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ANNUAL REPORT MANAGEMENT REPORT> CIUSSS DE L’OUEST-DE-L’ÎLE-DE-MONTRÉAL 2

TABLE OF CONTENTS

TABLE OF CONTENTS ......................................................................................................................... 2

SECTION 1 – MESSAGE FROM THE PRESIDENT AND CEO .................................................................... 3 MESSAGE FROM THE PRESIDENT OF THE BOARD OF DIRECTORS AND THE PRESIDENT & CEO ......................................... 3

SECTION 2 – DECLARATION REGARDING THE RELIABILITY OF DATA AND RELATED CONTROLS ............ 4

SECTION 3 – PRESENTATION OF THE INSTITUTION AND HIGHLIGHTS ................................................. 5

3.1 The Institution ......................................................................................................................................5 MISSION AND SERVICES OFFERED ....................................................................................................................................... 5 UNIVERSITY DESIGNATION AND PRIMARY SERVICES .......................................................................................................... 6 REGIONAL AND SUPRAREGIONAL VOCATION ..................................................................................................................... 6 ORGANIZATIONAL CHART ON MARCH 31, 2019 ................................................................................................................. 7

3.2 The Board of DirectorsCommittees, Boards, and Advisory Bodies ...........................................................8 3.2. 1 BOARD OF DIRECTORS ............................................................................................................................................... 8 3.2. 2 COMMITTEES, BOARDS AND ADVISORY BODIES ....................................................................................................... 9

3.3 HIGHLIGHTS ................................................................................................................................... 14

SECTION 4 – PERFORMANCE RESULTS FOR THE MANAGEMENT AND ACCOUNTABILITY AGREEMENT ....................................................................................................................................................... 15

SECTION 5 – RISK AND QUALITY MANAGEMENT ACTIVITIES ............................................................ 32

Accreditation ........................................................................................................................................... 32

Safety and Quality of Care and Services .................................................................................................... 32

Number of Persons Under Preventative Confinement, Per Mission ............................................................ 38

Complaints Examination and Advocacy ..................................................................................................... 39

Public Information and Consultation ......................................................................................................... 40

SECTION 6 – REPORT ON THE APPLICATION OF THE LAW CONCERNING END-OF-LIFE CARE .............. 41

SECTION 7 – HUMAN RESOURCES .................................................................................................... 42

SECTION 8 – FINANCIAL RESOURCES ................................................................................................ 44

SECTION 9 – MONITORING OF STATE RESERVES, COMMENTS AND OBSERVATIONS ISSUED BY INDEPENDENT AUDITOR ................................................................................................................. 46

SECTION 10 – DISCLOSURE OF WRONGDOINGS ............................................................................... 59

APPENDIX 1: CODE OF ETHICS ......................................................................................................... 60

APPENDIX 2 MALTREATMENT IN A FEW STATISTICS—YOUTH PROTECTION DIRECTORATE ............... 81

Approved by the Board of Directors on June 12, 2019


SECTION 1—MESSAGE FROM THE PRESIDENT AND CEO

MESSAGE FROM THE PRESIDENT OF THE BOARD OF DIRECTORS AND THE PRESIDENT & CEO

Four years after the founding of this new organization, the Centre intégré universitaire de santé et de services sociaux (CIUSSS) de l’Ouest-de-l’Île-de-Montréal provides its population and the clientèles it serves quality care and services that are constantly being improved. The organization continues to innovate and to set itself apart. How? This report and companion magazine of highlights illustrate the clinical, administrative, financial, educational, and research achievements and advances we have made.

Among the events that have marked this year, the nomination of Ms. Lynne McVey as President and Chief Executive Officer, certainly merits emphasizing. Her mandate began with an emphasis on continuity and communication. In that context, her visits at multiple facilities to meet and interact with employees of the CIUSSS de l’Ouest-de-l’Île-de-Montréal were very well received and helped to create an authentic and fruitful dialogue.

For several years, the CIUSSS de l’Ouest-de-l’Île-de-Montréal has been collaborating with Nunavik to improve the quality of services for their youth. To continue moving forward, Ms. McVey was invited to Nunavik for a conference chaired by the President and CEO of the territory’s Regional Health and Social Services Board, during which she shared the agreement that had been concluded between our organization and Nunavik, thus strengthening our partnership and this historic collaboration.

Last spring, the CIUSSS de l’Ouest-de-l’Île-de-Montréal, in partnership with Marguerite-Bourgeoys School Board, launched a pilot project to train beneficiary attendants directly at one of its facilities, Ste. Anne’s Hospital. This is one example of our organizational values—agility, respect, and partnership—in action. Within an institution as complex as ours, these values are essential to achieving our goals. In fact, they serve to inspire and mobilize us.

All of our achievements as well as the care and services we provide to our clients are the result of the exceptional work and unwavering dedication of our employees, community partners, physicians, and volunteers. Day in and day out, they are laying the foundations upon which we can continue to build. We would like to thank them warmly.

We all contribute to the greatness of our CIUSSS when we put the concerns of our patients, clients, our veterans, and families first each day.

All the best for 2019–2020!

_________________________________________________ Mr. Richard Legault, President of the Board of Directors

_________________________________________________ Lynne McVey President & CEO


SECTION 2—DECLARATION REGARDING THE RELIABILITY OF DATA AND RELATED CONTROLS

I am responsible for the information contained in this annual management report.

Throughout the year, reliable information systems and control measures were used to ensure that we attain the objectives set out in the management and accountability agreement with the Minister of Health and Social Services.

• The results and data of the Centre integré universitaire de l’Ouest-de-l’Île-de-Montréal 2018–2019 Management Report: accurately reflect the mission, mandates, responsibilities, activities and strategic directions of the organization;

• present the objectives, indicators, targets, and outcomes obtained;

• present accurate and reliable data.

I declare that to the best of my knowledge the information enclosed in this Annual Management Report and management controls associated with these data are reliable and reflect the situation as it existed on March 31, 2019.

_________________________________________________ Lynne McVey President & CEO


SECTION 3—PRESENTATION OF THE INSTITUTION AND HIGHLIGHTS

3.1 THE INSTITUTION

MISSION AND SERVICES OFFERED

The Centre intégré universitaire de santé et de services sociaux (CIUSSS) de l’Ouest-de-l’Île-de-Montréal is an institution that provides integrated health care and services to the population of the West Island and Dorval-Lachine-LaSalle, and to the clients of its facilities that provide general and specialized care across the Island of Montréal and in various regions of Québec.

The mission of the CIUSSS de l’Ouest-de-l’Île-de-Montréal is to provide a true integration of the services it delivers to the population.

• The institution is at the heart of a territorial service network (TSN) made up of local service networks (LSN) in the West Island and Dorval-Lachine-LaSalle.

• It is responsible for delivering health care services to the population in its health and social service territory, including a public health component.

• It has a responsibility to the people in its health and social service territory.

• As part of its multiple missions, it oversees the organization of services in its territory and the collaboration with establishments of the territories on which its facilities are located within the framework of its multiple missions; so as to ensure their complementarity, with consideration of the needs of the population, its clientèles, and its territorial realities.

• It enters into agreements with other facilities and partner organizations of its TSN (university hospitals, medical clinics, family medicine groups, network clinics, community agencies, community pharmacies, external partners, etc.).

Source: ministère de la Santé et des Services sociaux

Through the missions of its founding facilities, the CIUSSS de l’Ouest-de-l’Île-de-Montréal carries out the five major missions defined in the Act Respecting Health Services and Social Services to achieve better service integration for its target population and clientèles. Between April 1, 2018, and March 31, 2019, the institution operated:

• 4 local community service centres (CLSC);

• 4 hospital centres (CH): 3 hospitals providing general and specialized care, and 1 psychiatric hospital;

• 8 residential and long-term care centres (CHSLD);

• 1 child and youth protection centre (DPJ);

• 2 rehabilitation centres: 1 for people with intellectual disabilities or a pervasive development disorder (CRDITED) and 1 rehabilitation centre for youth with adjustment problems.


UNIVERSITY DESIGNATION AND PRIMARY SERVICES

University-designated because of its location in a health region where a university offers a complete undergraduate program in medicine, the CIUSSS de l’Ouest-de-l’Île-de-Montréal includes two university-designated facilities, i.e. Douglas Mental Health University Institute and St. Mary’s Hospital Center, as well as two research centres—Douglas Hospital Research Centre (FRQS-accredited and second among top-performing centres in its area of expertise in Canada) and St. Mary’s Research Center.

This year there were 1544 university trainees across all CIUSSS de l’Ouest-de-l’Île-de-Montréal facilities: 848 medical student residencies and 696 non-medical internships (social services, health care, engineering, administration, human resources, etc.).

The CIUSSS de l’Ouest-de-l’Île-de-Montréal is also a member of McGill University’s Réseau Universitaire Intégré de Santé (RUIS-McGill)*, offering several specialized and highly specialized services within the covered region.

REGIONAL AND SUPRAREGIONAL VOCATION

Some facilities of the CIUSSS de l’Ouest-de-l’Île-de-Montréal are designated bilingual and can provide all of their services in English.

In addition to the primary programs offered, the CIUSSS de l’Ouest-de-l’Île-de-Montréal also has a provincial mandate to provide ultra-specialized care and services for eating disorders as well as youth protection services and English-language residential and rehabilitation services to all youth in the province who require these services. The CIUSSS de l’Ouest-de-l’Île-de-Montréal also provides second-line mental health services to the Aboriginal communities of Nunavik and the Cree of James Bay.

The residential treatment program for operational stress injuries at Ste. Anne’s Hospital provides mental health care and superspecialized residential services to Canadian Armed Forces Veterans as well as members of the Royal Canadian Mounted Police.

The CIUSSS de l’Ouest-de-l’Île-de-Montréal was created on April 1, 2015. As of March 31, 2019, it comprises the following facilities:

West Montréal Readaptation Centre (WMRC) Dorval-Lachine-LaSalle Local Services Network (LSN)

• CLSC de Dorval-Lachine • CLSC de LaSalle • CHSLD Dorval • CHSLD Lachine

West Island Local Services Network (LSN)

• CLSC de Pierrefonds • CLSC du Lac-Saint-Louis • CHSLD Denis-Benjamin Viger • Lakeshore General Hospital

Grace Dart Extended Care Centre (GDECC) St. Mary’s Hospital Center (SMHC) Batshaw Youth and Family Centres (Batshaw) Ste. Anne’s Hospital (SAH) Douglas Mental Health University Institute (DMHUI) * The territory of the RUIS McGill covers 63% of the territory of the province and includes the following regions: Nunavik, James Bay Cree territory, Nord-du-Québec, Abitibi-Témiscamingue, Outaouais, the west of the Montérégie, and the western part of the island of Montréal.

