health pei annual schedule › photos › original › hpei_dec4_abs.pdfdraft 3. november 22, 2012...

Health PEI

Annual Schedule

Health PEI Board of Directors

November 2012- October 2013 DRAFT 3. 2012-11-22

2. Health PEI Board of Directors. Annual Meeting Schedule and Business Agenda. 2012-13 DRAFT 3. November 22, 2012

Table of Contents

1. Annual Board Meeting Calendar: 2012-13 3

2. Annual Agenda 4

3. Annual Committee Schedules

a. Compliance and Monitoring Committee 7

b. Quality and Safety Committee 8

c. Public Engagement Committee 9

4. Executive Updates to the Board 10

5. Quality and Safety Roadmap 11


1. Annual Board Meeting Calendar: 2012-13

Date Time Location Purpose Comments

2012-11-06 1200-1800 16 Garfield, M2/3 Regular Meeting

2012-12-04 1000-1600 QEH, Boardroom Regular Meeting HRA will be in attendance at 10:15 a.m.

2013-01-08 1000-1600 QEH, Boardroom Regular Meeting Minister Currie will attend 1:30pm – 2:45pm

2013-01-15 0900-1600 Classroom 234 Holland

College Royalty Centre

Planning and Development

2013-01-19 1400-1600 TBD Special Meeting Approval of 2013-14 Budget Submission

2013-02-05 1000-1600 PCH Boardroom Regular Meeting Public presentations: East Prince area

2013-02-19 0900-1600 Sage Room – Burns

Ave.

Planning & Development Date TBC. Focus on Strategic Plan


2013-04-02 1200-1800 Souris Hospital Board

Room

Board Meeting Public presentations: Eastern Kings area

2013-04-16 0900-1600 Ceridian Planning & Development


2013-06-04 1200-1800 Western Hospital Regular Meeting Public presentations: West Prince area

2013-06-18 0900-1600 Ceridian Planning & Development



2013-09-10 1200-1800 Kings County Memorial

Hospital

Regular Meeting Public Presentations Southern Kings

2013-09: 15-20 QMentum Survey Surveyors on-site. Meeting dates TBD



2013-11-?? 1830-2100 TBD AGM

2013-12-03 1000-1600 16 Garfield, M2/3 Regular Meeting Public Presentations Central Queens


2. Annual Agenda: Monthly Meetings of the Full Board November Month Com Policy Area Item Status (IC or Public) Requirement

Public

Nov CEO OE 2.0 Home Based & Long Term Care Update Public Monitoring

Nov BD GP 3.12 Annual General Meeting Public Reporting

In-camera

Nov CM OE2.5 Monthly Financial Review IC. GP3.11. 8h,i Monitoring

CM SD 1.0 Strategic / Scenario Planning Update Monitoring

Nov CM SD 1.0 HPEI Annual Report, incl. fy 2010-11 KPI review IC. GP3.11. 8h,i; 9.e. Decision

Nov CM OE2.4, 2.5 Q2 Financial Report and Review IC. GP3.11. 8h,i Monitoring

Nov CM OE 2.5 Capital Requests IC. GP3.11. 8h,i Decision

Nov BD GP3.9 CEO Remuneration IC.GP3.11.8b,c,d, Decision

Nov BD GP3.9 Annual Board Agenda IC IC. GP3.11. 8h,i Decision

Nov CEO GP3.13 Medical Staff Credentialing IC. GP.11 8b,c,d,f,h,i. 9c,f Decision

December Month Com Policy Area Item Status (IC or Public) Requirement

Public

Dec OE 2.0, GP3.13 Medical Affairs Update (Semi-Annual) Public Monitoring

Dec QS OE 2.1 Quality and Risk Report Q1-2 Public Monitoring

Dec PEC GP 3.12 Public Engagement Update / AGM Debrief Public Monitoring

In-Camera

Dec CM OE2.5 Monthly Financial Review IC. GP3.11. 8h,i Monitoring


Dec QS OE 2.1 Quarterly Risk Report Q2 IC. GP3.11.8 a,b,f,h,i. 9a,b,c,d,f Monitoring

