactive Voice Response (IVR) survey launched in May

VOICES Survey:

• Mail out & web based surveys administered Dec-Feb

MHAN Survey:

• Exploring in-house development

12

Champlain CCAC Strategy


Hospital Discharge Survey:

• Exploring in-house development

Personal Support Services (PSS) Patient Experience Survey:

• IVR survey conducted in 2015

Service Provider Monitoring: IVR survey and process under development

13

Champlain CCAC Strategy


Appendix


86

88

90

92

94

96

98

100

% P

osi

tive

KPI 1 – Overall Experience

15


80

82

84

86

88

90

92

94

96

98

100

% P

osi

tive

Rate management/handling of case by case manager Rate services Rate services provided by agency

KPI 1 – Overall Experience, by Question

16


KPI 1 - Overall Experience

Date Long Stay Short Stay

2012-13

Q1 91.1 93.6

Q2 94.3 93.5

Q3 93.2 94.7

Q4 92.7 93.8

2013-14

Q1 92.5 94.1

Q2 94.2 94.2

Q3 91.1 94.7

Q4 93.5 94.8

2014-15

Q1 92.1 94.3

Q2 91.9 92.9

Q3 91.6 92.8

Q4 92.7 94.5

2015-16

Q1 92.0 92.0

Q2 90.4 92.0

Q3 92.0 91.3

17


80

82

84

86

88

90

92

94

96

98

100

% P

osi

tive

* No data available for

Q2 of FY 2015/16.

KPI 2 – Client-Centred Care

18


70

75

80

85

90

95

100

% P

osi

tive

Felt involved in developing care plan Given needed information about CCAC services

* No data available for

Q2 of FY 2015/16.

KPI 2 – Client-Centred Care, by Question

19


KP1 2 – Client-Centred Care


2012-13

Q1 95.7 88.7

Q2 93.1 91.2

Q3 92.3 84.6

Q4 88.2 85.3

2013-14

Q1 90.1 86.9

Q2 91.5 84.5

Q3 92.3 90.6

Q4 89.4 91.9

2014-15

Q1 90.4 86.4

Q2 91.0 84.7

Q3 89.3 86.3

Q4 90.1 87.6

2015-16

Q1 88.9 86.7

Q2 No data No data

Q3 85.6 85.6

20


40

50

60

70

80

90

100

% P

osi

tive

* As of April 2013, a second question was added to KPI 6.

KPI 6 – Linking to Other Services

21


40

50

60

70

80

90

100

% P

osi

tive

CCAC link to other community services after discharge CCAC linked to other community services

* As of April 2013, a second question was added to KPI 6.

KPI 6 – Linking to Other Services, by Question

22


KPI 6 - Linking to Other Services


2012-13

Q1 35.0 52.4

Q2 38.9 57.1

Q3 71.4 45.1

Q4 66.7 54.6

2013-14

Q1 79.8 67.7

Q2 80.5 61.6

Q3 76.2 72.2

Q4 79.0 72.0

2014-15

Q1 80.4 68.6

Q2 81.2 72.3

Q3 78.4 75.7

Q4 76.4 65.0

2015-16

Q1 84.0 73.9

Q2 80.4 71.8

Q3 79.3 66.7

23


60

65

70

75

80

85

90

95

100

% P

osi

tive

KPI 9 – Safety

24


60

65

70

75

80

85

90

95

100

% P

osi

tive

Case manager discusses safety issues Told how to set up home to move around safely

KPI 9 – Safety, by Question

25


KPI 9 - Safety


2012-13

Q1 77.9 66.5

Q2 78.5 61.9

Q3 81.4 63.1

Q4 77.8 62.3

2013-14

Q1 80.4 60.6

Q2 78.7 61.4

Q3 79.8 63.5

Q4 76.0 67.8

2014-15

Q1 81.0 67.9

Q2 78.5 66.0

Q3 78.8 66.0

Q4 78.6 58.9

2015-16

Q1 79.8 67.8

Q2 78.8 64.2

Q3 81.3 63.2

26


70.0

75.0

80.0

85.0

90.0

95.0

100.0

Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3

2012-13 2013-14 2014-15 2015-16

% P

osi

tive

Long Stay Short Stay All

Ease of Contacting Case Manager

27


Ease of Contacting CM


2012-13

Q1 78.0 77.8

Q2 83.3 79.6

Q3 80.9 88.2

Q4 81.6 85.0

2013-14

Q1 82.2 81.0

Q2 83.0 87.9

Q3 81.1 78.1

Q4 86.3 89.2

2014-15

Q1 84.3 91.0

Q2 84.6 79.6

Q3 81.2 85.7

Q4 82.4 84.9

2015-16

Q1 81.6 83.7

Q2 80.6 80.0

Q3 76.7 74.0

28


Discussion

29

Work Status CodePlanned activity Work in progress, proceeded as expected Delays or issues encountered and being Escalations required to address issuesCompleted

Project Name Action Status Q1 Update (Apr, May, June) Q2 Planned Activities

Enhance the Care Coordinator Role: through role depth, role intensity, role scope and role expertise

1.1 Workforce and resource planning – support optimal 2015 caseload size

recommendations

Completed. Confirmed previously defined Care Model caseload sizes are

applicable. Identified additional resources required to address current

situation.

none - will address Action Plan item 1.2.

1.2 Care model restructuring to reduce large caseloads

Opportunities for caseload size reduction identified (short stay, intake,

placement and resource care coordinator). Resourcing analysis

conducted to support planning work.

Further work to develop implementation plan.

1.3 Develop evaluation framework for assessing caseload size n/a Develop evaluation framework to support implementation plan

2.1 Identify common CCAC & Health Links patients & ensure CC duplication is

minimized

Align this work with new Enhanced Care Model Pilot where CCAC is HL lead and more

work required

2.2 Support LHIN-identify/rationalize/reduce CC duplication Retreat planned with LHIN June 9 Discussions planned with LHIN.

2.3 Develop CC standards & build into evaluation/educ & tools Completed: National Case Management standards are in place Care coordinator education planned will combine IHI and refresher .

2.4 Establish clinical resources to ensure staff have appropriate skills / tools to

assist patients to access care across all Health, Community and Social Service

sectors

Refresher education referenced in 2.3 will include education on community services

via The HealthLine.

2.5 Redefine CC roles/responsibilities within an integrated team, multi-discipline

team & SPOLinkage to the new Enhanced Care Model Pilot.

2.6 Pilot shared decision making framework & tools such as Coordinated Care

Plan Tool ….

Adoption of the Consolidated Care Plan in CHRIS by a number of the

Champlain Health Links has grown and seems to be accelerating, During

May, CCAC added organizations and users from Seaway Valley CHC (UC

HL); Pinecrest-Queensway CHC, Arnprior District FHT, and Greenbelt FHT

(SONG HL); and West Carleton FHT (AROW).

Further work will link to the new Enhanced Care Model Pilot. (Note: The Ministry still

has to decide what of the 5 tool options they use for CCP - it is hopefully CHRIS, but

may not be)

2.7 Implement new std protocols/tools for transitions, DIVERT, Falls Prevention

and Med Mgmt Linkage to the new Enhanced Care Model Pilot.

2.8 Implement AcuteNet Completed; May 2016

Champlain CCAC Action Plan – Prioritization

Coloured cells indicate priority work for action in F2016-17Clinical care work related to patient experience QI

Other Work-in-progress OR Previously Planned

Mandatory work

To Maintain Increasingly High Needs Complex Patients at Home, we need to:

1 Review/balance caseload sizes

2

Streamline care coordination

initiatives in the region &

standardize care coordination

practices

Page 1 of 6


2.9 Improve SPO outcome reporting – SPR/APR

Completed automated provider reporting (APR) system enhancement for

outcomes and goal focused content reports in Nursing and PSS from 3

large Providers;

Implement APR with Peds in Aug 2016. Planning for further implementation into

Allied Health and all Providers started.

2.10 support CCAC/CSS reform strategies

Two new agencies were brought onto the SSO client information system

platform, Olde Forge and South East Ottawa CRC, (Total of 44 supported

agencies and over 600 user)s.

Completed client transfers and developed with LHIN a shared client and

escalation process between CCAC and CSS.

SSO client information system has two more small providers and a very large one in

the pipeline for future implementation planning.

. Awaiting further LHIN

direction/engagement.

3.1 develop strategy & materials to mentor clinical best practices Completed initial set of work focused on Palliative. Work will be leveraged for the first set of Clinical Audits planned for fall across

Nursing/PSS with 3 Providers.

3.2 strengthen CCAC professional practice/educ structures to align with clinical

needs

3.3 create advanced nursing & therapy roles within professional practice to

support educ, clinical best practice development and clinical protocols

3.4 Develop standardized processes and expectations, including performance

metrics for direct care clinical staff

Work in progress and has been linked and driven by Accreditation

preparations.Work will continue.

3.5 Train clinical staff/mgmt in the execution of their new rolesDiscussion paper developed to help document enhanced care

coordination roles/responsibilitiesLinkage to the new Enhanced Care Model Pilot.

4.1 provide CC services to HL where contracted (4 different HL) Work in progress

4.2 become lead agency for HL Work in progress

4.3 improve collaboration & integration with HL CC / CCAC CC Work in progress for alignment where CCAC is lead. Linkage to the new Enhanced Care Model Pilot.

4.4 serve as lead agency for HL 1 VP is clinical lead for this new HL. Work in progress.

4.5 identify resource req'ts and advocate for equitable distribution of CCAC CC

and admin resources in all HL

5.1 explore opportunities to change the NP / RPCT model & have NP provide

direct care or symptom mgmt with non-attached ptsDiscussions with Bruyère are in-progress. Discussions will continue.

5.2 revise Bruyère MOU to reflect expanded NP role & new model

6.1 Re-establish relationships with Primary Care providers

6.2 Explore opportunities to embed CCAC care coordination activities within PC

team processes and improve/ standardize expectations for communication with

primary care team / interdisciplinary team members overall

Linkage to the new Enhanced Care Model Pilot where care coordinator is integrated

with Primary Care.

3

Improve the training and clinical

support for CCAC Care

Coordinators, Therapists and

Nurses and development and

support for Clinical Care

Managers

6

Enhance development and

leadership with Health Links

5

4

Increase scope of practice and

role for Nurse Practitioners in

Palliative program and improving

the Central Referral and Triage

(CRT) processes (in partnership

with Bruyère)

2

Streamline care coordination

initiatives in the region &

standardize care coordination

practices

Advance Integration with Primary

Care across Champlain region

Page 2 of 6


7.1 ensure pt/caregiver perspective informs initiatives

Completed; all programs/initiatives are engaging patient advisors and

will continue to leverage this resource throughout (e.g.. Enhanced Care

Coordination, Equipment and Supplies Delivery Service

Enhancements/Waste Reduction, etc. (I would not say COMPLETE - track

as green - in progress)

7.2 improve how patient experience is measured & apply to QI

8.1 engage Patient/Caregiver Council role in developing/guiding caregiver

support program

8.2 inventory resources for caregivers; identify gaps / needs

8.3 engage private sector/govt to participate in foundation

9

Adopt Self-Directed Care funding

models9.1 implement SDC funding program

1 SDC Agreement implemented as of June 3, 2016. 2 other potential SDC

Agreements may be completed prior to end of Q1.

