open meeting of the board of directors - hdgh us/bod open... · to regional patient and trainee...

Open Meeting of the

Board of Directors

March 27, 2019 Hotel-Dieu Grace Healthcare

4:30 pm

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Prayer

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

May our decisions and actions bring forth justice and healing.

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

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

Amen

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Executive Summary March 8, 2019

Windsor Health Institute Wellness Through Research

Opportunities for a Health Research Enterprise in Windsor-Essex Region The geography of the Windsor-Essex-Erie-St.Clair region offer many treasures, being the most Southern point in Canada and budding up to a revitalizing economic giant across the international border, are no longer our best kept secret. Retirees are flocking to the Windsor-Essex-St.Clair region to enjoy the temperate climate, wine country, surrounding lakes and quick day trips to big city shopping and entertainment in Detroit. This region has one of the most rapidly growing aging populations in the province, which also puts tremendous demand on the healthcare system. The province has invested in a new regional Hospital System in our area that will provide desperately needed infrastructure to help meet this demand; this has created major impetus for change and a renewed focus on health in the region. Building on this momentum, Windsor Regional Hospital (WRH), Hôtel-Dieu Grace Healthcare (HDGH), St Clair College and the University of Windsor have joined forces to establish a collaborative research enterprise: the Windsor Health Institute (WHI).

WHI aims to create a united community bridging cutting edge health research with world-class care

This research enterprise will provide a platform to support and grow existing pockets of strength and planned investments in health research. WHI will promote economic diversification by harnessing Windsor’s industrial base, capitalizing on innovative research discoveries and providing jobs across the training sector. Importantly, WHI will transform the culture of academics within the region – impacting attraction and retention of high-quality medical professionals, researchers and trainees and will address the needs of the Windsor-Essex region to enhance patient care.

A successful health research institute has the potential to transform the culture of academic medicine propel the reputation of the Windsor region as a centre of healthcare

excellence and innovation. An appropriately resourced WHI will be a transformative driver of the knowledge-based economy for the region.

The Windsor Health Institute: Enabling Excellence Background consultation: The key regional advantages and strengths in health research, the research capacity, and requirements for expansion and growth were collected from a feasibility study conducted in 2009, a city-wide visioning day (2016) and a Faculty of Science visioning day (2017). The data gathered represents the visions of over 120 researchers and 25 different stakeholders. WHI governance: WHI oversight will be provided by a Board of Trustees consisting of leaders from each of the partnering institutions. Recommendations and strategic vision will be directed from an Executive committee with appointed representatives from each of the partnering institutions and major health groups/institutes within these organizations. The executive will receive direction from ad hoc advisory members, including representation from key regional partners. Driven by excellence, WHI will mobilize existing areas of strength and identify upcoming priorities central to regional patient and trainee needs. Paramount to success, WHI will build an integrated network of

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Executive Summary March 8, 2019

multidisciplinary health researchers to create a rich academic culture designed to seed novel innovative ideas to address our region’s most pressing health problems. WHI will provide leadership and the coordination required to grow these areas by:

Fostering health research advancement, providing grant opportunities, increasing funding success and supporting team building/networking.

Invigorating and empowering research training and education.

Promoting the successes and excellence of the organization through numerous community engagement initiatives, thereby elevating reputation, nurturing regional pride and aiding in recruitment and retention of leading health care professionals to our region.

Building WHI To flourish, health research requires strategic investment in operating and physical infrastructure. This requires a phased investment plan including:

Administrative support: Support for the Office of Directors is critical for this initiative to move to a stage of strategic planning.

Physical infrastructure: Commitment toward city wide planning and investment in health research infrastructure.

Critical mass of health research expertise: Commitment for the strategic investment in health positions across campus to grow centres of research foci.

To fulfill these objectives and achieve long-term sustainability, WHI will require investment over the next five years through cash and in-kind contributions from our

partners.

We are committed to finding grant opportunities to allow the WHI to realize its full potential.

Transformative Impact A regional health initiative of this scale will accelerate the transition of our region to a knowledge-based economy, providing a platform for economic diversification and transformation. The WHI will provide the necessary infrastructure, resources, and strategic co-ordination to support the expansion and growth of the Windsor-Essex region to solve complex challenges across the continuum of care. These resources will also drive the development and growth of health education programs and will provide hands on experience for Windsor students. WHI will succeed in the attraction/retention of health professionals and trainees in a region in need of primary care physicians and specialists; and provide a world-class training environment for highly-skilled knowledge workers in the health arena.

WHI will open new opportunities for cutting edge care for our community, and will

provide a rich training and work environment for our students/trainees and health care professionals. Patients treated at institutions with active health research have improved

outcomes.

Our region deserves nothing less.

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BOARD OF DIRECTORS OPEN MEETING AGENDA March 27, 2019 4:30 pm

HDGH Corporate Boardroom

`Item Topic Responsibility Time Action Encl

1.0 Call to Order, Opening Prayer & Land Acknowledgment

M. Horrobin 4:30 X 1.1 Introduction of new President of the Professional Staff Association; Dr. Harmandeep Virk

1.2 Quorum

1.3 Declaration of Conflict of Interest

2.0 Presentation – Windsor Health Institute Lisa Porter/M. Siu 4:35 Decision X

3.0

Education:

i. Mental Health and Addictions Program

(Finance and Government Relations – deferred)

S. Grbevski 5:00 Information

4.0 Approval of Full Agenda M. Horrobin 5:24 Decision X

5.0 Items requiring decision

5.1 Finance; deferred

i. Appointment of the Auditor – 2019/2020

ii. 2019/2020 Capital Budget

iii. 2019/2020 Operating Budget

5.2 Quality Improvement Plan K. Blanchette/ Dr.

A. Steen 5:25 X

5.3 Governance; i. Appoint Board Officers: Vice Chair

ii. Policies:

a. I – 1 Vision, Mission and Values b. I – 2 Ethics c. I – 5 Code of Conduct,

Confidentiality, and Conflict of Interest – Director and Non-Director Declaration

d. II – 4 Patient Complaints e. III – 6 Chief Executive Officer and

Chief of Staff Expense Reimbursement and Travel Policy

f. IV – 2 Asset Protection, Purchasing and Leasing

g. V- 12 Board Goals and Workplan h. V – 16 Review of Board Policies i. VI – 2 Support Relationship with

Hospital Foundation j. VI – 4 Contributions

B. Payne 5:35 X

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BOARD OF DIRECTORS OPEN MEETING AGENDA March 27, 2019 4:30 pm

HDGH Corporate Boardroom

iii. By-laws;

a. Past Chair b. French Language Services

Statement

6.0 Approval of Consent Agenda

6.1 Minutes of the previous Open Board meeting – January 30, 2019

M. Horrobin 5:40 Decision X

6.2 Minutes of the Quality Committee meeting – January 21 and February 19, 2019

6.3 Minutes of the Workplace Excellence Committee meeting – December 4, 2018

6.4 Minutes of the Medical Advisory Committee meeting – December 5, 2018 and February 13, 2019

7.0 Business Arising - none

8.0 Committee Reports

8.1 Quality Committee – (Feb 19 & Mar 18) K. Blanchette

5:42 Information

X

8.2 Workplace Excellence Committee – (Mar 8) M. Lomazzo X

8.3 Medical Advisory Committee - (Feb 13 & Mar 6) Dr. A. Steen X

9.0 Items for Information/Discussion

9.1 Schulich Medicine Annual Report Dr. Larry Jacobs, Associate Dean

5:45

Information

X

9.2 VP Medical Affairs, Quality Report Dr. A. Steen 6:05 X

9.3 VP Mental Health & Addictions Report S. Grbevski 6:07 X

9.4 Accreditation Planning K. Blanchette 6:09 X

10.0 Executive Highlights

10.1 Board Chair Report M. Horrobin 6:15

11.0 Date of Next Meeting April 24, 2019 5:00

12.0 Adjournment M. Horrobin 6:20

13.0 Correspondence X

14.0 Media reporting & dinner break 20 mins

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11%20June%2013-2018%20-%20MAC%20minutes%20-OPEN%20-FINAL.docx

11%20June%2013-2018%20-%20MAC%20minutes%20-OPEN%20-FINAL.docx

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FOR DECISION FOR ACTION FOR INFORMATION FOR TRACKING

ISSUES

The 2019/2020 Quality Improvement Plan requires approval by the Board. The Quality Committee has reviewed and provided feedback as needed.

BACKGROUND

The Excellent Care for All Act (ECFAA), 2010 sets out responsibilities for boards in overseeing

patient safety and quality, with the aim of improving patient care and enhancing experience. The

legislation places direct responsibility for oversight of the QIP with the Quality Committee of the

board. Their engagement and support are critical for successfully implementation of the QIP.

The board is in the position to ensure that the Quality Committee and management have thought

through critical elements of the QIP, such as the appropriateness of targets, resources and

measures of quality. Boards make certain that the organization has the capacity and support

necessary to ensure the success of their QIP and related efforts. Throughout the year, the

organization evaluates its progress on its QIP and the Quality Board and Board has opportunity

to ask management if goals are being met, sustainability of results and plan to address results

that require improvements.

There are three elements of QIP approval and board sign off :

1. Narrative Report

2. Progress Report ( as of Q3 results)

3. 2019-2020 Work plan

CONSIDERATIONS

Date: March 27, 2019 Author: A. Murray for K. Blanchette

Subject: Quality Improvement Plan ( QIP)

By-law/Policy Reference: None

Previous Board/Committee Consideration: Quality Committee; Jan 21, Feb 19 Mar 18

For the 2019-20 QIP the organization will focus on the key priority and mandatory system indicators outlined by Health Quality Ontario. There is recognition by the leadership and board, that capacity /resources will be challenged with Accreditation and HIS Implementation as key priorities for the coming year. In addition, potential for significant system changes in healthcare may impact quality improvement planning.

Health Quality Ontario System Priority/Mandatory QIP Work Plan Indicators :

Improve Patient Experience – Did you receive enough information on discharge : Target: 62% excellent

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CONCLUSION

Following the review and oversight by the Quality Committee, the Quality Improvement plan is proposed for approval.

RECOMMENDATION(S)

THAT the HDGH Board of Directors approve the 2019/2020 Quality Improvement Plan as

recommended by the Quality Committee.

Sustain reduction in ALC - % of patients who are ALC - : Target : 14.5%

Increase proportion of patients receiving Medication Reconciliation : Target : 95%

Reduce Employee related workplace violence incidents : Target : Continue BaselineCollection

Reduce number of readmissions: Target : 6% ( 4 cases/annually )

Improve information flow to primary care : % discharge summaries sent within 48 hours– Rehab: Target: 80%

Early identification of palliative care. Target : Collection of Baseline

Reviewed and approved by the HDGH Quality Committee of the Board .

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Insert Organization Name 1 Insert Organization Address

Quality Improvement Plan (QIP) Narrative for Health Care Organizations in Ontario

3/1/2019

This document is intended to provide health care organizations in Ontario with guidance as to how they can develop a Quality Improvement Plan. While much effort and care has gone into preparing this document, this document should not be relied on as legal advice and organizations should consult with their legal, governance and other relevant advisors as appropriate in preparing their quality improvement plans. Furthermore, organizations are free to design their own public quality improvement plans using alternative formats and contents, provided that they submit a version of their quality improvement plan to Health Quality Ontario (if required) in the format described herein.

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Click here to enter text.Overview

Hôtel-Dieu Grace Healthcare (HDGH) is committed to improving the health and wellbeing of the Windsor-Essex community through the delivery of patient-centred, valued based care. Hôtel-Dieu Grace Healthcare is a unique community hospital offering services in Mental Health and Addictions; Rehabilitative Care; Complex Medical and Palliative Care; and Children and Youth Mental Health. We offer a unique blend of services including but not limited to community and home based services. In collaboration with our healthcare and inter-sectorial partners, Hôtel-Dieu Grace Healthcare is providing care in new ways and in new locations throughout the region to address barriers, improve access and patient outcomes and improve the overall patient experience.

The mission of HDGH is to serve the healthcare needs of the community including those who are vulnerable and/or marginalized in any way be it, physically, socially or mentally. As a Catholic sponsored organization we provide patient-centered care treating the mind, body and spirit. We do this by providing holistic, compassionate and innovative care to those we serve.

HDGH’s vision “as a trusted leader transforming healthcare and cultivating a healthier community” conveys a strong commitment to providing safe, high quality patient and family centered care and services. HDGH is dedicated to improving the quality of life for patients across the continuum of institutional and community settings.

Rehabilitative Care

HDGH has a number of Rehabilitation programs and services that aim to assist patients in restoring their functional ability and reach their highest level of independence after encountering a catastrophic health event such as an acquired brain injury, cardiac event, stroke, bone break, etc. Through inpatient, outpatient, and community outreach formats, an inter-professional healthcare team works with patients to support personal goals, as well as physical, cognitive, and social needs.

Mental Health & Addictions

HDGH works tirelessly to achieve the reality of becoming our region’s Centre of Excellence for Mental Health. Through inpatient, outpatient, and community outreach programs, HDGH works with patients and clients with persistent and/or severe mental health issues, those in crisis, and those battling many forms of addiction. HDGH’s Mental Health and Addictions programs offer a range of treatment approaches to assist individuals with the unique symptoms and challenges of their illness, promote personal growth, and enhance quality of life.

Complex Medical and Palliative Care

HDGH’s Complex Medical Care (CMC) program provides restorative care for patients who no longer require services in an acute care hospital but because of their care needs require continuation of their rehabilitative journey in a safe environment with medical care oversight. An inter-professional healthcare team assists patients with setting goals, medical needs and working to improve their independence by increasing strength, mobility, and endurance to better manage daily activities and to return to the community.

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Through our Palliative Care program, HDGH supports patients who are within the last phase of a life limiting illness, transition through end of life with comfort and dignity. Our Palliative Care program is designed to help patients and families feel and stay as comfortable and peaceful as possible.

Children & Youth Mental Health

HDGH offers comprehensive child and youth mental health services through our Regional Children’s Centre (RCC). An accredited children’s mental health agency formerly funded by the Ministry of Children, Community and Social Services, and currently in transition to MOHLTC. RCC serves children, youth, and their families who are dealing with social, emotional, developmental, and/or behavioural challenges. RCC offers a variety of crisis stabilization, diagnostic, assessment, treatment, and consultative services in an on-site out-patient, educational and residential format, designed to promote healthy functioning within the home, school, and community. HDGH is also the Lead Agency for this region.

As one of the 31 Lead Agencies in the province, HDGH provides leadership at the local service area to lead practical change that works on the ground to improve services for children and youth facing mental health challenges, and their families. Through its legislated responsibility of planning as identified in Regulation 155/18 under the Child, Youth and Family Services Act, 2017, the Lead Agency works in collaboration with other partners to improve system level planning, consistency of services, and family and client engagement. Lead Agencies are responsible to ensure that core child and youth mental health services are accessible and of the highest quality, that gaps in service are identified and that areas of service duplication are addressed. As a Lead Agency, HDGH compiles data to inform service planning, builds partnerships across sectors, and engages children, youth and their families in order to increase access and improve quality of the services delivered.

The hospital’s 2018-19 Quality Improvement Plan continues to be driven by our three strategic drivers: Our Patients; Our People; and Our Identity. The 2019-20 QIP builds on the final year of our five year refreshed strategic plan.

We have completed the roll out of the communications plan on our Quality Framework and Quality Structure and implemented the majority of our Unit Based Councils in our Shared Governance model that encourages all staff to embed quality into their everyday practice. We also implemented a robust scorecard structure across our key Strategic Programs and key quality committees with connection to quality to our Quality Board and Board Committees. Our evidence-informed practice ensures compliance with accreditation standards and Required Organizational Practices and we are preparing for Accreditation, which is scheduled for June 2019.

Continuing to leverage the shared decision making model within a Shared Governance Framework, has proven to be very successful in creating and supporting a truly engaged front line staff; resulting in clinical outcome excellence as well as advancing a culture of patient safety and quality of work life

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In the driver of “OUR PATIENTS” – we are committed to improving patients’ quality of life through an evidence informed culture of quality and safety. We have made improvements in many of our quality & safety metrics. We continue to work on enhancement and connection of the patient experience and safety within our clinical operations and transition of the role of our PFAC from information sharing and consulting to more collaborative and advisory in nature. This is in alignment with the Patient’s First model of engagement.

HDGH is seen as a strong and trusted leader in partnership development in the community through the delivery of post-acute and community services with a focus on our patients. Our key initiatives for this year will be related to patient safety and supporting improvement across the healthcare system. Increased engagement activities supported by our expansion of real time survey strategies and expansion of Patient /Family representatives in an increasing number of key committees and quality improvement initiatives will provide a focus on patient voice in all quality improvement strategies and decisions. Our focus from a patient experience perspective will be on the discharge transition and improving the information our patients receive in insuring they feel they have enough information and support on discharge and are confident leaving our organization for their next phase in their recovery. We will be implementing patient surveying to all Mental Health & Addictions programs, as well as our outpatient Rehab areas through standardized tools. We will also focus on information transition from hospital to community so there is timely discharge summary information available in the community for patients follow up care. We will continue the excellent work around ALC and standardized discharge rounds and screening tools to support appropriate admissions with a focus on collaboration with patients /families and partners in alternate level care planning. We are also focusing on Medication Reconciliation on discharge for all inpatient and outpatient programs...

In the driver of “OUR PEOPLE” – we are committed to engaging, supporting and developing our people within a safe workplace. We are a leader in advancing the public conversation

around staff injury as a result of violence at work. We are pioneers in having a robust and comprehensive Workplace Violence Prevention Policy firmly in place and supporting the commitment to a safe workplace with ongoing comprehensive education. This aligns well with our corporate focus and strategic priority on our People, their safety and well-being. Our 2019-20 QIP will focus on the Mandated QIP indicator from HQO related to tracking the number of incidents within the OH & S definitions. Our focus this year will continue on ensuring accurate collection of this data and interpretation of the definition to ensure consistent and standard tracking of incidents across the province. With a planned educational rollout and

encouragement of reporting, we anticipate our incidents may increase and feel two years of collecting baseline data will improve our ability to provide accurate future target settings. We recognize that incidents do occur, however, our focus is to train staff and support a safety

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oriented work environment in order to minimize the occurrence and severity of incidents. We are also focused on our people development through a robust performance management program, opportunities for learning for front line staff and continued leadership development. We are developing an “Awareness Keeps You Safe” video series around the types of workplace violence and looking towards an install of PAL technology solution in 2019-20. We have a commitment from our Board of Directors who have identified safety as a strategic priority. Our CEO is also an active member of the leadership table for the Provincial Committee for workplace violence.

Focus on our third strategic driver of “OUR IDENTITY” – so that those in need understand who we are, the services we provide and our vision for a healthier community. This is highlighted in our strategic plan in the area of research, innovation, partnership and ensuring that we are a learning organization. We will continue to strengthen and increase partnerships within our community that support the best care for our patients. Contributing to these endeavors will help to build upon our medical programs and services; thereby, strengthening our value to the patients and community that we serve. We have set strategic goals to be the cleanest and safest hospital in the province.