Dec BD GP 3.13 President’s Council IC.GP3.118a,b,c,h,i. 9a,b,c,d,f Gov. Process

Dec CEO GP3.13 Medical Staff Credentialing IC. GP.11 8b,c,d,f,h,i. 9c,f Decision

January Month Com Policy Area Item Status (IC or Public) Requirement

Public

Jan CEO OE 2.0 Community Hospitals and Primary Health Care Update Public Monitoring

Jan PEC GP 3.12 Public Engagement Update / AGM Debrief Public Monitoring

In Camera

Jan CM OE2.5 Monthly Financial Review IC. GP3.11. 8h,i Monitoring


Jan CM OE2.3,2.4,2.5,2.6 Annual Audit Schedule IC. GP3.11. Decision

Jan Q&S OE 2.1 Walking Tour and Tracer Report IC. GP3.11.8 a,b,f,h,i. 9a,b,c,d,f Monitoring

Jan CEO GP3.13 Medical Staff Credentialing IC. GP.11 8b,c,d,f,h,i. 9c,f Decision

February Month Com Policy Area Item Status (IC or Public) Requirement

Public

Feb Public Presentations

Feb PEC GP 3.12 Public Engagement Update / AGM Debrief Public Monitoring

In camera

Feb CM OE2.5 Monthly Financial Review IC. GP3.11. 8h,i Monitoring

Feb CM SD 1.0 Business Plan Priorities – next FY IC. GP3.11. 8h,i Decision

Feb CM OE 2.4, 2.5 Q3 Budget Report and Review IC. GP3.11. 8h,i Monitoring

Feb CM OE 2.4, 2.5 Base Budget Submission IC. GP3.11. 8h,i Decision

Feb CM SD 1.0 Strategic / Scenario Planning Update Monitoring

Feb CEO GP3.13 Medical Staff Credentialing IC. GP.11 8b,c,d,f,h,i. 9c,f Decision


March Month Com Policy Area Item Status (IC or Public) Requirement

Public

Mar CEO OE 2.0 Health Information Update Public Monitoring

Mar PEC GP 3.12 Public Engagement Update Public Monitoring

In Camera

Mar CM OE2.5 Monthly Financial Review IC. GP3.11. 8h,i Monitoring

Mar CM SD 1.0 Strategic / Scenario Planning Update Monitoring

Mar QS OE 2.1 Quarterly Risk Report Q3 IC. GP3.11.8 a,b,f,h,i. 9a,b,c,d,f Monitoring

Mar CEO GP3.13 Medical Staff Credentialing IC. GP.11 8b,c,d,f,h,i. 9c,f Decision

April Month Com Policy Area Item Status (IC or Public) Requirement

Public

Apr Public Presentations

Apr PEC GP 3.12 Public Engagement Update Public Monitoring

In Camera

Apr CM OE2.5 Monthly Financial Review IC. GP3.11. 8h,i Monitoring

Apr CM OE 2.4, 2.5 Government preliminary response to budget request IC. GP3.11. 8h,i Information

Apr CM SD 1.0 Strategic / Scenario Planning Update Monitoring

Apr Q&S OE 2.1 Walking Tour and Tracer Report IC. GP3.11.8 a,b,f,h,i. 9a,b,c,d,f Monitoring

Apr CEO GP3.13 Medical Staff Credentialing IC. GP.11 8b,c,d,f,h,i. 9c,f Decision

May Month Com Policy Area Item Status (IC or Public) Requirement

Public

May CEO OE 2.0 Provincial Services Profile Update Public Monitoring

May PEC GP 3.12 Public Engagement Update Public Monitoring

In Camera

May CM OE2.5 Monthly Financial Review IC. GP3.11. 8h,i Monitoring

May CM Annual Business Plan IC. GP3.11. 8h,i Decision

May CM All Board Policies Annual Policy Review – Monitoring Report To be determined Monitoring