Developing a list of all potential candidates for SDC and working through Ministry SDC

program rollout, timeframe, expectations and budget for further implementations.

10.1 develop SPO care team continuity guidelines (# of PSW or nurses per team

per care plan hours)

Collaboratively working with Provider to define many aspects of service

expectations and service delivery standards; planning committee set

up/active

Leverage Onboarding Patient Improvement Pilots to implement and evaluate

outcomes.

10.2 implement patient communication and checklist materials for patients to

understand care plan, expectations, contacts

10.3. Conduct LEAN analyses of current processes and service delivery

expectations to identify and prioritize quality initiatives to address offer/referral

content of care plan, impact of acceptance metric, transition planning/case

conferencing, >1 SPO per patient, pathways & self-mgmt care, reduce Ax

duplication of CC/SP, direct communication CC/PSW & current process of when

Ax visits are complete at initial onboarding, delegated task changes, patient

status reporting to CC

Lean analysis planned mid-June; this work will support Onboarding

Patient Improvement Pilot Pilot launch in Q2.

10.4 define/pilot solutions to RH service delivery challenges

Meet with RHRA for clarity on regulations/expectations to identify

potential impacts to CCAC/Providers. Meeting and collaboratively

working through issues with individual retirement homes, providers and

CCAC. Some QI is evident. Will carry over into Q2.

Work planned to define problems/solutions and pilots.

10.5 modernize delivery of MES as per RFP new capabilitiesMeet with OMS supplier, patient advisor and provider representations to

identify problems and prioritize action plans.

Develop project plans for detailed work actions around 1st priorities of Waste

Reduction, Electronic Catalogues, Delivery Tracking Status

11.1 collaborate with colleges to establish an enhanced PSW curriculum related

to medical conditionsEstablished communication lines with college. Additional meetings planned with college and LHIN to discuss further.

Implement new service standards

for patient centered clinical care

and service delivery and develop

new practices to improve “On-

Boarding” of Complex Patients

Engage providers to enhance the

knowledge, skills and technical

expertise of front line health care

workers

To Modernize the Home and Community Care Delivery Models: through more continuity, more consistency, more quality of care, we need to:

Advance the engagement of Patients and Caregivers and provide services to support caregivers

8. Develop a “Champlain

Caregiver Initiative” to create a

fund exclusively focused on

caregivers’ needs

11

10

8

7Adopt & apply Carman Patient

Engagement Framework

Page 3 of 6


11.2 standardize PSW training/competency testing in medical diagnosis

education and technical skills (lifts) and reduce delegations & have SPO

demonstrate they have sufficient # of staff with skills/capabilities

11.3 support development of knowledge and skills with SPO nurses through

work of clinical care advanced practice staff and CCAC professional practice

structure where possible

12.1 increase events tracking of events/complaints/incidents & do trending

analysis & develop relevant action plans Analysis and planning work to begin

12.2 increase engagement with patients/caregivers for feedback on quality and

experience using IVR

Initiated work to use IVR to verify care delivery issues such as scheduling,

communicating and delivery of care (e.g.. late, missed, appointment

options, communications/awareness of status)

Develop tracking to identify time spent by clinical care on related issues brought to

their attention. Develop IVR survey plan. Initiate calls. (Q3 - may look to further refine

survey by leveraging actual Provider appointment scheduling system data)

12.3 complete palliative & clinic model evaluations

Clinic model evaluation started May 27 2016 with IVR calls to clinic

patients. Palliative model continues to generate data for future

evaluation purposes.

13.1 implement new provincial standards of Missed Care (MC) Contracts adjusted to reflect new MC KPI. Continue to work with providers to meet the new MC KPI.

13.2 augment current SPO performance metrics with new metrics

Contracts adjusted to reflect other new performance and QI metrics that

support Champlain focuses in palliative, clinics, congregate care billings,

wound care and more.

Continue to work with providers to implement processes and measure outcomes

associated with the new metrics. Continue to refine the mathematical calculations for

improved accuracy/relevancy.

13.3 develop/implement outcome-based & clinical best practice metrics in falls,

palliative and infection rates related to vascular access in home infusionsWork in progress Leverage work for Clinical Audit initiatives

13.4 add a clinical-based audit framework into inspection plans Developed clinical best practices/outcomes to be used in clinical audit

framework for palliative services. Planning for clinical audits of 3 providers of palliative care in fall.

13.5 complete 3 more SPO audits (clinical & contractual view)Contractual audit planning for 1 SPO in spring started; audit delayed from

June to July date due to new Contracts Manager. Planning for additional contractual Q3 audits of PSS providers

13.6 improve regular audit of SPO events/complaints & correlate to CCAC info

14.1 complete NBC - patient transitions to new SPO for region

14.2 pilot in RH a single SPO for nursing & PSS2 RH with nursing primes are identified. Natural patient attrition will

continue until nursing provider has all patients.

14.3 explore NBC for new rural regions, therapy or nursing

15.1 implement new practices/processes for more flexibility in duration of time

(45 min) associated with care plan visitCompleted May 9 2016.

13

Engage providers to enhance the

knowledge, skills and technical

expertise of front line health care

workers

Increase our ability to measure

and improve on quality of

patient/caregivers’ experiences

To Create Sustainability for Growth through effectiveness and innovation, we need to:

15

Optimize cost of service and care

delivery by aligning service

delivery times and durations with

patient needs

12

11

Increase and improve

performance oversight of

providers through better clinical

and contractual audit program

14

Continue to restructure our care

delivery programs and

relationships between providers

and the geographical areas they

serve (“Neighbourhood” Care)

Page 4 of 6


15.2 pilot new practices for flexibility of care over 30 dy vs weekly Exploring options for pilot within Peds groups.

16.1 Pilot On-Demand care delivery (scheduled and unscheduled care and

integrated enhanced care coordination)Planning work initiated with one provider. Pilot launch in Q2.

15.2 support reform & future state - Arnprior Rural Health Hub Discussions ongoing as appropriate.

17.1 Investigate potential options against a cost-benefit analysis to determine

feasibility

17.2 Issue a report and recommendation to meet this need

18

Clarify and communicate CCAC

actual capacity and occupancy

rates against our programs for

external partners and

stakeholders in the region

18.1 Develop mechanisms and report monthly our capacity vs occupancy rate

to hospitals /othersCompleted June 2016. Further refinements/improvements as identified.

19.1 pilot new Enhanced Care Coordinator model with other processes/services

and new technologies that enhance services and support care needs

2 Pilots being planned. (1) On-Demand care delivery and Enhanced Care

Coordinator. (2) Enhanced Care Coordinator and Integrated Primary

Care/HealthLinks.

Pilot launch in Q2.

19.2 incubate technology solutions / services that support tighter integration ,

improved clinical care monitoring, electronic sharing of patient information,

cost savings, etc.

RFP responses closed and evaluation and decisions are in-progress. Further planning work.

19.3 support hospitals with CCAC IS/IT resources for ED Notification

Completed 2 hospital implementations - Renfrew Victoria Hospital May

18; Arnprior Regional Hospital June 7.

19.4 Leverage IVR to reach patients for feedback on QI

Linked to 12.2. - Initiated work to use IVR to verify care delivery issues

such as scheduling, communicating and delivery of care (e.g.. late,

missed, appointment options, communications/awareness of status)

19.5 Assess & pilot new technologies/products/services to improve falls

prevention and more

May 26 the Champlain CCAC became the first health service provider in

the Champlain region to begin contributing patient data to the

cNEO/ConnectingOntario Clinical Data Repository or, as it has been

branded, the ConnectingOntario EHR.

dependent of 19.2 and more

19.6 Monitor implementations/opportunities to support patient monitoring &

intervention ( eShift, CDSM tool) and/or other

May 26 the Champlain CCAC became the first health service provider in

the Champlain region to begin contributing patient data to the

cNEO/ConnectingOntario Clinical Data Repository or, as it has been

branded, the ConnectingOntario EHR.

19.7 Chronic disease self-management monitoring & alerts to unusual /

negative trends

19

15

Optimize cost of service and care

delivery by aligning service

delivery times and durations with

patient needs

16

Pilot new models of care delivery

that improve patient-centered

care through new service

capabilities, integrated care

teams, enhanced care

coordination

17

Research and analyze alternative

residential care possibilities for

patients with needs between

home and long term care

Support innovation and research

in home care through IMPACT

Program

Page 5 of 6


20.1 develop/implement strategies to address 2015 Employee Engagement

survey resultsMeetings with department and directors to review survey results. Director level engagement with staff for further analysis/planning.

20.2 support staff through change management and communication initiatives

throughout transformation

Multiple Staff Conversations have been held and more planned to

communicate and do Q&A on transformation Continue communication work with staff and plan other work as appropriate.

20.3 engage front line staff in discussions & planning for implementation of key

strategies identified with Action Plan

Review of Action Plan done at Leadership meetings and with all front line

staff at Staff Conversations.

20.4 identify new / reinforce programs & strategies for employee wellness work in progress.

20.5 develop prof training & prgms that correspond with changing roles &

environment

Links to 2.3 - Care Coordinator education developed - case management

roles/responsibilities, standards and overall refresher.

Links to 10.3, 16.1, 19.1 - will continue to engage and support Pilot work and

Transformation work as appropriate.

Increase stability and engagement

of our employees 20

Page 6 of 6


People Services & Organizational Development

Update

Client Services, Quality and Safety CommitteeJune 13, 2016

Martin Hajek – Director, People ServicesDan Merritt – Director, Organizational Development

CASC de Champlain CCAC 2

Table of Contents

Integrated HR-OD Talent Management Framework

Indicators

• Employee Headcount

• Full Time Equivalents

• Age of Employees

• Length of Service

• Employee Turnover

• Absenteeism

• Labour and Employee Relations

• Exit Interviews

• Performance Development

• Education Hours

• Other Learning and Development

• Employee Engagement Survey

Highlights


Integrated HR-OD Talent Management Framework

Rewards & Recognition

Workforce Planning &

Management

Talent Acquisition

Onboarding

Performance Management

Learning & Development

Organizational Effectiveness

& DesignLabour

Relations

Health, Safety & Wellness

Compensation & Benefits

Employee Engagement


0

100

200

300

400

500

600

700

800

Employee HeadcountApril 2015 to March 2016

Full Time Part Time Job Share Casual Temp

• Headcount increased from 698 to 727 over the past 12 months (+29)

• Growth occurred in permanent full time (+13) and temporary employees (+21). Decline occurred part time employees (-5).