Our QIP, this year, will focus on Health Quality Ontario’s priority and mandatory indicators to improve efficiency across the system. We choose to focus on these priorities to support the system based approach communicated to hospitals, as well as consideration for the two major priorities impacting us this year.

The 2019- 20 QIP for the hospital is comprised of the following key improvement areas:

•1. Improve Patient experience and satisfaction - we are aiming to improve responses to key patient experience indicators rating their satisfaction as “excellent “. We are one of the increasing numbers of Ontario hospitals who will focus on improving the “top box” score of “excellent “. Our goal is to improve this performance organization wide over the next 3-5 years. Our continued focus in 19-20 will be:

Overall Experience and Would you Recommend our Organization – these two areimportant as they reflect the overall experience and help identify what areas of overall experience we may want to focus on at a high level . We will be targeting a 5-10% improvement in both these indicators monitored on our executive scorecard.

Coordination of Care - Information at admission so patients know where they aregoing, what to expect and feel well-informed before they arrive. This will involve partnership with acute care and HDGH intake team as the majority of our admissions come from acute care facilities.

Improvement strategies on information at discharge so patients feel informed andprepared to leave HDGH. This will be done with partnerships with community partners who largely impact our results.

Involving patients in care planning and decision making

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Overall treatment of Respect and Dignity – this is in alignment with our values and ourQuality Framework Patient values

2. Maintain provincial levels and continue a focus on sustainment of reduction in ALCdays and facilitation of timely discharges through partnership with home care and community partners

3. Increase proportion of patients receiving medication reconciliation upon discharge- inboth inpatient and outpatient settings. We will continue to work on all transition points in a patient’s journey, including focus on improving patients understanding of medications and reducing medication risk factors involved in transitions and ensuring that medication reconciliation is completed.

4. Reduce employee related workplace violence incidents & injuries - we will continue tobe a leader in Workplace Violence Prevention programming and invest in education and training for our staff as well as ensure robust and accurate reporting and encouragement of reporting.

5. Reduce the number of readmissions in mental health – we commit to evaluatingreadmission rates and continue full case by case reviews on readmissions within 30 days to our facility to ensure any gaps are identified in the system. Our focus will be on single point of contact for access to tertiary and ACT services. This includes improvements planned related to wait list management to facilitate access for clients that need ACT support to prevent acute care admissions

6. Improve information flow to community partners – with timely completion of dischargesummaries sent or available from the hospital to primary or community partners within 48 hours of discharge...

7. Early identification of palliative care – Ensure those identified at risk of dying and in needof palliative services have a documented assessment of those need in hospital record using palliative best practice standards .

Hôtel-Dieu Grace Healthcare has two major organization priorities occurring this fiscal year that will impact our overall capacity and quality improvement planning. One is preparing for an organizational wide Accreditation scheduled to occur June 3-7th, 2019. Our organization has strategically used this opportunity to engage staff at all levels of organization. Through the education of twenty-five leaders /PFAC members in Accreditation Canada Tracer Methodology, we are conducting weekly facility-wide tracers and able to provide feedback on change ideas to contribute to rapid change cycle improvements. We will continue these monthly after accreditation to support ongoing improvement initiatives. We mindfully included two of our PFAC members to this team and they will be part of some of our tracers. PFAC members also are partners in collaboration on many of our accreditation teams to ensure the

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voice of the patient is included in everything we do. This again, shows our strong commitment to fostering a shared responsibility for continuous quality improvement and a culture of safety with our patients/families. Everyone has a role in quality of care at HDGH.

The second major priority this fiscal year is preparing for a major Clinical Transformation and Regional planning, design, testing and training for deployment of a new Regional Health Information System. Our program, called e-Volve is the implementation of a fully integrated electronic program health information system [NC1]Our project officially will launch on April 1, 2019 with a planned go live of spring 2020. This will equip our organization with modernized technology which will further enable the delivery of high quality and safe care to our patients and support provincial priorities to advance patient centred care through technology. The project vision statement is “to transform the delivery of safest quality care and an exceptional patient experience through an optimized provincial hospital information system”. This will involve significant human resources this fiscal year from our organization and represent a significant investment over a ten year period. Implementation of improvements such as electronic documentation, ability to share information seamlessly, improvements in transitions of care, CPOE and closed loop medication will all lead to many quality improvements across the organization and to our community partners through the transition to modern technology. This will assist in providing the platforms needed to continue movement towards critical provincial Digital Health Strategies

Describe your organization's greatest QI achievement from the past year In 2018-19 we were successful in advancing and/or achieving targets for the majority of our indicators. The organization has demonstrated resilience and commitment to providing the best possible care to patients through deeply rooted processes that have continued to enable the organization to meet and in many cases exceed performance expectations. The board and leadership embrace challenge as an opportunity to review and further enhance the quality and safety platform. This shared commitment to quality and safety will be used to further strengthen and align processes to support recently announced healthcare restructuring changes and emerging digital innovations which focus on our patients and community.

Improvement in % of medication reconciliation’s completed on admission was one of our greatest (QIP) quality improvement initiatives achievement in the past year. To improve medication reconciliation process we were able to secure commitment from senior leadership in having an organizational-wide focus on medication reconciliation by securing additional pharmacy resources to ensure compliance. Having an organizational focus and resources on medication reconciliation proved invaluable in our ability to make tremendous progress on the admission med rec process. Our starting performance was ranging from 30-40%, with target set for 95% and we are proud to report that we have consistently sustained 100% compliance. By incorporating pharmacy techs and pharmacists, related to collection of the Best Possible Medication History (BPMH), who are important collaborative partners in healthcare team, improved the accuracy and completion of the medication reconciliation process.

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We have also focused on the next segment of the med rec process, the transfer/discharge med and the med rec process in our 16 outpatient clinic areas. We have employed value stream mapping to identify current state, identified gaps and ideal state. We developed a Standard Operating Procedure (SOP) to establish key role expectations, timelines, and standardize the work and templates to improve consistency of practice and improve quality off

the information. A learning package has been established with plans for training and roll out will be progress

Some other key highlights supporting our Quality Improvement Plan:

Overall Rating of Care – we had 10% improvement in overall rating of care in our realtime survey results in past year

100% of complaints are responded to in 72 hours.

Implementation in January 2019 of a new Admission Welcome Kit for patients based onreal time survey results and input from patients. /families and PFAC as to whatinformation is needed. The new kit is based on feedback and impact of new package isbeing evaluated.

Implementation of benchmarking improvement project in Complex Continuing Carethrough dedicated implementation teams of front line staff

Significant improvements in CMI (Case Mix Index) which supports accurate patient caredocumentation of CCRS (Complex Care Reporting System) data elements, education tostaff and focused auditing and case reviews. This has resulted in increased from .99 in17-18 to YTD 1.03 CMI. This also impacts funding for this program and ensures we arecapturing true patient activity and care. This was through focused resources andeducation roll out to staff.

Established an ALC avoidance framework assisted in achieving better than target ALCrates over this last fiscal year, 11.7% YTD which overall is below our target of 19.9 aswell as the provincial levels for post-acute care of 14.5%. Intake guidelines wereimplemented reinforcing restorative model of care which has assisted in ALCavoidance.

Improving Hand Hygiene Compliance and Reducing Hospital Acquired Infections (HAIs)has been an area of focus for many years at HDGH. Hand Hygiene Compliance –before contact continues to improve at 97% YTD compare to 93% YE last fiscal year(overall). Our HAI’s has resulted in a decline and a > 20% improvement YTD. Oursuccess is due to a multi-disciplinary approach and a combined implementation ofmultiple strategies to sustain performance. Some of the following strategies that hasled to our sustainment and success:

o “Secret Shopper” methods of obtaining hand hygiene auditso Training of all managers to the “Just Clean Your Hands” methodology to assist

with hand hygiene auditso Establishment of process to ensure nursing students/volunteers receive training

on hand hygiene, and 150 students have been trained this year.o CDI policy and order set updated to reflect best practiceo Use of ATP technology by Environmental Service (ES) to measure environmental

bio-burden has helped ES to focus in areas with high bio-burden as per ATPtesting

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o Implementation of the use of Clorox 360, an electrostatic technology that helpsdeliver disinfectants and sanitizers onto hard-to-reach surfaces

o Ongoing education and positive reinforcement to staff, patients and families onthe importance of hand hygiene.

Sustaining Infection Control Practices is the key to keep our patients safe and reducethe spread of infections, our hospital has not experienced any HAI outbreaks over thepast year. Our IPAC and ES team received acclaim from Public Health Ontario for itscollaborative working relationship in reducing HAIs, and working together to be theCleanest Hospital in Ontario

Implementation of Wound Champion Program

Implementation of naloxone strategy in collaboration with Windsor Essex County HealthUnit for access to naloxone, policy development, training strategy and roll out across theorganization, .This includes distributing kits to those who report opioid use. HDGH hasdistributed over 60 kits to patients this year.

Leading Practice submission to Accreditation Canada for “Workplace Violenceprevention “and “Quality Improvement Advocate Program and Quality ImprovementAdvocates /real time admission and discharge surveying.

Focus on readmission review in Mental Health and improvement strategies started oncentral access, home supports (ACT /Outreach programs) to support post dischargeneeds so patients do not attend ER /acute care. In the past year (YTD), there havebeen only two cases of readmission (3%) compared to nine in last fiscal and thirty casesin 2014/15.

One of our MH & A program’s most innovative projects this year has been around oureffort toward the adoption of a standardized, evidence based addiction screeningassessment and referral process for Windsor –Essex. . We have built capacity withinthe community on the short screener and engaged leaders across diverse settings. Theshort screener is the first component of the GAIN assessment that screens the personto see if they have an addiction issue versus MH issue etc. HDGH collaborated withCAMH to rollout training for relevant community partners to utilize the screening tool.The purpose of this to ensure appropriateness of referral to Assessment/Referral,especially in our community where addiction resources are so scarce. We want toensure those who are being referred truly have an addiction issue. We have receivedoverwhelming positive feedback from community partners on this. Another example ofpositive change was from House of Sophrosyne – they provided us with an examplewhere they used the screener and through this it changed where they referred. In thiscase they referred someone to TSC instead of Assessment Referral. This is exactly theresults we were looking for. Also more longer term, by building capacity on thescreener, we can decrease the time required to refer to other forms of addictiontreatment. Creating a responsive system with timely access is key for addictions. Thisstrategy will be presented by HDGH /CMHA in May at the Addictions and mental HealthAnnual Conference( AMHO )as this is considered a new leading best practice

Operational review completed by Jill Mustin Powell on Withdrawal ManagementServices (WMS) with xxx 80% of recommendations implemented in past year –remaining recommendations will occur over the next two years.

Expansion of Transitional Stability Centre ( TSC ) and increased partnership with CMHA

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Key improvements in clinical performance monitoring and communication ofperformance results with revised scorecards and alignment of key monitoring ofmetrics and action plans. Patient Safety boards on the units for the public will beimplemented in March 2019.

Mapping of all key work flows and optimization planning across the organization inpreparation of moving to regional electronic health information system

Development of Quality Matters, People Matters & Identify Matters communication topublic

Development of Quality Matters Quarterly Infographic to highlight key qualityachievements and improvement initiatives for each quarter

CNE job shadowing project to increase visibility at unit level for staff and to assessstaffing impact on patient care. Allowed direct contact with patients on feedback onquality of their care, and opportunity for staff to discuss any concerns/challenges. Thisassisted in sharing their best practices/learnings and process improvements. This willbe extended to Rehab and TNI in this fiscal year. This resulted in progressing work onstandardization of job roles of the charge nurse and unit clerk so that unit clerks canassist with acknowledging call bells and flagging calls to staff. A call bell project wasinitiated from this review.

Collaboration with acute care and HDGH on a standardized communication patienttransfer tool to capture key patient information with goal of improving patient handoffs.Staff education on utilization of tool was completed and rolled out throughout bothorganizations. An escalation process at both organizations was also implemented.We have established quarterly meetings between organizations to discuss processimprovements, develop action plans and share any learnings.

Quality care is an on-going strategic goal of our Board of Trustees and Senior Management team. As an organization we value continuous quality improvement and acknowledge that quality care is the responsibility of all employees, physician’s and volunteers in collaboration with our patients/families. It is our organization’s expectation that all leaders are accountable in remaining committed to seeking ways to improve patient safety, patient programs and the overall quality of care and service provided at Hôtel-Dieu Grace Healthcare.

.

Patient/client/resident partnering and relations

Patient feedback from comments and responses to surveys continues to guide our targeted quality improvement initiatives and projects. Implementation of our pilot Quality Improvement Advocate positions and real time personal connection with new admissions and real time survey process in house has proved extremely beneficial to selecting and moving forward with timely, patient-centred improvement projects. Our unique model includes Quality Improvement Advocates, who are retired nurses personally greeting a high % of our new admissions to organization (currently 62%). Through that greeting and discussion on their transition from acute care to our organization, we have specific questions that we ask to glean transition and admission experience information and how they were treated. We have recently expanded this

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project to include our PFAC members completing a random check-in with patients/families on monthly basis. This is another lens into really understanding what our patients are experiencing and how can we take that feedback and change their experience in a positive way. In having a former patient/family member from PFAC interview /survey our patients, our patients are reacting very positive to this model and love that they can talk to someone that was a patient, just like they are. We have submitted this new initiative as a Leading Practice Submission to Accreditation Canada and presented at the International Patient Symposium held in Windsor this year. Please see our video on this amazing pilot project – we are so proud of our Quality Improvement Advocate’s and our PFAC members. We plan to expand the number of PFAC members conducting check in real time face to face surveys with fellow patients over the next year. To learn more, visit: https://www.youtube.com/watch?v=Jo1ikws3-qA&feature=youtu.be

The hospital’s Patient and Family Advisory Council is now well established, and has contributed to a new Declaration of Values for patients and staff and provided consultation and collaboration on content and considerations on all the new material for the Welcome Package. The hospital is committed to recognizing patients and families as members of the care team, and to engaging with them in all aspects of the patient journey, from provision of direct care to system planning. Staff are becoming more comfortable with doing things with patients and families rather than to them. Our experience scores related to feeling involved as much as they would like to be in planning and decisions on cares has increased by >30% positive and responded definitely Yes.

Plans are moving forward to add Patient Advisors to key hospital committees such as Quality and Ethics. We have a PFAC member on the Quality Board and Board of Directors in addition to numerous committees within the hospital. They often attend some Unit Based Council meetings and connect with front line staff. They will be participating on specific departmental work, such as equipment selection and the user experience. They also have a special “seal of approval” that is used on any brochures or information provide to patient/families which indicates that they have reviewed the material and contributed to the content with “patient eyes”.

Review of the hospitals Quality Improvement Plan and patient experience survey results have become a standing Agenda item at Patient and Family Advisory Council meetings. The Council was also involved in the development of the hospital’s Quality Improvement Plan through a review of patient experience results for the year and discussion on each QIP indicator from a patients view lens. This advisory information is then shared with the QIP leads so they include this in all Action Plans and change plans. We also collate the patient experience feedback from both NRC and Real time survey’s and these are always included in improvement planning and we find opportunities to link metrics in the survey’s to the quality improvement projects we are working on or to identify opportunities that are most important to our patients. The quality improvement idea of having members of our PFAC survey/interview patients came from one of our PFAC members. They also developed the three key questions they wanted to ask the patients. Our member felt that connecting with current patients would help them glean even

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more information on things important to patients as some of our members may have not been a patient or family member at HDGH for a few years. They felt this was a great way to connect directly with current patients and bring that back to the full PFAC team. It would also give them direct visibility to what patients were feeling and enable them to ask what they would want to improve most.

The hospital remains committed to ensuring that the patient voice remains strong. Expanding on opportunities to further improve patient care and service delivery from the patient and family perspective is now embedded in our daily practices

Workplace Violence Prevention It is well documented that Healthcare workers are at high risk of injury due to aggression and for this reason; the Minister of Health and the Minister of Labour created provincial committees to study what else can be done by organizations to reduce/eliminate these injuries in the future. The CEO and CHRO of HDGH, continue to be involved in the provincial work. In addition, HDGH has pursued a strategic partnership with the Ontario Nurse’s Association that has culminated in joint site visits to other employers seeking best practices as well as a joint media event to highlight the leading workplace violence prevention practices HDGH has implemented. HDGH is a leader in development of Workplace Violence Policies and Procedures and Staff Safety is a key strategic goal under our Driver of “Our People”. In fact, our Strategic Plan has identified our goal of being the “Safest Hospital in Ontario”. To that end, we have added an FTE to our Health and Safety Team whose primary responsibility will be to audit our initiatives to ensure compliance among our staff and leadership team. Our goal is to prevent incidents and injuries due to violence through various initiatives and processes. In particular, by implementing mandatory non-violent crisis intervention training programs that are refreshed annually and de-briefing each and every incident to analyze root causes and put measures in place to reduce the likelihood of a similar injury occurring again. We will continue to monitor through our Executive Scorecard, our HDGH custom indicator related to injuries against incidents. The mandated Workplace Violence indicator related to total incidents will continue on our QIP this year, as in accordance with the OH & S definition.

We have established the Workplace Violence Prevention Committee and have established regular monthly reports and metrics for this committee to monitor. In addition, we have partnered with both ONA and PSHSA to update and introduce the VARB tools into our workplace, including the chart flagging process and tool. A small working group of key personnel are actively working on the establishment of a chart-flagging policy and process – this is a complex project given our unique inpatient, outpatient and off-site programs. We will conduct a refreshed violence risk assessment in 2020 using the PSHSA online tool. A broad communications plan is currently rolling out that will include on-line and poster publication to educate our staff, patients and public that we have zero tolerance for violence, aggression or disrespect of health care workers and to encourage employees to report incidents of violence or aggression. In addition, we have initiated the creation of a four part series of videos for use in educating our staff called “Awareness keeps you Safe” – the first is Lockdown/Active Shooter and this has been completed. Next year we will complete three more – Patient/Family Violence, Worker to Worker Violence and Domestic Violence.

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As for metrics on the mandatory indicator, we can report the total number of incidents that meet the OHSA definition of violence. We are in the process of tracking these in RL6 via safety/security incidents and cross checked against the data that our Safe Workplace Advocate maintains in RL6 as well to ensure accuracy and standardization of reporting. When we have at least two years of data, we will set a target and this target may actually be an increase due to the significant effort being made to raise staff awareness of workplace violence prevention and encouraging staff to report all incidents of violence. Our primary messages to staff are “Violence is Not Part of the Job” and “It Hurts to be Quiet”.