May CM SD 1.0 Strategic / Scenario Planning Update Monitoring

May CEO GP3.13 Medical Staff Credentialing IC. GP.11 8b,c,d,f,h,i. 9c,f Decision

June Month Com Policy Area Item Status (IC or Public) Requirement

Public

June Public Presentations

June CM OE 2.4, 2.5 Approved Annual Budget Public Information

June QS OE 2.1 Annual Quality & Safety report previous FY. Public Monitoring

June PEC GP 3.12 Public Engagement Update Public Monitoring

In camera

June CM OE2.5 Monthly Financial Review IC. GP3.11. 8h,i Monitoring

June CM SD 1.0 Strategic / Scenario Planning Update Monitoring

June CM SD 1.0 Strategic Initiatives progress Update To be determined Monitoring

June QS OE 2.1 Quarterly Risk Report Q4 of previous FY IC. GP3.11.8 a,b,f,h,i. 9a,b,c,d,f Monitoring

June BD GP 3.13 President’s Council IC.GP3.118a,b,c,h,i. 9a,b,c,d,f Gov. Process

June CEO GP3.13 Medical Staff Credentialing IC. GP.11 8b,c,d,f,h,i. 9c,f Decision


July Month Com Policy Area Item Status (IC or Public) Requirement

Public

July CEO OE 2.0 Medical Programs Public Monitoring

July PEC GP 3.12 Public Engagement Update Public Monitoring

In Camera

July CM OE2.5 Monthly Financial Review IC. GP3.11. 8h,i Monitoring

July CM OE2.4, 2.5 Q1 Budget Report and Review IC. GP3.11. 8h,i Monitoring


July Q&S OE 2.1 Walking Tour and Tracer Report IC. GP3.11.8 a,b,f,h,i. 9a,b,c,d,f Monitoring

July CEO GP3.13 Medical Staff Credentialing IC. GP.11 8b,c,d,f,h,i. 9c,f Decision

August Month Com Policy Area Item Status (IC or Public) Requirement

Public

Aug PEC GP 3.12 Public Engagement Update Public Monitoring

In Camera

Aug CM OE2.5 Monthly Financial Review IC. GP3.11. 8h,i Monitoring

Aug CM OE 2.4, 2.6 Audited Financial Statements IC. GP3.11. 8h,i Monitoring


Aug CEO GP3.13 Medical Staff Credentialing IC. GP.11 8b,c,d,f,h,i. 9c,f Decision

September Month Com Policy Area Item Status (IC or Public) Requirement

Public

Sep Public Presentations

Sep PEC GP 3.12 Public Engagement Update Public Monitoring

In Camera

Sep CM OE2.5 Monthly Financial Review IC. GP3.11. 8h,i Monitoring

Sep CM OE 2.4, 2.6 Auditor – Management Letter IC. GP3.11. 8h,i Monitoring


Sep QS OE 2.1 Quarterly Risk Report Q1 IC. GP3.11.8 a,b,f,h,i. 9a,b,c,d,f Monitoring