• Permanent, full time employees continue to be the foundation of our work force

• Casual and temporary employees are used only for absence replacement and short term projects

4

Employee Headcount


0

100

200

300

400

500

600

700

800

Number of BudgetedFull Time Equivalent Positions

April 2015 to March 2016• Although headcount increased,

budgeted FTE remained constant over the past 12 months

• Budgeted FTE has remained relatively stable since staff reductions in February 2015

5

Full Time Equivalents


0

50

100

150

200

250

0-25 26-35 36-45 46-55 56-65 65+

Regular Employees by AgeMarch 31, 2016

• Average age of regular employees is 46, unchanged from previous year

• Age distribution does not indicate any immediate issue. The number of employees aged 55+ is noteworthy, but not a significant concern at this time.

• Older employees may be more likely to retire in the face of significant organizational changes

6

Age of Employees


• Significant number of highly experienced employees in the organization

• Average length of service is 10.3 years

• Median length of service is 8.4 years

7

Length of Service

0

20

40

60

80

100

120

140

160

180

0-2 2-5 5-10 10-15 15-20 20-25 25+

Regular Employees Length of Service

March 31, 2016


• Turnover is within target range (below 10%)

• Turnover is being closely monitored since introduction of the Patients First white paper

• There has been an increase in MPE departures, with uncertainty about the future of CCAC being cited as a contributing factor

• High turnover rates in Q1-Q3 reflected the voluntary early retirements offered in 2015

8

Employee Turnover

0%2%4%6%8%

10%12%14%16%18%20%

2014/15Q1

2014/15Q2

2014/15Q3

2014/15Q4

2015/16Q1

2015/16Q2

2015/16Q3

2015/16Q4

Annualized Turnover RateApril 2014 to March 2016

Rate


• Employees with 1-5 years make up the largest portion of employee departures

• 92% of employees leaving for a “better job opportunity” had tenure of 5 years or less

9

Departures by Length of Service

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

< 1 yr 1 - 5 yrs 6 - 10 yrs 11 - 20yrs

21 + yrs


• Continuing to experience high levels of sick leave among Team Assistants and Care Coordinators

• Mental health issues are the primary diagnosis for sick leave. Mental health strategy continuing through 2016-17.

• Increasing the level of organizational expertise in managing disability and return to work

• Focusing on employee engagement and attendance management strategies

10

Absenteeism

0

2

4

6

8

10

12

14

Days of AbsenceApril 2015 to March 2016

Rate Target


• Relationships with both Unions remain positive. Union-Management meetings are held regularly.

• Grievance rates remain very low, with no grievances currently outstanding. Only one arbitration hearing in 2015-16, which was settled by the Parties.

• One employment related human rights complaint was filed in 2015-16. Mediation with Ontario Human Rights Commission is scheduled for mid-June 2016.

• There were no complaints lodged or infractions cited with respect to any employment legislation in 2015-16.

• One wrongful dismissal claim was settled in 2015-16. There were no other employment related legal proceedings initiated.

11

Labour and Employee Relations


Exit Interviews: SummaryFiscal Year 2015-2016


Number of

Departures

Not Eligible

for Exit

Interviews

Eligible for Exit

Interviews

Exit Interviews

Conducted

63 18 45 27

Offer rate: 100%

Participation rate: 60%

Participation profile: 23 full time and 4 part time employees

Exit Interviews 2015-2016 at a glance…

13


Primary Reason for Leaving

RetirementsBetter Job

OpportunityOther

25% 44% 14.8%

Exit Interviews 2015-2016 at a glance…

14


• 33% of interviewees stated that continuous change was a cause for departure.

• Overall lowest rating continues to be “I had career advancement opportunities with the CCAC” followed by “The amount of work I was expected to do was reasonable.”

• 73% of employees would recommend the CCAC as a good place to work, down from 85% last fiscal year.

• Positive themes were with regards to work drawing on skills, abilities and experiences, respect and teamwork, and flexible work arrangements.

Exit Interview 2015-2016 Trending

15


Enablement 2015-2016

16


Work Life 2015-2016

17


Total Compensation & Recognition 2015-2016

18


Communication & Senior Leadership 2015-2016

19


Organizational Effectiveness 2015-2016

20


Comments

I believe the therapists on staff are often forgotten in our

Ottawa-centric organization and it's a

shame.

The current climate of uncertainty significantly influenced decision.

Potential for a more strategic opportunity may have convinced me to stay along with a compensation

re-evaluation and increase.

Very heavy and needed to learn to identify priorities and boundaries. Amount of work is tremendous- very hard to

have work life balanceOn call adds to the heavy workload often very busy.

Good feedback from manager and team. We support

one another.

There has to be more opportunity for growth and development within corporate services. Part of that is for regular staff to feel that leadership actively cares about this aspect of the

workplace.

Working from home was a big asset.

Flexibility. I put more time in from home

(less social interruptions).

21


Performance Development (performance management) activities include the evaluation and appraisal of work objectives, goal setting, learning & development planning, and ongoing feedback and coaching.

Unionized staff – 2015-16 fiscal year

98% completion.

MPE staff – process currently open

40% completion (as of June 3).

100% completion is expected.

22

Performance Development

%

MPEUnionized

98%

40%


Education Hours

• Documentation Standards

• Engagement

• CCAC Rounds / Professional Practice

• Learning Cafés

• Service Offers

• Ethics

• AcuteNet system

• Patient Safety

• Workplace Violence & Harassment

• Self-defense and situational awareness

• Person Driven Care techniques: AIDET

• Self-care and mindfulness

• Leadership

• Health and Safety

• Orientation programs

• CHRIS & RAI training

• Responding to conflict

• Dementia care


Other Learning and Development

• # Orientation sessions: 29

• # new employees trained: 77

• # employees trained related to internal movement: 44

• # employees trained related to return-to-work: 28

• # eLearning courses deployed: 7 (excluding Orientation-related courses)


Employee Engagement

The December 2015 Employee Engagement Survey

Results were communicated to the Board in March 2016.

The Engagement Action Plan will be presented to the Board

in June 2016.


• Ongoing enhancements to recruitment and selection processes

• MPE job evaluation

• 5th Champlain Summit

• Introduction of the “Inspire” recognition program

• CUPE job evaluation

• Implementation of Coaching and Peer Support program for new hires

• AcuteNet training and implementation support

• Mentoring and support for new leaders

• 2015 Employee Engagement Survey – 87% participation rate

• 2016 National Capital Top Employer award

• 2016 Platinum Quality Healthcare Workplace Award

26

Highlights

Champlain

Board Scorecard

May 2016

(Data as of April 2016)

Champlain

Operational Dashboard

2

Patient

Financial

Quality

People

Patient Trends Apr-15 FY 2015/16Target (T) / Baseline (B)

Local (L) / Provincial (P)Mar-16 Apr-16 FY 2016/17

Referra l Volume 4790 4585 B: 4600 (L) 4809 4762 4762

Monthly CCAC Patient Capacity 102% 102% T: 100% (L) 105% 110% 110%

% of Patients Reassessed Within

Guidel ines of Care71% 71% T: 80% (L) 73% 73% 73%

Total PSS Patients Ful ly Waitl i s ted 1511 315 T: 0 (L) 1 0 0Total PSS Patients Partia l ly Waitl i s ted 558 255 T: 0 (L) 62 0 0Total PT Patients Waitl i s ted 189 102 T: 0 (L) 34 17 17

Total OT Patients Waitl i s ted 476 174 T: 0 (L) 17 24 24

Quality Trends Apr-15 FY 2015/16Target (T) / Baseline (B)


Service Wait-time Community (90th

Percentile Days Waiting)**78 57 T: 21 days (P) 25 29.8 29.8

2014/15 Q4 FY 2015/16 Target / Baseline 2015/16 Q3 2015/16 Q4 FY 2016/17

5 day wait time – Complex PSS* 72.9% 78.8% T: 95% (P) 83.7% 82.0% 75.6%Adjusted 5 day wait time - Complex PSS N/A N/A T: 95% (L) 91.7% 89.2% 84.9%5 day wait time – nursing* 93.6% 96.6% T: 95% (P) 93.9% 92.7% 93.8%% of Care Visits Delivered 99.85% 99.79% T: 99.95% (P) 99.79% 99.77% 99.78%

2014/15 Q3 FY 2015/16 Target / Baseline 2015/16 Q2 2015/16 Q3 FY 2016/17

Patient Experience* 91.4% 91.5% T: 94.5% (L) 90.9% 91.7% 91.5%*QIP Metrics

** MSAA Metrics

People Trends 2014/15 Q4 FY 2015/16Target (T) / Baseline (B)

Local (L) / Provincial (P)2015/16 Q3 2015/16 Q4 FY 2016/17

Staff Turnover 11.0% 11.0% T: 8.5% (L) 8.6% 13.7% 13.7%

% of Performance Agreements completed on

time

316/348

90.8%

316/348

90.8%

T: 217 (L)

100%

109/144

76%

188/217

87%

188/217

87%

Apr-15 FY 2015/16Target (T) / Baseline (B)


Absenteeism annualized rate 10.6 10.6 T: 9 days (L) 12.5 12.7 12.5

Financial Trends Apr-16

FY 2015/16

Variance vs.

Plan

FY 2015/16

Variance vs.

Plan %

FY 2015/16

Projected Deficit

Tracking to Budget Targets -$1,571k -$1,571k -7.89% TBD

FYTD Target

+$0k

Champlain

3

Financial People

Metric Definition Discussion Questions

Referral Volume

The count of new referrals to the CCAC during the time period. Only referrals that initiate Case Management intake Assessments are counted in this indicator.

Is CCAC demand increasing? Is it from hospitals, physicians, or community?

Monthly CCAC Visit Capacity

The count of patients, by population groups, who received direct care visits or S&E as compared to the budgeted number of patients.

Are care plans efficient, ensuring creating additional capacity? Are there alternate parts of the health system to address particular care needs?

% of Patients Reassessed Within Guidelines of Care

Percent of patients (per population coding), who receive their RAI reassessments within guidelines. E.g. Complex Population patients are to receive a reassessment every 3-6 months, whereas Community Independence patients are to receive reassessments every 12 months.

Are Care Coordinators focusing their time on assessing patients? Are processes and tools in place to ensure efficiencies in processes, allowing time for Care Coordinators to assess their patients?

Total Personal Support Services (PSS) Patients Waitlisted

A snapshot view of the count of the number of PSS patients on the waitlist as at the end of the month, divided by those who are fully waitlisted (having no PSS service), and those that are partially waitlisted (having some PSS service, but assessed for needing more).

What is being done to manage patient risk?

Total Physiotherapy (PT) Patients Waitlisted

A snapshot view of the count of the number of PT patients on the waitlist as at the end of the month

How are patient risks being managed?

Total Occupational Therapy (OT) Patients Waitlisted

A snapshot view of the count of the number of OT patients on the waitlist as at the end of the month

How are patient risks being managed?


Tracking to Budget targetsNet surplus/deficit as calculated by Revenue minus Expenses, as per plan.

Are we tracking to budget plans? Are our cost/patients to plan? Is demand for service to expectations? What additional actions if any, are required at this time?


Staff Turnover Rate at which employees leave an organization. Calculated as number of permanent employees who terminate or cease employment, divided by the average number of permanent employees on staff

If not as expected, what is the underlying cause and mitigating action plan?