• CHSLD LaSalle • CHSLD Nazaire-Piché • Residential Unit at Hôpital de LaSalle • Hôpital de LaSalle


ORGANIZATIONAL CHART ON MARCH 31, 2019


3.2 THE BOARD OF DIRECTORS, COMMITTEES, BOARDS, AND ADVISORY BODIES

3.2. 1 BOARD OF DIRECTORS

Mr. Richard Legault President Expertise: Human, property, and information resources

Ms. Isabelle Brault Vice-President Expertise: Governance and ethics

Ms. Lynne McVey Secretary President and Chief Executive Officer

Ms. Micheline Béland Users’ Committee

Dr. Samuel Benaroya Affiliated universities

Ms. Nada Dabbagh Regional Committee on Pharmaceutical Services

Ms. France Desjardins Expertise: Community organizations

Ms. Marianne Ferraiuolo Multidisciplinary Council

Mr. Rafik Greiss Expertise: Auditing, performance and quality management English Language Committee

Dr. Nebojsa Kovacina Regional Department of General Medicine

Vacant Affiliated universities

Ms. Judy Martin Expertise: Youth protection

Ms. Maya Nassar Committee of the Council of Nurses

Vacant Council of Physicians, Dentists and Pharmacists

Ms. Caroline Storr-Ordolis Expertise: Rehabilitation

Mr. Marcel Villeneuve Expertise: Risk management, finance and accounting expertise

Mr. Gary Whittaker Expertise: Rehabilitation

Ms. Diane Néron Expertise: Mental health

Ms. Joanne Beaudoin Experience: Social services user

CODE OF ETHICS AND PROFESSIONAL CONDUCT FOR MEMBERS OF THE BOARD OF DIRECTORS

No disciplinary body determined any disciplinary issues or sanction during the year.

See Appendix 1 for The Code of Ethics and Professional Conduct for Members of the Board of Directors.


3.2. 2 COMMITTEES, BOARDS AND ADVISORY BODIES

Governance, Ethics, Human Resources, and Administration Committee

Mr. Marcel Villeneuve President

Ms. Isabelle Brault

Dr. Nebojsa Kovacina

Ms. Judy Martin

Mr. Richard Legault President of the Board of Directors

Ms. Lynne McVey Ex Officio Member, President and Chief Executive Officer

Audit Committee

Mr. Rafik Greiss President

Ms. France Desjardins

Ms. Diane Neron

Mr. Marcel Villeneuve

Mr. Richard Legault Ex Officio Member, President of the Board of Directors


Public Advisory and Service Quality Committee

Ms. Judy Martin President

Ms. Micheline Beland

Ms. Isabelle Brault

Ms. Line Robillard Service Quality and Complaints Commissioner


Ms. Lynne McVey President and CEO


Review Committee

Ms. France Desjardins President

Dr. Gary Inglis

Dr. Chryssi Paraskevopoulos

University Affairs Committee

Dr. Samuel Benaroya President

Ms. Joanne Beaudoin

Ms. Nada Dabbagh

Ms. Caroline Storr-Ordolis



Users and Residents Committee

Ms. Micheline Beland President Dorval-Lachine-LaSalle Users Committee

Mr. John Brkich Treasurer Grace Dart Extended Care Centre Residents Committee

Mr. Elgadi Abdelkarim President of the Users Committee of the Douglas Mental Health University Institute

Ms. Diane Sabourin Vice-President of the West Montréal Readaptation Centre Users’ Committee

Ms. Catherine Bubnich Member of the Lakeshore General Hospital Users Committee

Ms. Johanne Comeau Member of the CHSLD Nazaire-Piché Residents Committee

Mr. Guy Lacoste Member of the CHSLD Lachine Residents Committee

Ms. Jeanine Lemire Member of the CHSLD Dorval Residents Committee


Partnership and Population-based Committee

Ms. France Desjardins President


Ms. Marianne Ferraiuolo

Ms. Maya Nassar

Mr. Gary Whittaker



Evaluation Committee for Disciplinary Measures

Ms. Isabelle Brault President

Dr. Samuel Benaroya Vice-President


Dr. Nebojsa Kovacina

Mr. Richard Legault President of the Board of Directors

Council of Physicians, Dentists, and Pharmacists (CPDP)

Dr. Marcel Fournier President St. Mary’s Hospital Center

Dr. Hélène Daniel Committees Vice-President, CLSC Representative

Dr. Alfred Homsy Departments Vice-President, Representative—DLL Hôpital de LaSalle

Dr. Joan Mason Secretary, Representative—DMHUI Douglas Mental Health University Institute

Dr. Fadi Habbab Treasurer, SMHC Representative St. Mary’s Hospital Center

Dr. Marie-Christine Godin Representative—CHSLDs Centre d’hébergement de Dorval

Ms. Hélène Paradis Representative—Pharmacy Lakeshore General Hospital

Dr. Tom Kaufman Representative—ODI Lakeshore General Hospital

Dr. Christian Zalai Representative—ODI Lakeshore General Hospital

Dr. Catherine Duong Representative—DLL Hôpital de LaSalle

Dr. Frédérique Van Den Eynde Representative—DMHUI Douglas Mental Health University Institute

Dr. Sujith Sivaraman Representative—SMHC Board of Directors Representative—Specialists


St. Mary’s Hospital Center

Dr. Nadine Larente Director of Professional Services


Council of Nurses (CN)

Ms. Maya Nassar President Youth Program Directorate

Ms. Dencia Jean-Paul Vice-President—Co-opted Nursing Directorate

Ms. Beverley-Tracey John Secretary Nursing Directorate

Ms. Joy Theodore Treasurer Access, Quality, Performance, and Project Bureau Directorate

Ms. Karine Mayas Support for Elderly Autonomy Program Directorate

Mr. Christian Larrivee Mental Health and Addiction Programs Directorate

Ms. Diane Babin Nursing Directorate

Ms. Evelyne Beauchamp Co-opted—substitute Professional Services Directorate

Ms. Isabelle Carrier Co-opted Mental Health and Addiction Programs Directorate

Ms. Ramatou Nzie

Co-opted Intellectual Disability, Autism Spectrum Disorder, and Physical Disability Programs Directorate

Mr. ER ric Labonte Co-opted Professional Services Directorate


Multidisciplinary Council

Ms. Catherine Liu-Castanet President CLSC Dorval-Lachine

Ms. Monique Laverdure Vice-President Batshaw Centres

Ms. Kenza Sassi Secretary Former Lachine Hospital

Ms. Flora Marsella Treasurer St. Mary’s Hospital Center

Ms. Nathalie Bernard Communications CLSC de Dorval-Lachine

Ms. Marianne Ferraiuolo CLSC de Pierrefonds

Ms. Monique Bureau West Montréal Readaptation Centre

Ms. Laura Carfagnini St. Mary’s Hospital Center

Mr. Jerry Belony Douglas Mental Health University Institute

Ms. Jacinthe Divay CLSC de Dorval-Lachine

Mr. Charles Boisvert CLSC du Lac-Saint-Louis

Ms. Venise Calluzzo Assistant to the Director, Multidisciplinary Services Directorate

Ms. Sophie Ouellet Director of Multidisciplinary Services


Executive Committee of the Council of Midwives

Ms. Trista Leggett President

Ms. Catherine Mason Vice-President

Ms. Rachida Amrane Secretary

Ms. Christiane Leonard Responsible for Midwives Services



Risk Management Committee

Ms. Christiane Leonard Interim President, Vice-President Responsible for Midwives Services

Ms. Brigitte Lefebvre Secretary Administrative Assistant, Quality, Risk Management, and Ethics Directorate

Ms. Manon Allard Associate Director of Access to Hospitalization, Nursing Directorate

Ms. Brigitte Auger Intellectual Disability, Autism Spectrum Disorder and Physical Disability Programs Directorate

Ms. Nadine Bergeron Administrative Assistant, Director of the Support for Elderly Autonomy Program

Mr. Bernard Cyr Associate Director, Operations—Professional Services Directorate

Ms. Linda See Director of Youth Protection

Ms. Anca Ghiran Head of Risk Management

Mr. Marc Boutin / Ms. Anissa Mounib

Administrative Assistants, Mental Health and Addiction Programs Directorate

Ms. Stephanie Iazensa

Associate Director of Integration and Clientele Trajectories, representing the Multidisciplinary Services Directorate (MSD), the Multidisciplinary Council (MC), the Quality, Assessment, Performance and Ethics Directorate (QAPED), and the Associate Executive Director (AED)

Ms. Katherine Moxness Director of the Youth Program

Ms. Maya Nassar Clinical nurse, representing the Executive Committee of the Nurses (CN)

Ms. Helene Paradis Pharmacist, representing the Council of Physicians, Dentists, and Pharmacists (CPDP)

Ms. Sarah-Beth Trudeau Associate Director of for Quality, Risk Management, and Ethics

Vacant Physician, representing the CPDP

Ms. Merilyne Ng Ah Chey Users’ Committee member

Vacant Users’ Committee member

OTHER COMMITTEES AND ADVISORY BODIES

Other committees and advisory bodies are also in place within the organization: the Operational Coordination Committee; the Clinical Ethics Committee; the Research Ethics Committee; the Permanent Control Measures Committee, etc.

3.3 HIGHLIGHTS

Highlights from our directorates are available as a separate volume that is an integral part of this annual management report. Both documents comply with the circular on annual management reports by public and private institutions and regional authorities.


SECTION 4—PERFORMANCE RESULTS FOR THE MANAGEMENT AND ACCOUNTABILITY AGREEMENT

CHAPTER III: SPECIFIC EXPECTATIONS

Attente spécifique

Description de l’attente spécifique État de réalisation

Commentaires

Santé publique Implanter dans chaque établissement de santé et services sociaux un comité stratégique de prévention et de contrôle des infections (CS-PCI) (02.1)

Chaque établissement doit mettre en place un CS-PCI et s’assurer qu’il remplisse son mandat : • réviser annuellement les objectifs et les priorités en PCI et faire des recommandations aux instances visées; • suivre l’évolution de la situation épidémiologique au regard du risque infectieux; • suivre l’application des mesures en PCI; • suivre les données de surveillance sur les infections nosocomiales (IN) et les audits; • adopter le bilan annuel de PCI et assurer le suivi auprès du C. A.; • entériner le choix des indicateurs relatifs à l’évaluation du programme PCI; • assurer l’harmonisation et la standardisation des pratiques PCI; • recevoir et entériner les politiques et procédures en PCI et formuler les recommandations aux instances appropriées pour leur mise en œuvre; • déterminer les enjeux et les recommandations de PCI à acheminer au Comité de Direction (CODIR); • déterminer les enjeux de ressources matérielles et humaines qui nuisent à l’atteinte des objectifs du programme; • acheminer les recommandations nécessaires au CODIR. Chaque établissement doit s’assurer que le CS-PCI est rattaché au président-directeur général (PDG) ou à une autre structure décisionnelle déléguée par le PDG. Le CS-PCI doit tenir au moins quatre rencontres par année.

Réalisé s/o

Services sociaux Plan territorial d’amélioration de l’accès et de la continuité (PTAAC) (03.1)

Les établissements doivent compléter et transmettre le gabarit fourni par le ministère de la Santé et des Services sociaux (MSSS) pour le suivi de l’implantation PTAAC.

En cours Dû le 31 mai

Plan d’action sur le trouble du spectre de l’autisme (TSA) (2017-2022) (03.2)

Les établissements doivent compléter l’outil de suivi du plan d’action TSA 2017-2022.