Sep CEO GP3.13 Medical Staff Credentialing IC. GP.11 8b,c,d,f,h,i. 9c,f Decision

October Month Com Policy Area Item Status (IC or Public) Requirement

Public

Oct CEO OE 2.0 Acute Care (PCH & QEH)Update Public Monitoring

Oct PEC GP 3.12 Public Engagement Update Public Monitoring

In Camera

Oct CM OE2.5 Monthly Financial Review IC. GP3.11. 8h,i Monitoring

Oct CM SD 1.0 Strategic / Scenario Planning Update Monitoring

Oct CM OE 2.2 HR Indicator Report To be determined Monitoring

Oct BD GP 3.9 Annual Committee Review reports IC.8h,i Monitoring

Oct BD GP3.9 Annual Committee Schedules – next FY To be determined Decision

Oct PE GP3.12 Annual Public Engagement Workplan – next FY Public Decision

Oct CEO GP3.13 Medical Staff Credentialing IC. GP.11 8b,c,d,f,h,i. 9c,f Decision


3. Compliance and Monitoring Committee Annual Schedule

Month Policy Area Item Requirement

Nov

OE2.5 Monthly Financial Review Monitoring

OE2.4, 2.5 Base Budget Development Information

SD 1.0 Strategic / Scenario Planning Update Monitoring

Dec



OE 2.3, 2.4, 2.5, 2.6 Annual Audit Schedule Decision

Jan OE 2.4, 2.5 Q3 Forecast Monitoring

SD 1.0 Business Plan Priorities Review / Discussion

SD 2.4, 2.5 Base Budget Submission Decision


Feb OE2.5 Monthly Financial Review Monitoring


Mar


OE 2.4, 2.5 Government preliminary response to budget request Information

OE 2.3, 2.4, 2.5, 2.6 Audit Schedule Update Monitoring


April


All Board Policies Annual Policy Review Schedule Decision


May


OE 2.4, 2.5 Approved Annual Budget Information

Annual Business Plan - Submission Decision

SD 1.0 Strategic Initiatives Progress Update Monitoring


June


OE2.4, 2.5 Q1 Forecast Monitoring

OE2.4, 2.5 Review of year-end financial results (previous FY) Monitoring


GP 3.7, 3.8 Annual Committee Self-Assessment

July OE2.5 Monthly Financial Review Monitoring


Aug


OE 2.4, 2.6 Auditor – Management Letter Monitoring


Sep


OE 2.2 HR Indicator Report Monitoring

GP 3.9 Review of annual committee activities Policy Compliance

GP 3.9 Annual Committee Schedule, year beginning November Policy Compliance


Oct OE2.5 Monthly Financial Review Monitoring

OE2.4, 2.5 Q2 Forecast Monitoring

SD 1.0/ GP 3.12 HPEI Annual Report – D1, incl. fy 2010-11 KPI Decision

OE 2.5 Capital Requests Submission Decision


Meetings: 3rd

Wednesday of each month. 1:00-3:00 pm


4. Quality and Safety Committee Annual Schedule

Month Policy Area

Item Requirement

Aug . 9, 2012 Meeting rescheduled to September 5, 2012

Sep. 5, 2012 OE 2.1 Q1 Risk Report Monitoring

OE 2.1 Quality &Safety Award Monitoring

OE 2.1 QMentum Timeline & Progress Update Monitoring

Sep 13, 2012 OE 2.1 Quality and Safety Walking Tour / Tracer. Public Health and Primary Care. Charlottetown.

Monitoring

Nov. 8, 2012 OE 2.1 Quality & Safety report previous Q1-2 Monitoring

OE 2.1 Quarterly Risk Report Q2 Monitoring

OE 2.1 Quality &Safety Award Monitoring


Dec. 13, 2012 OE 2.1 Quality and Safety Walking Tour / Tracer. Addictions and Mental Health. Charlottetown.

Monitoring

Feb. 14, 2013 OE 2.1 Q3 Risk Report Monitoring


Mar. 14, 2013 OE2.1 Quality and Safety Walking Tour / Tracer. Western Hospital. Alberton. Monitoring

May. 09, 2013 OE 2.1 Annual Quality & Safety report previous FY. Monitoring

OE 2.1 Quarterly Risk Report Q4 of previous FY Monitoring


Jun. 13, 2013 OE 2.1 Quality and Safety Walking Tour / Tracer. Lab / DI / Pharmacy (TBD) Monitoring

Aug 08, 2013 OE 2.1 Q1 Risk Report Monitoring


GP 3.9 Review of annual committee activities Policy Compliance

GP 3.9 Annual Committee Schedule, year beginning November Policy Compliance

Sep 12, 2013 OE 2.1 Quality and Safety Walking Tour / Tracer (TBD) Monitoring

Meetings: 2nd

Thursday of months when scheduled to meet.