% of Performance Appraisals Completed on Time

FYTD percent of staff whose performance appraisal is completed on time.

Is staff development being appropriately managed?

Absenteeism annualizedRate

Total number of sick hours, paid and unpaid for all permanent and temporary staff (excludes casuals), divided by number of permanent staff.

If not as expected, what is the underlying cause and mitigating action plan?

Patient Quality

Operational Dashboard: Glossary


Service Wait-timeCommunity (90th

Percentile Days Waiting)

Wait time from patient intake / application date for referrals sourced from the community (e.g. Family, Self) to receiving the first direct care service visit, where the patient is an adult patient on Home Care services. The 90th percentile focuses on ensuring that 90% of patients will receive a visit in the targeted time frame, or better.

Should service eligibility or service guidelines be reviewed/reduced? What advocacy should the Board engage in?

5 day wait time –Complex PersonalSupport Services (PSS)

Measures the percent of patients whose 1st PSS visit was achieved within 5 days, from Service Authorization Date to the 1st PSS Visit Date for the episode of care. patients with an “On-Hold” episode between the authorization and 1st visit, are excluded from the measure. (On hold is used, for example, if a patients discharge is delayed from hospital due to complications)

How have Quality Improvement Plan (QIP) action plans improved performance?

Adjusted 5 Day Wait Time-PSS

Measures the percent of patients whose 1st PSS visit was achieved within 5 days, from Service Authorization Date or Patient Availability Date to the 1st PSS Visit Date for the episode of care.

Where are the remaining areas of focus to improve the performance? Is the target achievable?

5 day wait time -Nursing

Measures the percent of patients whose 1st Nursing visit was achieved within 5 days, from Service Authorization Date to the 1st Nursing Visit Date for the episode of care. patients with an “On-Hold” episode between the authorization and 1st visit, are excluded from the measure. (On hold is used, for example, if a patients discharge is delayed from hospital due to complications)

How have QIP action plans improved performance?

% of Care Visits Delivered

Measures the percent of visits provided to patients, of all scheduled visits, for direct care visits. The metric is self reported by SPOs on a quarterly basis.

Are there variances amongst providers or services? Are there adverse affects on patients due to missed care?

Patient Experience

Measures the percent positive rating for overall satisfaction with care. How have Person Driven Care action plans improved patient experience?

Champlain

Supporting Complex Patients Sustainable Health Care

4

Strategic Dashboard

Supporting Complex Patients Apr-15 FY 2015/16Target (T) / Baseline (B)


Reassessment of Complex Patients within

Guideline94% 88% T: 90% (L) 86% 90% 90%

% of Complex Patients with a Care

Coordinator Contact (tel./FtoF) within 3

months88% 83% T: 85% (L) 79% 81% 81%

% of Complex Patients with 1 Care

Coordinator in past 12 Months95% 92% B: 95% (L) 90% 91% 91%

% of Patients with Targeted Number of SPO

Staff Within Past 3 MonthsNote: Feasibility being explored

% of Complex Patients With a Completed

Mediconciliation88% 74% T: 90% (L) 77% 81% 81%

Sustainable Health Care Trends Feb-15 FY 2015/16Target (T) / Baseline (B)

Local (L) / Provincial (P)Jan-16 Feb-16 2015/16 YTD

ALC Rate 12.9% 12.4% T: 12.7% (P) 12.5% 12.9% 12.6%

2014/15 Q3 FY 2015/16 2015/16 Q2 2015/16 Q3 FY 2016/17

Very High and High MAPLe Score %

supported by Champla in CCAC,

compared to Provincia l Averages

58%

(2)56.3% T: Top Quartile (L)

61.2%

(1)

62.0%

(1)

61%

(1)

2.0 1.0 T: 'Long Stay (L)Top Quarti le*

1.3 1.3 1.3

7.3 7.3 T: 'Short Stay (L)Top Quarti le**

7.0 7.0 7.0

Apr-15 FY 2015/16 Mar-16 Apr-16 FY 2016/17

% Cl inic Vis i t Uti l i zation 25.5% 29.3% T: 25% (L) 29.0% 28.5% 28.5%

Ranking relative to other CCACs for

average cost/Patient across a l l

Patient groups

*Champla in i s ranked cons is tently amongst the highest MAPLe proportion provincia l ly; Long Stay populations us ing provincia l

reference rates .

** Champla in continues to increase specia l programs, such as NPWT and CHIPP programs, impacting avg. cost; Short Stay

Population costs are ca lculated us ing loca l CCAC rates .

Champlain

Supporting Complex Patients Sustainable Health System

Metrics Definition Discussion Questions

Reassessment of Complex Patients within Guidelines

Percent of patients (per population coding), who receive their RAI reassessments within guidelines. E.g. Complex Population patients are to receive a reassessment every 3-6 months,.

Are Care Coordinators focusing their time on assessing patients? Are processes and tools in place to ensure efficiencies in processes, allowing time for Care Coordinators to assess their patients?

% of Complex Patients with a Care Coordinator Contact (tel./FtoF) within X Months

Count of the number of complex population patients who have had a Care Coordinator contact within last 3 months out of all complex population patients.

Are complex patients being monitored closely? Are there risks for some patients? If patients do not have a contact within last 3 months, what are the potential impacts?

% of Complex Patients with 1 Care Coordinator in Past 12 Months

Percent of complex patients active in the current month, who have had 1 Care Coordinator consistently assigned to the patient in the past 12 months.

When there are transitions, are Care Coordinators briefing peers effectively? What may cause higher number of assigned Care Coordinators (turnover, reassignments, etc.)?

% of Complex PSS Patients with Targeted Number of SPO Staff Within Past 3 Months

Percent of complex patients active in the current month, who have had the appropriate number of SPO staff assigned to the patient, within the past 3 months.

Is there consistency in care within the PSS care team? Do high numbers of SPO assigned staff create risk or a need for constant retraining? How do SPOs ensure consistency of care within the care team?

% of Complex Patients With aCompleted Medication Reconciliation

% of Complex Population patients with a BPMH completed within 30 days of either a RAI-HC completed with triggers for needing a Medication Reconciliation, or within 30 days of an initial face to face visit by a RRN or MHAN nurse.

Are there risks to patients if the CCAC is not completing a medication reconciliation? Are there other health professionals completing the Med Rec? Are there barriers to completing a Med Rec. ?

Metrics Definition Discussion Questions

ALC Rate New Indicator: Counts the total ALC bed days as a percentage of Total Bed days, during the period. Includes sub-acute (rehab and complex care bed and counts patients not yet discharged).

Are our programs appropriately supporting LHIN-Wide ALC targets? What if any additional actions are required to improve performance?

Very High & High MAPLe Score % supported by Champlain CCAC

The proportion of CCAC patients assessed by a RAI-HC, with a MAPLe Score of High or Very High, out of the total number of patients with a RAI-HC assessment.

What is the financial impact of sustaining higher needs patients? What effects does this have for provincial HBAM funding/

Ranking relative to other CCACs for average cost/patient across all patient groups

Using the LHIN Benchmark report, average costs per patient are reported by population group. Ranking can be achieved through the comparison of average cost per patient, across peers.

Are we delivering appropriate service levels to different patient populations (HBAM neutral or positive) and properly balancing cost & patient risk/safety?

% Clinic Visit Utilization Percent of Clinic Visits out of total Visit Nursing and Clinic Nursing Visits

Strategic Dashboard: Glossary

Champlain

OPERATIONAL METRICS

Champlain

Patient Trends 2: Referrals

7

Owner(s):Sophie Parisien

Variance Explanation

N/A

Actions and Status

Referral Source for New Referrals

Apr2015

FY 2015/16

Avg. BaselineMar 2016

Apr 2016

FY 2016/17

Avg.

Hospital 2,351 2313 2300 2439 2,469 2,469

Community-Physicians

541 564 550 711 609 609

Community-Other

1,898 1708 1700 1659 1,684 1,684

Total 4,790 4585 4600 4809 4,762 4,762

Indicator Characterization

Definitions Referrals: Count of new referrals to the CCAC within the period, broken down by source of the referrals, and outcome of the referral (admit to CCAC or Non-Admit to CCAC).

Reliability High

Frequency Monthly

Target Informational

Champlain

Patient Trends Patient Capacity

8

Owner(s):Jamie Stevens


N/A

Actions and Status

MonthlyPatient Capacity

Apr2015

FY 2015/16

YTD TargetMar2016

Apr2016

FY 2016/17

YTD

OverallPatient Capacity Percentage

101.8% 101.7% 100% 105.2% 110.3% 110.3%


Definitions The count of patients, by population groups, who received direct care visits or S&E as compared to the budgeted number of patients.

Reliability High

Frequency Monthly

Target 100%

<99% 99-99.4% 99.5-100.5% 100.6-101% >101%

Champlain 9

9


Definitions 1) Proportion of patients who are within population RAI-HC reassessment guidelines at the end of the month

2) Average number of RAI-HC completed per month per community Care Coordinator FTE.

Reliability High

Frequency Monthly

Target:% patients within Reassessment

80%

<70% >=70% to <80% >=80%

Target:Average number of RAI-HC completed per month per CC-FTE

28

<15 >= 15 to <28 >=28

Owner(s):Kevin Babulic (RAI-HC)Glenda Owens (RAI-PC)


Actions and Status

MetricApr

2015

FY 2015/16

Avg.Baseline

Mar 2016

Apr 2016

FY 2016/17

Avg.

% of patientswith RAI-HC reassessment within guidelines

71.0% 71.3% 69.6% 72.8% 72.8% 72.8%

% of patientswith RAI-PC reassessment within guidelines

59.8% 61.1% 60.8% 56.1% 46.7% 46.7%

Average number of RAI-HC completed per month per community carecoordinator

19.9 19.6

Baseline11

Target30

18.4 19.1 19.1

Average number of RAI-PC completed per month per community carecoordinator

19.0 17.1

Baseline 17

TargetNA

16.2 18.7 18.7

Person Driven CareRAI-HC Assessment Completion

Champlain

Patient Trends PSS Waitlist

(Month end Snapshot)

RAI ScoreApr

2015

FY 2015/16 Avg.

TargetMar

2016Apr

2016

FY 2016/17

Avg.

16+

Fully Waitlisted 372 80.7 N/A 0 0 0

Partially Waitlisted 159 71.3 N/A 21 0 0

11-15


Partially

Waitlisted377 201.2 N/A 39 0 0

8 -10


Partially


0 -7


Partially


To

tal

Fully Waitlisted 1511 315 N/A 1 0 0

Partially


% patients Assessed within Target

87.6% 43.1% 85% 100% 0.0% 0.0%


Definition % of patients on the PSS waitlist who have been reassessed while on the waitlist within target days

# of PSS patients on the waitlist as at the end of the month

Reliability High

Frequency Monthly

Target 85%

Less than 75% between 75%-85% 85% or more

Owner(s):Kevin Babulic


# patients • on Full waitlist = 0; • on partial waitlist = 307

Partially waitlisted fall under assessment standards fall of active patient standards and as such do not follow waitlisted patient reassessments

Actions and Status

% patients on PSS waitlist Ax within target: is of little value given partially waitlisted patients do not receive this, and is marked blue, not red as no action is required

Champlain 11

MetricApr

2015

FY 2015/

16Avg.