Executive Compensation (Pending Approval from Board) In 2014, the Province began the process of developing public sector compensation frameworks to manage executive compensation in the BPS. The Broader Public Sector Executive Compensation Act of 2014 (BPSECA) authorized the government to establish frameworks, and set out principles that all designated employers must follow. These included ensuring that there is a consistent and evidence-based approach to setting compensation, ensuring that there is a balance between managing compensation costs while allowing employers to attract and retain the talent they seek, and ensuring that there is transparency in how executive compensation decisions are made.

Following consultation with multiple stakeholders in the BPS, in 2016 the Province introduced Ontario Regulation 304/16 in support of the BPSECA, effective September 6, 2016. This Regulation lays out the details and implementation timelines for executive compensation for all employers within the BPS.

The Regulation states that all BPS employers must have a compensation framework in place for designated executives. The framework must be compliant with the Regulation, and have been available for community feedback for a thirty-day period.

The requirements of the BPSECA and Ontario Regulation 304/16 have been considered, and the Policy developed to ensure that HDGH is compliant with the requirements. The HDGH Compensation plan was approved by the Ministry of Health in February 2018.

Positions included: The following positions at HDGH are included in the Performance-based compensation plan as described herein:

President & Chief Executive Officer;

Vice President, Medical Affairs;

Vice President, Clinical Programs;

Vice President, Corporate Services, Business Development & Chief Financial Officer;

Vice President, External Affairs & Executive Director, Foundation; and

Chief Human Resources Officer

Each of the above named executive’s compensation is linked to the achievement of specified performance targets which are reflected in the annual Quality Improvement Plan (QIP).

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Achievement of performance targets is evaluated annually the period of April 1- March 31of the given year to determine executive compensation. All the executives are evaluated against the same performance indicators and targets.

The performance indicators are selected as follows:

ALC Rate - % of patients who are ALC ( all inpatients )

Improve information flow to primary care with timely discharge summaries sent fromhospital to community

“Did you receive enough information on discharge?” – percent excellent score

Medication reconciliation on discharge – The total number of patients with medicationsreconciled as a proportion of the total number of patients discharged from Hospital.

Readmission Rate for Mental Health

Each indicator is weighted equally (20% each). If less than 50% of the target is achieved, no P4P is paid. If more than 50% of the target is achieved, that percent of the P4P is paid out (for example, if a target is 60% achieved, then 60% of the P4P for that indicator would be paid out.

Note 1: The mandatory violence indicator was not chosen because HDGH continues to collect baseline data. There is a significant education roll out occurring on “reporting” and increasing reporting and we will establish two years of data to establish baseline and ensure alignment of capture of incidents data. Note 2: We did not include palliative indicator as we are collecting baseline data in 19-20 on this new priority indicator.

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Excellent Care for All Quality Improvement Plans (QIP): Progress Report for 2018/19 QIP

The Progress Report is a tool that will help organizations make linkages between change ideas and improvement, and gain insight into how their change ideas might be refined in the future. The new Progress Report is mostly automated, so very little data entry is required, freeing up time for reflection and quality improvement activities.

Health Quality Ontario (HQO) will use the updated Progress Reports to share effective change initiatives, spread successful change ideas, and inform robust curriculum for future educational sessions.

***** Note: These current performance are based on Q3 result (not year end results)

ID Measure/Indicator from

2018/19

Org Id

Current Performance as

stated on QIP2018/19 (

previous year end result )

Target as stated on

QIP 2018/19

Current Performance

2019

Comments

1 "Would you recommend this hospital to your friends and family?" (Inpatient care) ( %; Survey respondents; April - June 2017 (Q1 FY 2017/18); CIHI CPES)

927 69.00 71. 70.00 ( Q3 ) Current Performance is based on April – December data. Pending Q4 results

Realizing that the QIP is a living document and the change ideas may fluctuate as you test and implement throughout the year, we want you to reflect on which change ideas had an impact and which ones you were able to adopt, adapt or abandon. This learning will help build capacity across the province.

Change Ideas from Last Years QIP (QIP 2018/19)

Was this change idea implemented as intended? (Y/N

button)

Lessons Learned: (Some Questions to Consider) What was your experience with this indicator? What were your key learnings? Did

the change ideas make an impact? What advice would you give to others?

Implementation of patient experience framework and supporting experience scorecards across organization.

Yes Established framework based on NRC /Patient First structure . We have supporting scorecards developed which will roll out in April . Indicators are monitored at various committee levels and quarterly reports provided to programs and reviewed with Patient Family Advisory Committee to assist in advisement on quality improvement initiatives based on patient feedback.

Empowerment of patients and families to be involved in their health care journey

Yes Inclusion of patient /families in setting goals. Pilot occuring on RH4 on new Care Planning Tool and tool provided to patient/families . Metrics related to questions in surveys related to inclusion in decision making and setting goals of care. Working of new CAre Plan pilot .

Identify plan for frontline care providers an customer service focu

No Not completed - budget/capacity challenges. Looking at potential of combination of service excellence training and Just culture training as option

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Real time surveying of patients/families . Patient /Family Advisory /COmmittee members conducting patient to patient surveys.

Implemented role of Quality Specialist Advocates to meet with new admissions ( and conduct small survey ) and meet with them just before discharge ( and conduct small discharge survey ) . Very positive pilot and patient's very supportive and appreciative of the personal touch of talking to someone on arrival and just before leaving.

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ID Measure/Indicator

from 2018/19

Org Id

Current Performance as stated on QIP2018/19

Target as

stated on QIP 2018/19

Current Performance

2019

Comments

2 # Of Code White (current definition used by OH & S) without injuries. Based on the % of total incidents ( lost healthcare claims and lost time ) ( %; Employees , Code White incident; 17- 18 ( up to Q3 ); In house data collection )

927 82.90 90.00 80.00 ( Q3 ) This indicator is different from

the mandatory HQO indicator

(# of Violence Incidents) and

is the indicator that we have

been collecting data on for

several years. While we did

not reach the target of 90%, we

have continued our efforts to

raise awareness of the issue of

workplace violence in

healthcare and encourage staff

to report. We embarked on a

communications plan in the

last year that has resulted in an

increase in reporting. The

communications plan was two-

fold: targeting the public with

posters and banners advising of

our zero tolerance for

violence/aggression policy and

secondly, targeting our staff

with posters and

communications encouraging

them to report any incidents of

violence with the slogan “It

Hurts to be Quiet” and

“Violence is Not Part of the

Job”. We are hopeful that this

will help reach our target next

year. As well, we have

introduced a new “Threshold

Case Review” policy that

allows for deep dives into root

causes of any violence

patterns, repeat offenders or

egregious incidents by our

multi-disciplinary Workplace

Violence Prevention

Committee (WVPC) to ensure

every control measure

reasonable in the

circumstances is being

implemented and followed by

our staff and learnings,

improvement and prevention

initiatives are spread

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throughout the

organization. We are also

embarking on the creation of a

four-part video series aimed at

staff education called

“Awareness Keeps You Safe”

– the first video has been

completed and deals with

Lockdown/Active Shooter

education. The remaining

videos – Patient/Family

Violence, Worker to Worker

Violence and Domestic

Violence will follow next

year. We have also added a

full-time Safety Advisor

position whose first piece of

work was to facilitate the

update of all job hazard

analysis for every position at

our organization and whose

on-going responsibilities will

include auditing our workplace

violence initiatives to ensure

compliance. We believe this

auditing will have a significant

impact on our

performance. Of note is that

after we trained all 1100 of our

staff in mandatory 8 hour

Crisis Intervention Training in

2016, all of the re-

certifications have come due

starting late last year. We

believe that perhaps a

contributing factor to not

reaching our target this year

was that the training we

provided to all staff to help

them de-escalate violent

situations was needing to be

refreshed. As a result, one of

our learnings from this year is

that we cannot let up on our

efforts to keep workplace

violence at the forefront of our

education and awareness plans

with staff – it is a constant

process of learning and

improving.

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Change Ideas from Last Years

QIP (QIP 2018/19)

Was this change idea implemented as intended? (Y/N button)

Lessons Learned: (Some Questions to Consider) What was your experience with this indicator? What were your

key learnings? Did the change ideas make an impact? What advice would you give to others?

Workplace Violence Committee to establish

Y Committee fully operational

Partner with ONA and PSHSA (Public Service Health and Safety Association) to update and introduce the PSHSA Violence Prevention Toolkit.

Y We have actively pursued and nurtured a partnership with the

Ontario Nurses Association (ONA). As a result of this partnership,

we are working together to enhance our non-violent crisis

intervention training and will be making site visits to other hospital’s

in the Province together with ONA provincial and local

representatives to review best practices. In addition, we are working

closely with them as we work through the establishment of a chart-

flagging policy and procedure for our organization. This is a

complex endeavour due to the unique nature of our inpatient and

multiple outpatient and off-site programs. The partnership has been

fruitful and culminated with a joint media event during which ONA’s

Provincial Health and Safety Specialist spoke

publiclyhttp://www.iheartradio.ca/am800/news/hotel-dieu-grace-

healthcare-working-to-improve-staff-safety-1.8992013 about the

amazing work we have done as an organization and the value of our

partnership. In terms of our work with the Public Service Health and

Safety Association (PSHSA), we have also cultivated a strong

relationship with that organization we well. We presented jointly

with the PHSHA at the Sixth International Conference on Violence

in the Health Sector in Toronto in the fall of 2018. Together, we

were awarded best abstract at the conference. Using the PSHSA’s

guides, we have incorporated most of their tools and suggestions into

our existing Workplace Violence Prevention Program. We were

particularly interested in completing our updated Violence Risk

Assessment for the organization using PSHSA’s on-line tool. We

have attended a number of sessions to learn to use the tool and we

have registered as a user. However, due to the nature of the work to

be done and the intensive resources required to complete this project

successfully, the Executive Leadership Council has deferred this to

2020-2021 due to the fact that we have a number of significant

organization wide initiatives that require focus this year

(Accreditation and Health Information System Implementation).

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2018/19

Org Id


Target as


Current Performance

2019

Comments

3 Average Latency - Ministry of Child /Youth Services Indictor - P11a. Regional Children's Centre. ** Average Time from initial contact to wait list. ( Days; Children's Mental Health; 17-18; MCYS Indicator - P11a)

927 CB CB CB The definition for this indicator was never defined through MCYS, most likely due to changes occurring at that level. Comments are related to general work that was completed around assessing and improving wait times in the program.




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Conduct a Current State Mapping Session to establish Improvement Plan for 18-19

Yes Current state mapping related to access and flow of patients was completed. This is very helpful in identifying where gaps are occurring and initiatives established around various factors that impact wait time.

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ID Measure/Indicator

from 2018/19

Org Id


Target as


Current Performance

2019

Comments

4 Did you receive enough information during the admission process ( %; Survey respondents; Q3 - YTD 17-18; NRC Picker)

927 18.00 23.00 24.6 ( Q3 ) Welcome Package implemented in Jan 2019 – additional questions on real time survey to assess welcome package information. Real time results for this indicator are : 63% with >20% increase over past year –asked at discharge and does not have influence of acute care experience in results




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Lessons Learned: (Some Questions to Consider) What was your experience with

this indicator? What were your key learnings? Did the change ideas make an impact? What advice would you give to

others?

In partnership with Intake team and acute care, review data collected during the Quality Improvement Advocate Pilot position and develop a work plan based on Patient feedback and Patient Family Engagement Council.

Yes This was critical - using real time survey results from actual conversations with patients about what information did they require that did not get during admission process. Also identified key challenges from patient perspective on transition from acute care - their experience in acute was also very much influencing this indicator. Real time survey's has allowed us to create a new Welcome Package based on their feedback which was implemented in January 2019

Transition patient greeting activities from pilot position to unit managers by end of 18-19.

No We have identified need for Quality (non unit staff) Advocate positions to continue in a more permanent role as part of learnings from our pilot. We will extend pilot most likely at least 6-12 more months and review at that time if this is appropriate to move to unit managers. Other priorities are also influencing this.

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2018/19

Org Id


Target as stated on

QIP 2018/19

Current Performance

2019

Comments

5 Did you receive enough information from hospital staff about what to do if you were worried about your condition or treatment after you left the hospital? ( %; Survey respondents; April - June 2017(Q1 FY 2017/18); CIHI CPES)

927 31.00 38.00 35.6 ( Q3 ) Overall YTD improvement of 4.6% which is considered significant by NRC. Real time results : 57%




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Lessons Learned: (Some Questions to Consider) What was your experience

with this indicator? What were your key learnings? Did the change ideas make

an impact? What advice would you give to others?

Through partnership with social work, patients/families , LHIN Community Homecare ( CCAC ) and program /unit based councils, create a work plan

Yes Working collaboratively with partners to communicate experience feedback from patients. Have developed work plan for 19-20 with 4 key items for implementation.

Empowerment of patients and families to be involved in their health care journey

Yes

Identify plan for frontline care providers and customer service focus

No

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2018/19

Org Id


stated on QIP2018/19

Target as stated on

QIP 2018/19

Current Performance

2019

Comments

6 Medication reconciliation at admission. The total number of patients with medications reconciled as a proportion of the total number of patients to the hospital. ( %; All inpatients; 17-18; Hospital collected data)

927 47.00 100.00 94.50 (Q3) Consistently over 95% for past six months...


Change Ideas from Last Years QIP (QIP

2018/19)


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Lessons Learned: (Some Questions to Consider) What was your experience with this indicator? What were your key learnings? Did the change ideas make an impact? What advice would you

give to others?

In collaboration with Quality/PMO team , develop a detailed action plan to ensure compliance by Q4, 18-19

Yes To improve medication reconciliation process we were able to secure commitment from senior leadership in having an organizational-wide focus on medication reconciliation by securing additional pharmacy resources to ensure compliance. Having an organizational focus and resources on medication reconciliation proved invaluable in our ability to make tremendous progress on the admission med rec process. Our starting performance was ranging from 30-40%, with target set for 95% and we are proud to report that we have consistently sustained 100% compliance. By incorporating pharmacy techs and pharmacists, related to collection of the Best Possible Medication History (BPMH), who are important collaborative partners in healthcare team, improved the accuracy and completion of the medication reconciliation process.

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2018/19

Org Id


Target as


Current Performance

2019

Comments

7 Medication reconciliation at discharge: Total number of discharged patients for whom a Best Possible Medication Discharge Plan was created as a proportion the total number of patients discharged. ( Rate per total number of discharged patients; Discharged patients ; October – December (Q3) 2017; Hospital collected data)

927 CB 100.00 CB Pilot completed and final implementation and education plan in progress. Working with IT provider on required reporting and required system changes to support. Current performance is not validated (approx. 30%)




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In collaboration with Quality and PMO team, develop a detailed action plan to ensure 100% of applicable discharges compliant by Q4.

Yes The next segment of the med rec process, the transfer/discharge med and the med rec process in our 16 outpatient clinic areas. We have employed value stream mapping to identify current state, identified gaps and ideal state. We developed a Standard Operating Procedure (SOP) to establish key role expectations, timelines, and standardize the work and templates to improve consistency of practice and improve quality off the information. A learning package has been established with plans for training and roll out will be progress

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2018/19

Org Id


stated on QIP2018/19

Target as stated on

QIP 2018/19

Current Performance

2019

Comments

9 Rate of psychiatric (mental health and addiction) discharges that are followed within 30 days by another mental health and addiction admission ( Rate per 100 discharges; Discharged patients with mental health & addiction; January - December 2016; CIHI DAD,CIHI OHMRS,MOHTLC RPDB)

927 9.26 6.00 3.00 ( q2) This represents 2 cases. Only 2 quarters reported by CIHI




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Lessons Learned: (Some Questions to Consider) What was your experience

with this indicator? What were your key learnings? Did the change ideas make an impact? What advice would you give to

others?

Complete deep dives on each re-admission within 30 days to identify potential preventative measures and opportunities for improvement

Yes Proven to be very manual process. Completed on every re-admission. Very low volumes.

Ensure proper information and communication is available to patients/family at discharge.

Yes Completed – package developed and implemented. Based on feedback from patients /families

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ID Measure/Indicator from 2018/19 Org Id


Target as stated on

QIP 2018/19

Current Performance

2019

Comments

10 Total number of alternate level of care (ALC) days contributed by ALC patients within the specific reporting month/quarter using near-real time acute and post-acute ALC information and monthly bed census data ( Rate per 100 inpatient days; All inpatients; July - September 2017; WTIS, CCO, BCS, MOHLTC)

927 15.43 16.50 11.7 * (Q3 ) Still require Q4

results which will

be higher- YE will

be approximately

13-14%.




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Lessons Learned: (Some Questions to Consider) What was your

experience with this indicator? What were your key learnings? Did the

change ideas make an impact? What advice would you give to others?

Provide all patients/SDMs with Estimated Date of discharge ( EDD) in writing shortly following admission and also documented on chart ( Leading Practice #2)( 2-7 days of admission

Yes In process of implementation (March 2019). Challenges with physicians setting EDD on admission.

The roles/responsibilities and expectation s of SDM are clearly explained in writing on admission ( leading practice #9)

Yes Still to be implemented is “Partners in Care “letter

for patients and families on admission that will

introduce the concept of collaborative relationship,

roles, responsibilities. To go to PFAC March /April

2019.

Develop a standardized Complex Discharge Rounds ( CDR and ALC Deep dive process within IP Mental Health

Yes Collaboration with social work group and MH

managers as cases occur.

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DRAFT 2019-20 DRAFT QIP Workplan Priority Strongly recommend - unless you are at benchmark/target -narrative required if not on as to why

Quality Improvement Plan - indicators and targets Mandatory Must be on QIP

* Additional For consideration /recommendation by HQO o support system wide indicators

Custom - HDGH HDGH specific

HQO Domain Objective Measure/Indicator Unit/Population Source/PeriodCurrent

PerformanceCurrent Target 19-20 Target Draft Target justification HQO Indicator Lead Executive Sponsor

Planned improvement initiatives

(Change Ideas)Methods Process measures

Target for process

measure

Efficient Reduce ALC ALC Rate - % of patients

who are ALC

All IP beds

(CCC,MH,

Rehab)

IPORT 11.7% (Q3) -

expect 13-

14% for YE

forcast

19.90% 14.50% Lower

is

better

Based on current status, provincial and

LHIN targets and taking into

consideration post acute factors which

tend to be higher rates - LHIN overall

target 12.7%. 15-16 target was 19.9 (14-

15 was 19.9 actual) and we are currently

at 11.7but our highest quarter is still to

be included for Q4 - expect us to be

around 13-14%. Target has been 19.9 for

2 years.

Current State:

Complex - 23.8% rEHAB - 4.1%

Current provincial ALC rate - post acute :

14.5 and ESC LHIN16.5% . Senior Mgmt

recomment to set target at provincial

rate for sub acute - expect intense system

change and need to be realistic on this

indicator. majority of cases are waiting

for LTC

Priority P.Kolowickz

Eleanor Groh

J.Karb/S.Grbev

ski

1. Standardized Discharge Rounds

2. Development of supporting

Policiesand Screeningn Tools to support

approrpirate admission.