Réalisé s/o


Attente spécifique


Commentaires

Services sociaux (suite) Stratégie d’accès aux soins et aux services pour les personnes en situation d’itinérance ou à risque de le devenir (03.3)

« La Stratégie est un ensemble de moyens qui orientent les établissements ciblés en matière de santé et de services sociaux afin d’intensifier les soins et les services aux personnes en situation d’itinérance ou à risque de le devenir et vise une contribution de tous les programmes-services. Plus précisément, l’implantation de la Stratégie permettra aux établissements :

• d’assurer le repérage et l’évaluation des besoins des personnes en situation d’itinérance ou à risque de le devenir;

• de les accompagner au moyen d’une offre de services et d’une organisation de services définies, adaptées à leur réalité et inspirées des meilleures pratiques afin de prévenir le passage à la rue ou d’en favoriser la sortie;

• de mobiliser et de dynamiser l’ensemble des programmes-services dans l’atteinte des objectifs poursuivis;

• de mettre en place et de consolider des collaborations formelles entre les intervenants du réseau et entre les différentes régions et, lorsque requis, avec les partenaires du milieu communautaire.

L’attente spécifique consiste à élaborer un plan de travail pour l’implantation de la Stratégie et à mesurer son taux d’implantation par l’intermédiaire d’un formulaire GESTRED. »

Réalisé s/o

Trajectoire de services optimale pour les jeunes et leur famille en situation de négligence (03.4)

Une trajectoire de services bien définie permet d’assurer la coordination optimale des services et le suivi systématique de l’usager. Elle vise également à améliorer la qualité et l’efficience des services. Pour chaque région sociosanitaire, l’établissement devra définir une trajectoire de services optimale pour les enfants et leur famille en situation de négligence.

Annulé

(bulletin EGI volume 14 no.7)

Résultats, mesures alternatives et bonnes pratiques pour le respect des délais d’attente des usagers en statut « niveau de soins alternatif » (NSA) (03.5)

Les établissements fusionnés, qui ont une responsabilité populationnelle, ont des obligations dans la prévention et la réduction des NSA. Ainsi, ils doivent produire un état de mise en œuvre des pratiques en amont, en intra hospitalières et en aval, conformément au Guide de soutien NSA. Les établissements fusionnés doivent également faire état des résultats pour le respect des délais d’attente, incluant les résultats des usagers en attente ou en provenance des établissements non fusionnés.

Réalisé s/o

Amélioration de la qualité des soins d’hygiène offerts dans les CHSLD (03.7)

L’évaluation à jour, le plan d’intervention et le travail en interdisciplinarité permettront aux équipes d’offrir un choix personnalisé basé sur différents facteurs (habitudes, sécurité, niveau de collaboration et d’autonomie, portrait clinique). Un état de situation portant sur l’optimisation de l’organisation du travail pour les soins d’hygiène sera demandé aux établissements.

Réalisé s/o


Attente spécifique


Commentaires

Services de proximité, urgences et pré hospitaliers État d’avancement du Plan d’action triennal 2016-2019 — Maladie d’Alzheimer et autres troubles neurocognitifs majeurs (04.1)

Autoévaluation sur l’état d’implantation des actions au Plan d’action déposé au 1er juin 2016. Un état de situation faisant état des réalisations dans chacun des CIUSSS et des CISSS devra être produit.

Réalisé s/o

État d’avancement du Plan d’action par établissement réalisé sur la base du Plan d’action national 2016-2018 - Continuum de services pour les personnes à risque de subir ou ayant subi un accident vasculaire cérébral (AVC) (04.2)

Autoévaluation sur le Plan d’action déposé le 31 octobre 2016 composé à partir des actions et des objectifs retrouvés dans le Plan d’action national, incluant l’état d’avancement des travaux. Les causes de la non-atteinte des objectifs du Plan d’action doivent être notées.

En cours Dû le 30 juin

Mise en place d’un comité tactique télésanté en établissement (04.3)

Compléter le gabarit produit par le MSSS indiquant l’existence du comité, les membres et le nombre de rencontres tenues au cours de l’année. Les établissements peuvent se référer au document décrivant le mandat et une proposition de composition de ce comité (http://extranet.ti.msss.rtss.qc.ca/Orientations-et-gouvernance/Telesante/Gouvernance.aspx) et également préciser dans le cadre de référence sur la gouvernance, la gestion de projets et des services utilisant la télésanté à la même adresse.

Réalisé s/o

Financement, infrastructures et budget Réaliser le Plan de résorption du déficit de maintien des actifs immobiliers au 31 mars 2020, conformément aux cibles fixées par l’établissement pour chacun des bâtiments déficitaires concernés (07.1)

Le différentiel entre l’indice de vétusté physique (IVP) d’un bâtiment et le seuil d’état établi, soit 15 %, doit diminuer proportionnellement, à tout le moins, à la cible de résorption du déficit de maintien (RDM) à atteindre au 31 mars 2020 pour ce bâtiment. Le calcul de l’IVP est basé sur la valeur résiduelle des travaux de maintien ce qui implique la mise à jour systématique des listes de besoins. Pour ce faire, l’établissement doit absolument faire les liaisons requises entre les projets du « plan de conservation et de fonctionnalité immobilière » (PCFI) et les travaux des listes de besoins constituant ces projets. Le MSSS vise la résorption définitive du déficit de maintien des bâtiments. Conséquemment, pour tous les bâtiments dont la cible de RDM est de 100 % au 31 mars 2020, la valeur des travaux de maintien à réaliser doit se traduire par un IVP nettement au deçà du seuil d’état établi au terme du cycle de cinq ans suivant l’inspection en raison du vieillissement continu des bâtiments.

Pas demandé en 2018-2019.

Prochain livrable 31 mars 2020 (bulletin EGI volume 15 numéro 2).


Attente spécifique


Commentaires

Coordination réseau et ministérielle Gestion des risques en sécurité civile — Santé et Services sociaux (08.2)

Poursuivre l’implantation du processus de gestion des risques en sécurité civile en assurant des liens avec la gestion intégrée des risques de l’établissement. À cet effet, l’établissement doit maintenir en fonction un responsable du processus ayant complété le programme de formation. Ensuite, l’établissement doit mettre en place ou maintenir un comité formé de représentants de toutes les directions et programmes pour les travaux de gestion des risques en sécurité civile. L’établissement doit également déterminer, en fonction de son appréciation et de ses préoccupations, la portée retenue pour circonscrire le processus de la gestion des risques. Finalement, l’établissement doit compléter la phase d’appréciation des risques du processus, selon la portée retenue.

Réalisé s/o

Plan de maintien des services ou activités critiques — Santé et Services sociaux (08.3)

Pour accroître sa résilience en matière de sécurité civile, l’établissement doit amorcer l’élaboration d’un plan de maintien des services ou activités critiques. À cet effet, pour 2018-2019, l’établissement doit procéder à l’identification de ces services et de ces activités jugés critiques.

Réalisé s/o

Planification, évaluation et qualité Mise en œuvre d’un Plan d’action en santé et bien-être des hommes (SBEH) par les établissements (09.1)

Le plan d’action de l’établissement doit être rédigé et doit respecter les directives se trouvant dans le document « Lignes directrices — Plan d’action SBEH des établissements de santé et de services sociaux ». Lors de la transmission du plan d’action au MSSS, l’établissement doit transmettre la fiche de reddition qui démontre que les actions en place permettent de répondre aux principaux objectifs identifiés dans le document des lignes directrices.

Réalisé s/o


CHAPTER IV: ANNUAL COMMITMENTS

Indicateur Résultat au 31

mars 2017-2018 Engagement

2018-2019 Résultat au 31


2019-2020

Santé physique — Cancérologie

Plan stratégique 1.09.33.01 – PS Pourcentage des patients traités par chirurgie oncologique dans un délai inférieur ou égal à 28 jours (de calendrier)

75,4 90 77,5 90

1.09.33.02 – EG2 Pourcentage des patients traités par chirurgie oncologique dans un délai inférieur ou égal à 56 jours (de calendrier)

98,7 100 98,5 100

Commentaires : • Concernant le pourcentage des patients traités par chirurgie oncologique dans un délai inférieur ou égal à

28 jours (de calendrier) nous avons un écart en lien avec la coordination des traitements de chimiothérapie et la chirurgie. Il est a noté que l’ensemble des patients qui doivent avoir une chirurgie oncologique urgente n’ont pas d’attente pour avoir leur chirurgie.

Santé publique — Prévention et contrôle des infections nosocomiales

Plan stratégique 1.01.19.01 – PS Pourcentage de centres hospitaliers de soins généraux et spécialisés ayant des taux d’infections nosocomiales conformes aux taux établis — diarrhées associées au Clostridium difficile (installations offrant des services de la mission-classe « centre hospitalier de soins généraux et spécialisés » (CHSGS)

100 95 100 100

Plan stratégique 1.01.19.02 – PS Pourcentage de centres hospitaliers de soins généraux et spécialisés ayant des taux d’infections nosocomiales conformes aux taux établis — bactériémies à Staphylococcus aureus résistant à la méthicilline (installations offrant des services de la mission-classe CHSGS)

100 95 100 100






2019-2020

Santé publique — Prévention et contrôle des infections nosocomiales (suite)

Plan stratégique 1.01.19.04 – PS Pourcentage de centres hospitaliers de soins généraux et spécialisés ayant des taux d’infections nosocomiales conformes aux taux établis — bactériémies nosocomiales associées aux voies d’accès vasculaires en hémodialyse (installations offrant des services de la mission-classe CHSGS)

100 95 100 100

Plan stratégique 1.01.26 – PS Taux de conformité aux pratiques exemplaires d’hygiène des mains dans les établissements

71,5 75 72,5 80

Commentaires : • Les diarrhées à Clostridium difficile (DACD) sont demeurées stables au cours de l’année 2018-2019 et de rares

éclosions ont été recensées. La conformité à l’hygiène des mains ainsi que des rehaussements des désinfections par les équipes d’hygiène et salubrité ont permis de maintenir des taux acceptables de transmission nosocomiale.

• Les bactériémies en Hémodialyse (HD) demeurent basses depuis plusieurs années. La vigilance des équipes de soins et le respect des mesures d’asepsie assurent la sécurité des patients suivis en HD.

• La transmission du Staphylococcus aureus résistant à la méthicilline (SARM) demeure faible contribuant au faible taux de bactériémies.

• Le taux d’hygiène des mains, bien qu’en deçà de la cible prévue, démontre une augmentation par rapport à l’année 2017-2018. La mobilisation des équipes de gestion de toutes les directions cliniques a été mise à contribution pour le soutien au projet 20 — Optimisation de l’adhésion aux pratiques exemplaires en hygiène des mains.