TargetMar

2016Apr

2016

FY 2016/17

Avg.

Total Waiting 189 101.5 N/A 34 17 17

% DelayedStart patients Reassessed on Time

98.9% 96.7% 85% 91.1% 94.1% 94.1

Owner(s):Glenda Owens


Actions and Status

Patient Trends Adult PT Waitlist

11


Definition % of patients on the PT waitlist who have been reassessed while on the waitlist within target days

# of PT patients on the waitlist as at the end of the month

Reliability High

Frequency Monthly

Target 85 % Assessed on Time

< 75% 75-85% >= 85%

Champlain

Patient Trends Adult OT Waitlist

12



Working to ensure we see this metric maintained or surpassed. Work with Short Stay Rehab CC’s to conduct re-assessment calls for Retirement Home patients and LTC home patients

Actions and Status

MetricApr

2015

FY 2015/16

Avg.

TargetMar

2016Apr

2016FY 2016/17

Avg.

Total Waiting 476 174.0 N/A 17 24 24

% DelayedStart patients Reassessed on Time

88.6% 91.3% 85% 70.5% 100.0% 100.0%


Definition % of patients on the OT waitlist who have been reassessed while on the waitlist within target days

# of OT patients on the waitlist as at the end of the month

Reliability High

Frequency Monthly


< 75% 75-85% >= 85%

Champlain

Patient Trends 7: School Therapy Waitlist

(Month end Snapshot)

13


Definition Number of pediatric patients on School Waitlists for OT, PT, and SP

Reliability High

Frequency Monthly

Target N/A

patientsWaiting

Apr 2015

FY 2015/

16 Avg.

Target

Mar 2016

Apr 201

6

FY 2016/

17 Avg.

OT 682 384.6 279 271 271

PT 37 33.9 28 27 27

SP 220 186.9 124 139 139

Champlain 14


Definition 90th percentile days waited from the patient’s referral date to the date of the Intake Assessment.

Reliability Medium – Indicator is directional

Frequency Monthly

Target 10 Days

<= 10 days > 10 Days or <= 15 Days

> 15 Days

Metric

Apr2015

FY 2015/16

Avg. Target

Mar 2016

Apr 2016

FY 2016/17

Avg.

90th

Percentile Days Waiting for Ax

22 13.6 10 Days 11 13 13

Patient Trends 3: Intake Efficiency (All teams)

14

Champlain15


Definition Average number of days to initial assessment, measured from the patient application date to the initial assessment completion date.


Frequency Monthly

Target N/A

Metric

Apr2015

FY 2015/

16Avg.

Mar2016

Apr2016

FY 2016/17

Avg.

Average Days to InitialAssessment 10 8.5 10 12 8.5

Median Days to InitialAssessment 1 1 1 1 1

Patient Trends 3: Intake Efficiency (All teams vs Hospital/Intake)

15

Champlain16

Patient Trends 1st RAI-HC/PC Efficiency

16


Definition Average number of days to initial HC/PC assessment, measured from the initial assessment date on the referral, to the first HC or PC assessment in the home.


Frequency Monthly

Target 3 Days

<= 3 days > 3 Days and <= 5 Days > 5 Days

Metric

Apr2015

FY 2015/16

Avg. Target

Mar2016

Apr2016

FY 2015/16Avg.

Complex: Average Days to Initial HC/PC Assessment

22.0 14.6 7 Days 12.3 13.3 13.3

Chronic: Average Days to Initial HC/PC Assessment

28.1 18.610 Days

15.1 16.6 16.6

Comm. Independence: Average Days to Initial HC/PC Assessment

25.0 19.4 14 Days 16.1 16.1 16.1

Champlain

Patient Trends 1: Paid Service patients by Population

17


Definition Distinct count of patients, where a paid unit of service, equipment, or supplies occurred within the period, broken down by Patient Population Groups. This excludes Case Management only patients, LTCH placement only patients

Reliability High

Frequency Monthly


Population Apr2015

FY 2015/16YTD Avg.

FY 2014/15

Avg.

Mar2016

Apr2016

FY 2016/17YTD Avg.

Total patients 18,385

Non-Summer:19,836

Summer:17,615

Non-Summer:17,655

Summer:14,884

21,039 21,323

Non-Summer:21,323

Summer:-

Detail

Short Stay-Acute 856 890 679 899 891 891

Short Stay-Wound 1,496 1,631 1196 1,568 1,577 1,577

Short Stay-Rehab 973 1,042 762 1,098 1,057 1,057

Short Stay-Oncology

721 720 642 768 766 766

Community Independence

1,726 1,603 4538 1,563 1,556 1,556

Chronic 6,327 7,593 3890 8,277 8,401 8,401

Complex 2,919 2,925 2494 2,943 2,957 2,957

Enhanced 525 547 535 580 589 589

Paeds 3,276 3,005 2957 3,878 4,057 4,057

Uncategorized 118 84 365 83 73 73

Champlain

Quality 1: Service Wait Times

(Community)

18


Definition Wait time from patient intake / application date for services from the community, to receiving the first paid service (excludes patients receiving Case Management services, LTCH placement assistance, and any patient waiting over 1 year)

Reliability High

Frequency Monthly

Target 21 Days

21 days or less 21.1 to 30 days More than 30 days

Apr2015

FY 2015/1

6Avg. Target

Mar2016

Apr2016

FY 2016/17

Avg.

90th

Percentile Community Wait Time

78 57 21 25 29.8 29.8

Median Wait Time

6 7.3 N/A 6 7 7

Average CommunityWait Time

27 21.4 N/A 12 14 14

Owner(s):Penny Sands/ Brenda Toonders


Mar. Comment : We will continue working with the Service Providers to bring this down

Actions and Status

Champlain

% of Completion

within 5 days

2014/15Q4

FY 2014/15

Avg.

Target 2015/16Q3

2015/16Q4

FY 2015/16

Avg.

Combined Hospital & Community

PSS 72.9 78.8 95 83.7 82.0 75.6

Adjusted PSS TBD TBD 95 91.7 89.2 84.9

Nursing 93.6 93.6 95 93.9 92.7 93.8

Hospital

PSS 79.9 82.3 82.8 85.0 86.4

Nursing 93.9 94.0 93.1 94.3 92.4

Community

PSS 65.6 75.2 65.9 82.6 79.0

Nursing 92.9 92.8 82.8 93.3 93.1

Quality1-b : 5 Day Wait Time : Complex Patients

(Community & Hospital)

19


Definitions Reliability Frequency Target

Percent of complex patients receiving their first PSS or Visit Nursing within 5 days from the authorization of the service to the first visit.

High Monthly Nursing: 95% PSS Complex: 95%

< 90% 90-95% 95% or

greater

< 90% 90-95% 95% or

greater

Owner(s):Kevin Babulic (PSS)Sophie Parisien (NUR)


Mar. Comment :

NURSING: Reports reviewed with Managers who are following up with staff individually.

Jan. Comment :

PSS: Dec at historical highest percentage ever 93%. Manager follow with individual successful

Actions and Status

Mar. Comment :

NURSING: Continue to monitor and follow-up with staff to ensure everyone is entering first service start date within 5-day timeframe.Sophie reviewing 5-day target with teams at Jan/Feb roadshow

Jan. Comment :

PSS: Education complete. +++ rigor re follow up on individual basis and monitor

Clients Percent Accumulated

111 90% 90%

1 1% 91%

1 1% 92%

3 2% 94%

Client Unavailable per SPR/APR 0 0% 94%

CC Data Entry 3 2% 97%

SPOs 4 3%

123Total Clients

Patient has chosen to delay service initiation

Clinical need for service to begin on a specific date

Patient is currently

available for service

Complex-PSS Clients

Met the Target

This service is being pre-planned

Champlain

% of Direct Care Visits Delivered

2014/15Q4

FY 2015/16

Avg.*

Target 2015/16Q3

2015/16

Q4

FY 2016/1

7Avg.

Overall99.85% 99.79% 99.95%

99.79%

99.77%

PSS99.80% 99.75% 99.95%

99.74%

99.72%

Visit &Clinic Nursing 99.99% 99.98% 99.95%

99.99%

99.98%

Shift Nursing99.99% 99.91% 99.95%

99.84%

99.94%

Therapies99.99% 99.69% 99.95%

99.85%

99.93%

*Note: FY 2015/16 Targets where at 99.5%

Quality% of Direct Care Visits Delivered

20

Owner(s):Brenda Toonders

VarianceExplanation

Actions and Status


Definition

Reliability High

Frequency Monthly

Target 99.95%

<=99.49 99.5-99.94 >=99.95

Champlain

Metric 2014/15Q3

FY 2013/14

Avg

Target 2015/16Q2

2015/16Q3

FY 2016/17

Avg.

Patient Experience: Overall Satisfaction

91.4% 91.5%94.5%

90.9% 91.7%

QualityPatient Experience

21


Definition % positive rating for overall satisfaction with care.

Reliability Moderate – Quarterly results are Interim until full year results are available

Frequency Quarterly

Target 94.5%

< 92.5% 92.5 – 94.5% >= 94.5%

Owner(s):Jennifer Proulx


Actions and Status

Champlain

% of Service Authorizations with Required 1st Visit Date

Entered

Apr2015

FY 2015/16Avg. Target

Mar2016

Apr2016

FY 2016/17Avg.

Overall Organization

81 87 100% 95 96 96

Intake Team 94 94 100% 97 98 98

Hospital Teams 82 84 100% 91 92 92

Community Teams 69 82 100% 95 96 96

PSS 79 81 100% 91 93 93

Nursing 69 80 100% 92 94 94

Therapies 99 100 100% 100 100 100

Quality% of Service Authorizations with Required 1st

Visit Date Entered

22

Indicator Characterization Definitions Reliability Frequency Target

% of Service Authorizations with Required 1st Visit Date Entered

High Monthly 95%

< 90% 90-95% 95% or greater

Champlain

% of Service Authorizations with Required 1st Visit Date

Entered

Apr2015

FY 2015/16Avg. Target

Mar2016

Apr2016

FY 2016/17Avg.

Overall Organization

88 85 95% 84 87 87

External PSS 86 78 95% 79 82 82

External Nursing 90 88 95% 87 90 90

External Therapies 78 78 95% 76 75 75

Internal Nursing 93 93 95% 86 92 92

Internal Therapies 83 83 95% 71 79 79

Quality% of SPO 1st Visits Achieved within Required 1st

Visit Date

23


% of Service Authorizations with Required 1st Visit Date Entered

High Monthly 95%

< 90% 90-95% 95% or greater

Note: To be included in the metric, the Service Requested by or Required 1st Visit Date fields must

be populated, in order to measure SPO performance against these dates. Therapies, MHAN, and

RPCT may have very few authorizations with these dates filled in, due to past

practice/expectations, causing potentially large swings in performance for Therapies and Internal

Nursing.