5. Public Engagement Committee – Annual Schedule

Date Policy Area

Item Requirement

2012-10-23 Board to Board Conversations– Seniors Health / Seniors Secretariat Linkage

2012-11-07 GP 3.12 Engagement Plan: 2012-13

Board to Board Conversations

Annual Board Meeting Schedule - Community linkage

2012-11-14 GP 3.12 Annual General Meeting Reporting

2012-12-12 GP 3.12 Annual General Meeting – Evaluation Monitoring

GP 3.12 Board Conversations – Children’s Health / Education Linkage

2013-01-09 GP 3.12 Committee Meeting

2013-01-?? GP 3.12 Board to Board Conversations - Chronic Disease Prevention & Management Linkage


2013-02-?? GP 3.12 Board to Board Conversations - Special Populations Linkage


2013-03-?? GP 3.12 Board to Board Conversations – Health Care Providers Linkage


2013-04-?? GP 3.12 Board to Board Conversations – Children’s Health Linkage


2013-05-08 GP 3.12 Board to Board Conversations – Review of Findings & Recommendations

2013-06-12 GP 3.12 Annual meeting theme and dates confirmed Planning

2013-06-12 GP 3.12 Annual Meeting Key Note Speaker Candidate List Planning

2013-07-10 GP 3.12 AGM key note speaker confirmed Planning

2013-09-11 GP 3.12 Committee Evaluation / Annual Report Monitoring

2013-10-09 GP 3.12 Engagement Plan – Next Fiscal Year Planning

2012-10-?? GP 3.12 Board to Board Conversations - Seniors Health

Meetings: 2nd

Wednesday of the Month. 1:00-4:00 pm


6. Divisional Updates – Annual Schedule

Month Policy Area Item Status (IC or Public)

Requirement

2012-11 OE 2.0 Home Based & Long Term Care Update

Includes: Includes division profile, Manor Replacement, and Home Care Renewal

Public Monitoring

2012-12 OE 2.0, GP3.13 Medical Affairs Update (Semi-Annual)

Includes division profile, PMAC, President’s Council, and Medical Staff By-laws

Public Monitoring

2013-01 OE 2.0 Community Hospitals and Primary Health Care Update

Includes: Includes division profile, Integrated chronic disease prevention & management, PHC networks, Stroke Care Model, Mental health Services Strategy

Public Monitoring

2013-02 Public Presentations – East Prince

2013-03 OE 2.0 Health Information Update

Includes Divisional Profile, IM & technology Steering Committee, and iEHR (CPOE, EMR, etc)

Public Monitoring

2013- 04 Public Presentations – Eastern Kings

2013-May OE 2.0 Provincial Services Profile Update

Includes Divisional Profile and UM & PF

Public Monitoring

2013-May OE 2.0 Financial Services Update (To start 2012) Public Monitoring

2013-06 Public Presentations – West Prince

2013-07 OE 2.0, GP3.13 Medical Affairs Update (Semi-Annual)

Includes division profile, PMAC, President’s Council, and Medical Staff By-laws

Public Monitoring

2013-09 Public Presentations – Southern Kings 2013-10 OE 2.0 Acute Care (PCH & QEH) Update

Includes: PCH & QEH profiles, QEH Ambulatory Care, Integrated Emergency Services, Integrated Surgical Services

Public Monitoring

2013-11 OE 2.0 Corporate Development & Innovation Update

Includes: Divisional profile, CMOC, ACOD, & PNAC (Wait Times presented in March)

Public Monitoring

2013-12 Public Presentations – Central Queens

Presentation Guidelines - Divisional Updates

15 slides max for presentation (10-15 min presentation. 10-15 min discussion. 30 minute agenda time frame). Additional

supporting documentation welcomed.

Division Profile: Organization Chart; Client / Customer, Service, staff profiles (3 slides)

Priorities, Challenges and Results: Current Goals and priorities within the division, Key Indicators / metrics (2-3 slides)

Strategic Initiatives and / or Leadership Committees: Principal Projects, accomplishments / challenges, performance indicators.

(1-2 slides per strategic initiative)

7. Quality and Safety Roadmap

Board Governance Team

Quality and Safety Roadmap (August – October 2012)

Date: October 16, 2012

Item S1 S2 Ref. Mitigation Lead Time

Self

-Ass

ess

me

nt

1. Does the governing body evaluate the performance of its chair?

13.6 To Date: Committee self-assessments. Policy review. GFK & SA completed. Board member competence check list.

Define a process for chair and member evaluations (including survey tools) and schedule (Annual), with reference to Policy GP 3.4. Explore potential for “360” reviews.