3. Review Role of ACT services to

support

1. Continuation of the standardized complex

discharge rounds ( CDR ) and 90 day ALC reviews as

part of a robust discharge planning policy.

Documnetation tool has been developed to capture

the finding of the CDR and ALC review 2.

DEvelopment of robust admission policy, including

critieria and with input from patients/famiies , to

guide admission to HDGH. Review ALC admission

screening tools already in use accross Ontario for

the purpose of adopting for HGH.

3. Engage in discussions regarding review of ACT

services to discuss barriers for discharge from TNI

1. 100% of ALC patients have a CDR

/ALC review 2. 100% of all patints

considered for admission would

have screening tool completed

1. 100% 2.

100%

Timely Improve

Information Flow

to Primary Care

/System

Discharge Summaries sent

from hospital to community

care provider within 48

hours of discharge ( Rehab )

All IP Beds Mmodal

Transcription

System /Manual

73%

( Rehab )

currently 7

days target -

68%

approx 52%

meeting

target overall

for 48 hours .

34% -Complex

- REhab 73% ,

TNI - 30%

80% Higher

is

better

Working with vendor to obtain reports

and establish a current state benchmark.

Will require commitment to best practice

by physicians . Very little impact from

weekend discharges. *** For 19/20

- you can limit to one program area - i.e

Complex or Rehab . Weekend discharges

will be removed from tracking as there is

currenlty no physician attendance on

weekends . Look at 5-10% improvement

recognizing the Rehab program are

performing well currently - monitor all

programs on MQA scorecard

Priority A.Murray A.Steen 1. Develop best practice work plan

with physicians/MQA to increase

timeliness of dictation

2 Develop HIM improvement plan to

improve timeliness of the transcription

turnaround times.

1. Review current state process and map out future

state ( including with HIS implementation) to

identify gaps from physician perspective and

develop workplan 2. Work with vendor to

improve reporting to monitor and flag transcription

times . Establish baseline dictation to transcription

times . 3. Work with

vendor to address number of transcriibed reports

going to the review que and being delayed .

Currently 46% (estimated )

1. Implement workplan itmes

identified in gap analysis for 19-20

2. Monitor dictation to

transcription times 3.

Reduction in Number of dsicharge

summaries going into hold que for

review.

1. 100% identified

tasks completed

prior to March

2020. 2. Set

target based on

baseline 3.

Reduce by 15%

Patient-Centred Improve patient

experience

Did you receive enough

information on discharge -

% excellent score

CCC/Rehab Real Time Internal

Discharge Survey

38% - NRC

57% real

time

57% - real

time ( Jan

2018 - Dec

2018)

62% Higher

is

better

Ont Avg - 57.6

LHIN - 54.1%

Previous Year - HDGH - 17/18 - 34%

and 18/19 - 33% NRC identifies that a

normal improvement rate is 1-2%

annually - a 5% target would be stretch

target Real time

results : 57% ( 222/390 ) Top Box

. Majority of concernrs from patients are

related to LHIN/homecare delays and

concerns

Recommend aggresive target of 5-10%

improvement goal - Ontario avg . Work

on timing of discharge interview ( as

close to actual discharge as possible ) and

inititaives around follow up call post

discharge

Priority A.Murray /E.Groh A.Steen /J.Karb Implement all patient experience

workplan items supporting to

discharge information

1. Create discharge package with input from

patients/families and real time survey feedback

2. Creation of Caring About Your Discharge

Brochure 3. Creation of

Discharge Sheet for Patients with all follow up

informaiton ( based on feedback from real time

survey's ) 4. Monitor impacts of

Medication REconciliation imrpvoements on patient

experience 5. REview planning

opportunity for follow up discharge call process

I. Implement Improvement

Initiatives by end of 19/20- 100%

2 Monitor Patient Experience - I

understand my medications.

1. 100% 2.

improve 20% over

baseline ( 18/19

YE )

19-20 Workplan - DRAFT

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DRAFT Safe Reduce

employee

related

workplace

violence

incidents &

injuries

total overall # of workplace

violence incidents (as per

OH& S definition) - new

mandatory indicator

All Hospital Collected -

OH & S

30YTD ( Q3

)

CB CB Lower

is

better

Baseline established - 17/18 - 45, 18-19

YTD - 30 ( Q3 ) - forcasting 40 for YE .

Still to review other hospital results in

February when data is released from

HQO . Orgnaizations are still trying to

align to the OH & S definition . Due to

education rollout on "reporting" ,

anticipate numbers may go up this year

and feel that two years baseline will give

a more accurate baseline reflection to

then set targets .

Mandatory S. McGeen M. Benson-

Albers

Continued Implementation of

Workplace Violance Workplan for 19-20

identified items .

1. Completion of communications plan roll out

2. Development of work group to research best

practice and create chart flagging process that

focuses on patients and staff . 3. Review of

Violence Risk ASsessment tool with input from Joint

Health and SAfety Committee, managers, frontline

staff and patients. 4.

REview of education/traning for staff to determine

any enhancements that should be introduced.

1. Communications Plan rollout

completed - 100% of tasks

identified for 19/20

1. 100%

communication

tasks completed

Effective Early

Identification of

Palliative

% of documented

assessment of needs for

palliative care patients

CCC/Rehab Hospital Collected -

manual until EMR

implementation

CB CB CB This measure the proportion of

hospitalizations in the most recent 6

months where patients were identified at

risk of dying and in need of palliative care

and had documented assessments of

their pallative care needs in their

hospitalization records. REviewing

technical standards to establish current

state. Tools described are already in use

at our organization so will be tracking of

that patient population. Only if we are

at 100% would we have reason to not

include this as it is priority

Clinical teams reviewing the best practice

standards **

Priority E.Groh J.Karb Develop a Palliative Care working

group

1. Estalblish baseline through review of current

state analysis . Develop Plan for non-

palliative care unit trigger process /Pallative Care

Dcoumentation and chart review .

2. Review HQO Palliative Care standards and

identify processes and supporting documentation

tools and create a best practice work plan .

1. Review documentation on all

flagged palliative patients identified

as at risk of dying and in need of

palliative care. 2. Verify

palliative documentation on

medical record

1. 100% reviewed

2. 100% of records

reviewed

Effective Reduce

readmission

rates for mental

health and

addictions

Rate of psychiatric (mental

health and addiction)

discharges that are

followed within 30 days by

another mental health and

addiction admission

MH - IP OMHRS/MH 3% ( Q2 ) 6% 6% Lower

is

better

Peer Group - 8.3%

Provincial - 11.6%

ESC LHIN - 14.1%

This indicator has had significant

improvement over the past 4 years. At

relalignment this indicator was approx

30% -signifcant work continues on intake

and dicharge planning .

recommend keeping/maintaining target

of 6% ( 4 cases annuall ) This continues

well below benchmark or provincial and

peer average

Priority P.Kolowickz S.Grbevski Review Program Strucutre for TNI

Intake

1. Combine Existing TNI intake with ACT so there is

single point, coordinated access fr tertiary and ACT

services using a standarized process for program

acceptance.denial and appeal. 2. Wait List

management to help improve efficienceis and

faciliate access for clients that need ACT support to

prevent acute care readmission.

1. Standard Process established .

2. Wait list management process

established 3. Monitor

patient experience metrics related

to access on new OPOC survey for

TNI /ACT services.

Effective Increase

proportion of

patients

receiving

medication

reconciliation

upon discharge

Medication Reconciliation

on discharge: The total

number o f patients with

medications reconciled as a

proportion of the total

number of patients

discharged from hospital

(excluding deaths)

CCC/Rehab/M

H

HMM/hopsital

collected

CB CB 95% Higher

is

better

Accreditation Canada required - estimate

we are currentl ( Feb 2019) at around

35% . Will confirm current state and

enter that in navigator once confirmed

before March 30. Still CB.

Priority M.Campigotto J.Karb Continued implementation of work

plan.

1. Standardize discharge med rec process and forms

throughout organization(inpatientand outpatient

clinci areas 2. Develop training

strategies and roll out plans to inter-professional

team 3.

Complete software development to support and

capture reporting and data for completed discharge

med recs in electronic system

1.. Implementation completed in

100% of areas identified .

2. Education /training completed in

all areas 3. Software and report

requirement identified are 100%

completed

1. 100% 2.

100% traning

identfied

completed

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ISSUES

The current term for the Vice Chair (B. Payne) will end in June 2019

BACKGROUND

In September 2018, the Governance Committee approved the process to begin recruitment for a Vice Chair for the term of 2019/2020.

Next steps recommended at that time:

Canvass Directors September 2018; Ken Blanchette nominated and accepted -

completed

Interviews October 2018; delayed to late November due to calendar conflicts -

completed

Governance Committee approved recommendation to the Board of Directors for

appointment; February 2019 meeting - completed

Appoint at November 2018 Board meeting; delayed due to timing of Board and

Governance meetings - March 27 meeting

Approval by members January 2019; delayed due to timing of meetings - April 25

meeting

Mentorship and Education to incoming Vice Chair Feb 2019-June 2019; underway

Through the canvass and interview process Ken Blanchette has accepted the nomination and

stands for appointment as Vice Chair 2019/2020

Date: March 27, 2019 Author: D. Dutot for B. Payne

Subject: Succession Planning – Vice Chair 2019/2020

By-law/Policy Reference: June 5, 2018 By-law, Article 8.3 Term of Office Restrictions Policy IX-7 Process for selection of Board Officers

Previous Board/Committee Consideration: September 10, 2018 Governance Committee and February 4, 2019

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CONSIDERATIONS

CONCLUSION

Appoint Ken Blanchette as Vice Chair beginning term 2019/2020

RECOMMENDATION(S)

THAT Dr. Ken Blanchette be appointed Vice Chair 2019/2020 by the Board of Directors

as recommended by the Governance Committee.

Quality Framework: Governance best practice

Risks: not filling the vacancy with a qualified or dedicated Director

Strategy/Identity: Governance Excellence

Legal Analysis: Governance best practice

Financial Analysis: no impact

Stakeholder Implications: Confidence in the Board

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ISSUES

Current Policies require updating and reformatting for new logo

BACKGROUND

In September a workplan was presented and approved.

In November a Policy Framework was presented and approved. In February 10 policies were reviewed for consideration

CONSIDERATIONS

CONCLUSION

For approval 10 policies have been selected: I – 1 Vision, Mission and Values:

o No content changeso Logo update

I – 2 Ethicso Change by-law referenceo Logo update

I – 5 Code of Conduct, Confidentiality, and Conflict of Interest – Director and Non-DirectorDeclaration

o Content: included purposeo Combined Code of Conduct, Director & Non-Director declaration and Privacy and

Security Policy (as Confidentiality)o New Conflict of Interest sectiono Logo change


Subject: Policies


Previous Board/Committee Consideration: Sept 10, Nov 5, 2018 & Feb 4, 2019 Governance Meetings

The Policy Framework consists of 47 policies that require review, amendments and reformatting. Approval of these will be broken down into 4 manageable groups. This is the first group of policies to be amended and reviewed.

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II – 4 Patient Complaintso Change by-law referenceo Addition of legislated requiremento Logo change

III – 6 Chief Executive Officer and Chief of Staff Expense Reimbursement and Travel Policyo Combination of both previous CEO & COS policies; they were exactly the sameo Logo changeo ‘Chair of Professional Advisory’ to ‘Chief of Staff’

IV – 2 Asset Protection, Purchasing and Leasingo Combination of two policieso Inclusion of by-law reference

V- 12 Board Goals and Workplano No content changeo Logo change

V – 16 Review of Board Policieso No content changeo Logo change

VI – 2 Support Relationship with Hospital Foundationo Updated name and information for CLTFo Logo change

VI – 4 Contributionso No content changeo Logo changed

RECOMMENDATION(S)

THAT the Board of Directors approve the 10 policies as recommended by the Governance Committee.

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VISION, MISSION AND VALUES

Issued by: HDGH Board of Directors NUMBER: I – 1

Authorized by: HDGH Board of Directors ISSUE DATE: February 2015

Category: Stewardship REVIEW DATE: January 2019

Committee: Governance Page: 1 of 1

OUR VISION

A trusted leader transforming healthcare and cultivating a healthier community

OUR MISSION

The Mission of Hotel-Dieu Grace Healthcare is to serve the healthcare needs of our community including those who are vulnerable and/or marginalized in any way be it physically, socially or mentally.

As a Catholic sponsored healthcare organization we provide patient-centred care treating the body, mind and spirit.

We do this by providing holistic, compassionate and innovative care to those we serve.

OUR VALUES

Respect

Compassion

Teamwork

Social Responsibility

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ETHICS





Article 4.07 (b) (i)(ii) 14. of the June 5, 2018, by-law provides that the Board’s responsibilities to

Catholic Health International (CHI), through the members of the Corporation will include governing

the affairs of the Corporation in support of and in accordance with the Mission, Philosophy and

Values as well as the Health Ethics Guide1; and ensuring the Mission Philosophy and Values and

Health Ethics Guide are integrated into the strategic plan and the operations of the Hospital.

Consistent with the duties of the Chief Executive Officer (CEO), Article 6.0214.4 of the by-law,

the CEO is responsible to the Members, through the Board, for ensuring that the Health Ethics

Guide is integrated into the operations of the hospital; and that for taking such action as the CEO

considers necessary to ensure compliance.

The CEO is also responsible for working with the Board of Directors to ensure the ethical

framework is applied in Board decision making processes.

1 The Health Ethics Guide is published by the Catholic Healthcare Alliance of Canada approved by the Permanent

Council of the Canada Conference of Catholic Bishops in March, 2000, as may be amended from time to time.

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CODE OF CONDUCT, CONFIDENTIALITY, AND CONFLICT OF

INTEREST - DIRECTOR AND NON-DIRECTOR DECLARATION





PURPOSE[DD1] The Hôtel-Dieu Grace Healthcare Board of Directors believes it must fulfill its fiduciary obligations professionally, ethically and maintaining strict confidentiality

CODE OF CONDUCT

This Code of Conduct and Ethics applies to every employee, staff member and Director of the

Corporation. Every employee and director is expected and required to assess every decision and

every action on behalf of the organization in light of whether it is right, legal and fair. This applies

at all levels of the organization, from major decisions made by the Board of Directors to day-to-

day management decisions.

The independence and unity of the Board is essential to its effectiveness and respect in the

hospital and the community. In fulfilling their responsibilities, Board members serve as moral

agents. Every decision affects the health and well-being of individuals, organizations and

communities. As oral agents, Board members strive for the most ethical course of action; both

by themselves and by the organizations they lead.

1. The Board commits itself and its members to ethical, business-like and lawful conduct,including proper use of authority and appropriate decorum when acting as Boardmembers.

2. Board members interaction with the Chief Executive Officer or with staff must recognizethe lack of authority vested in the individuals except when explicitly Board authorized.

3. Board members interaction with the public, press or other entities must recognize thelimitation and inability of any member to speak for the Board other than as provided for inthe by-laws or any policy.

4. Board members will not express individual judgments of the CEO’s or staff’s performance,except as required to provide input into the evaluation process.

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Hôtel-Dieu Grace Healthcare

POLICY – Code of Conduct, Confidentiality, and Conflict of Interest -

Director and Non-Director Declaration

Page 3 of 5

5. Board members will respect the confidentiality of in-camera sessions and issues of asensitive nature, which may include:

a. personnel or human resource or bargaining information;b. information about patients or physicians;c. job applicants;d. real estate;e. litigation issues, etc.; orf. any other matter of a confidential nature.

6. In the event of a breach of any of the above, the issue will be referred to the CorporateGovernance Committee for review, to take appropriate action, including the removal fromthe Board of Directors or committees upon recommendation to the Board.

CONFIDENITALITY[DD2]

Every director, officer, employee and professional staff member of the corporation shall respect

the confidentiality of matters brought before the Board, keeping in mind that unauthorized

statements could adversely affect the interests of the corporation.

In compliance with the Public Hospitals Act, the Board of Directors of Hôtel-Dieu Grace

Healthcare recognizes the importance of respecting and ensuring the confidentiality of all patient

and employee-related information.

Every director, officer, employee, physician, volunteer and student of the Hospital will respect the

confidentiality of matters brought before the Board, or before any Board Committee.

All directors must adhere to the by-laws, policies and procedures regarding confidentiality of

information. These policies, without limitation, include confidential information, release of patient

information, facsimile of patient information, release of information to the media and personnel

records.

The Chief Executive Officer (CEO) is responsible for ensuring the protection of the personal

information of patients and their families, staff, physicians, volunteers, and students, and all

corporate and business information.

The CEO will take all reasonable steps to ensure that such organizational policies are

implemented consistent with legislative requirements and enable the hospital to handle such

information in a secure and confidential manner.

CONFLICT OF INTEREST [DD3]

Article 9.0 of the June 5, 2018 by-law provides that every Director has a responsibility to report

any such Conflict of Interest to members of the Corporation and the Board of Directors.

Board members have a fiduciary duty to conduct themselves without conflict to the

interests of Hôtel-Dieu Grace Healthcare. In their capacity as Board members, they must

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Page 3 of 5

subordinate personal, individual business, third-party, and other interests to the welfare

and best interests of Hôtel-Dieu Grace Healthcare.

A conflict of interest is a transaction or relationship which presents or may present a

conflict between a Board member’s obligations to Hôtel-Dieu Grace Healthcare and the

Board member’s personal, business or other interests.

All conflicts of interest are not necessarily prohibited or harmful to Hôtel-Dieu Grace

Healthcare. However, full disclosure of all actual and potential conflicts, and a

determination by the disinterested Board of Directors (or Governance Committee) – with

the interested Board member(s) recused from participating in debates and voting on the

matter – are required.

All actual and potential conflicts of interests shall be disclosed by Board members to the

Hôtel-Dieu Grace Healthcare Board Chair through the annual disclosure form and/or

whenever a conflict arises. The disinterested members of the Hôtel-Dieu Grace

Healthcare Board of Directors (or Governance Committee) shall make a determination as

to whether a conflict exists and what subsequent action is appropriate (if any). If the

determination and action is determined by the Hôtel-Dieu Grace Healthcare Governance

Committee, they shall inform the Board of Directors of such determination and action. The

Board shall retain the right to modify or reverse such determination and action, and shall

retain the ultimate enforcement authority with respect to the interpretation and application

of this policy

This policy shall also apply to non-director members of Board Committees.

On[DD4] an annual basis, all Directors and Non-Directors shall be provided with a copy of this

policy and required to complete and sign the declaration form below. All completed forms shall

be provided to and reviewed by the Hôtel-Dieu Grace Healthcare Governance Committee, as

well as all other conflict information provided by Board members.

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Page 3 of 5

DIRECTOR AND NON-DIRECTOR DECLARATION

As a director/non-director of Hôtel-Dieu Grace Healthcare, I acknowledge and accept that the

Board of Directors is accountable to:

The Government of Ontario, government agencies and institutional partners for:

compliance with government regulations, policies and directions;

implementation of directly mandated programs;

implementation of approved capital projects; and

fulfillment of obligations under formal agreements and grants.