Champlain24


Definitions Number of high and adverse risk events reported and recorded within Champlain Event Learning System. Top five events by volume and by risk provided for information purposes.

Reliability Moderate

Frequency Monthly


Numberof events

Mar 2015

FY 2015/

16 Avg.

BaselineFeb

2016Mar

2016

FY 2016/17

Avg.

Number of Events

32 34 34 33 31 31

Number ofComplaints

58 57.2 57.2 42 34 34

Quality 2: Patient Events & Complaints

24

Champlain 25


Definitions The number of days for a complaint to be resolved with the patient, from the time the complaint was recorded.


Frequency Monthly

Target 20 days

<=20 days 21-30 days >=31 days

MetricMar

2015

FY 2015/16

Avg.Target

Feb2016

Mar2016

FY 2016/17Avg.

Average ResponseTime (days)

20.9 30.8 20 days 17.8 49.2 49.2

Percent of complaintsresolved in 20 days

66.6% 65.9%N/A

70.9% 44.6% 44.6%

Number of unresolved complaints at the end of the month

N/A TBD

Quality 3: Patient Complaints Resolution Time

25

Champlain26

MetricApr

2015

FY 2015/16

Avg.

BaselineMar

2016Apr

2016

FY 2016/17

Avg.

% of palliative / end

of life patients who

died in their

preferred place of

death

78.1% 75.1% 74.5% 70.6% 70.1% 70.1%

Quality Palliative Patients: Preferred Place of Death

26


Definition Count the number of palliative / end of life patients who died in their preferred place of death. Patient must be discharged with a disposition of death in the period selected


Frequency Quarterly

Target 85%

< 70% 70-84.9% >= 85%

Champlain27

Target Total Trend 2015-05 2015-06 2015-07 2015-08 2015-09 2015-10 2015-11 2015-12 2016-01 2016-02 2016-03 2016-04

90% 29.7% 19.2% 17.2% 32.3% 36.7% 27.1% 29.6% 34.0% 28.6% 39.3% 34.4% 29.6% 29.7%

90% 0.0%

90% 33.0% 15.7% 38.4% 54.5% 47.3% 57.7% 61.1% 54.3% 52.8%

8-10 Clients 6.4 4.1 7.3 4.6 5.2 7.4 6.6 7.3 7.4 7.3 7.3 7.9 6.1

5-10 Clients 4.2 3.0 1.7 2.4 4.1 5.7 4.4 3.7 5.7 7.5 7.9 6.6 3.7

5-10 Clients 19.1 20.7 25.4 37.6 40.8 30.0 15.0 17.1 13.2 10.0 10.5 8.1 7.9 • Average Number of Primary Care/Specialist/Care team

Consultations Per Nurse Per Week

• Percent of patients died in preferred place of death

• Percent of patients will have a medication reconciliation

Productivity

• Average Number of Face-To-Face Visits Per Nurse Per Week

• Average Number of Telephone Visits Per Nurse Per Week

Metric

Performance

• Percent of patients are seen within 5 days of referral

Quality HPCN / RPCT Provincial Metrics

27

Champlain28

Quality RRN Provincial Metrics

28

Champlain29

Quality MHAN Provincial Metrics

29

Champlain30

Apr2015

FY 2015/16

Avg. TargetMar2016

Apr2016

FY 2016/17Avg.

Total % 76 76 80 78 79 79

Arterial Ulcer

0 45 62 67 100 100

Diabetic Foot

73 65 65 71 66 66

Wound-Pilonidal

78 81 82 85 74 74

Pressure Ulcer

85 84 84 90 71 71

Surgical 78 80 83 85 83 83

Traumatic 71 74 76 72 84 84

Venous Leg 0 61 62 53 55 55

Quality 4: % OBC Wound patients within Target

Visits

30


Total number of Outcome Based wound patients achieving a number of visits below or equal to wound pathways’ target visits over the total number of healable wound patients.

Moderate Monthly 80%

Less than 70% 70%-80% 80% or more

2015-05 2015-06 2015-07 2015-08 2015-09 2015-10 2015-11 2015-12 2016-01 2016-02 2016-03 2016-04

Arterial Leg Ulcer 0% 67% 75% 0% 67% 50% 43% 50% 67% 0% 67% 100%

Diabetic Foot Ulcer 60% 67% 71% 64% 55% 75% 53% 76% 50% 65% 71% 66%

Pilonidal Sinus 75% 93% 90% 60% 86% 65% 93% 93% 76% 80% 85% 74%

Pressure Ulcer 85% 92% 94% 87% 71% 88% 88% 85% 78% 70% 90% 71%

Surgical Wound 81% 78% 80% 81% 76% 86% 77% 79% 79% 79% 85% 83%

Traumatic Wound 67% 79% 86% 77% 73% 71% 70% 68% 74% 74% 72% 84%

Venous Leg Ulcer 0% 81% 65% 63% 63% 68% 70% 62% 73% 57% 53% 55%

Total 76% 80% 81% 75% 72% 78% 74% 76% 74% 73% 78% 79%

% OBC Wound Clients Within Target Visits

2015-05 2015-06 2015-07 2015-08 2015-09 2015-10 2015-11 2015-12 2016-01 2016-02 2016-03 2016-04

Arterial Leg Ulcer 0% 0% 0% 0% 0% 33% 0% 0% 0% #DIV/0! 0% 0%

Diabetic Foot Ulcer 0% 0% 5% 14% 12% 9% 18% 4% 15% 3% 8% 5%

Pilonidal Sinus 7% 14% 5% 0% 6% 8% 5% 4% 0% 16% 0% 0%

Pressure Ulcer 9% 20% 12% 27% 5% 5% 5% 18% 20% 0% 11% 8%

Surgical Wound 8% 11% 9% 6% 10% 5% 2% 6% 6% 3% 8% 7%

Traumatic Wound 5% 1% 4% 4% 4% 2% 4% 8% 5% 6% 3% 5%

Venous Leg Ulcer 0% 0% 5% 17% 14% 8% 21% 4% 7% 11% 0% 14%

Total 7.8% 7.8% 7.3% 7.4% 8.3% 5.0% 5.6% 6.9% 7.2% 4.7% 5.8% 6.4%

% of Discharged OBC Goal Met Clients Readmitted within 30 days

Champlain

People1: Staff Turnover Rates

31

Owner(s):Martin Hajek


High numbers in Q4 are the result of early retirement offers being given to Care Coordinators.

Only 2 MPE departures in Q4, being one in HR and 1 Executive.

Actions and Status

31



Rate at which employees leave an organization. Calculated as number of permanent employees who terminate or cease employment, divided by the average number of permanent employees on staff

High Quarterly Less than 10% Prorated annualized

10% or less 10%-11%12% or more

Employee Category

Q4 YTD2014/15Annualized



CM 13.4% 8.0% 12.9%

TA 1.3% 7.6% 9.5%

Other Union

8.7% 6.6% 13.0%

MPE 17.7% 16.7% 24.9%

Total 11.0% 8.6% 13.7%

Champlain

Employee Category

12 monthsending

Apr 2015

12 monthsending

Mar2016

12 monthsending

Apr2016

Annual cost based on 12

months ending

May 2015(thousands)

CM 11.6 12.7 13.2 $1,025k

TA 13.3 21.8 21.5 $385k

Other Union 9.4 10.0 10.0 $331k

MPE 4.1 3.1 3.2 $72k

Total 10.6 12.5 12.7 $1,813k

Owner(s):Martin Hajek


Increase in the number of employees absent for greater than 30 days. Climbing rate is primarily due to long term (>30 days) absences. Seeing related increase in Long Term Disability claims.

Actions and Status

Refresh of the Wellness program, including mental health initiatives, will occur at the beginning of new fiscal, with a focus on preventable health conditions.

Increase focus on first 30 days of absence, with a view to ensuring appropriate intervention and medical documentation to facilitate early return to work.

Revising Attendance Management program management to ensure that attendance is reviewed on a consistent, regular basis. Review of all employees’ attendance will occur with managers quarterly.


Definition Total number of sick hours, paid and unpaid for all permanent and temporary staff (excludes casuals), divided by number of permanent staff. .

Reliability High

Frequency Monthly and Annually

Target 9 days or less annually

9 days or less– Above 9, up to

11 daysAbove 11 days

People2: Absenteeism

32

Champlain

Engaged & Proactive PeoplePerformance Agreement Completion

33


Definition FYTD percent of staff whose performance appraisal is completed.


Frequency Quarterly

Target 80%

<75% 75 – 79.9% >= 80%

Owner(s):Dan Merritt


The completed % is currently at 77%. There is strong evidence of progress within the process - many employees now have moved from the 1st step to the 2nd (middle) step in the process. This is a sign that managers and employees are engaged in completing the process. Only 6% remain at Step 1.

Actions and Status

Weekly reminders to Managers and Directors continue.

Source FYTD(as at end of 14/15-

Q4)

Target FYTD(as at end of 15/16-

Q3)

FYTD(as at end of 15/16-

Q4)

Performance Agreement

YTDCompletion

%

188/21790.8%

95%109/14450.2%

188/21786.6%

YTD Completion

Target100% 75% 100%

Champlain34

Number of Health & Safety

Events

Apr 2015

FY 2015/16

Avg.

Target / Baseline

Mar 2016

Apr 2016

FY 2016/17

Avg.

Number of WSIB Claims 1 0.76 1 1 1 1



Number of staff WSIB claims submitted per month.

Moderate Monthly

1 WSIB Claim or less

1 or less More than 1

People3: Staff WSIB Reported Incidents

34

Champlain

Financial / Sustainability1: Tracking to Monthly Financial Targets

35


Definition Net surplus/deficit as calculated by Revenue minus Expenses

Reliability High

Frequency Monthly

Target Balanced Budget as annual aggregate target

Greater than

-2.5% variance

-1.5%To

-2.5%

-1.5% To

+1.5%

+1.5%To

+2.5%

Greater than

+2.5% variance

Owner(s):Sara Bisson / Jamie Stevens


Actions and Status

Financial Trends Apr-16

FY 2015/16

Variance vs.

Plan

FY 2015/16

Variance vs.

Plan %

FY 2015/16

Projected Deficit

Tracking to Budget Targets -$1,571k -$1,571k -7.89% TBD

FYTD Target

+$0k

Champlain 36

Sustainable Health SystemAvg. Cost/Patient

36



Average costs are calculated by summing all costs within the period (Services, supplies, equipment) divided by the sum of unique patients with costs. This is further divided into Lines of Business groupings. It excludes Case Management costsProvincial averages to be determined for comparison as they become available.

High MonthlyAt or below target Avg. Cost

0% 0-5% 5% or more

CCM Population

Apr2015

FY 2015/16

Avg.

Budget Target

Mar2016

Apr2016

FY 2015/16

Avg.