Soutien à domicile de longue durée

1.03.05.01 – EG2 Nombre total d’heures de service de soutien à domicile longue durée rendues à domicile par les différents modes de dispensation de services

714 909 745 837 838 431 872 200

Plan stratégique 1.03.11 – PS Nombre de personnes desservies en soutien à domicile de longue durée (adultes des programmes Soutien à l’autonomie des personnes âgées (SAPA), Déficience intellectuelle, trouble du spectre de l’autisme et déficience physique (DI-TAS et DP)

5 540 5 792 5 920 5 883






2019-2020

Soutien à domicile de longue durée (suite)

Plan stratégique 1.03.12 – PS Pourcentage de personnes recevant des services de soutien à domicile de longue durée ayant une évaluation mise à jour et un plan d’intervention (adultes des programmes SAPA, DI-TAS et DP)

74,3 90 59,2 90

Indicateur retiré 1.03.14 – EG2 Nombre total d’heures de service de soutien à domicile longue durée rendu à domicile par les différents modes de dispensation de services aux personnes ayant un profil ISO SMAF de 4 à 14

654220 hres (source: Fiche bilan P6 2018-2019 du MSSS)

s. o. s. o. s. o.

Indicateur retiré 1.03.15 – EG2 Nombre de personnes desservies en soutien à domicile longue durée (adultes des programmes-services SAPA, DP et DI-TAS) ayant un profil ISO SMAF de 4 à 14

3370 usagers (Source: Fiche bilan P6 2018-2019 du MSSS)

s. o. s. o. s. o.

Commentaires : • 1.03.05.01 : L’ajout de ressources humaines avec les investissements « soins à domicile » (SAD) ont permis

d’augmenter de façon significative l’intensité des services de notre clientèle. • 1.03.11 : La mise en place de rencontres mensuelles entre les finances, le programme SAPA et l’équipe de

performance ainsi que l’exercice de qualité de données nous a permis d’obtenir des données précises. • 1.03.12 : Nous avons de la difficulté avec cet indicateur, bien que nous ayons mis en place une démarche

clinique structurée et structurante sous le thème: une démarche clinique dynamique en accord avec le projet de vie de l’usager et que nous utilisons les rapports qui ont été développés par l’équipe de performance de notre CIUSSS pour une utilisation provinciale. Les résultats sont suivis à toutes les périodes. Les intervenants invoquent le fait qu’ils priorisent des sorties d’hôpitaux plutôt que la rédaction de plan interdisciplinaire. Pour faire la nuance, les usagers 4-14 ayant un « outil d’évaluation multiclientèle » (OEMC) à jour sans le plan interdisciplinaire à la P13 était de 77,3 %. Des travaux avec la Direction des soins infirmiers (DSI) et la Direction des services multidisciplinaires (DSM) seront entamés pour rehausser la performance des intervenants. De plus, certains problèmes informatiques ont eu des répercussions sur la cadence.

• 1.03.14 : Cet engagement a été retiré par le MSSS. • 1.03.15 : Cet engagement a été retiré par le MSSS.

Soutien à l’autonomie des personnes âgées

Plan stratégique 1.03.07.01 – PS Pourcentage des milieux hospitaliers ayant implanté les composantes 1, 2 et 6 de l’approche adaptée à la personne âgée (AAPÂ)

0 100 0 100






2019-2020

Soutien à l’autonomie des personnes âgées (suite)

Plan stratégique 1.03.07.02 – PS Pourcentage des milieux hospitaliers ayant implanté les composantes 3, 4 et 5 de l’approche adaptée à la personne âgée (AAPÂ)

33,3 66,7 33,3 66,7

Plan stratégique 1.03.10 – PS Pourcentage de réseaux de services intégrés pour les personnes âgées (RSIPA) implantés de façon optimale

100 100 100 100

1.03.13 – EG2 Pourcentage de personnes nouvellement admises en CHSLD ayant un profil ISO-SMAF de 10 à 14

72,5 80 66,5 80

Commentaires :

Hôpital général du Lakeshore : indicateur 1.03.07.01 : 82,5 % — indicateur 1.03.07.02 : 41,19 % Composante 1 : Il y a eu plusieurs départs de personnes-clés au sein de l’équipe AAPÂ. Malheureusement, la possibilité de remplacer celles-ci est conditionnelle à la collaboration d’un de nos partenaires. Conséquemment, cela complique la réorganisation et l’implantation d’une nouvelle structure de gouverne de l’AAPÂ dans notre CIUSSS. Nous avons proposé un plan d’action et une nouvelle structure pour déployer les formations et le suivi AINÉES afin de pallier la situation. Composante 2 : Des discussions sont amorcées avec la Direction des services professionnels et la Direction des services multidisciplinaires afin d’harmoniser les critères d’accès aux consultations professionnelles ainsi que les formations AAPÂ qui seront offertes aux professionnels DSM et aux médecins pour tous les hôpitaux du CIUSSS. Un comité interdirection a travaillé à définir les critères de procédures d’accès et de priorisation aux consultations professionnelles. La trajectoire-patient et les rôles des différents professionnels ont été actualisés. Composante 3 : Nous avons offert des formations développées à l’interne afin de rejoindre plus facilement et de mobiliser le personnel soignant au printemps 2018. Le manque de personnel complique la possibilité de libérer suffisamment de participants pour assister aux formations.

Hôpital de LaSalle : indicateur 1.03.07.01 : 75 % — indicateur 1.03.07.02 : 10,61 % Composante 1 : Il y a eu plusieurs départs de personnes-clés au sein de l’équipe AAPÂ. Malheureusement, la possibilité de remplacer celles-ci est conditionnelle à la collaboration d’un de nos partenaires. Conséquemment, cela complique la réorganisation et l’implantation d’une nouvelle structure de gouverne de l’AAPÂ dans notre CIUSSS. Nous avons proposé un plan d’action et une nouvelle structure pour déployer les formations et le suivi AINÉES afin de pallier la situation. Composante 2 : Des discussions sont amorcées avec la Direction des services professionnels et la Direction des services multidisciplinaires afin d’harmoniser les critères d’accès aux consultations professionnelles ainsi que les formations AAPÂ qui seront offertes aux professionnels DSM et aux médecins pour tous les hôpitaux du CIUSSS. Composante 3 : Nous avons offert des formations développées à l’interne afin de rejoindre plus facilement et de mobiliser le personnel soignant au printemps 2018. Le manque de personnel complique la possibilité de libérer suffisamment de participants pour assister aux formations. Nous avons de très bons leaders AAPÂ à l’unité de médecine/chirurgie, ce qui a été reconnu lors de la visite de transition d’Agrément Canada en décembre 2018.

Centre hospitalier de St. Mary : indicateur 1.03.07.01 : 89,44 % — indicateur 1.03.07.02 : 76,26 % Composante 1 : Il y a eu plusieurs départs de personnes-clés au sein de l’équipe AAPÂ. Malheureusement, la possibilité de remplacer celles-ci est conditionnelle à la collaboration d’un de nos partenaires. Conséquemment, cela complique la réorganisation et l’implantation d’une nouvelle structure de gouverne de l’AAPÂ dans notre CIUSSS. Nous avons proposé un plan d’action et une nouvelle structure pour déployer les formations et le suivi AINÉES afin de pallier la situation. Composante 2 : Des discussions sont amorcées avec la Direction des services professionnels et la Direction des services multidisciplinaires afin d’harmoniser les critères d’accès aux consultations professionnelles ainsi que les


formations AAPÂ qui seront offertes aux professionnels DSM et aux médecins pour tous les hôpitaux du CIUSSS. Composante 3 : Nous avons offert des formations développées à l’interne afin de rejoindre plus facilement et de mobiliser le personnel soignant au printemps 2018. Le manque de personnel complique la possibilité de libérer suffisamment de participants pour assister aux formations. Composante 4 : Un comité dirigé par la Direction des soins infirmiers travaille actuellement à concevoir une collecte de données harmonisée incluant l’AINÉES, qui sera déployée dans nos trois hôpitaux. 1.03.13 – EG2 : Si on exclut les places achetées en CHSLD privés non conventionnés du calcul, le CIUSSS atteint un résultat de 75,6 % de personnes nouvellement admises en CHSLD publics avec des profils de 10 à 14.





2019-2020

Déficiences

Plan stratégique 1.05.15 – PS Délai moyen d’accès pour un service spécialisé chez les enfants de moins de 5 ans présentant un TSA

492,66 250 360,30 156

1.45.04.01 – EG2 Taux des demandes de services traitées en CLSC, selon les délais définis comme standards du Plan d’accès aux services pour les personnes ayant une déficience physique — TOUS ÂGES — TOUTES PRIORITÉS

83,2 90 67,9 90

1.45.05.01 – EG2 Taux des demandes de services traitées en CLSC, selon les délais définis comme standards du Plan d’accès aux services pour les personnes ayant une déficience intellectuelle ou un trouble du spectre de l’autisme — TOUS ÂGES — TOUTES PRIORITÉS

96,1 98 86,5 98

1.45.05.05 – EG2 Taux des demandes de services traitées en centre de réadaptation en déficience intellectuelle (CRDI), selon les délais définis comme standards du Plan d’accès aux services pour les personnes ayant une déficience intellectuelle (DI) ou un trouble du spectre de l’autisme (TSA) — TOUS ÂGES — TOUTES PRIORITÉS

32,1 90 47,6 90

Plan stratégique 1.46-PS Pourcentage des jeunes de 21 ans ou plus ayant une déficience ou un TSA venant de terminer leur scolarité et ayant accès à une activité de jour ou de soutien à l’intégration au travail

48,8 (P6 2017-2018)

90 90,9 90


Commentaires :

• 1.05.15 : a) Une trajectoire de services pour les enfants TSA 0-7 ans a été créée entre les services spécifiques offerts

par les équipes CLSC et celles de Centre de réadaptation en déficience intellectuelle et en troubles envahissants du développement (CRDITED). Les enfants sont desservis en services spécifiques durant leur attente pour un service spécialisé. Toutefois, les équipes spécifiques ont de la difficulté à offrir des interventions aux enfants TSA de moins de 5 ans, car les demandes pour le dépistage sont de plus en plus importantes. En spécialisé, les enfants sont pris en charge à un plus jeune âge et ainsi reçoivent des services spécialisés pendant de plus longues périodes jusqu’à leur entrée scolaire. Pour l’année 2018-2019, grâce aux investissements dans le cadre du plan d’action TSA, nous avons augmenté le nombre d’usagers recevant des services d’intervention comportementale intensive (ICI), 20 h de services/semaine.

b) Nous nous approchons de plus en plus de la cible. Nous sommes passés de 501 jours en 2016-2017 à 360 jours en 2018-2019.

• 1.45.04.01 : a) Les travaux du MSSS sur certains éléments du cadre de référence pour l’organisation des services en DP,

DI et TSA (services spécialisés vs spécifiques) devraient permettre de mieux établir une trajectoire de services pour la clientèle DP. Un groupe de travail relevant du comité de coordination opérationnelle (CCO) a également été mis en place afin de mieux définir la trajectoire des services en DP.

• 1.45.05.01 : a) Les demandes grandissantes pour le dépistage des jeunes enfants en première ligne ont eu un impact

négatif sur l’accès aux services de stimulation précoce. Des travaux sont en cours afin que la Direction des programmes jeunesse de notre CIUSSS prenne en charge cette responsabilité.