Catholic Health International and the Salvation Army for:

governing the affairs of the corporation in accordance with the mission, philosophy and

values as well as the Health Ethics Guide;

ensuring the mission, philosophy and values, and the Health Ethics Guide are integrated

into the strategic plan and operations of the hospital; and

respecting the powers reserved to the Members as set out in the by-law of the Corporation

(Article 3.0).

Its patients, their family members and communities served for:

the quality of the care and safety of patients;

operating in a fiscally sustainable manner within its resource envelope and utilizing its

resources efficiently and effectively to fulfill the hospital’s mission in patient care,

education and research;

engaging the communities served when developing plans and setting priorities for the

delivery of health care; and

the appropriate use of community/donor contributions to the hospital.

The Erie St. Clair LHIN for:

building relationships and collaborating with the Local Health Integration Network (LHIN),

other health service providers, and the community to identify opportunities improving

services within the local health system for the purpose of providing appropriate,

coordinated, effective and efficient services;

ensuring that HDGH operates in a manner that is consistent with provincial plans, the

LHIN’s integrated health service plan and its Hospital Service Accountability Agreement

with the LHIN in order to achieve performance standards;

providing an evidence-based business plan in support of requests for resources to meet

the HDGH mission;

informing the LHIN, of any gaps between needs of the communities served and scope of

services provided;

apprising the LHIN and the communities served of board policies and decisions which are

required to operate within its Hospital Services Accountability Agreement;

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Page 3 of 5

University and College for:

providing an appropriate environment and resources to facilitate education and training ofundergraduate and post-graduate health.

As a director, I agree to comply with the performance expectations as stated in the by-laws,

policies and Board Charter. In addition, I confirm that I have read and understand and/or will

comply with the specific provisions as outlined in this policy, Article 9.0 “Conflict of Interest”,

Article 16.1 “Confidentiality and Public Relations”, Policy V – 2 Role and Responsibilities of the

Board, and the Board Charter.

As a non-director serving on a Board Committee, I have read and understand the performance

expectations as stated in the by-laws, polices and Committee Charter. I understand that I am

also expected to comply with certain provisions as it pertains to my role as a non-Director.

As a director/non-director, I confirm that I do not have a conflict of interest which would prevent

me from serving as a Director of the Board pursuant to Conflict of Interest Guidelines developed

by the Board as appended.

As a director/non-director, I recognize that interaction with the public, press or other entities must

recognizes the limitation and inability of any member to speak for the Board other than as provided

for in the by-laws or any policy.

I hereby consent to act as a director/non-director of Hôtel-Dieu Grace Healthcare. I also hereby

consent pursuant to the provisions of the June 5 2018 by-law of Hôtel-Dieu Grace Healthcare to

the holding of meetings of the Board of Directors or of any committee of the Board of Directors by

means of such telephone, electronic or other communication facilities as permit all persons

participating in the meeting to communicate with each other simultaneously and instantaneously.

These consents will continue in effect from year to year so long as I am a director/non-director of

the Board.

I agree to abide by the confidentiality provisions in the hospital by-law and hospital privacy policies

and I undertake to advise the hospital in writing of any change of address as soon as possible

after such change.

Dated: ______________________________________

Signature: ______________________________________

Print Name: ______________________________________

Address: ______________________________________

______________________________________

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PATIENT COMPLAINTS

Issued by: HDGH Board of Directors NUMBER: II – 2


Category: Corporate Performance REVIEW DATE: January 2019

Committee: Quality Page: 1 of 2

Article 18.01 8.02 (f)(i) of the June 5, 2018 By-law indicates that the Board shall assign establish

such committees as required by the Public Hospital Act, with to the respective standing and

special committees responsibility for the oversight and monitoring of specified Performance

Metrics.

Section 4 of Tthe Quality Committee Charter Terms of Reference specifies that the Quality

Committee shall: monitor and report to the Board on quality issues and on the overall quality of

services provided in the corporation, with reference to appropriate data; and will review reports

and consider recommendations from management and relevant hospital committees regarding

the quality of patient care programs and services and the results of other quality evaluation

activities carried out in the hospital, including changes that may be required as a result of

government policy.

The identification, investigation and management of individual patient feedback or concerns

which, in part, form the basis of this trend analysis, are addressed by hospital staff through a

process for which the Chief Executive Officer bears responsibility.

The Board also encourages feedback from staff, patients, and families as a key instrument to

continuous improvement to achieving the goal of outstanding care. To optimize the usefulness

of feedback provided to Board members, members will refer such feedback to be addressed

within the hospital staff, patient and community relations processes. The Board will not review

individual concerns.

Should a concern relating to a patient’s situation be addressed to a Director of the Board or Board

committee member verbally, that member should accept such feedback with thanks and, to avert

the potential for unintended errors in message transmission by the member, encourage the

complainant to forward it directly to the CEO whose responsibility it is to ensure that it is addressed

using the established resolution process. The Director who received the information will also

inform the CEO of the conversation.

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POLICY – Director and Non-Director DeclarationPatient Complaints

Page 2 of 2

If the concern is addressed to either a Director of the Board or member of a Board committee in

writing, he/she will forward a copy of the letter to the CEO and will provide notice of receiving the

concern to the Board Chair. Thereafter, the concern will be addressed using the established

resolution process.

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CHIEF EXECUTIVE OFFICER AND CHAIR OF PROFESSIONAL

ADVISORY COMMITTEECHIEF OF STAFF EXPENSE REIMBURSEMENT

AND TRAVEL POLICY

Issued by: HDGH Board of Directors NUMBER: III – 6


Category: Oversight of Management and

Professional Staff

REVIEW DATE: January 2019


The responsibilities of the Chief Executive Officer (CEO) and the Chair of Professional Advisory CommitteeChief of Staff (CPACCOS) include duties that require commitments for the hospital, including attendance at hospital related events. It is expected that the CEO/CPACCOS will discuss with the Board Chair the requirements associated with carrying out external duties, both in the community and outside Erie St. Clair area. The CEO/CPACCOS will be compensated for reasonable expenses while carrying out such duties and while traveling on Hôtel-Dieu Grace Healthcare related business. With respect to fundraising, the CEO/CPACCOS and Board Chair will review on an ongoing basis the listing of events to determine the costs which will be covered by the Hospital.

Such reimbursement and/or compensation will be consistent with the expense and travel policies and practices for other employee groups within Hôtel-Dieu Grace Healthcare. In the event that the terms and conditions of employment for the CEO/CPACCOS and the policies for other employee groups within Hôtel-Dieu Grace Healthcare conflict, the terms and conditions of employment will prevail.

The Board Chair, on the recommendations of the Vice President Operations and Chief Financial Officer, will approve allowable expenses and travel claims.

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ASSET PROTECTION AND PURCHASING AND LEASING

Issued by: HDGH Board of Directors NUMBER: IV - 2


Category: Financial Oversight REVIEW DATE: January 2019

Committee: Finance and Audit Committee Page: 1 of 1

The Chief Executive Officer (CEO) is accountable to the Board of Directors to ensure that assets

are reasonably protected, adequately maintained and not placed at unnecessary risk, for the

acquisition of goods and services and property subject to the reserve powers as set out in Article

3.2 of the June 5, 2018 by-law . Accordingly, the CEO will ensure that appropriate administrative

policies and procedures are in place and that these policies and procedures are monitored for

compliance and reviewed periodically by the Finance and Audit Committee of the Board.

The CEO will ensure that Hôtel-Dieu Grace Healthcare

i) maintains adequate liability and property insurance, including Directors liability anderrors and omissions coverage with an appropriate deductible; and

ii) maintains an asset registry.ii)iii) establishes [DD1]practices for leasing, acquisition or disposal of real estate property

(in accordance with the reserve powers), will comply with the Board Investment Policy IV -3 and any Board resolution for Signing Officers, which is passed from time to time

The [DD2]Chief Executive Officer (CEO) is accountable to the Board of Directors of the Hôtel-Dieu

Grace Healthcare to ensure that the hospital has in place administrative policies and procedures

for the acquisition of goods and services and real property subject to the reserve powers as set

out in Article 2.03 of the By-law.

The practices established by the hospital for the leasing, acquisition or disposal of real property

(in accordance with the reserve powers), will comply with the Board Policy VIII-5 and any Board

resolution for Signing Officers, which is passed from time to time.

The Board authorizes the CEO to initiate any commitments contained within an approved

Operating or Capital Plan or otherwise approved by motion of the Board or its delegated

authorities, including any and all: contracts, requisitions, purchase orders, travel authorizations

and any other agreement, financial or otherwise. If emergency expenditures or commitments are

necessary, they must be subsequently submitted for approval at the next appropriate meeting.

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POLICY – Patient Asset Protections, Purchasing and LeasingComplaints

Page 2 of 2

The CEO is accountable to the Board of Directors for ensuring that appropriate administrative

policies and procedures are in place regarding purchasing and leasing, and that these policies

and procedures adhere to legislated or agreements with the Ministry of Health and Long-Term

Care and the Erie St. Clair Local Health Integration network (ESC LHIN). Compliance with this

policy will be monitored and reviewed annually by the Finance and Audit Committee of the Board.

For greater clarity, it is the CEO’s responsibility to ensure appropriate practices are followed in

competitive tendering or invitation for proposal in all purchases of supplies, services, capital,

leases, or agreements, consistent with procurement policies.

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BOARD GOALS AND WORK PLAN

Issued by: HDGH Board of Directors NUMBER: V - 12


Category: Board Effectiveness REVIEW DATE: January 2019


On an annual basis, the Board of Directors will establish goals for the Board consistent with the HDGH mission, vision, the strategic plan, and key issues which are a priority for the Board in the coming year. The Board goals will be reflected in the direction for the Board Standing and Ad Hoc committees and the Board work plan. The Board will review its progress toward the achievement of the annual Board Goals on a quarterly basis. The Board will also establish an annual work plan for the Board which addresses the key areas of the Board duties and responsibilities as delineated in the Board Charter The Board will evaluate its success in the achievement of its work plan as part of the annual board evaluation process and at the meeting of the Board of Directors prior to the annual meeting.

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REVIEW OF BOARD POLICIES

Issued by: HDGH Board of Directors NUMBER: V - 16


Category: Board Effectiveness REVIEW DATE: January 2019


In keeping with best practices in governance, the Governance Committee will annually review Hôtel-Dieu Grace Healthcare’s Board Policies for relevance, and to ensure compliance with By-laws and applicable legislation, and will make recommendations to the Board for revisions as required.

The Board Secretary will be responsible for ensuring that all Board policies are reviewed annually and revised consistent with Board approval.

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SUPPORT RELATIONSHIP WITH HOSPITAL FOUNDATION

Issued by: HDGH Board of Directors NUMBER: VI - 2


Category: Communication and Community

Relationships



A strong and positive relationship between the Hôtel-Dieu Grace Healthcare and the Hôtel-Dieu Grace HealthcareChanging Lives Together Foundation (CLTF) is essential at several levels:

1. The Board of Directors will support the Foundation in their endeavours. The Board will berepresented at the Foundation events when requested by the Foundation.

2. Individual Directors are expected to support the Foundation, and are encouraged tocontribute financially to the Foundation in their fundraising efforts.

3. Regular communications will be essential and achieved through a number of mechanisms:(i) the HDGH CLT Foundation President Board Chair will be invited to make a

presentation to the HDGH Board of Directors semi-annually on their activities on behalf of the hospital;

(ii) the HDGH Board Chair and CEO will meet and consult at least semi-annually with their counterparts in the HDGH CLT Foundation on strategic directions and priorities to ensure alignment of interests. The HDGH Board Chair will report to the HDGH Board on the conclusions and recommendations of these meetings.

(iii) The [DD1]Executive Director of the Foundation may when requested provide the HDGH Board of Directors a report and update on activities of the Foundation

(ii)(iv) Two HDGH Board delegates will represent the HDGH Board as voting members of the CLT Foundation

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CONTRIBUTIONS

Issued by: HDGH Board of Directors NUMBER: VI - 4


Category: Communication and Community

Relationships



Hôtel-Dieu Grace Healthcare will not make direct contributions to political campaigns or to any

elected official.

With the approval of the Board Chair, the Hospital may purchase tickets to events for a provincial

political party, where the presence of the hospital management or the Board is deemed to be

appropriate (e.g. an address to the public or to the health service sector by the government or by

a political party).

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ISSUES

Current by-laws require two minor amendments; 1. Inclusion of a Past Chair position2. French Language Services (FLS) statement

BACKGROUND

Historically the by-laws have been absent of any language for the position of Past Chair,however; there is a desire of the Board to include this moving forward.

Required to include French Language Statement in the Board by-laws

CONSIDERATIONS

CONCLUSION

Include suggested articles to June 5, 2018 by-law

Recommend to the Members for approval

RECOMMENDATION(S)

THAT the June 5, 2018 by-laws be approved as recommended by the Governance Committee and recommended to the Members for approval.


Subject: By-laws


Previous Board/Committee Consideration: June 5, 2018 by-laws approved by the members and February 4, 2019 revision by Governance Committee

These changes have not been vetted through legal they are worded at the suggestion ofthe Governance Coordinator

Governance Committee reviewed and discussed proposed changes (included in attached)

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ARTICLE 13 OFFICERS

13.1 Officers

(a) Officers1 shall include:2

(i) the Chair;3

(ii) one or more Vice-Chairs;

(ii)(iii) Past Chair

(iii)(iv) the CEO; and

(iv)(v) the Secretary;4

(v)(vi) and may include any such other officers as the Board may determine. Subject

to section 3.2(f), the Officers shall be appointed following the annual meeting of

Corporate Members at which the Directors are elected or at such other times

when a vacancy shall occur. A person may hold more than one office with the

exception of Chair and Vice-Chair.

ARTICLE 14 OFFICERS DUTIES5

14.3 Past Chair

The Chair, upon expiration of their term of office, shall serve on the Board for the next ensuing two

years as Past Chair. The Past Chair shall be an Ex-officio Director and shall also serve as a member

of the Executive Committee.

In the event that the term limit of the individual who is Past Chair shall have expired, the Board of

Directors shall have the authority to retain this individual on the Board, in the position of Past Chair,

for a term of one year.

(a) The Past Chair shall be appointed by the Board, subject to the approval of the

Corporate Members in accordance with section 3.2(f).

(a)(b) The Past Chair shall;

1 Officers are appointed to facilitate the work of the Board in accordance with the terms of their appointments. Officers and directors are distinct from one another, although often officers are also directors and in the case of the President, this is mandated by Corporations Act (Ontario) section 289(1).

2 See Public Hospitals Act (Ontario) Regulation 965 section 4(1)(a). 3 Corporations Act (Ontario) section 289 requires appointment of a president, referred to as the “Chair” here, who

need be a director. 4 Corporations Act (Ontario) section 289 requires appointment of a secretary who need not be a director. 5 See Public Hospitals Act (Ontario) Regulation 965 section 4(1)(a).

Formatted: List Paragraph, No bullets or numbering,

Widow/Orphan control, Adjust space between Latin

and Asian text, Adjust space between Asian text and

numbers

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https://www.canlii.org/en/on/laws/stat/rso-1990-c-c38/latest/rso-1990-c-c38.html?autocompleteStr=corporations%20act&autocompletePos=2

https://www.canlii.org/en/on/laws/stat/rso-1990-c-p40/latest/rso-1990-c-p40.html?autocompleteStr=public%20hospitals%20act%20ontario&autocompletePos=1

https://www.canlii.org/en/on/laws/regu/rro-1990-reg-965/latest/rro-1990-reg-965.html



https://www.canlii.org/en/on/laws/stat/rso-1990-c-p40/latest/rso-1990-c-p40.html?autocompleteStr=public%20hospitals%20act%20ontario&autocompletePos=1

https://www.canlii.org/en/on/laws/regu/rro-1990-reg-965/latest/rro-1990-reg-965.html

(i) assist with the appropriate succession of board members;

(ii) support the Chair in his/her role, provide continuity to the organization by

providing historical context for issues;

(iii) perform such other duties as may be prescribed from time to time by the

Board

Formatted: Numbered + Level: 1 + Numbering Style: i,

ii, iii, … + Start at: 1 + Alignment: Left + Aligned at:

1.25" + Indent at: 1.5"

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ARTICLE 12 RESPONSIBILITIES OF DIRECTORS

12.2 French Language Services Plan

(a) The Board of Directors is committed to

i. the active offer of French Language Services

ii. the provision of French Language Services upon request

iii. inclusion of the French Language Services Plan in new Director orientation

iv. endeavor to achieve Francophone representation on the Board of Directors ;

1. 1 Francophone per board of 9 or less OR

2. 2 Francophones per board of 10 or more

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Board of Directors OPEN Meeting Minutes

1453 Prince Road, Windsor Corporate Boardroom

January 30, 2019

Directors Present

M. Horrobin, Chair, B. Payne, Vice Chair, K. Blanchette, L. Lombardo, R. Shahbazi, C. DeBiasio, D. Wellington, P.

Soulliere, J. Clark (telecon) E. Kelly, A. Daher, H. Ambreen, C. Gallant

Directors Absent

M. Lomazzo

Ex-Officio Present M. Campigotto, Chief Nursing Officer, Dr. A. Steen, Chief of Staff, J. Kaffer, Chief Executive Officer, L. O’Rourke,

Patient Family Rep,, F. Bagatto, CHI Director,

Ex-Officio Absent

Dr. D. Hellyer, President Professional Staff Association

Administration Present

D. Dutot (Recorder), M. Campagna, M. O’Shea, B. Marra, M. Broga, M. Benson-Albers. J. Karb

1.0 CALL TO ORDER, OPENING PRAYER & LAND ACKNOWLEDGEMENT

The Board Chair called the meeting to order at 4:42 pm

Prayer and Land Acknowledgement

1.1 QUORUM

Confirmed

1.2 CONFLICT OF INTEREST

No conflicts were declared

2.0 RISK MANAGEMENT - EDUCATION

S. Tompkins provided Risk Management Education:

Integrated Risk Management Program: to achieve vision as a trusted leader, ensuring patient

and staff safety, assessment of risk, mitigate impact on patients, and assist Board in fulfilling

responsibilities

Developed program and implemented for 4 years,

Objectives reviewed

Framework is simplified to ensure appropriate monitoring

Identification is done with the assistance of HIROC

Sources of Risk at HDGH

Assess risks: anything high risk is on the Risk Profile Summary- updates provided to the Board

and Standing committees (domains were reviewed)

Risk Mitigation

Monitor/Report/Learn: ensure effective processes

ACTION: Presentation to be posted to Board Portal Resources

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January 30, 2019

3.0 APPROVAL OF FULL AGENDA

It was moved by L. Lombardo and seconded by B. Payne THAT the January 30, 2019

agenda be approved as amended. CARRIED

4.0 ITEMS REQUIRING DECISION

4.1 Year-to-date Financials; December 31, 2018

P. Soulliere and M. Campagna reviewed the YTD Financial Statements as presented to the

Finance and Audit Committee:

Surplus in hospital operations for Ministry purposes of $1.7M compared to a budgeted

deficit of $1M. Primarily due to the timing of the HIS implementation. The budget had

contemplated a September 2018 start date. Costs are minimal at this point in time, $0.3M

spend YTD, project timelines have been deferred mostly into next fiscal year

Received two HIROC cheques, totaling $0.4M this fiscal year

Most vacancies previously reported are now filled

It was moved by P. Soulliere and second by C. Gallant THAT the Board of Directors approve

the December 31, 2018 Year-to-Date Financial Statements, as recommended by the

Finance and Audit Committee. CARRIED

4.2 Professional Staff By-laws

Dr. Andrea Steen reviewed the briefing note circulated in advance of the meeting;

Last by-laws were approved in December 2017

Changes highlighted;

o Language is streamlined and references the prototype from a 2011 Ontario Health

Association (OHA)/Ontario Medical Association (OMA) publication;

o The re-naming of the Professional Advisory Committee (PAC) to Medical Advisory

Committee (MAC);

o Changing the title of the “Chair of the Professional Advisory Committee” to “Chief

of Staff”;

o For all new Associate Active Appointments, the duty to apply within six (6) months

for an academic appointment with the Schulich School of Medicine and Dentistry;

and

o Physicians appointed to the Consulting Staff Category are reviewed annually at

the time of re-appointment by the Chief of Staff rather than the Windsor Regional

Department Chief, last approval was in Dec 2017, used prototype from OHA &

OMA

Approvals by all professional groups

o December 14, 2018 Quarterly Professional Staff meeting

o December 20, 2018 Medical Advisory Committee

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January 30, 2019

It was moved by B. Payne and seconded by L. Lombardo THAT the Hôtel-Dieu Grace

Healthcare Board of Directors approve the January 30, 2019 Professional Staff By-Laws

recommended by the Medical Advisory Committee. CARRIED

4.3 Lead Agency Update; Core Services Delivery & Community Mental Health Report 2019/2020

Dr. Mary Broga, reviewed the report included in the package. This information is required earlier

than in past years due to the changes of the ministries. Children and Youth Mental Health was

transferred from the former Ministry of Children & Youth Services to Ministry of Health and Long-

Term Care in October 2018. With this transfer, MOHLTC asked that Lead Agencies submit their

Mental Health Plans by mid-February rather than at year-end.