SS-Acute $460 $465 $501 $448 $479 $479

SS-Wound $597 $572 $494 $602 $558 $558

SS-Rehab $229 $239 $321 $273 $267 $267

Stable Oncology

$345 $335 $366 $320 $296 $296

Community Independence

$418 $440 $381 $491 $464 $464

Chronic $585 $613 $696 $660 $632 $632

Complex $1,089 $1,134 $1,124 $1,209 $1,144 $1,144

Enhanced $2,282 $2,380 $2,652 $2,314 $2,314 $2,314

Paeds$325 $453

$397(summer: $1400)

$280 $297$453

(Summer: $302)

Total

$651 $677

$639($734

summer due to Paeds)

$690 $662$678

(Summer: $666)

Champlain

STRATEGIC METRICS

Champlain


Definition % of complex patients (per population coding), who receive their RAI reassessments within guidelines.


Frequency Monthly


<= 79.9% 80-89.9% >= 90%

Supporting Complex PatientsReassessments within Guidelines

38

Owner(s):Kevin Babulic / Glenda Owens


Actions and Status

Population growth of the higher acuity segment of Champlain CCAC patients, as reflected in high and very high MAPLe scores, is significant and maintenance of this level of compliance is contingent on care coordinator staffing

MetricApr

2015

FY 2015/16

Avg.Target

Mar2016

Apr2016

FY 2015/16

Avg.

Reassessment of complex patients within Standards of Care guidelines

94% 88% 80% 86% 90% 90%

Champlain


Definition % of Complex Patients with a Care Coordinator Contact (Te./FtoF/RAI) within 3 months


Frequency Monthly

Target 85%

<75% 75-84.9% >=85%

Supporting Complex PatientsCare Coordinator Contacts

39



Actions and Status

MetricApr

2015

FY 2015/16

Avg.Target

Mar2016

Apr2016

FY 2016/17

Avg.

% of Complex Patients with a Care Coordinator Contact (Te./FtoF/RAI) within 3 months

87.7% 82.6% 85% 79.2% 80.5% 80.5%

Champlain

Supporting Complex Patients Number of Care Coordinator Transitions within 1 year

40


Definition The count of the number of Care Coordinator transitions that a patient experiences over the previous 12 months.

Reliability High

Frequency Monthly

Target 95%

<=89.9% 90-94.9% >=95%

Metric

Apr2015

FY 2015/16

Avg. TargetMar2016

Apr2016

FY 2016/17

Avg.

% of Complex

Patients with 1 CC in past 12 months

94.7% 91.5% 95% 89.6% 91.4% 91.4%

Average # of Caseload

Transitions1.0 1.1 TBD 1.2 1.1 1.1

Average # of Care

Coordinator Transitions

1.0 1.2 TBD 1.3 1.3 1.2

90th Percentile# of Care


1 1.8 TBD 2 2 1.7

Median # of Care


1 1 TBD 1 1 1



Actions and StatusGraph a distribution

chart of the current

month (where it is a

reflection of the prior 12

months’ experience)

Champlain

Supporting Complex Patients Number of SPO Staff within 3 months

41


Definition

Reliability High

Frequency Monthly

Target 95%

<=89.9% 90-94.9% >=95%

% of Patients

with Targeted Number of SPO Staff

Within Past 3 Months

Apr2015

FY 2015/16

Avg. TargetMar2016

Apr2016

FY 2016/17

Avg.

Owner(s):Brenda Toonders


Actions and Status

New metric: definition to

be determined. (e.g. PSS

only? All services?

Based on setting up a

reporting mechanism by

Providers to contracts…

likely audit based

Charts could be line chart

trend, plus second chart

could be YTD team

comparison

Champlain

Supporting Complex Patients Medication Reconciliation

42


Definition % of Complex Population patients with a BPMH completed within 30 days of either a RAI-HC completed with triggers for needing a Medication Reconciliation, or within 30 days of an initial face to face visit by a RRN or MHAN nurse.

Reliability High

Frequency Monthly

Target 90%

<=79.9% 80-89.9% >=90%

Metric

Mar2015

FY 2015/16

Avg. TargetFeb

2016Mar2016

FY 2016/17

Avg.

% of Complex Patients With a

Completed Medication

Reconciliation

88.0% 73.5% 90% 77.3% 81.1% 81.1%



Actions and Status

Champlain

Sustainable Health SystemALC %

43


Definition % of bed days used by ALC patients

Reliability Moderate – Reliant upon Hospital/LHIN reporting

Frequency Quarterly

Target 12.7%

<=12.7 >12.7 & <=13.3

> 13.3%

Owner(s):Sophie Parisien


Longer than average and more severe flu season impacting discharges to RHs and LTC. No significant changes to hospital practices re Home First/H2H practices.

Actions and Status

- Discuss with hospital partners and bring up to ED/ALC working group to look at various optimization opportunities (including Home First/H2H) to help decrease ALC % back to below target

- Continue to work with hospital teams to ‘case find’ and promote proactive discharge planning practices

Source Feb2015

2015/16 YTD

LHINTarget

Jan 2016

Feb 2016

2015/16 YTD

% of bed days used by ALC patients

12.9% 12.4% 12.7% 12.5% 12.9% 12.6%

Champlain

Metric Q3-2014/15

FY2014/15

Avg.

Target Q2-2015/16

Q3-2015/16

FY2015/16

Avg.

Percent of patients

58.0% 56.3%Top

Quartile61.3% 62.0% 61.0%

Rank 2 1Within

the top 41 1 1

Number of patients

6,690 6,917 4,500 7,547 7,748 7,527

At Home Percent of patients in Community

(MAPLe 4,5)

44


Definition Count of CCAC patients with an open referral with a MAPLe (Method of Assigning Priority Levels) score of High or Very High

Reliability Medium – Indicator is dependent on when RAI assessment was last conducted

Frequency Quarterly

Target 75th Percentile Ranking

59th Percentile or less 60-75th Percentile75th Percentile or

more



Actions and Status

Champlain

LHIN Benchmarking

Population

Cost Calculation

Provincial Average

ChamplainPercentile Ranking

Adult Short Stay Acute (Episode)

Local CCAC Rates

807 863 7

Adult Short Stay Rehab (Episode)

Local CCAC Rates

689 592 4

End of Life (Episode) Local CCAC Rates

5703 4727 2

Adult - Community Independence

(Monthly)

ProvincialRates

398 303 1

Adult – Chronic (Monthly)

ProvincialRates

712 603 2

Adult – Complex(Monthly)

ProvincialRates

1560 1421 5

Sustainable Health SystemRelative Ranking Avg. Cost/Patient

45


Definition Average costs are calculated by summing all costs within the period (Services, supplies, equipment) divided by the sum of unique patients with costs. This is further divided into Lines of Business groupings. It excludes Case Management costsProvincial averages to be determined for comparison as they

Reliability High

Frequency Monthly

Target 75th Percentile Ranking

59th Percentile or less

60-75th Percentile75th Percentile or

more

Owner(s):Penny Sands


Short Stay Populations are compared without adjusting rates to a provincial reference rate. Champlain’s nursing rates are 14% higher than provincial average, affecting the current ranking. Furthermore, Champlain’s specialty programs, such as NPWT, DIALPD, Pleurx, etc., affect the short stay population average costs.

Actions and Status

Champlain

Sustainable Health SystemNursing Clinic Percent

46


Definition Percent of Clinic Visits out of total Visit Nursing and Clinic Nursing Visits


Frequency Monthly

Target 25%

< 20% >=20% to <25% >= 25%

Owner(s):Sophie Parisien / Brenda Toonders


N/A

Actions and Status

Jan. Comment: Maintain momentum to continue achieving 30%/month

Metric Apr2015

FY 2015/16

Avg. TargetMar2016

Apr2016

FY 2016/17

Avg.

% Clinic Visits

25.5% 29.3% 25% 29.0% 28.5% 28.5%

Champlain

Sustainable Health SystemLTCH Length of Stay

47


Definition Average length of stay (in years) of patients in long stay LTC beds, based on patients who left LTCH in the past 12 months.

Reliability Moderate – Reliant upon Hospital/LHIN reporting

Frequency Quarterly

Target 2.5 Years

<=2.5 Years 2.6-3.0 Years > 3.0 Years

Note: Provincial data has been excluded from the above chart where there are

data points with missing data from 1 or more CCACs.

Source Sep 2014

Baseline Aug2015

Sep2015

LTCH LOS (Years)2.9 2.8 2.7 2.8

Champlain

Sustainable Health SystemCSS Referral Volumes

48


Definition Count of referrals to the CSS Agencies within the period.


Frequency Monthly

Target 400

< 350 350-400 >= 400

SourceApr

2015

FY 2015/16

Avg.

BaselineMar

2016Apr

2016

FY 2015/16

Avg.

Adult Day Program 166 199 182.8 179 205 205

Assisted Living 36 36 56.3 33 33 33

ABI - Personal Support/Independence

Training10 7 22 9 5 5

Respite/PSS for Seniors 157 109 20.5 80 118 118

Service Arrangement/Coordina

tion0 2 0 1 0 0

ABI Supportive Housing 2 3 11 2 0 0

Transportation -Patient 12 9 0 6 6 6

Personal Support CSSA Publicly Funded 0 63 0 17 0 0

Personal Support/Independence

Training0 0 0 0 0 0

Geriatric Mental Health 0 127 0 81 0 0

Total 383 435 273.8 408 367 367

Champlain


Definition % of patients whose 1st visit occurred within 48 hours of the patient availability date to the 1st visit date

Reliability Moderate – Manual tracking of hospital discharge date

Frequency Monthly


< 70% 70-90% >= 90%

Person Driven CareHospital Transition: % RRN Patient Contact within 24

hrs

49

Metric Apr 2015

FY 2015/1

6Avg.

Target Mar2016

Apr2016

FY 2016/17

Avg.

% RRN (Face to Face) visits completed in 48 hrs. of patient availability date

81% 78% 90% 84% 90% 90.0%

Champlain

Engaged & Proactive PeopleHealthline Visits

50


Definition The count of site visits during the period, to Healthline.


Frequency Monthly


Source Apr2015

FYTD2015/16

Avg

Baseline Mar2016

Apr2016

FYTD2016/17 Avg

# of Healthline

visits49,030 46,917 28,792 49,028 48,642 48,642

% Variance from

Baseline70.3% 62.3% N/A 70.3% 68.9% 68.9%

Champlain

Engaged & Proactive PeoplePublic Website Visits

51


Definition The count of site visits to the Champlain CCAC public website.


Frequency Monthly


Source Apr2015

FYTD2015/16

Avg

Baseline Mar2016

Apr2016

FYTD2016/17

Avg

# of Public Website Visits

6,473 6,478 6,000 6,792 6,317 6,317

Champlain

COORDINATED ACCESS METRICS

Champlain

Acute Hospitals 1: Home First Volumes

53


Definition Count of new hospital patients admitted to the Home First Program per month


Frequency Monthly

Target 90 Home First Enhanced patients per month

<80 80-89 90-105 106-110 >110

CategoryApr

2015

FY 2015/

16Avg. Target

Mar2016

Apr2016

FY 2016/17

Avg.