• 1.45.05.05 : a) Un nombre important d’usagers sont présentement desservis en CRDITED même s’ils ne requièrent pas

nécessairement des services spécialisés. La première ligne (CLSC) n’a pas pour le moment les effectifs nécessaires pour assurer le « retour » des usagers en première ligne et assurer le maintien de leurs acquis fait en services spécialisés. Cela a donc un impact sur la capacité du CRDITED à offrir des services même si les investissements dans le cadre du plan TSA ont permis de desservir un plus grand volume. Les travaux en lien avec l’implantation du cadre de référence pour l’organisation des services en DP, DI et TSA devraient également contribuer à mieux répondre aux besoins des usagers.

b) Les efforts se poursuivent afin d’atteindre la cible et les écarts se réduisent année après année. • 1.46 :

a) Une planification des services socioprofessionnels à offrir pour les élèves terminant leur scolarité a été faite. De nouvelles places ont été ajoutées à certaines ententes avec des organismes communautaires offrant des activités de jour.

b) s/o c) La collecte de données a été plus rigoureuse cette année. Plusieurs vérifications ont été faites avec les

commissions scolaires.





2019-2020

Dépendances

Plan stratégique 1.07.06 – PS Taux d’implantation de l’offre de service de détection et d’intervention précoce en dépendance

68,5 70 85,7 90

Commentaires : • La Direction du programme de santé mentale et dépendance (DPSMD) a déployé un important plan de

formation et d’appropriation des outils de détection en dépendance, et ce, à travers l’ensemble des directions cliniques.






2019-2020

Santé mentale

Plan stratégique 1.08.13 – PS Nombre de places en soutien d’intensité variable (SIV) reconnues par le Ministère

270 306 306 397

Plan stratégique 1.08.14 – PS Nombre de places de suivi intensif (SI) dans le milieu reconnu par le Ministère

360 340 360 360

Commentaires : • La totalité des postes requises a été déployés de manière à rejoindre le nombre de places attendues, pour le

volet SI. Ce déploiement est en cours également pour SIV.

Urgence

Plan stratégique 1.09.01 – PS Durée moyenne de séjour pour la clientèle sur civière à l’urgence

15,64 12 17,08 12

Plan stratégique 1.09.43 – PS Pourcentage de la clientèle dont le délai de prise en charge médicale à l’urgence est de moins de 2 heures

61,0 80 57,8 80

Plan stratégique 1.09.44 – PS Pourcentage de la clientèle ambulatoire dont la durée de séjour à l’urgence est de moins de 4 heures

49,4 80 45 80

Commentaires : • Dans le cadre du projet de la diminution des temps de séjour aux urgences, nous avons créé trois groupes de

travail et proposé de développer les alternatives à l’hospitalisation au CIUSSS de l’Ouest-de-l’Île-de-Montréal (1. Accueil clinique; 2. Accès 24 h/5; 3. Réorientation des patients non urgents P4 et P5) afin d’éviter une visite aux urgences. Nous avons également maintenant en poste un coordonnateur médical responsable de la fluidité des patients dans notre organisation.

• Pour l’urgence psychiatrique de l’Institut universitaire en santé mentale Douglas (IUSMD), un processus de prise en charge accélérée des patients évalués de niveau d’urgence P4-P5 est en cours d’implantation et devrait permettre, en 2019-2020, de réduire considérablement le volume à l’urgence et accélérer la prise en charge ambulatoire, pour les patients connus.

Soins palliatifs et de fin de vie

Plan stratégique 1.09.05 – PS Nombre d’usagers en soins palliatifs et de fin de vie à domicile

795 870 847 963

Plan stratégique 1.09.45 – PS Nombre de lits réservés aux soins palliatifs et de fin de vie

29 32 29 38






2019-2020

Soins palliatifs et de fin de vie (suite)

Plan stratégique 1.09.46 – PS Pourcentage de décès à domicile chez les usagers décédés ayant reçu des soins palliatifs et de fin de vie à domicile

9,7 12,5 16,0 14,7

Commentaires : • 1.09.05 – PS : Nous demeurons sur la bonne voie d’atteindre la cible. Nous souhaitons démarrer un chantier sur

les soins palliatifs (de l’offre de service à l’implantation) à domicile pour l’année 2019-2020. Plusieurs partenaires seront impliqués notamment les médecins.

• 1.09.45 – PS : Un enjeu de couverture médicale nous empêche de poursuivre l’ouverture des lits restant pour atteindre notre cible.

Santé physique — Services de première ligne

Plan stratégique 1.09.25 – PS Nombre total de groupe de médecine familiale (GMF)

5 6 5 6

Plan stratégique 1.09.27 – PS Pourcentage de la population inscrite auprès d’un médecin de famille

71,66 85 73,2 85

Plan stratégique 1.09.48 – PS Nombre de groupe de médecine de famille réseau (GMF-R ou super-clinique)

1 2 3 4

Commentaires :

• Nombre de GMF : l’engagement était de 6 en raison de la désaffiliation du Medicentre Lasalle du GMF Monk. Nous anticipions qu’ils se désaffilient à l’automne, mais finalement il y a eu des délais et ils sont devenus GMF indépendant le 1er avril 2019.

• La cible de 85 % est la cible provinciale qui ne s’applique pas par région. Les discussions avec le MSSS pour la situation de Montréal plaçaient la cible montréalaise à 78 % pour permettre l’atteinte de la cible provinciale. Nous sommes présentement autour de 73 %. Si nous avons des nouveaux facturants qui font de la prise en charge, il nous sera possible de faire des attributions en vertu de l’entente 321 (MSSS-FMOQ). La Chef de service de la première ligne DSP et les deux Coordonnateurs médicaux locaux travaillent à faire des attributions intra réseau locaux pour permettre de réduire la liste au CSSS ODI et augmenter notre taux d’inscription.

Chirurgie

Plan stratégique 1.09.32.00 – PS Nombre de demandes de chirurgies en attente depuis plus de 1 an pour l’ensemble des chirurgies

36 0 8 0

Commentaires : • Au 31 mars2019, nous avons seulement 8 patients qui sont en attente d’une chirurgie mineure. Par la suite,

nous validerons la disponibilité des patients pour une programmation prochaine au bloc opératoire.






2019-2020

Santé physique — Imagerie médicale

Plan stratégique 1.09.34.00 – PS Pourcentage des demandes en imagerie médicale qui sont en attente depuis moins de trois mois pour les modalités d’imagerie médicale ciblées

99,6 95 82 100

Plan stratégique 1.09.34.02 – PS Pourcentage des demandes en imagerie médicale qui sont en attente depuis moins de trois mois pour les scopies

s. o. s. o. 100 s. o.

Plan stratégique 1.09.34.04 – PS Pourcentage des demandes en imagerie médicale qui sont en attente depuis moins de trois mois pour les échographies obstétricales

s. o. 95 100 100

Plan stratégique 1.09.34.05 – PS Pourcentage des demandes en imagerie médicale qui sont en attente depuis moins de trois mois pour les échographies cardiaques

100 100 58,1 80

Plan stratégique 1.09.34.06 – PS Pourcentage des demandes en imagerie médicale qui sont en attente depuis moins de trois mois pour les échographies mammaires

100 100 93,8 100

Plan stratégique 1.09.34.07 – PS Pourcentage des demandes en imagerie médicale qui sont en attente depuis moins de trois mois pour les autres échographies

100 100 98,7 100

Plan stratégique 1.09.34.08 – PS Pourcentage des demandes en imagerie médicale qui sont en attente depuis moins de trois mois pour les tomodensitométries

98,1 100 93,5 100

Plan stratégique 1.09.34.09 – PS Pourcentage des demandes en imagerie médicale qui sont en attente depuis moins de trois mois pour les résonances magnétiques

99,7 95 78,9 100


Commentaires :

a) Les facteurs qui expliquent l’atteinte ou la non-atteinte de l’engagement, les mesures correctrices mises en place pour favoriser son atteinte : Deux des 8 engagements sont atteints à 100 %, soit les scopies et les échographies obstétricales. Pour les scopies, cela s’explique par le nombre peu élevé d’examens à l’Hôpital général du Lakeshore et l’ajout d’un radiologue au Centre hospitalier de St. Mary qui est associé, entre autres, à ce type d’examens. Quant aux échographies obstétricales, le résultat de 100 % démontre qu’il n’y a aucun enjeu de délai dans les 3 centres hospitaliers concernés. On doit noter que ce résultat est d’autant plus appréciable que l’Hôpital de LaSalle et le Centre hospitalier de St. Mary sont deux centres d’obstétrique importants à Montréal, avec un volume très élevé d’échographies. Trois engagements sont atteints de 90 % à 100 %, soit les échographies mammaires, les « autres » échographies ainsi que les tomodensitométries. Les facteurs qui expliquent ces résultats sont les suivants :

- Nombre élevé et croissant de demandes des consultations externes privées, incluant des cas en attente depuis plus de 2 ans;

- Le taux élevé de non-disponibilité et d’attente de réponses des patients à qui on offre un examen; - Bris de service de 15-20 jours en 2018-2019 en raison d’appareils défectueux en tomodensitométrie.

Plusieurs cas qui proviennent de l’Urgence ont priorité sur les examens des clients externes. La majorité des patients refusent un transfert vers un autre hôpital du CIUSSS et préfèrent l’attente. Même si dans certains cas, la cible n’est pas atteinte, il a encore de la disponibilité pour les demandes provenant du centre de répartition des demandes de service (CRDS) puisque les facteurs qui expliquent la non-atteinte de l’engagement ne sont pas liés à un manque de ressources. Les mesures correctrices en place pour favoriser l’atteinte de ces engagements sont les suivantes :

- Allongement des plages horaires; - Des surplus de volume ont été absorbés par des postes vacants qui ont été comblés; - Les travaux de remplacement de deux CT scan ont débuté, fin des travaux prévue en septembre 2019.

Trois engagements sont atteints à moins de 90 %, soit l’imagerie médicale ciblée, les échographies cardiaques et les résonances magnétiques. Les facteurs qui expliquent ces résultats sont les suivants :

- La non-disponibilité et l’attente de réponses des patients qui ont un rendez-vous prévu; - Pénurie de technologues formés; - Manque de disponibilité des cardiologues pendant les échographies cardiaques; - En imagerie médicale ciblée, un certain nombre d’examens sont effectués quelques jours seulement

après les 3 mois. Les mesures correctrices en place pour favoriser l’atteinte de ces engagements sont les suivantes :

- Un technologue est actuellement en formation; - Ajustement des horaires et des vacances afin d’optimiser la disponibilité des technologues.

b) Appréciation de l’évolution des résultats par rapport aux résultats de l’année précédente : Six des 8 résultats ont connu une évolution négative par rapport à ceux de l’année précédente. Les principales raisons sont celles évoquées au point A, soit 1 — la demande croissante des ultra-sons, spécialement depuis l’ouverture de ces examens dans des cliniques privées; 2— la non-disponibilité et l’attente de réponses des patients à qui on offre un rendez-vous; et 3 — la pénurie des ressources humaines disponibles (technologues et médecins).

c) Les problèmes connus liés à la qualité des données, à la méthodologie de l’indicateur : Aucun problème connu en lien avec la qualité des données.