The goal when developing the plans is to ensure that local plans align with Provincial plans.

Priorities were developed through consultation with the following:

Core Service Providers (Children First, RCC, Maryvale, Family Respite)

Directors’ Forum (representatives from Education, Public Health, Child Welfare,

Developmental Services, Municipality, Youth Justice, Probation, Primary Care, Family

Services, Adult Mental Health)

The plan approved in March 2018 successfully achieved three priorities;

1. JK/SK Intensive Services

2. Crisis Continuum alignment

3. Care Pathways for cross sector partners

The working tables continue to develop strategies to address Central Access, Youth

Homelessness and Children & Youth with Challenging Behaviors.

Actions taken to date were reviewed and briefly discussed.

The recommended priorities for child and youth mental health for Windsor- Essex include:

Central Access

Youth Homelessness

Children and youth with Challenging Behaviours

Strengthening the interface between Primary Care and Child & Youth Mental Health

Services

It was moved by B. Payne and seconded by P. Soulliere THAT the HDGH Board of Directors

approve the recommended priorities of; Central Access, Youth Homelessness, Children

and youth with Challenging Behaviours, Strengthening the interface between Primary Care

and Child & Youth Mental Health Services. CARRIED

5.0 APPROVAL OF CONSENT AGENDA – 5.1 TO 5.3

The Chair inquired if anyone wished to remove any item; nothing was suggested or amended.

It was moved by C. Gallant his and seconded by K. Blanchette THAT the consent agenda

be approved as presented and amended. CARRIED

6.0 BUSINESS ARISING – NONE

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January 30, 2019

7.0 COMMITTEE REPORTS

The Committee reports were included in the meeting package and provided for information

purposes.

7.1 Quality Committee – Jan 21

K. Blanchette reviewed the report submitted for information

Operations Utilization Committee Report

Quality Framework was reviewed

Accreditation Update

7.2 Workplace Excellence Committee – Dec 4

There was no discussion/questions, the report covered the following:

Policy Update; Substance Abuse

Accessibility Working Group

Workplace Violence Committee Update

Continuous Improvement Plan

Annual Safety Report

7.3 Finance and Audit Committee – Jan 28

P. Soulliere provided a verbal report:

YTD financial statements approved

Financial scorecard reviewed

Non-Competitive Procurement Sole Source

Attestation of Regulatory Compliance

Investment Certificate

HAPS & CAPS timeline

7.4 Medical Advisory Committee – Nov 7

Dr. Steen report included, no questions/discussion

8.0 ITEMS FOR INFORMATION

8.1 VP Medical Affairs, Quality

Deferred to March

8.2 VP External Affairs & Executive Director Changing Lives Together Foundation

B. Marra included a written report; discussion regarding Ethics. Board complimented the detail

of the report. There were no questions or further discussion.

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January 30, 2019

8.3 French Language Services Plan

J. Wyle provided a briefing note for M. Benson-Albers to present to the Board. Points of

highlight:

Beginners Conversational French course offered, full session and all staff graduated

Automated French phone system fully working

8.4 Accreditation Planning

K. Blanchette discussed the accreditation planning and status to date;

Board working group had to cancel meeting and will rebook

Few moderate concerns all being addressed

Accreditation leads participated in tracer methodology training

Medication Reconciliation on admission is meeting target, on discharge still has some

work required

Creation of documents and updating to brochures is going well

9.0 EXECUTIVE HIGHLIGHTS

9.1 Board Chair Report

M. Horrobin sent letter to ESC LHIN to request that HDGH attend a LHIN Board meeting to

present highlights and work at HDGH; no response has been received to date.

Board Chair and CEO attending a CHAO meeting on Feb 27. Discussion for the day will focus

on how Catholic Healthcare can fully participate and thrive during a time of healthcare

integration.

Patient Safety Symposium – St. Clair, HDGH and DMC on February 8, 2019

10.0 DATE OF NEXT MEETING – March 27, 2019

11.0 ADJOURNMENT

The Chair adjourned the meeting at 5:36 pm

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QUALITY COMMITTEE MINUTES - OPEN MEETING

MONDAY, JANUARY 21, 2019 7:30 AM CORPORATE BOARDROOM

MEMBERS PRESENT: K. Blanchette, Chair

H. Ambreen

D. Wellington

L. O’Rourke

Dr. A. Steen, COS, VP Med

H. Wong

B. Eagen

K. Brisebois

ADMINISTRATION: A. Murray

D. Dutot

S. Grbevski

S. Tompkins

K. Quinlan

J. Karb

J. Kaffer. CEO

REGRETS: M. Campigotto, CNO

GUESTS: none

1.0 CALL TO ORDER & PRAYER

The Chair called the meeting to order at 7:32 a.m.

1.1 Quorum

Confirmed


None declared


2.1 Agenda – January 21, 2019

There were no amendments suggested or made.

It was moved by K. Brisebois and seconded by L. O’Rourke THAT the agenda of the

January 21, 2019 Open meeting be approved as circulated. CARRIED

2.2 Minutes – November 12, 2018

It was noted that L’O’Rourke was not included in attendance; the minutes were amended to

include her in attendance.

It was moved by L. O’Rourke and seconded by H. Ambreen THAT the minutes of the

November 12, 2018 Open meeting be approved as amended. CARRIED



4.1 Operations Utilization Committee

A. Murray highlighted the briefing note included in meeting package; outlining the purpose of

this committee, work completed throughout 2018, scorecard and focus for 2019. The CFO is

the Chair of this committee and J. Karb, VP Restorative Care is a member.

Purpose: ensuring that bedded inpatient space is optimized from a quality of care, access and

flow, alignment with HDGH mandate, community and funding perspective.

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J. Karb outlined the project of standardizing care; this benefits the patient by identifying and

providing the appropriate level of care.

4.2 Quality Framework

The framework was drafted and Board approved in 2018, so it is still fairly new. A

communications plan was just developed for implementation/roll out across the organization.

A review of the framework will be included on the committee and Board workplan annually.

There are some potential changes to the framework over the next year; this will be brought

forward to the Quality Committee.

4.3 Accreditation Update

K. Quinlan reviewed the infographic included with the meeting materials. Patient family

representatives have been very involved in many areas of accreditation. Accreditation leads

completed tracer education; this will be used as an ongoing Quality Improvement Initiative.

Concerns:

Some areas have not completed the draft evidence and action plans (target date of

completion was end of December)

Medication Reconciliation on Discharge

Medication Reconciliation in the Outpatient and Ambulatory Clinics.

Improving the “Safety Metric Boards” on units

Need ROP owners to update information for Accreditation Handbook

Next steps:

Front line staff selected and have joined working groups as well as Patient Family Advisory

Council members for some standards to add to evidence and assist with action plans.

Course correction for areas that have not completed evidence, next target date of

completion set for end of January

Medication Reconciliation on Discharge, SOP being created with necessary forms from

HMM system, building system to monitor and report metrics through HIM

Medication Reconciliation in Outpatients; Current state mapping completed for all 14

programs and draft BPMH document created for trial on units

Met with Operations and Clinical Practice Managers about the “Safety Metric Boards” draft

created and will be seeking feedback from Unit Based Councils, Infection Protection Quality

Committee and Patient Family Advisory Council

Creation of Discharge package and “caring about your safety brochure”

Completion of all brochures (well over half completed and available for print)

Communications plan for Need to Know articles, poster boards on units, Accreditation

Jeopardy and Accreditation Handbook

Mock Accreditation scheduled for March 29, 2019

5.0 OTHER BUSINESS - none

6.0 DATE OF NEXT MEETING – February 19, 2019

7.0 ADJOURNMENT

The Chair adjourned the meeting at 7:45 am

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QUALITY COMMITTEE MINUTES - OPEN MEETING

TUESDAY, FEBRUARY 19, 2019 7:30 AM CORPORATE BOARDROOM

MEMBERS PRESENT: B. Payne, Acting Chair (Vice

Chair of Board)

H. Ambreen

D. Wellington

Dr. A. Steen, COS, VP Med

H. Wong

B. Eagen

L. O’Rourke

ADMINISTRATION: A. Murray

D. Dutot

S. Grbevski

S. Tompkins

K. Quinlan

J. Karb

M. Campigotto, CNO

J. Kaffer, CEO

REGRETS: K. Blanchette, Chair K. Brisebois

GUESTS: none

1.0 CALL TO ORDER & PRAYER

The Chair called the meeting to order at 7:33 a.m.

1.1 Quorum

Confirmed


None declared


2.1 Agenda – February 19, 2019


It was moved by B. Eagen and seconded by L. O’Rourke THAT the agenda of the

February 19, 2019 Open meeting be approved as circulated. CARRIED

2.2 Minutes – January 21, 2019


It was moved by H. Ambreen and seconded by L. O’Rourke THAT the minutes of the

January 21, 2019 Open meeting be approved as distributed. CARRIED



4.1 Emergency Preparedness Committee

Deferred to March meeting

4.2 Ethics Committee

B. Marra provided an update; H. Markwell is still providing Ethics services to HDGH on a

contract basis, she visits onsite once per month and attends the Ethics Committee meetings

while here. There has been some discussion around the Ethical Decision Making Framework,

YODA is utilized and familiar to front line staff.

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The Committee has been working through a fulsome review of related policies.

Through the Values Integration Appraisal Process, there were several recommendations for

improvements to service delivery by Spiritual Care, and some relative to Ethics; these are

under review and many have been actioned.

Some front line staff have attended the Ethics training through St. Paul’s University. HDGH

will be one of four hospitals that may undertake a partnership with St. Paul’s.

The Patient Advocate will be retiring in June, looking to restructure Ethics, Spiritual Care, and

Patient Advocate; details are unknown but will be shared with the Committee when finalized.

The long standing relationship with H. Markwell, will help to assist with the review of these

portfolios.

4.3 Infection Prevention and Control Scorecard – Q3

M. Campigotto reviewed the following highlights:

Hand hygiene rate is 98% before patient contact and 97% after patient contact

Training has been provided to all managers in order to complete audits

One case of C. Diff; patient admitted from acute care immunocompromised and taking

antibiotic. Not other patients with C-diff on unit.

MRSA very good; no bacteremia in last 5 quarters

One patient admitted from acute care with VRE

4.4 Accreditation Update

K. Quinlan reviewed the Q3 report circulated in advance of the meeting:

Welcome packages have begun distribution, ‘information upon admission’ results

should improve at next report

Data for ‘information upon discharge’ is still low, looking to create a discharge

information package

Real time surveys began in January, have received good feedback. The report will be

provided to PFAC

Group of staff received training to complete Tracers from Accreditation Canada, this

will be an ongoing initiative to ensure all quality standards are continually being met.

Currently taking place weekly in preparation of Accreditation.

Flags: improved

Mock Accreditation scheduled for March 29, 2019

5.0 OTHER BUSINESS - none

6.0 DATE OF NEXT MEETING – March 18, 2019

7.0 MOTION TO MOVE IN-CAMERA

It was moved by B. Eagen and seconded by D. Wellington THAT the meeting move in-camera.

CARRIED

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Board of Directors

Workplace Excellence Committee

Open Meeting Minutes

Conference Room #1,

December 4, 2018 7:30 am

Directors Present:

M. Lomazzo (Chair) M. Winterton R. Shahbazi A. Daher (telecom)

C. DeBiasio (until 8:10) J. Barile(7:54) S. Bender(7:47)

Guests: J. Wyllie

Administration: M. Benson-Albers, CHRO D. Dutot, Governance Coordinator

S. McGeen, Director HR

Regrets: J. Kaffer K. Gregoire A. Tuovinen

1.0 CALL TO ORDER & OPENING PRAYER The Chair called the meeting to order at 7:31 a.m. followed by the prayer

1.1 Confirmation of Quorum Confirmed

1.2 Declaration of Conflict of Interest None was declared

2.0 FOR APPROVAL/RECOMMENDATION 2.1 Agenda; December 4, 2018 There were no amendments suggested or made. It was moved by M. Winterton and seconded by C. Debiasio THAT the agenda of the December 4, 2018, Workplace Excellence Committee meeting be approved as circulated. CARRIED

2.2 Minutes; September 11, 2018 There were no amendments suggested or made. It was moved by R. Shahbazi and seconded by M. Winterton THAT the minutes of the September 11, 2018, Open Workplace Excellence Committee meeting be approved as amended. CARRIED

3.0 BUSINESS ARISING

Job Hazard Analysis update: included in Item 4.4 Annual Safety Report

Substance Use Policy update: Draft policy approved by Senior Management Counciland will be assigned for staff to review and sign off, through the Halogen program

4.0 FOR INFORMATION 4.1 Accessibility Working Group; Statement of Commitment J. Wyllie, Chair of the Accessibility Working Group and Executive Coach, described the steps that have taken place to date. Group began meeting in 2017, and have explored how other faith based hospitals/organizations are addressing accessibility and conducted ‘walkabouts’ of the HDGH campus, to assist in the development of an ‘Accessibility Plan’ A draft plan will be shared with the Mission Achievement Team in January. A call out will take place in the new year for frontline and community representatives to establish the Accessibility Advisory Committee; plan to target members with lived experiences.

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4.2 Workplace Violence Committee Update Report included in the meeting package, M. Benson-Albers highlighted some of the details:

Formal communications plan to increase awareness to staff

Regular reports at each monthly meeting for monitoring

eVOLVE project must include the capability for chart flagging

Hoping to update Violence Risk assessment

Updating Workplace Violence Policy

4.3 Continuous Improvement Plan/Health & Safety Risk Management/Integrated Risk Management/health & Safety Update and Metrics S. McGeen pointed out the information included in the meeting package and asked if there was any questions, there was brief discussion regarding some of the metrics. No lost time injuries in September and October lower than last year. Sick time noted to have spiked in October in both 2018 and 2016 – discussion about if is a trend and what reason may be.

4.4 Annual Safety Report MBA highlighted the report table dropped for the committee. This is a draft document and the final will be provided to the Board in January 2019. The annual report highlights much of the data and initiatives that has been reported out and taken place over the last year. She pointed out several items that are of importance.

5.0 OTHER BUSINESS

6.0 DATE OF NEXT MEETING: February 12, 2019

7.0 MOTION TO ADJOURN The Chair adjourned the meeting at 8:26 am

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Open Minutes Hôtel-Dieu Grace Healthcare Medical Advisory Committee

Corporate Administration Boardroom December 5, 2018

Present: Dr. A. Steen (Chair) M. L. Hebert Dr. L. Cortese Dr. N. Liem Ms. L. DiRosa Ms. M. Campigotto, CNO Mr. J. Karb, VP Dr. J. Cohen Dr. M. Askew Dr. H. Virk Dr. D. Hellyer

Regrets: Ms. J. Kaffer, CEO Dr. K. Levang Ms. S. Grbevski, VP Dr. L. Jacobs Dr. B. Burke

Recorder: Ms. A. Brooks

1. CALL TO ORDERThe Chair, Dr. A. Steen, called the open meeting of the Medical AdvisoryCommittee to order at 1207hrs.

1.1 QUORUM

Quorum was established.1.2 DECLARATION OF CONFLICT

None declared.1.3 APPROVAL OF THE AGENDA MOTION It was MOVED by Dr. L. Cortese and SECONDED by Dr. J. Cohen, that the agenda for December 5, 2018 be approved as written. CARRIED.

2. PRESENTATIONS/REPORTS2.1 PROGRAM UPDATE PRESENTATION – DR. M. ASKEW

Dr. M. Askew presented an update on the Complex Medical Care area andthe Geriatric Rehab Program (RH1).

o It was stated that a pilot has been started on 3 North with DischargeMedication reviews and has been progressing well with no issues sofar.

o Discussions have been held on 3 North regarding treating patients withaddiction concerns.

o 3 North has started co-horting patients with amputees in rooms and ithas been going well. Co-horting the amputees together has beengood for pain management and overall morale of the patients.

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o It was commented that staff have found it helpful to have Dr. Seslijaattend CMC to assist with patient goals for rehabilitation.

o The Geriatric Rehab program (RH1) remains quite busy with a higherrate of admissions to the unit.

3. CONSENT AGENDA ITEMS3.1 APPROVAL OF THE MINUTES MOTION It was MOVED by Dr. J. Cohen and SECONDED by Dr. L. Cortese, that the minutes of the Medical Advisory Committee held on November 7, 2018 be approved as written. CARRIED.