Enhanced 78 78 90 93 85 85

2015-05 2015-06 2015-07 2015-08 2015-09 2015-10 2015-11 2015-12 2016-01 2016-02 2016-03 2016-04

CCAC Enhanced Services 84 69 63 62 88 86 82 67 83 83 93 85

Adult - Complex-Adult 8 2 1 3 4 6 10 5 5 1 8 5

Adult - Complex-Palliative 12 11 15 14 22 15 19 11 18 16 20 17

Adult - Complex-Senior 64 56 47 45 62 65 53 50 60 65 64 63

Home First and Enhanced Service Client Count

Champlain

Long Term Care Homes1: % of LTCH placements with a MAPLe

score of 4 or 5, by Source

54


Definition Percent of patients with a MAPLe (Method of Assigning Priority Levels) score of High or Very High, out of the total number of patients placed into LTC homes within the previous quarter (Note: MAPLe scores are determined from a RAI assessment on a patient) Note 1: Crisis placement designation from Hospital may impact this indicator; Note 2: Home First should help improve indicator results over time

Reliability High

Frequency Monthly

Target 78%

Less than 75% 75% -78% 78% or more

Prior Location Apr2015

FY 2015/16

Avg.

Baseline Mar2016

Apr2016

FY 2016/17

Avg.

Hospital 80.7% 80.3% 78% 71.4% 76.8% 76.8%

Private Dwelling

82.5% 84.8% 78% 86.2% 89.9% 89.9%

RetirementHome

89.2% 85.3% 78% 68.6% 87.8% 87.8%

Total 84.1% 83.7% 78% 74.7% 85.6% 85.6%

Champlain

Long Term Care Homes2: Admission from Community/Hospital

55


Definition % Admission to LTCH by Community/Hospital: The count of patients placed into LTCH for their initial placement by location prior to placement, divided by the overall initial placements in the period.

Number of Admissions to LTCH by Community/Hospital: The count of patients placed into LTCH for their initial placement by location prior to placement..

Reliability High

Frequency Monthly

Target Hospital Percentage is 40% or less

40% or less 40.1% to 50% 50.1% or more

Apr 2015

FY 2015/1

6Avg.

Target Mar 2016

Apr 2016

FY 2016/

17Avg.

Hospital 36.5% 30.6% 40% 29.3% 27.5% 27.5%

Community 63.5% 69.4% 60% 70.7% 72.5% 72.5%

Champlain

At Home2: Number of patients in Community

85 & Over

56


Definition Count of CCAC patients who are actively case managed by the CCAC during the period.

Reliability High

Frequency Monthly

Target 6276 patients

Less than 6276 6276 or more

Apr 2015

FY2015/16

Avg.

Target Mar2016

Apr2016

FY2016/17

Avg.

6,903 7,207 6,276 7,422 7,513 7,513

Champlain

Primary Care1: Referrals to CCAC by Physicians

57


Definitions Referrals: Count of new referrals to the CCAC within the period, broken where the referral source is identified as physicians.

Reliability High

Frequency Monthly

Target 550 patients Referred per Month

499 or less 500 - 549 550 or more

Referral Source for New Referrals

Apr2015

FY 2015/16

Avg.

Target Mar2016

Apr2016

FY 2016/17

Avg.

Community-Physicians

541 564 550 711 609 609

Champlain

Sustainable Health SystemALS-HRS Unfilled Demand

58


Definition Count of unique patients waiting to be placed into Assisted Living Services, by referral source category.


Frequency Monthly


Source Apr2015

FY 2015/16

Avg. BaselineMar2016

Apr2016

FY 2016/17Avg.

Hospital 9 6 9.2 5 5 5

Community 121 112 59.7 94 85 85

Total 130 117 68.9 99 90 90

Champlain

Adult Day Program 1: Waitlists

59


Definition Count of CCAC patients who are waiting for Adult Day Programs (ADP), by region and provider, as at the end of the period.

Reliability Moderate – New process with ADP partners

Frequency Monthly


Region Apr2015

Baseline Mar2016

Apr2016

Ottawa 328 127.0 359 362

Eastern 32 4.5 32 26

Renfrew 3 8.8 4 0

NLNG 18 NA 26 22

Total 381 140.1 421 410

Champlain

PROVINCIAL MIS EXPENDITURE COMPARATORS

Champlain

Provincial Comparators1: Cost per Patient Groupings

Patient Grouping

Data updated to compare: 2015/16-Q3

ChamplainCentral

EastCentral HNHB

SouthWest

Province

Adult Short Stay Acute/Oncology/Wound(Episode)

$863 $728 $771 $867 $932 $807

Adult Short Stay Rehab (Episode) $592 $702 $632 $646 $561 $689

End of Life (Episode) $4,727 $5,517 $5,414 $4,609 $5,546 $5,703

Long stay adult Complex (CCM Population)-Monthly $1,421 $1,410 $1,650 $1,593 $1,863 $1,560

Long stay adult Chronic (CCM Population) -Monthly $603 $558 $632 $933 $783 $712

Long stay adult Community Independence (CCM Population) -Monthly

$303 $322 $344 $508 $447 $398

Medically Fragile Children-Monthly $3,295 $3,159 $3,091 $2,475 $4,065 $2,912

Source: OACCAC

Excludes case management, equipment and supplies


Definition Average costs are calculated by summing all costs within the period (Services) divided by the sum of unique patients with costs. This is further divided into Lines of Business groupings. It excludes Case Management costs

Reliability High

Frequency Quarterly

Target Target set against provincial average cost. Green: At or below target Avg. CostYellow: Between Target and 5% above TargetRed: Above 5% of target

Champlain

Provincial Comparators1: Cost per Service Unit

Data updated to compare: 2014/15-FY

Champlain Central East

Central HNHB SouthWest

Province

Personal Support 32.82(+1.9%)

31.60 31.91 30.82 36.19 32.19

Nursing – Visit 64.61(+13.8%)

56.78 56.02 50.14 53.44 56.78

Nursing – Shift 43.67(-7.0%)

51.00 49.78 48.18 38.52 46.98

Occupational Therapy 96.91(-15.7%)

122.0 112.86 112.47 129.48 114.92

Physiotherapy 101.95(+19.4%)

90.07 61.62 82.28 105.54 85.41

Speech 76.64(-34.2%)

128.86 129.32 101.69 144.87 116.53

Social Work 85.19(-36.0%)

128.40 162.94 138.68 139.71 133.18

Nutrition 119.87(+0.4%)

112.46 105.21 122.24 129.43 119.45

Source: OACCAC

Champlain

Provincial Comparators2: Proportion of Expenditures: (Admin,

CM, Patient Care)

Expenditures Category

Data updated to compare: 2014/15-Q4

Champlain Central East

Central Toronto Central

HNHB SouthWest

Avg of Peer

CCACs

Province(Avg.)

Total Expenditures 230,203k 272,247k 286,320k 246,802k 309,527k 208,557k

Patient Care 73.5% 70.3% 75.0% 73.7% 75.2% 69.6% 72.9% 70.5%

Case Management / I&R 19.3% 21.5% 17.7% 19.5% 18.6% 22.9% 19.9% 19.8%

Administration7.1%

(with SSO)7.6% 6.9% 6.5% 6.2% 6.7% 6.8% 7.2%

Other 0.1% 0.6% 0.4% 0.3% 0.0% 0.8% 0.4% 0.3%

Administration + Other 7.2% 8.2% 7.3% 6.8% 6.2% 7.5% 7.2% 7.5%

Total FTEs 613.4 794.2 651.8 604.6 740.2 599.9 667.4 483.0

Case Management / I&R 465.3 645.7 523.8 515.2 611.3 469.9 518.3 378.3

Direct Care Staff 65.4 23.2 20.9 14.0 34.5 29.3 31.2 29.7

Administration76.8

(including 6 SSO FTEs)

114.1 98.9 69.6 91.2 85.4 89.3 68.5

Other (e.g. In-service Education; Marketed

Services)5.9 11.2 8.2 5.8 3.2 15.3 8.3 6.3

Source: OACCAC Finance Reports

Champlain

Term Definition

ADP Adult Day Program Services: Adult Day Programs are funded by the LHIN, provided by community support services; provide supervised group programs to frail elderly and/or individuals with progressive cognitive disorders such as dementias

ALC Alternate Level of Care (ALC): A patient whose care is being provided in an acute care setting where the patient is no longer in an acute phase, and can be cared for in another area of the health care sector

ALS-HRS Assisted Living Services for High Risk Seniors: Program to provide patients with an enhanced level of personal support services through near on-call availability.

Ax Assessment, typically a RAI-HC or RAI-CA assessment, sometimes a local CCAC Assessment tool

CAP Patient Assessment Protocol: Identifies the MDS-HC items that alert the assessor to the patient’s potential problems or needs. Once flagged by a triggered condition, a more in-depth review of the relevant causes of the patient’s identified problems and needs is necessary

C.E.L.S. Champlain Events Learning System:

CCM Patient Care Model: Grouping patients into categories according to the needs of the patient

CM Case Manager

CSS Community Support Services: Community support services are intended for seniors or people with disabilities who prefer to stay at home. Services can be offered at the patient’s home or in the community.Funded via LHIN, local Cities and other sources for basic operation and salary costsOffer mostly fee based services

FTE Full Time Equivalent

LOS Length of Stay

LTCH Long Term Care Homes

MAPLe Method of Assigning Priority Levels (MAPLe) for community and/or facility services, as calculated by the RAI-HC assessment instrument

MPE Management and Professional Exempt

PSS / HOM Personal Support Services

RAI-CA Resident Assessment Instrument – Contact Assessment

RAI-HC Resident Assessment Instrument – Home Care

RAI Score A score derived from outputs from the InterRAI RAI-HC

SAH Stay at Home (SAH) program where patients require more than the legislated maximum of 60 hours of Personal Support Services (PSS) per month

TA Team Assistant

Therapies Aggregation of the therapy services provided by the CCAC, including: Occupational Therapy (OT), Physiotherapy (PT), Speech & Language Pathology (SLP), Nutrition (NUT), Social Work (SW)

64

Glossary of Terms

Champlain

Term Definition

AGH Almonte General Hospital

ADMH Arnprior District Memorial Hospital

Bruyere, BCC Bruyere Continuing Care Hospital

CCH Cornwall Community Hospital

CPDMH Carleton Place District Memorial Hospital

GMH Glengarry Memorial Hospital

HDMH Hawkesbury District Memorial Hospital

HM Hopital Montfort – Monfort Hospital

HNHB Hamilton Niagara Haldimand Brant Community Care Access Centre

KDH Kemptville District Hospital

PRH Pembroke Regional Hospital

QCH Queensway Carleton Hospital

ROMHC Royal Ottawa Memorial Health Centre

RVH Renfrew Victoria Hospital

SFMH St. Francis Memorial Hospital

SJCCC St. Joseph’s Continuing Care Centre

TOH-Civic The Ottawa Hospital – Civic Campus

TOH-General The Ottawa Hospital – General Campus

WDMH Winchester District Memorial Hospital

65

Glossary of TermsCont’d

board client services, quality & safety committee...

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