2019-2020

Ressources matérielles

2.02.02 – EG2 Niveau de réalisation moyen des étapes requises pour l’élimination des zones grises en hygiène et salubrité

Non disponible 100 % 33,3 % 100 %

Commentaires : a) Cible non atteinte dans 2 des 3 sites visés b) Constat suite à des audits récents c) Mesures mises en place pour corriger :

i. Participation au comité PCI à titre de membre (2 sièges pour la Direction des services techniques [DST]) et suivi des résultats

ii. Mise en place d’un groupe de travail « zones grises » en mars 2019 pour corriger la situation partout et se conformer aux exigences ministérielles.

Ressources humaines

Plan stratégique 3.01-PS Ratio d’heures en assurance salaire

7,05 4,8 7,46 6,17

Plan stratégique 3.05.02 – PS Taux d’heures supplémentaires

4,66 3,1 5,94 3,99

Plan stratégique 3.06.00 – PS Taux de recours à la main-d’œuvre indépendante

3,77 3,58 5,48 4,02

Commentaires :

3.01-PS Ratio d’heures d’assurance salaire a) La cible pour cet indicateur n’a pas été atteinte au moment de la présente reddition de comptes. Certaines des

actions mises de l’avant pour corriger la situation comprennent des études des causes de l’augmentation, la production de recommandations ainsi que diverses activités de promotion de la santé, de la sécurité et du mieux-être en milieu de travail : • Politique de gestion intégrée de la prévention, de la présence et de la qualité de vie au travail élaborée; • Participation à un projet de recherche avec les HEC portant sur le climat de travail et mise en place des

recommandations qui en découlent (3e sondage terminé en mai 2019); • Mise en place d’actions visant l’accroissement de la gestion de proximité (en cours); • Réorganisation de l’équipe du service de prévention et de promotion de la santé, ajout de ressources,

formation, coaching et révision de processus (organisation du travail, meilleures pratiques, etc.) (en cours);

• Intégration du volet climat de travail à l’équipe de prévention et promotion de la santé; • Déploiement de la nouvelle équipe de soutien en amélioration continue de la prévention (ESACP); • Capsules de formation pour les gestionnaires sur 12 sujets touchant la gestion de la présence au travail

(en cours); • Travaux réguliers avec le comité paritaire santé et sécurité au travail (SST) (en continu).

b) On constate également une hausse de 0,41 % depuis l’année dernière, ce qui représente une hausse considérablement moins importante que l’année d’avant où l’on constatait une hausse de 1,16 % entre 2016-2017 et 2017-2018. Plusieurs stratégies ont été déployées depuis le constat d’une tendance à la hausse en prévision de résultats à plus long terme tel qu’exprimé au point précédent. Nous constatons que les actions mises de l’avant portent déjà leur fruit et prévoyons une baisse pour l’année en cours.

c) s/o

3.05.02 – PS Taux d’heures supplémentaires a) La cible pour cet indicateur n’a pas été atteinte au moment de la présente reddition de comptes. Plusieurs

mesures correctives ont été mises sur pied en plus de celles des années passées et de celles mentionnées pour


l’assurance salaire. Ces dernières découlent de différentes initiatives comme le plan d’action du sous-comité paritaire de la planification de la main-d’œuvre concernant le temps supplémentaire, le temps supplémentaire obligatoire et la main-d’œuvre indépendante pour les secteurs critiques, diverses campagnes de recrutement massif et autres, dont : • Salons de recrutement et d’embauche plus fréquents; • Programmes de garantie d’heures à durée indéfinie pour différents titres d’emploi (en cours); • Travaux d’arrimage des cahiers de postes et révision de processus en vue d’accélérer le processus de

dotation (en cours); • Travaux en lien avec l’application de la lettre d’entente sur la stabilité des postes, blitz prévu avec la

Fédération interprofessionnelle de la santé du Québec (FIQ) pour juin et juillet 2019 (surdotation, postes plus attractifs et retentis, horaires atypiques, etc.);

• Réorganisation en cours des services en lien avec les activités de remplacement (services 24 h/24 et 7 jours/7, processus harmonisés, plus grand support aux clients pour la confection et la planification d’horaire, campagnes de sensibilisation pour les disponibilités, etc.);

• École pour les préposés aux bénéficiaires (PAB) à l’Hôpital Ste-Anne en partenariat avec la Commission scolaire Marguerite-Bourgeoys (embauche de 11 étudiants sur 12 pour la première cohorte, deuxième cohorte en cours);

• Travaux réguliers avec le comité paritaire SST. b) On constate également une hausse de 1,28 % depuis l’année dernière. Une partie de l’écart est possiblement en

lien avec une hausse de l’assurance salaire. c) s/o

3.06.00 – PS Taux de recours à la main-d’œuvre indépendante a) La cible pour cet indicateur n’a pas été atteinte au moment de la présente reddition de comptes. Plusieurs

mesures correctives ont été mises sur pied en plus de celles des années passées et de celles mentionnées pour l’assurance salaire. Ces dernières découlent de différentes initiatives comme le plan d’action du sous-comité paritaire de la planification de la main-d’œuvre concernant le temps supplémentaire, le temps supplémentaire obligatoire et la main-d’œuvre indépendante pour les secteurs critiques, diverses campagnes de recrutement massif et autres, dont : • Salons de recrutement et d’embauche plus fréquents; • Programmes de garantie d’heures à durée indéfinie pour différents titres d’emploi (en cours); • Travaux d’arrimage des cahiers de postes et révision de processus en vue d’accélérer le processus de

dotation (en cours); • Travaux en lien avec l’application de la lettre d’entente sur la stabilité des postes, blitz prévu avec la FIQ

pour juin et juillet 2019 (surdotation, postes plus attractifs et retentis, horaires atypiques, etc.); • Réorganisation en cours des services en lien avec les activités de remplacement (services 24 h/24 et 7

jours/7, processus harmonisés, plus grand support aux clients pour la confection et la planification d’horaire, campagnes de sensibilisation pour les disponibilités, etc.);

• École pour les PAB à l’Hôpital Ste-Anne en partenariat avec la Commission scolaire Marguerite-Bourgeoys (embauche de 11 étudiants sur 12 pour la première cohorte, deuxième cohorte en cours);

• Travaux réguliers avec le comité paritaire SST. b) On constate également une hausse de 1,71 % depuis l’année dernière. Une partie de l’écart est possiblement en

lien avec une hausse de l’assurance salaire. c) s/o


Légende

Atteinte de l’engagement annuel atteint à 100 % Atteinte de l’engagement annuel égal ou supérieur à 90 % et

inférieur à 100 % Atteinte de l’engagement annuel inférieur à 90 %





2019-2020

Multiprogrammes

Plan stratégique 7.01.00 – PS Pourcentage des premiers services de nature psychosociale qui sont dispensés dans un délai de 30 jours (mission CLSC)

56,2 67,5 49 75

Commentaires :

Facteurs expliquant la non-atteinte de l’engagement : • Nos statistiques de performance validées en interne indiquent que notre pourcentage de services de première

ligne de nature psychosociale dispensés dans un délai de 30 jours est en réalité de 70 % (Pourcentage des assignations au programme Jeunes en difficulté pour lesquelles un premier service psychosocial a été rendu dans un délai maximal de 30 jours - mission CLSC). Malgré les initiatives et la rigueur, cela ne correspond pas au pourcentage ministériel qui reste à 56,2.

• Nous continuons d’être confrontés à une importante pénurie de personnel, ce qui affecte notre délai d’accès et notre performance.

• Des efforts importants ont été déployés pour augmenter nos indicateurs de performance et mieux répondre aux besoins de notre clientèle. Des projets sont en cours, axés sur l’intégration des services de première et deuxième ligne, créant ainsi une trajectoire plus fluide pour la prestation de services. Nous nous sommes assurés que tous les intervenants aient une charge de travail optimale et que les révisions soient fréquentes afin de pouvoir assimiler plus rapidement. Les activités de groupe se poursuivent (Triple P, Habiletés parentales) favorisant une réponse plus rapide et plus efficace aux besoins de nos clients.

• Un processus de révision est en cours afin d’identifier et corriger ces divergences futures qui semblent provenir de la qualité de nos données et non de nos pratiques cliniques et de la fluidité de notre trajectoire.

Mesures en cours pour corriger : • Nous continuons à travailler en étroite collaboration avec nos départements de ressources humaines afin

d’afficher rapidement les postes et rencontrer les candidats appropriés. • Un processus de révision est en cours avec notre service de la qualité et de la performance afin de mieux

comprendre et reproduire la formule du Ministère et ainsi permettre un suivi efficace et des corrections rapides.

• Un processus est en cours pour sensibiliser/former tout le personnel aux codes appropriés devant être saisis afin d’obtenir un portrait plus précis du rendement et sensibiliser le personnel à l’importance de la rigueur dans nos statistiques.

• Des échantillons de performance de qualité ainsi que des audits doivent être effectués à intervalles réguliers pour garantir que les informations sont correctement saisies.


SECTION 5 – RISK AND QUALITY MANAGEMENT ACTIVITIES

ACCREDITATION

The CIUSSS de l’Ouest-de-l’Île-de-Montréal is accréditai bye Accreditation Canada.

A transitional visit took place in December 2018. In response to the recommendations made, the development and implementation of harmonized programs and practices regarding certain organizational practices across the CIUSSS de l’Ouest-de-l’Île-de-Montréal are underway, particularly with regard to suicide prevention, prophylaxis of venous thromboembolism, and the safety of infusion pumps.

Directorates are actively working to prepare for the first accreditation visit to the CIUSSS de l’Ouest-de-l’Île-de-Montréal, which will take place in 2019.

SAFETY AND QUALITY OF CARE AND SERVICES

The consolidation of a safety culture is an ongoing concern for the organization.

IN ACTION

The following actions are carried out to continuously promote the declaration and disclosure of incidents and accidents:

• Launch of activities during Canadian User Safety Week;

• Assistance to various directorates within the organization in terms of declaration and disclosure of incidents;

• Regular follow-up with managers and directorates pertaining to quality of declarations, analyses, and sharing of recommendations;

• Technical support regarding the use of SISSS software in private resources and government-regulated private institutions on the territory of the CIUSSS de l’Ouest-de-l’Île-de-Montréal;

• Development and deployment of risk management tools;

• Maintenance and updates on web sections dedicated to risk management;

• Risk analyses in certain directorates;

• Decentralization of declaration input in various sectors;

• Training in risk management, safety culture, and declaration and disclosure of incidents provided to 120 individuals (personnel, managers, owners of residential resources);

• Workshops on this topic were also held with the collaboration of the Academic Affairs, Teaching and Research Directorate and network partners.


MAIN RISKS IDENTIFIED THROUGH A LOCAL MONITORING SYSTEM

The local register of incidents and accidents recorded 12 002 reported events, a decrease of 8% compared with the previous year (12 980 events). However, it should be noted that data for 2017–2018 include all data saved, whereas data collection for 2018–2019 is still ongoing at the date of this annual report.