3.2 REGIONAL PHARMACY & THERAPEUTICS COMMITTEE – November 14, 2018

Members reviewed the minutes from the November 14, 2018 meeting.The following motions were presented for acceptance:

1811-01 P&T

1811-02 P&T 1811-03 P&T 1811-04 P&T 1811-05 P&T 1811-06 P&T 1811-07 P&T

Approve cyproheptadine for formulary addition in the ER only, for use in severe serotonin syndrome in consultation with a toxicologist. Approve the addition of Tolnaftate (Tinactin) powder to formulary. Approve Antiplatelet switching guideline Approve the desvenlafaxine therapeutic interchange to the formulary agent venlafaxine. Approve Tetanus interchange Approve the addition of liver function testing to the medical directive for lab ordering. Approve the Tamiflu automatic stop medical directive once outbreak has been lifted from Infection Control.

MOTION It was MOVED by Dr. J. Cohen and SECONDED by Dr. L. Cortese, that the motions from the November 14th Pharmacy& Therapeutics Committee are approved with the exception of motions: 1811-01 P&T, 1811-03 P&T,1811-05 P&T, and 1811-07 P&T. CARRIED.

3.3 INFECTION PROTECTION & CONTROL COMMITTEE – November 15, 2018

The minutes from the November 15, 2018 meeting were presented tomembers as information.

3.4 MENTAL HEALTH & ADDICTIONS PROGRAM MEETING MINUTES – November 7, 2018.

The program meeting minutes were presented to members as information.

3.5 RESTORATIVE CARE PROGRAM MEETING – No Meeting in November 2018.

4. BUSINESS ARISING

None to report.

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5. REPORTS5.1 REPORT OF THE ASSOCIATE DEAN, WINDSOR FACULTY AFFAIRS–SCHULICH – Dr. L. Jacobs

The report of the Associate Dean was presented to members as informationto members. Highlights include:

o The Windsor Campus hosted the annual Anatomy & Healthcare Day(AHD) on November 14. This year’s AHD included participation of all three local school boards, each bringing twenty students to the innovative educational event.

o On November 26, the Windsor Campus hosted a town hall update ofcurriculum renewal. Course leadership opportunities are available withthe change in curriculum. Drs. Sophia Thomas and Sabeen Anwarwere both welcomed into their roles as Windsor Leads for the newPrinciples 1 and 2 courses. Other opportunities will soon beannounced.

o Windsor faculty who were 2018 Award of Excellence teachers werehonoured at the University of Windsor’s Celebration of TeachingExcellence event.

o Schulich student Holiday party is scheduled on December 10, 2018 atAmbassador Golf Club. Tickets are $40. Faculty are welcome toattend.

5.2 REPORT OF THE CEO – Ms. J. Kaffer

No report.

5.3 REPORT OF THE VP, MENTAL HEALTH & ADDICTIONS– Ms. S. Grbevski

No report.

5.4 REPORT OF THE INTERIM VP RESTORATIVE CARE – Mr. J. Karb

No report.

5.5 REPORT OF THE CHIEF NURSING OFFICER – Ms. M. Campigotto

The CNO stated that the policy on Cannabis Use will be circulated to MedicalAdvisory Committee members for approval within the next few weeks throughemail.

5.6 REPORT OF DIRECTOR OF QUALITY AND HEALTH INFORMATION MANAGEMENT – Ms. A. Murray

No report.

5.7 REPORT OF THE CHAIR – Dr. A. Steen

The Chief of Staff announce that the bylaws will be presented for vote at theStaff Quarterly meeting on December 14th for approval. They will go to theBOD in January for final approval.

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The Chief of Staff noted that during the Joint Credentials Committee meetingit was discussed that physicians that receive complaints from College ofPhysicians and Surgeons of Ontario (CPSO) need to be disclosed to theMedical Affairs Office and Chief of Staff. Physicians that do not reportcomplaints could face disciplinary actions including but not limited to aninterview before the Joint Credentials Committee.

It was announced that the Medical Advisory Committee (MAC) for Januarywill be cancelled and due to absences, the next MAC meeting will take placeon February 13th.

The Chief of Staff spoke to members about auto-forwarding of hospital email.It was stated that some physicians have their HDGH email addresses set upto automatically forwarded to their personal email address. Do to thesensitive information and privacy concerns this is unable to occur as personalemail addresses are unsecure. It was noted that this concern will bediscussed at the December 14th Quarterly Staff Meeting as well.

6. DATE OF THE NEXT MEETING

The next Medical Advisory Committee will meet on Wednesday, February 13,2018 at 12:00pm.

7. ADJOURNMENTThe Medical Advisory Committee Open meeting was adjourned at 1223 hours.MOTIONIt was MOVED by Dr. H. Virk and SECONDED by Dr. L. Cortese to move tothe In Camera Medical Advisory Committee Meeting. CARRIED.

Submitted by:

Dr. A. Steen, Chief of Staff, Hôtel-Dieu Grace Healthcare

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Open Minutes Hôtel-Dieu Grace Healthcare Medical Advisory Committee

Corporate Administration Boardroom February 13, 2019

Present: Dr. A. Steen (Chair) M. L. Hebert Dr. L. Cortese Dr. N. Liem Ms. L. DiRosa Ms. M. Campigotto, CNO Ms. J. Kaffer, CEO Dr. J. Cohen Dr. H. Virk Mr. J. Karb, VP Dr. D. Hellyer Dr. K. Levang

Regrets: Ms. S. Grbevski, VP Dr. L. Jacobs Dr. B. Burke Dr. M. Askew

Recorder: Ms. A. Brooks

1. CALL TO ORDERThe Chair, Dr. A. Steen, called the open meeting of the Medical AdvisoryCommittee to order at 1207hrs.

1.1 QUORUM

Quorum was established.1.2 DECLARATION OF CONFLICT

None declared.1.3 APPROVAL OF THE AGENDA MOTION It was MOVED by Dr. L. Cortese and SECONDED by Dr. J. Cohen, that the agenda for December 5, 2018 be approved as written. CARRIED.

2. PRESENTATIONS/REPORTS2.1 C-Difficile Order Set – S. Picco

S. Picco presented the C-Difficile Order Set to members. The medication onthe Order Set was discussed. ACTION J. Cohen will present the C-Difficile Order Set for review at the next Restorative Care Meeting in February. MOTION It was MOVED by Dr. D. Hellyer and SECONDED by Dr. J. Cohen to approve the C-Difficile Order Set as written. CARRIED.

3. CONSENT AGENDA ITEMS3.1 APPROVAL OF THE MINUTES

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MOTION It was MOVED by Dr. L. Cortese and SECONDED by Dr. D. Hellyer, that the minutes of the Medical Advisory Committee held on November 7, 2018 be approved as written. CARRIED.

3.2 REGIONAL PHARMACY & THERAPEUTICS COMMITTEE – January 16, 2019

Members reviewed the minutes from the January 16, 2019 meeting. L.Hebert discussed the action item regarding Jellido in the Pharmacy &Therapeutics minutes.ACTIONA memo from HDGH Pharmacy will be circulated to the physicians fromMedical Affairs informing the physicians of the change with Jellido.

The following motions were presented for acceptance:190116-01 Approve the deletion of both etidronate and procyclidine from formulary.

190116-02 Approve and adopt the porposed therapeutic substitution of Tapentadol (Nycynta ER) to Tramadol XL (Tridural XL).

190116-13 Approve future order sets not having HS sedation module included. Future order sets submitted to the Order Set Committee for revisions will have the HS sedation module removed.

MOTION It was MOVED by Dr. D. Hellyer and SECONDED by Dr. L. Cortese, that the motions from the January 16th Pharmacy& Therapeutics Committee are approved. CARRIED.

3.3 INFECTION PROTECTION & CONTROL COMMITTEE – December 20, 2018 and January 17, 2019

The minutes from the December 20 and January 2019 meeting werepresented to members as information.

3.4 MENTAL HEALTH & ADDICTIONS PROGRAM MEETING MINUTES – December 12, 2018, January 9, 2019.


3.5 RESTORATIVE CARE PROGRAM MEETING – December 20, 2018 & January 17, 2019.


4. BUSINESS ARISING

None to report.

5. REPORTS5.1 REPORT OF THE ASSOCIATE DEAN, WINDSOR FACULTY AFFAIRS–SCHULICH – Dr. L. Jacobs

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The report of the Associate Dean was presented to members as informationto members. Highlights include:

o The Class of 2020 participated in a career guidance “speed-dating”session. Brief interviews were offered with the Associate Dean (career exploration), 4th year coordinator (clinical electives), and Learner Equity and Wellness coordinator (CaRMS match strategy). This was a well-received initiative.

o Work continues with medical school curriculum renewal to a fullycompetency-based model. Year 1 and 3 are set to transition thisSeptember. There will be many new opportunities for leadership, smallgroup facilitation, clinical skills teaching and coaching to be announcedsoon.

o Dr. B. Burke has stepped down as Windsor Assistant Program Directorfor Psychiatry. A search is currently underway for his replacement. Dr.Burke was instrumental in the development of Western’s firstdistributed Specialty Residency Training Program.

o Dr. Chandlee Dickey, Chair/Chief Psychiatry for London, visitedWindsor on January 25, 2019 where she met with a number of faculty,staff and residents.

o Nominations remain open for the Windsor Campus Awards ofExcellence. These can be made at:https://www.schulich.uwo.ca/about/awards/awards_of_excellence/awards_of_excellence__windsor_campus_forms.html. The Gala isscheduled for April 9, 2019. Tickets, including table sponsorship, willbe available in February.

5.2 REPORT OF THE CEO – Ms. J. Kaffer

The CEO gave members a brief update on the latest government updates. Itwas stated that currently there has been no direction regarding Healthcarechanges given by the government to the hospital. Members discussed thelatest government news item regarding leaked documents indicated widescale changes to the Healthcare system. The CEO stated that once officialnotification has been given to the hospital members will be updated. TheCEO noted that there may be substantive change in the Healthcare systemwithin the structure of the LHIN’s or through the creation of a super agency.At this time no Healthcare partners are aware of the changes that will occur.Provincial legislation will be tabled at the next house sitting on February 19th

and more information will be provided at that date.

5.3 REPORT OF THE VP, MENTAL HEALTH & ADDICTIONS– Ms. S. Grbevski

No report.

5.4 REPORT OF THE INTERIM VP RESTORATIVE CARE – Mr. J. Karb

No report.

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https://www.schulich.uwo.ca/about/awards/awards_of_excellence/awards_of_excellence__windsor_campus_forms.html

https://www.schulich.uwo.ca/about/awards/awards_of_excellence/awards_of_excellence__windsor_campus_forms.html

5.5 REPORT OF THE CHIEF NURSING OFFICER – Ms. M. Campigotto

No report.

5.6 REPORT OF DIRECTOR OF QUALITY AND HEALTH INFORMATION MANAGEMENT – Ms. A. Murray

The Go live date for the new HIS Project is set at April 2020.

Cerner will be on site in March 2019. The Chair stated that physicians arecurious to see what the new system will look like. The Director informedmembers that in March demos will be completed with specific work groups.There are 20 specific work groups. Physicians will be asked to participatewithin some of the work groups. The Director will give interested physiciansinformation regarding time commitment. The Chair noted that a Joule Courseon Leading change will be held on February 22nd and 12 physicians fromHôtel-Dieu Grace Healthcare will be in attendance.

5.7 REPORT OF THE CHAIR – Dr. A. Steen

The next Professional Staff Quarterly will occur on March 8th. Arepresentative from Ellis Graphics will be on site for any physicians wanting topurchase White Coats. The Professional Staff will be holding the annualelection for the Professional Staff Association slate of officers.

The Chair spoke to members about the Annual Canadian LeadershipConference that will be held on April 25 – 27th. The Chair noted that this is anexcellent course with great speakers. Physician members were remindedthat they are able to use CME funding that is included as part of theirleadership role to pay to attend. The flyer for the event was discussed withmembers.

The Rehabilitation Lead notified members that Beyond Disability will beholding an Open House with community partners on Feb. 22nd on campus. Itwas stated that eight or nine organizations will be present, such as; iDecide(legal aid), Handi-Transit, Windsor Amputees, and ALSO. TheCommunications Department will be advertising the event (for staff andpublic). The Chair stated that the Geriatric Conference on February 23rd, willalso feature some booths from local not for profit organizations such asOsteoporosis Canada, Alzheimer’s Society, and others, to inform physiciansabout services available in the community.

Windsor’s 6th Annual Geriatric Conference will take place on Saturday,February 23rd, 2019 in the Brown Auditorium. Registration attendance iscurrently over 50% full.

6. DATE OF THE NEXT MEETING

The next Medical Advisory Committee will meet on Wednesday,March 6,2019 at 12:00pm.

7. ADJOURNMENTThe Medical Advisory Committee Open meeting was adjourned at 1243 hours.MOTION

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It was MOVED by Dr. H. Virk and SECONDED by Dr. L. Cortese to move to the In Camera Medical Advisory Committee Meeting. CARRIED.

Submitted by:

Dr. A. Steen, Chief of Staff, Hôtel-Dieu Grace Healthcare

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Quality Committee - Open Meeting Report For Information only

Date of Meeting: February 19, 2019

Author: D. Dutot for B. Payne

MEETING HIGHLIGHTS

Ethics Committee Update:

o H. Markwell is still providing Ethics services to HDGH on a contract basis, she visitsonsite once per month and attends the Ethics Committee meetings while here. There hasbeen some discussion around the Ethical Decision Making Framework, YODA is utilizedand familiar to front line staff.

o The Committee has been working through a fulsome review of related policies.

o Through the Values Integration Appraisal Process, there were several recommendationsfor improvements to service delivery by Spiritual Care, and some relative to Ethics; theseare under review and many have been actioned.

o Some front line staff have attended the Ethics training through St. Paul’s University.HDGH will be one of four hospitals that may undertake a partnership with St. Paul’s.

o The Patient Advocate will be retiring in June, looking to restructure Ethics, Spiritual Care,and Patient Advocate; details are unknown but will be shared with the Committee whenfinalized. The long standing relationship with H. Markwell, will help to assist with thereview of these portfolios.

Infection Prevention and Control Scorecard:

o Hand hygiene rate is 98% before patient contact and 97% after patient contact

o Training has been provided to all managers in order to complete audits

o One case of C. Diff; patient admitted from acute care immunocompromised and takingantibiotic. Not other patients with C-diff on unit.

o MRSA very good; no bacteremia in last 5 quarterso One patient admitted from acute care with VRE


o Welcome packages have begun distribution, ‘information upon admission’ results shouldimprove at next report

o Data for ‘information upon discharge’ is still low, looking to create a discharge informationpackage

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o Real time surveys began in January, have received good feedback. The report will beprovided to PFAC

o Group of staff received training to complete Tracers from Accreditation Canada, this willbe an ongoing initiative to ensure all quality standards are continually being met.Currently taking place weekly in preparation of Accreditation.

o Flags: improved

o Mock Accreditation scheduled for March 29, 2019

DECISIONS

none

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Quality Committee - Open Meeting Report For Information only

Date of Meeting: March 18, 2019

Author: D. Dutot for K. Blanchette

MEETING HIGHLIGHTS

Emergency Preparedness Committeeo R. White was present at the meeting to present the following;

o Work completed in the 5 years at the Tayfour Campuso Work to be undertaken

Patient Family Advisory Council Reporto L. O’Rourke, PFAC representative provided the following highlights;

o PFAC is actely engaged in participating in the Accreditation process. There are

members participating in 6 of the Accreditation Standards Committees.

o Rehabilitation PFAC member travelled with HDGH staff to Chicago to meet with

hospitals that offer similar services to observe their programs and bring back learnings

o 2 PFAC members are conducting ‘real time surveys’ with patients. This brings a great

deal of comfort to the patient knowing that they are speaking with a past patient or

family member and not always staff. This has had tremendous success, and is a

valued resource to enhance the quality in care delivery

o 4 PFAC members will be highlighted on elevator wraps, bringing awareness to the

committee and the benefits

o Committee continues to review all written materials used for patient education

o 2 new members have been recruited

o Position of PFAC Chair has now been assumed


o See Quality Chairperson Accreditation update

DECISIONS

none

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Workplace Excellence Committee - Open Meeting Report For Information only


Author: D. Dutot for M. Lomazzo

MEETING HIGHLIGHTS

Occupational Health & Safety Policieso Summary of polices provided are based on all polices associated with the Joint

Occupational Health and Safety Committeeo Identifies polices, date reviewed and if the policy was accepted as is or with changeso Responsibility of the Workplace Excellence Committee as per the Terms of

Reference

Workplace Violence Committee:o Full roll out of communications and awareness plan

o Media event held along with ONA

o Updated as to recent activities of committee

Continuous Improvement Plan:

o Sick and Special Consideration leave are higher than past year

Changing Lives Together Awards and Recognition Programo Revised program was launched late last yearo Various levels of awardso Peer to peer, manager to peer ( and vice versa)o Hallway display of President’s Awards

DECISIONS

none

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Produced by:

DEPARTMENT OF RESEARCH AND EVALUATION


March 2019

Research

Evaluation

KTE

Windsor’s 6th Annual Geriatric Conference Report

HÔTEL-DIEU GRACE HEALTHCARE, FEBRUARY 23, 2019

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Introduction

Windsor’s 6th Geriatric Conference was held at Hotel-Dieu Grace Healthcare on February 23, 2019. The

objectives of the Conference were to support attendees to:

The objectives of this conference are:

To better understand the healthcare needs of my older patients

Offer relevant advice to my geriatric patients

Keep abreast of recent updates in the geriatric medicine field

This event was an Accredited Group Learning Activity (Section 1) as defined by the Maintenance of

Certification Program of the Royal College of Physicians and Surgeons of Canada, and approved by

Continuing Professional Development, Schulich School of Medicine & Dentistry, Western University. You

may claim a maximum of 6.0 hours (credits are automatically calculated).

This one-credit-per-hour Group Learning program meets the certification criteria of the College of

Family Physicians of Canada and has been certified by Continuing Professional Development, Schulich

School of Medicine & Dentistry, Western University for up to 6.0 Mainpro+ credits.

This program was supported in part by an educational grant from the following: Amgen Canada Inc,

Sterinova Inc, Pfizer Inc, AstraZeneca Canada Inc, Sanofi Inc, and The Royal College of Physicians and

Surgeons in the form of Educational Grants.

The Agenda for the Conference can be found in Appendix A. A total of 84 people attended the

Conference. Participants included Family Physicians, Nurse Practitioners, Physiotherapist and Medical

Students.

Overall Feedback

Thirty-nine (39) people responded to the paper survey, for a response rate of 46%. The feedback

reveals that the Conference was very well received with:

97.44% agreeing that the content was presented clearly

94.78% agreeing that the activity will benefit their role

94.88% agreeing that the activity was relevant to their role

97.44% agreeing that the program enhanced their knowledge

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Respondents also felt that attending the Conference had a very positive impact on their abilities, with:

97.44% agreeing that the conference had a positive impact on their ability to keep abreast of

recent updates in the geriatric medicine field

97.44% agreeing that the conference had a positive impact on their ability to offer relevant

advice to their geriatric patients

97.44% agreeing that the conference had a positive impact on their ability to better understand

the healthcare needs of their older patients

Session Specific Feedback

Respondents were also asked to provide feedback on the individual lectures/sessions offered. Findings

indicate that all session were very well received and all speakers very highly rated. Proportions of

respondents selecting ‘agree’ or ‘strongly agree’ to session specific questions are highlighted below.