Review and confirm member and chair effectiveness and performance criteria in policies.

Integrate into annual Board Schedule. Schedule for 2X / yr as standing Board agenda item.

Conduct process assessment process

Develop & confirm process for chair to provide performance feedback to members.

NTG

12-12

12-12

12-12

13-01

13-02

13-03

2. Does the governing body evaluate the performance of its members?

13.7

3. We formally evaluate our own performance on a regular basis.

GFT 18

4. Contributions of individual members are reviewed regularly.

GFT 20

5. As a team, we regularly review how we function together and how our governance processes could be improved.

GFT 21

6. There is a process for improving individual effectiveness when nonperformance is an issue.

GFK 22

7. As individual members, we receive adequate feedback about our contribution to the governing body.

GFK 25

8. We review our own structure, including size and sub-committee structure.

GFT 34 Board policy in place. Annual Committee Review

completed. Confirm review of structure as part of

annual board monitoring schedule.

CM 12-11

9. Does the governing body regularly evaluate its own performance and effectiveness?

13.4, 13.5 Annual Policy review cycle developed. Develop and

confirm process / schedule for annual evaluation of

performance and effectiveness

CM 12-12






Mo

nit

ori

ng

10. Is the governing body involved in monitoring the CEO’s performance?

7.4, 7.5, 7.7 Board policies addressing operational expectations (of the CEO)

and Board – Management Delegation (BMD) are in place.

Annual Board schedule in place to monitoring Operational

Expectations policies (CEO performance).

BMD policies and policy compliance should be reviewed.

With appointment of new CEO, OE policies should be reviewed,

monitoring gaps identified, monitoring reports adjusted.

Special Board meeting to discuss the criteria and expectations for

the new CEO / criteria for annual performance criteria. (Focus

Policy – BMD 4.4)

Chair

CM

13-06

12-12

11. We regularly review, understand, and ensure compliance with applicable laws, legislation and regulations

GFT 1 Annual OE policy monitoring schedule

With appointment of new CEO, OE policies should be reviewed,

monitoring gaps identified, monitoring reports adjusted (See item

10)

Chair

CM

13-06

Succ

ess

ion

– B

oar

d

12. Have the types of characteristics, skills, and competencies needed by members of the governing body been identified?

2.1 Current: NTG established. Board competency matrix defined

and member self-assessment completed.

Develop & confirm member reappointment, recruitment &

selection process

Develop & confirm chair selection process

NTG

12-11

12-11 13. How are new members recruited? 2.4

14. We actively recruit, recommend and/or select new members based on needs for particular skills, background, & experience.

GFT 31

15. We have explicit criteria to recruit and select new members. GFT 32

16. We have a process to elect or appoint our chair. GFK 37

17. How are members prepared for their work with the governing body?

2.5, 2.6, 2.7 Orientation Binder and orientation processes are in place.

Development is ongoing (Annual planning and development

schedule)

Ongoing education.

NTG

18. Our renewal cycle is appropriately managed to ensure continuity on the governing body.

GFT 33 See 12-17 NTG






Succ

essi

on

– O

rg

19. How is the CEO selected? 7.1, 7.2,

7.3, 7.8

Process has been defined Chair

20. Does the governing body provide input into the organization’s talent management plan?

7.9 Chair is actively involved in talent management / succession

planning at senior level

The organization has an organizational development program in

place which Includes - leadership development, workplace

resilience, and succession planning as components.

ACOD monitoring update is included on Annual Board Monitoring

Schedule

Chair

De

cisi

on

Mak

ing

& R

ole

Cla

rity

21. Does the governing body develop and review their roles, responsibilities, and accountabilities?

1.1, 1.2 Role and responsibility statements exist – Legislation and policy.

Board By-laws – under development. Complete by year end

Set out annual schedule for review (Board agenda item)

Chair

13-03

12-11

22. How does the governing body make decisions?

3.1, 3.2, 3,3 Legislation, Government Policy Direction, Treasury Board Policies

and Board Policies provide clear direction on scope.