There were 1275 reported incidents (11% of all reported events). The three main types of incidents identified are: medications 471 (4% of all reported events), others 314 (3% of all reported events), and treatment/intervention 234 (2% of all reported events).

There were 10 121 reported accidents (84% of all reported events). The three main types of accidents identified are: Falls 4758 (40%) Other 2095 (17%), and Medications 1834 (15%). The Other category includes injuries of known and unknown origin, running away, self-mutilation, error relating to the file, bedsores, etc.

A total of 606 events (5%) were not categorized as either an incident or an accident in the local register of incidents and accidents.

ACTIONS UNDERTAKEN BY THE RISK MANAGEMENT COMMITTEE AND MEASURES IMPLEMENTED BY THE INSTITUTION

The Risk Management Committee met four times between April 1, 2018, and March 31, 2019. The current overview was adopted during the meeting held on May 6, 2019.

In 2018–2019, Accreditation Canada visited the CIUSSS de l’Ouest-de-l’Île-de-Montréal for the first time since its establishment. In this context, the quality committees prioritized the development of an organizational security plan. A special session was convened and followed up on at each meeting of the Risk Management Committee.

The Committee followed up on quarterly reports on incidents, accidents, sentinel events, and related corrective measures during Committee meetings.

The Risk Management Committee supports CIUSSS de l’Ouest-de-l’Île-de-Montréal teams who give their staff the opportunity to attend training sessions on the declaration, disclosure, and concepts of risk management.

The committee was informed of the activities carried out during the National User Safety Week across the CIUSSS de l’Ouest-de-l’Île-de-Montréal to promote user safety. Workshops on this topic were also held with the collaboration of the Academic Affairs, Teaching and Research Directorate and network partners.

In addition, the Infection Prevention and Control Department provided a status report during a committee meeting. The Operational Coordination Committee ensures regular follow-up on matters of infection prevention and control.

Finally, a status report on the progress of the work on control measures was presented to the Risk Management Committee.

The Committee recommended that:

1. The Emergency Department, in collaboration with the departments involved, do an analysis of the response to a Code Blue: Professional Services Directorate, Nursing Directorate, and Multidisciplinary Services Directorate.

2. The regulations and procedures for disclosing information required by a user or their family following an accident be adopted by the organization.

3. Each directorate carry out a systematic follow-up (at least quarterly) to ensure that the summary analyzes are completed by its managers.

4. Follow-up on the completion of the summary analyzes be done with the managers concerned during their statutory meetings.


The CIUSSS de l’Ouest-de-l’Île-de-Montréal has implemented measures with regard to the primary risks for incidents/accidents previously identified, as well as the prevention and control of nosocomial infections. These include:

• Roll-out of an organizational project on proper hand hygiene practices in residential care centres;

• The dissemination of new policies and care regulations regarding the safe distribution and administration of medications.

PRINCIPAL FINDINGS—APPLICATION OF USER CONTROL MEASURES (ART 118.1 ARHSSS)

• On October 15, 2018, recommendations were made to the CIUSSS de l’Ouest-de-l’Île-de-Montréal by the Commission des droits de la personne et des droits de la jeunesse following a stud examining the CISSS and CIUSSS youth rehabilitation missions in Québec with regard to the use of isolation and restraints in youth protection. Follow-up was done by the staff of the Batshaw Youth and Family Centres.

• A plan to harmonize protocols for control measures across the CIUSSS has been sent to the Commission des droits de la personne et des droits de la jeunesse (CDPDJ). The protocol on control measures was adopted by the Board of Directors on October 3, 2018. It was also submitted to the CDPDJ. It consists of explicit measures related to the exceptional and rigorous use of control measures. Several reminders were given to ensure that staff understand the protocol and the difference between a disciplinary measure and a control measure. Several training sessions were also conducted to ensure comply with best practices by staff authorized to apply mechanical or physical control measures.

• Deployment is currently underway. The protocol is available in French and English on the intranet. An information pamphlet for users has also been published in both French and English.

• A PowerPoint-based training module is being finalized.

• The emphasis is on our objective to progressively reduce the use of control measures.

• Our statistics for the year 2018–2019 show a progressive decrease in the user of control measures across all CIUSSS de l’Ouest-de-l’Île-de-Montréal missions. This decrease is probably due to increased awareness among professionals and the ongoing promotion of alternative measures.

• Tools for the compilation of data on physical health remain a challenge. However, thanks to collaboration across directorates and the deployment plan currently underway, an electronic tool will soon be available for the compilation of data for all of the indicators identified according to best practices.


MEASURES IMPLEMENTED BY THE INSTITUTION OR ITS PUBLIC ADVISORY AND SERVICE QUALITY COMMITTEE FOLLOWING RECOMMENDATIONS FORMULATED BY THE FOLLOWING BODIES

Service Quality and Complaints Commissioner

In accordance with the Regulation respecting the complaints procedure and pursuant to the mandate of the Public Advisory and Service Quality Committee, the Service Quality and Complaints Commissioner periodically report all improvement resulting from the application of the complaints procedure to this committee.

The implementation of these improvement measures is monitored rigorously with each of the bodies and directorates concerned. The complaint and intervention file are closed once the measures have been implemented. This approach is part on an ongoing goal of improving the quality of care and services provided to users and their loved ones.

Systemic measures are focused on adapting care and services (such as adding staff or services, informing and educating stakeholders, reducing delays, improving communications); adapting the environment and the environment (such as technical and material adjustments, improving security measures and protection); and, the adoption/revision/application of rules and procedures (such as clinical or administrative protocols).

At the 2018–2019 year end, 55% of the systemic improvement measures were in the process of being implemented. Among the 155 improvement measures, 68 measures had been implemented, and 87 measures were underway.

These are some of the improvements implemented:

• Directing our diverse clientèles toward the appropriate access portals when enquiring about access to mental health services.

• Assisting with requests to update forms in the medical file of a user leaving the Emergency to ensure they are transported to the correct address.

• Intervening with the Home Support Service to ensure a better continuity of services to a user.

• Reminding foster families to use appropriate language and tone when speaking with youths.

• In collaboration with managers and stakeholders, examining the needs in the areas of intellectual disabilities and access to services, to allow for specific services in support of clients and loved ones.

Ombudsman

The CIUSSS de l’Ouest-de-l’Île-de-Montréal received 6 reports from the Ombudsman in the 2018–2019 fiscal year, including a total of 15 recommendations. Following are the recommendations were received regarding various directorates of the organization:

• Modify, as planned, the Emergency Room Departure Summary sheet to document the patient’s clothing upon departure. o Follow-up: Implemented

• Revise the procedure for the rental of therapeutic mattresses, so that a user in need of such a mattress has uninterrupted access to one despite a transfer of unit. o Follow-up: Implemented

• Disseminate to all nursing staff and managers concerned the revised procedure for the rental of therapeutic mattresses. o Follow-up: Implemented

• Analyze the possibility of implementing collective prescriptions that allow necessary test samples to be drawn and solutes to be administered to women with symptoms of hyperemesis gravidarum at the Hôpital de LaSalle Emergency Department. o Follow-up: Implemented


• As planned, draft a protocol on hyperemesis gravidarum for the Emergency Department and Unité familiale des naissances (UFN) at Hôpital de LaSalle, creating the necessary links to the protocol on Initial Obstetric Triage. o Follow-up: Implemented

• Train relevant personnel at the Hôpital de LaSalle to apply the protocol on hyperemesis gravidarum. o Follow-up: Implemented

• Educate medical unit staff on the importance of documenting discussions about the needs and requests made by relatives of a hospitalized user. o Follow-up: Implemented

• Remind the staff of Medical Unit 3-North that psychosocial services are available for loved ones, and that it is their responsibility to make the request when such a need is expressed or identified. o Follow-up: Implemented

• Continue working toward meeting the commitments set out in the 2018–2019 Management and Accountability Agreement in terms of the number of dedicated palliative care beds. o Follow-up: In progress

• By January 31, 2019, inform psychiatrists and medical students of the DMHUI Emergency Room about services and their respective trajectories (Module d’évaluation liaison [MEL], Module d’intervention rapide [MIR], and the refera service). o Follow-up: Implemented

• By January 31, 2019, remind nursing personnel who work at or may do occasional shifts at the DMHUI referral service that sectorization is not permitted. o Follow-up: Implemented

• By February 15, 2019, take the necessary steps to ensure that the nursing staff of the DMHUI referral service direct users to resources that meet their needs so that they can be cared for in a timely manner. o Follow-up: Implemented

• By 1 March 2019, implement a written procedure about referral trajectories through the Module d’évaluation liaison (MEL) and distribute it to all the staff concerned involved in references. o Follow-up: Implemented

• Take the necessary steps to ensure that all health and social services network and representatives of the Public Curators who work with these residents are attentive to their living environments, including respect for the rights of residents.

o Follow-up: Implemented

• Implement a process by which institutions can record information from interveners who are following vulnerable clients living in private homes where issues have been identified. Follow up on such situations in an effort to remedy noted deficiencies. Inform the Québec Public Curator should someone under their care be residing there. o Follow-up: Implemented

All of the ombudsman’s recommendations have been implemented by the CIUSSS de l’Ouest-de-l’Île-de-Montréal.


Coroner

The CIUSSS de l’Ouest-de-l’Île-de-Montréal received 3 reports from the coroner in the 2018–2019 fiscal year, including a total of 3 recommendations. The following recommendations were received regarding various directorates of the organization:

• Design a consent form that, when signed by patients, would allow institutions to share medical information, with the goal of improving communication between health professionals and ensuring better follow-up for patients at risk of suicide;

o Follow-up: In progress

• Complete revision of a file by the Professional Services Directorate;


• Take the appropriate means to better train family auxiliaries, including those from private agencies, as concerns quality and safety of services.


All of the coroner’s recommendations have been implemented by the CIUSSS de l’Ouest-de-l’Île-de-Montréal.

Other Instances

The CIUSSS de l’Ouest-de-l’Île-de-Montréal received a report from the Commission des droits de la personne et des droits de la jeunesse, recommending that:

• Interveners with the Signalements Reception and Processing Department and those from the Assessment/Orientation Department of Batshaw Youth and Family Centres are trained to assess and manage the risk of homicide by the Centre intégré de recherche appliquée en intervention psychosociale (CRAIP) or receive equivalent training on homicide risk assessment and management.

The CIUSSS de l’Ouest-de-l’Île-de-Montréal verified the training of all interveners in these sectors.


NUMBER OF PERSONS UNDER PREVENTATIVE CONFINEMENT, PER MISSION

The mission of the CIUSSS de l’Ouest-de-l’Île-de-Montréal, covered by Section 6 or Section 9 of the Act Respecting the Protection of Persons Whose Mental State Presents a Danger to Themselves or to Others (CQLR c P-38.001) is the CH mission. There were no preventative confinements in the CHSLD, CLSD, and CR missions of our institution.