53.9

41.0

43.6

56.4

43.6

53.9

51.3

41.0

T H E P R O G R A M C O N T E N T E N H A N C E D M Y K N O W L E D G E

T H E A C T I V I T Y W A S R E L E V A N T T O M Y R O L E

T H E A C T I V I T Y W I L L B E N E F I T M Y R O L E

T H E C O N T E N T W A S P R E S E N T E D C L E A R L Y

OVERALL FEEDBACK

Strongly Disagree Disagree Neutral Agree Strongly Agree

53.9

53.9

56.4

43.6

43.6

41.0

B E T T E R U N D E R S T A N D T H E H E A L T H C A R E N E E D S O F M Y O L D E R P A T I E N T S

O F F E R R E L E V A N T A D V I C E T O M Y G E R I A T R I C P A T I E N T S

K E E P A B R E A S T O F R E C E N T U P D A T E S I N T H E G E R I A T R I C M E D I C I N E F I E L D

THE CONFERENCE HAD A POSITIVE IMPACT ON MY ABILITY TO...


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18.4

16.2

8.1

81.6

83.8

91.9

T H E S P E A K E R I N C O R P O R A T E D R E L E V A N T A N D P R A C T I C A L E X A M P L E S

T H E S P E A K E R E N A B L E D M E A N I N G F U L D I S C U S S I O N

T H E S P E A K E R E X P L A I N E D C O N C E P T S C L E A R L Y / E F F E C T I V E L Y

ADULT IMMUNIZATION


7.7

10.3

12.8

35.9

30.8

35.9

56.4

59.0

51.3


T H E S P E A K E R E N A B L E D M E A N I N G F U L D I S C U S S I O N .


COPD/ASTHMA IN THE ELDERLY


20.5

20.5

18.0

28.2

23.1

15.4

51.3

56.4

66.7




IDENTIFYING AND PREVENTING MALNUTRITION IN COMMUNITY DWELLING

SENIORS


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13.2

10.5

5.3

31.6

34.2

31.6

52.6

52.6

60.5




ALCOHOL USE DISORDER IN THE ELDERLY


5.6

5.6

2.8

27.8

27.8

33.3

66.7

63.9

63.9




SPASTICITY: EVALUATION & MANAGEMENT


27.8

25.7

16.7

33.3

28.6

41.7

36.1

42.9

41.7




ADDRESSING THE IMPACT OF COGNITIVE FRAILTY AND DEMENTIA ON THE

REHABILITATION OF OLDER ADULTS


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5.6

2.8

5.6

27.8

25.0

16.7

63.9

69.4

75.0




DESPRESCRIBING CARDIAC MEDICATION IN THE ELDERLY


13.3

13.8

10.0

86.7

86.2

90.0




UPDATES IN GERIATRIC MEDICINE THROUGH CLINICAL VIGNETTES


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Appendix A: Conference Agenda

WINDSOR’S 6th ANNUAL GERIATRIC

CONFERENCE

Brown Auditorium, Hôtel-Dieu Grace Healthcare Saturday, February 23, 2019

7:30 – 8:25 am Registration, Breakfast and Exhibitor Viewing

8:25 – 8:30 am Opening Remarks – Dr. Andrea Steen

8:30 – 9:20am Adult Immunization – Dr. Marina Salvadori, Keynote Speaker

9:20 – 10:00 am COPD in the Elderly – Dr. Syed Anees

10:00 - 10:30 am Identifying and Preventing Malnutrition in Community Dwelling

Seniors - Dr. Angela MacDonald

10:30 – 11:00 am Break & Exhibitor Viewing

11:00 – 11:45 am Alcohol Use Disorder in the Elderly – Dr. Kristina Levang

11:45 – 12:30 pm Spasticity: Evaluation & Management – Dr. Dana Seslija

12:30 – 1:15 pm Lunch Break & Exhibitor Viewing

1:15 – 2:00 pm Addressing the Impact of Cognitive Frailty and Dementia on the

Rehabilitation of Older Adults – Ms. Sonya Vani

2:00 – 2:45 pm Deprescribing Cardiac Medication in Elderly –

Dr. Roland Mikhail

2:45 – 3:30 pm Updates in Geriatric Medicine through Clinical Vignettes –

Dr. Wassim Saad

3:30 – 3:35 pm Closing remarks – Dr. Andrea Steen

3:35 – 3:40 pm Completion of Evaluations

** 25% of time allotted will be dedicated to Q & A period

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Schulich School of Medicine & Dentistry – Windsor Campus

Dr. Murray O’Neil Medical Education Centre, Room 1100, 401 Sunset Ave., Windsor, ON, Canada N9B 3P4

Telephone: 519-561-1411 Fax: 519-561-1413 www.uwindsor.ca/medicine

Update to HDGH Board of Directors (March 27, 2019)

The Class of 2019 recently completed the first round of the CaRMS match. In total 164 of

172 students matched in the first round. 45% of the class matched into family practice.

Work continues with medical school curriculum renewal to a fully competency-based model.

The new curriculum will address the school’s commitment to community we serve and

increase the focus on our social accountability mission. Year 1 and 3 are set to transition

this September. Many new opportunities for leadership, small group facilitation, clinical

skills teaching and coaching will be announced soon.

Dr. Brian Burke has stepped down as Windsor Assistant Program Director for Psychiatry. A

search is complete for his replacement and will be announced soon. Dr. Burke was

instrumental in the development of Western’s first distributed specialty residency training

program.

The medical school admissions committee is looking to recruit physicians to assist in file

reviews and interviews for upcoming years.

Interprofessional Education Day is scheduled for March 26, 2019. Over 100 students from

health related disciplines will be coming together for a joint learning opportunity.

Nominations have closed for the Windsor Campus Awards of Excellence. The Gala is

scheduled for April 9, 2019 at the St. Clair Centre for the Arts. Thank you to HDGH for the

sponsorship! Tickets can still be purchased:

https://www.schulich.uwo.ca/about/events/windsor_programs_celebration_of_excellence_

cart.html

Submitted March 20, 2019 by: Lawrence Jacobs, MD FRCPC FACP Associate Dean, Windsor Campus

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https://www.schulich.uwo.ca/about/events/windsor_programs_celebration_of_excellence_cart.html

https://www.schulich.uwo.ca/about/events/windsor_programs_celebration_of_excellence_cart.html

Portfolio Report

Prepared by: Andrea Steen March 2019 Programs: Medical Affairs and Quality Strategic Driver: People, Patients, Identity

Professional Staff

There has been ongoing education for the Professional Staff with two Grand Rounds,Fall 2018 and Annual Geriatric Conference Feb 2019. The Geriatric Conference waswell attended by approximately 100 participants and helps to promote HDGH interestand expertise in Geriatric Care. Two of our own physicians were speakers at this year’sconference.

In order to foster an environment of leadership development, a CMA Joule course,Leading Change, was attended by 11 of our physicians. This course was very wellreceived by HDGH physicians and was an excellent leadership opportunity for some ofour young physicians who look to be leaders in the HIS Cerner implementation.

In response to the need for physician engagement in the HIS project, a Chief MedicalInformation Officer was recruited to represent HDGH at all the decision making tablesand to help lead physician involvement in the training over the upcoming year.

A widely recognized palliative care course (LEAP mini) was taught to all the staff on3South. It was attended by some of our frontline physicians and taught by our palliativecare physicians. It was meant to increase the knowledge of all staff working with patientsat end of life.

As part of our ongoing Human Resources Plan, a new psychiatrist and a new physiatristhave both been added to our staff. These are very difficult to recruit positions and thiswas a big win for our patients at HDGH.

There was a Complex Medical Care hospitalist program started November 2018. Thisoccurred to improve compensation to physicians doing difficult work with complexpatients. This was a strategy to retain physicians in a very difficult to recruit area ofhospital work.

There is ongoing work on the Program Medical Director contract renewal. Followingevaluation of both Medical Directors the motion will come to Board for renewal of thisposition. We have two excellent Medical Directors who remain committed and engagedin continuing their work at HDGH.

One on one meetings with each psychiatry resident has occurred this year and will be anongoing initiative. This allows the VPMA to have conversations and developrelationships with our residents while looking at future recruitment of these amazingyoung physicians.

Quality Initiatives

The MQA committee continues to review mortality data at HDGH, looking for any qualitygaps in care that can be addressed by Program Medical Directors. The scorecard forMQA looks at physician data and areas needing improvement while acknowledgingexcellent care as well.

The QIP for 2019/20 is coming to completion by March 31 2019. There are sevenindicators for this coming year. There has been review of the indicators by the Qualitycommittee, PFAC and MQA, as well as the entire leadership team. It will reach theBoard of Directors for final approval.

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Portfolio Report

The Quality Advocates continue to completeadmission and discharge surveys, feeding real-time data to our staff and physicians. This way of collecting

data continues to inform frontline staff and managers on areas where they are excelling and other areas of opportunity. They have also started in-person mental health surveys to collect data in this area. This has been a new initiative in the past few months. Another exciting change has been the addition of four members of the Patient Family Advisory Council completing real time surveys with our patients.

Also this past six months, surveys are being sent out to all palliative family members andthis is the first time we have collected any information on patient and family experiencesin this area.

Accreditation is fast approaching June 2019, and there has been tremendous work doneby the Quality manager and her team. There was an Accreditation learning day to teachstaff about the Tracer methodology. An entire Mock Accreditation day is planned forMarch 29 2019.

In preparation for the 2019 Accreditation process, Physicians were asked tocomplete a “Physician Work life Pulse Survey” to assist us in assessing the quality oftheir work environment. In other words, the quality of a care provider’s work lifedirectly influences the quality of care that they provide. We had an impressive 60%response rate (an increase of 20% from 2016) with a notable 68% improvement inthe areas of health & safety, practice environment, senior leadership, and team/unit.No items were red flagged.

Identity

Quality projects with Schulich medical students have focused on opportunities forpractice improvements in line with Choosing Wisely Canada guidelines. This project waspresented to the restorative physician group for education.

There is ongoing engagement with LHIN hospital partners in the HIS project E-volve.Continuing to act as an HDGH representative on the E-volve Steering Committee.

Representing HDGH on the OHA Provincial Physician Leadership Council, connectingwith colleagues from hospitals across the province. Started as Vice Chair January 2019.

Medical Affairs supported the International Patent Safety Symposium hosted by HDGH,Detroit Medical Centre and St Clair College February 2019. The Director and Manager ofQuality presented our patient advocate project and the successes this program hasgenerated.

Goals for 2019/20

A successful Accreditation in June 2019

Engaged, involved professional staff in the HIS/Cerner project with excellentparticipation on work groups in the next year.

Ongoing recruitment as per our Human Resources plan, of high quality, excellentphysicians

Continue to provide learning opportunities in our areas of practice to our physicians,including leadership opportunities for emerging and present leaders.

Begin work on Physician Wellness with MAC leadership. This work will also need toextend to our Psychiatry residents. This is an area being recognizing as a risk forhospitals as physician experience burnout and dissatisfaction with their work. This will beespecially important with the implementation of a new HIS system that will have a hugeimpact on physician workflow.

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Portfolio Report

Prepared by: Sonja Grbevski, VP Mental Health & Addictions (MH&A) Date: March 18, 2019

Program(s): Mental Health & Addictions & Children’s and Youth Mental Health Services, Regional Children’s

Centre (RCC)

Strategic Driver: Our Patients, Our People and Our Identity

Background/Introduction: the key objectives/ mandate for this portfolio include:

Continue to improve upon our Mental Health & Addictions programs - across the lifespan – through theimplementation of a recovery philosophy and the use of best practice.

Continue to improve the quality of care and the patient experience through improved transitions of care,collaborative care planning and enhanced quality of life.

Ensure the right skill mix and continued staff development in a healthy work-life culture of to Support thework of the MH&A program.

Establish HDGH as a recognized Centre of Excellence in MH&A inclusive of improved access to the right carein an environment that is safe for all.

Program Updates:

Claudia den Boer, CEO, Canadian Mental Health Association (CMHA) has joined the executive leadershipteam at HDGH and will now serve as the Executive Lead for Community Mental Health. This new positionallows Claudia to facilitate further service coordination and integrated oversight of community mentalhealth programs. Inpatient Mental Health programs as well as Child and Youth Mental Health servicesprovided through the Regional Children’s Centre (RCC) will remain under the leadership of Vice President,Sonja Grbevski.

Work continues towards a Centre of Excellence designation. A recovery kickoff event was held March 7th ledby Dr. Marianne Farkas, Licensed Psychologist, Boston University. The goal of the day was to raiseawareness and begin the development of a shared vision for a more recovery oriented MH&A program forHDGH & CMHA. Approximately 100 guests were present including Managers, Frontline staff and people withlived experiences. The event was well received by all.

Assertive Community Treatment (ACT) - Chatham ACT has relocated to the new facility. In 2 weeks, WindsorACT will vacate its current location and move to the Jeanne Mance Building. Renovations are underway.

The Crisis & Mental Wellness Centre - group programming further revised to allow for additionalpsychotherapeutic groups, which compliments past psychoeducational groups. MOU being finalized withLaSalle Police Service. Hoping to commence new police/crisis partnership similar to Mental Health ResponseUnit (MHRU) in April.

Residential Treatment Facility (RTF) – ongoing discussions for programming review with consultant; hopefulto start once her current commitment to CKHA ends.

Dual Diagnosis (DD) - working with physician team to create discharges through appropriate discharges.New support model will have CMHA DD worker operate on a pre-discharge model to assist with discharges.

Improving medication reconciliation process for Wellness Program for Extended Psychosis (W-PEP) &Injection Clinic.

Dr. Musgrave preparing for LHIN wide review of ACT, Crisis (HDGH) and EI, ICM (CMHA)

Accreditation - For Mental Health Standards, Telehealth Standards, and Substance Use and AddictionServices – populated evidence for each standard and verified evidence with frontline staff. Peer review of 100

Portfolio Report

completed for both MH & Substance standards. Continue to engage frontline through staff meetings, mock tracers, etc.

Safety Improvements – Jill Mustin Powell Report suggested ~120 recommendations (swipe card proxyaccess, additional PAL repeater, etc.). Approx. 80% complete. Remaining 20% will be accomplished over 1-2years.

Zero Suicide Initiative – completed organization readiness/current state data collection. Continue toimplement strategy, rolling out Columbia Screener tools and training staff.

Regional Children’s Centre (RCC):

Administration - RCC leadership team is at full complement. Rochelle Lee is the new Director of Child &Youth Mental Health and Kyle Williamson is the Operations Manager for Intensive Treatment Services.Jeanne Lucier has assumed the permanent role of Program Coordinator.

Outpatient Services - all treatment staff are receiving training on the recent enhancements to the clientinformation system (EMHware). Groups being offered to children and youth are in the process of beingexpanded, with assistance from the PMO in order to determine metrics to gather data. Staff have receivedtraining in Brief and Narrative Therapy, Trauma Assessment & Treatment and Unified Protocols for Transdiagnostic Treatment of Emotional Disorders in Children and Adolescents.

Crisis Services - This team has recently moved to a model where the children and youth presenting to the EDare followed up by the Crisis Services team members. The crisis team now attends rounds at Maryvale andprovides service coordination to these clients post discharge as required.

Youth Justice - services provided to this client population are currently under review to improve access toservices and strengthen community partnerships. The possibility of an outreach office space in Leamingtonis being explored.

Service Coordination - the team has recently commenced with overseeing clients needing or activelyreceiving Complex Special Needs funding. Consultations with the Ministry of Community and Social Servicesare ongoing.

Intake/Central Access - the Intake department continues to see an increase in the number of referralscoming into the Centre. The Central Access mechanism is currently under review in order to better alignservices for clients in the Windsor-Essex community. More information to follow.

Community of Practice – community of practice recently completed the design of a peer to peer model withthe support of a grant from the Trillium Foundation. Three new YiP (Youth In Partnership) committees are indevelopment. The Arabic newcomers Triple P video is complete and ready for distribution to settlementagencies. The winners of the YiP film contest “How Do I Keep Myself Mentally Healthy” will be announced inthe next few weeks.

Developmental Services - the Developmental Services team is currently exploring possible partnershipopportunities for the Autism Spectrum Disorder (ASD) population with Children First.

Intensive Treatment Services (ITS) - continues to work on updating all policies and procedures as they relateto the revised Child, Youth and Family Services Act. Preparation for the residential licensing process willbegin in the coming weeks. ITS is also having tunable lighting installed at the Glengarda Building. ITS will beworking with PMO office and St. Clair College with respect to metrics and seeing if this lighting showssuccess in children’s mental health.

RCC has partnered with Problem Gambling and Digital Dependency services to deliver the “Heads Up” Groupfor parents of children 6-12 where digital dependency has been identified an issue. First group starts in May.

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Accreditation Update For Information only


Author: D. Dutot for K. Blanchette

Working groups continue to be meeting and working on collecting the evidence to meet thestandards and ROP’s with front line involvement as well as members from PFAC.

Standard Operating Procedures for Medication Reconciliation on Discharge has been completedand Education/Training for all members of the Health care team is rolling out this week.(Physician/NP’s, Pharmacy, and Nursing)

Standard Operating Procedure for Medication Reconciliation in all of our Outpatient Programsincluding RCC for both Admission and Discharge have been created as well as standardized forms to be used on admission and discharge. Education and training for all departments will start this week.

Patient Safety Metric Boards have all been mounted in “publicly displayed areas” (as before weonly had them behind nursing stations) Unit Based Councils will take the lead to update theseboards monthly with 3 indicators (Hand Hygiene 1st and 4th moment, Med Rec on Admission,highlights from Real Time surveys for that month and a patient safety tip of the month)Education rolling out to all UBC’s

20 HDGH Tracers for Quality Improvement have been completed and information is beingcollated for each of the tracers with real time feedback being provided to staff and patients.

Accreditation Information Boards are displayed on all units providing weekly updates on ROP’sand other accreditation Information along with articles in the “Need To Know”, managers arereviewing this information at weekly staff huddles.

Mock Simulated On Site Survey is scheduled for Friday March 29th with Patricia McKernan (surveyor from Accreditation Canada)

We now have a confirmed Patient Surveyor for our actual on site survey in June. Heather Thiessen

Pre Survey Teleconference with Accreditation is set up for Tuesday April 16th to review ouronsite survey schedule.

Governance Accreditation Working Group met March 4 and 18, reviewed the GovernanceStandards and complied list of evidence to be provided to the surveyors.

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open meeting of the board of directors - hdgh us/bod open... · to regional patient and trainee...

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