The Board uses the ethical decision making framework

The Board identifies when decision making authority is shared

with funders / government

Chair

CM

QS

23. Does the governing body follow an ethics framework and code of conduct?

1.3, 1.4 Ethics framework & Board Member Code of Conduct (GP 3.3)in

place. Continue Board development on application of Ethical

decision making framework

Chair

CM

QS

12-11

24. Are the roles and responsibilities of the chair provided in a written document?

2.3 Policy is in place Chair

CM

25. What is the governing body’s role in the financial management of the organization?

8.1, 8.3, 8.4

Board Policy, C&M Committee, and Annual Monitoring Schedule

in place. While powers are clear, there are opportunities for

improvement in relation to role clarity. Review Policy GP 3.2.

Chair

CM

26. What is the governing body’s role in resource allocation decisions?

8.5, 8.6, 8.7

Chair

CM

13-03

Stra

tegi

c

Dir

ect

ion

27. Does the governing body help to develop the organization’s values statement?

5.1 Processes are well defined and the Board is actively engaged in

all aspects.

Chair

28. Does the governing body oversee the organization’s strategic planning process?

6.1, 6.2, 6.3 Processes are well defined and the Board is actively engaged in

all aspects.

Chair






Qu

alit

y Im

pro

vem

en

t

29. What is the governing body’s role in promoting quality improvement?

11.1, 11.2,

11.3, 11.4,

11..5, 11.6

Q&S on regular board meeting agendas. Works regularly with

CEO to integrate QI. Integrated risk management approach &

contingency planning. Promotes learning. Recognition awards.

Q&S

30. We benchmark our performance against other similar organizations and/or national standards.

GFT 19 To date: Self- assessments with AC tools. QI exercises in

organization are consistent with best practices. Walking tours.

Q&S dialogue at Board level. Board reviews KPI which are

benchmarked. Committee level meeting processes reviewed

(committee self-assessment). Annual workplans (Committee &

Board level), monthly status reports (Committee), and annual

reports (Committee and Board).CPSI Workshop. Board design

was informed by Governance review.

Learn about Tracer Methodology & seek opportunities to

promote in organization.

Q&S

31. Does the governing body use information about performance to identify areas for improvement?

12.1, 12.2,

12.3

Review use of performance information to explore opportunities

for improvement

Q&S 13-06






Enga

gem

en

t

32. How does the governing body demonstrate accountability to the public or its stakeholders?

Engagement Strategy (3 year), Annual Engagement Plans, Annual

Report, Annual Meeting, Publication of minutes (including public

monitoring reports).

Chair

PEC

33. Does the governing body engage staff and clients when updating the mission statement and organization’s mandate?

4.2, 4.3 Organization actively engages with staff and clients. Ensure this

information is communicated to the Board

Organization is working with DHW to develop an engagement

plan

PEC

34. Are staff, service providers, and clients and families able to provide input into the organization’s values statement?

5.2 Quality Council has public members

Develop more opportunities for engagement of public bodies at

board meetings

Organization developing plan

PEC

QS

13-01

35. Does the governing body know who its stakeholders are? 10.1, 10.2 Comprehensive stakeholder contact list in place. Regularly used

and actively managed.

Current: Board to Board conversations; Physician engagement;

AGM; Web Site; Media meetings

PEC

36. Is there a communication plan to provide information to stakeholders and the community?

10.3, 10.4 Engagement Strategy (3 year), Annual Engagement Plans, Annual

Report, Annual Meeting, Publication of minutes (including public

monitoring reports).

Current year: Board to Board Engagement Plan.

Review Policy GP 3.11 re. timeliness of Posting Board minutes.

Change to 45 day standard

PEC

37. Is the governing body involved in the community? 10.5, 10.6 Plans: Build in off-site meetings as part of annual meeting

schedule and to invite local stakeholders to present.

PEC /

Board

12-11

health pei annual schedule › photos › original › hpei_dec4_abs.pdfdraft 3. november 22, 2012...

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