CH Mission Establishment

Total

Number of Persons Under Preventative Confinement

1 404 1 404

Number of requests for provisional custody presented to the court by the institution on behalf of a physician or other professional who practises within the establishment

n/a 86

Number of Temporary Confinement Orders Issued by the Courts and Executed

80 80

Number of Requests for Confinement under Section 30 of the Civil Code Submitted to Court by the Institution

n/a 720

Number of Individual Users Under Confinement authorized by the courts under section 30 of the Civil Code and executed (including renewal of an authorized detention)

673 673

(): number too small to allow publication.


COMPLAINTS EXAMINATION AND ADVOCACY

SERVICE QUALITY AND COMPLAINTS COMMISSIONER

The full report of the Service Quality and Complaints Commissioner is available at: www.ciusss-ouestmtl.gouv.qc.ca/en/publications/reports-and-reviews/#c45562.

PROMOTING THE COMPLAINT REVIEW SYSTEM

The Office of the Service Quality and Complaints Commissioner has worked extremely hard to increase its visibility both inside the CIUSSS de l’Ouest-de-l’Île-de-Montréal and outside. A fourth visibility campaign is planned for May 2019. The Office of the Commissioner has also made multiple presentations and followed up with the Vigilance and Quality Services Committee of our organization.

Highlights:

• Permanent appointment to the position of Commissioner;

• Permanent appointment to the position of Associate Commissioner;

• Website continuously updated;

• Media outreach activities.


PUBLIC INFORMATION AND CONSULTATION

The CIUSSS de l’Ouest-de-l’Île-de-Montréal is responsible for providing citizens with information about the services offered by its local service network and continues to expand its communications approach to fulfil that mission.

Among the primary communication channels:

The web portal (www.ciusss-ouestmtl.gouv.qc.ca), online since June 2015, remains very popular with more than 430 000 users this year.

The site facilitates access to care and services. Targeted campaigns were carried out to promote citizen partnerships in the improvement of care and services. Other care and service campaigns have been rolled out, such as the Travel Health Clinic and the Community Birthing Centre. In addition, Ministerial public health campaigns on topics including cannabis, “making the right choice”, and influenza and gastroenteritis were relayed. As a result the Users’ Committee is now more prominent, which also helps in recruiting members. It also provides users with a means of expressing their satisfaction. Partners also have a dedicated zone.

The Info-CIUSSS telephone line (514-630-2123) and email address [email protected]—well-publicized to residents of the CIUSSS de l’Ouest-de-l’Île-de-Montréal territory since their inception—also remain very popular. Each week there are on average 25 calls and 25 requests for information or comments by email.

In an effort to effectively inform the public about the services offered and to support the activities of its public health and health promotion teams, the CIUSSS de l’Ouest-de-l’Île-de-Montréal not only broadcasts information via its portal, but also makes active use of social media. Over 400 posts were published this year.

• Facebook

o 886 new followers this year, for a total of 9779;

o 33 614 interactions

• Twitter

o 145 new followers this year, for a total of 5427;

o 7201 profile visits

• LinkedIn

o 2460 new LinkedIn followers, for a total of 7667;

o 8470 unique visitors

The 31 dynamic screens at the Douglas Mental Health University Institute, the Dorval-Lachine-LaSalle installations and Ste. Anne’s Hospital are another source of public information.

The public is also invited to attend the meetings of the Board of Directors at each regular session. The invitation is published at least 15 days prior to each regular session.


SECTION 6—REPORT ON THE APPLICATION OF THE LAW CONCERNING END-OF-LIFE CARE

As part of the application of the Act respecting end-of-life care, and in accordance with the mandate given by the CEO, the Interdisciplinary Support Group (ISG) provides clinical, administrative, and ethical support to professionals in the field who respond to a request for medical aid in dying (MAID).

Activity Information requested December 10,

2017, to March 31, 2018

April 1, 2018, to March 31, 2019

Total

Palliative and End-of-Life Care

Number of end-of-life people receiving palliative care

526 1 273 1 799

Continuous Palliative Sedation

Number of times continuous palliative sedation (CPS) was administered

5 12 17

Medical Aid in Dying Number of requests for medical assistance in dying received;

13 31 44

Number of times medical assistance in dying was provided

5 13 18

Number of times medical assistance in dying was not administered and the reasons

8

• 1 request where the user died became unable to consent during the process;

• 6 requests did not meet the requirements of Section 26.6 of the Act;

• 1 request where the user died before the end of the process;

18

• 1 request where the user died became unable to consent during the process;

• 6 requests did not meet the requirements of Section 26.6 of the Act;

• 4 requests where the user died before the end of the process;

• 7 requests withdrawn by the user.

26

• The ISG met for each of the MAID requests received that were deemed eligible. • A member of the ISG provided support to the care team in each MAID request. • A member of the ISG held meetings with the care team as needed after the administration of MAID.

As per its mandate, the ISG provided clinical, administrative, and ethical support to health professionals responding to a MAID request. It supported the care teams for each MAID request received. To ensure the maintenance of optimal care trajectories in the MAID process at the CIUSSS de l’Ouest-de-l’Île-de-Montréal, the ISG met before each administration of MAID.


SECTION 7—HUMAN RESOURCES

HUMAN RESOURCES CHART ON MARCH 31, 2019, HEADCOUNT BY JOB CATEGORY

Job Category (MSSS, unionized) 2018–2019

10 - Nursing and cardiorespiratory care personnel 3110

20 - Labourers, para-technical, and auxiliary personnel 3468

30 - Office personnel, technicians and administrative professionals 1464

40 - Health and Social Services technicians and professionals 2141

50 - Personnel not targeted by Law 30 76

60— Management personnel 359

Total 10 618


WORKFORCE MANAGEMENT AND CONTROL

The target is set at 15 566 045 hours worked; that target was exceeded by 1.7%, representing 260 661 hours worked. New investments and the reorganization of services over the course of the year explain this difference, along with a growth in our clientèles and service delivery in certain sectors, as well as the start of work to implement the lettre d’entente sur la stabilité des postes favorisant le rehaussement de postes.

Sous-catégorie d'emploi

déterminée par le SCT

Valeurs

observées

Heures

travaillées

Heures

supplém.

Nbre

ETC

Nbre

individus2014-15 810 939 3 221 446 508

2015-16 743 066 2 852 408 509

2016-17 719 460 3 464 395 470

2017-18 653 091 3 501 359 422

2018-19 637 476 3 410 351 409

Va ria tion (21.4 %) 5.9 % (21.2 %) (19.5 %)

2014-15 1 748 042 7 059 968 1 323

2015-16 1 775 611 5 690 982 1 349

2016-17 1 901 581 7 637 1 052 1 410

2017-18 2 053 371 11 493 1 136 1 578

2018-19 2 144 946 12 752 1 186 1 631

Va ria tion 22.7 % 80.7 % 22.6 % 23.3 %

2014-15 3 893 552 171 823 2 081 2 905

2015-16 3 882 810 151 285 2 074 2 951

2016-17 4 038 728 198 370 2 152 3 009

2017-18 4 196 423 234 020 2 234 3 159

2018-19 4 156 604 321 157 2 209 3 177

Va ria tion 6.8 % 86.9 % 6.2 % 9.4 %

2014-15 6 065 519 120 866 3 306 4 568

2015-16 5 965 559 90 835 3 252 4 621

2016-17 6 356 999 155 668 3 470 4 744

2017-18 6 381 553 211 300 3 481 4 851

2018-19 6 591 267 277 785 3 593 5 047

Va ria tion 8.7 % 129.8 % 8.7 % 10.5 %

2014-15 1 378 271 13 987 701 1 081

2015-16 1 370 242 12 023 697 1 140

2016-17 1 617 392 20 932 822 1 275

2017-18 1 626 593 24 299 829 1 313

2018-19 1 634 577 37 511 832 1 330

Va ria tion 18.6 % 168.2 % 18.7 % 23.0 %

2014-15 25 317 26 14 72

2015-16 15 852 46 9 50

2016-17 11 314 98 6 35

2017-18 8 285 50 5 25

2018-19 9 166 55 5 31

Va ria tion (63.8 %) 108.6 % (63.3 %) (56.9 %)

2014-15 13 921 641 316 983 7 514 10 271

2015-16 13 753 140 262 731 7 422 10 466

2016-17 14 645 474 386 170 7 897 10 760

2017-18 14 919 316 484 663 8 043 11 154

2018-19 15 174 036 652 670 8 176 11 443

Variation 9.0 % 105.9 % 8.8 % 11.4 %11.2 %

15 403 979

14 015 872

Total du personnel

14 238 623

15 031 644

15 826 706

(63.6 %)

8 335

15 898

6 - Étudi ants et s tagi a ires

25 343

11 412

9 221

20.1 %

1 650 892

1 382 266

5 - Ouvri ers , personnel d'entretien et de service

1 392 258

1 638 324

1 672 088

11.0 %

6 592 853

6 056 394

4 - Personnel de bureau, technicien et a ss imi lé

6 186 385

6 512 667

6 869 052

10.1 %

4 430 443

4 034 095

3 - Personnel infi rmier

4 065 375

4 237 098

4 477 761

22.9 %

2 064 864

1 781 301

2 - Personnel profess ionnel

1 755 101

1 909 218

2 157 698

(21.3 %)

656 592

745 918

1 - Personnel d'encadrement

814 160

722 924

640 886

Total heures

rémunérées

11045168 - CIUSSS de l'Ouest-de-l'Île-de-MontréalComparaison sur 364 jours pour avril à mars

2014-04-06 au 2015-04-04 2018-04-01 au 2019-03-30


SECTION 8—FINANCIAL RESOURCES

USE OF BUDGETARY AND FINANCIAL RESOURCES PER PROGRAM

EXPENSES PER PROGRAMS—SERVICES

Schedule Preceding Year Current Year Variation in Expenses

Expenses % Expenses % $ %

Service Programs

Public Health 5 562 966 1% 5 203 923 1% - 359 043 -0.8%

General Services—Clinical and Support Activities 17 198 726 2% 24 223 276 3% 7 024 550 14.8 %

Support for Elderly Autonomy 155 194 016 19% 155 237 408 18% 43 392 0.1 %

Physical Disability 7 862 706 1% 5 820 262 1% -2 042 444 -4.3%

Intellectual Disability & Autism Spectrum Disorder 49 755 932 6% 53 074 930 6% 3 318 998 7.0 %

Youth in Difficulty 68 076 879 8% 71 197 014 8% 3 120 135 6.6 %

Addiction 0 0% 0 0% 0 0.0 %

Mental Health 96 962 068 12% 103 615 330 12% 6 653 262 14.0 %

Physical Health 214 718 459 26% 239 953 310 28% 25 234 851 53.3 %

Support Programs

Administration 61 995 448 8% 61 002 293 7% - 993 155 -2.1%

Support to Services 73 720 261 9% 76 391 120 9% 2 670 859 5.6 %

Building & Equipment Management 64 413 952 8% 67 117 245 7% 2 703 293 5.8 %

Total 815 461 413 100% 862 836 111 100% 47 374 698 100%

The financial statements included in the annual financial report (AS-471) are available for consultation on our website at www.ciusss-ouestmtl.gouv.qc.ca.


BALANCED BUDGET

Under Sections 3 and 4 of the Act to provide for balanced budgets in the public health and social services network (CQLR c E-12.0001), the institution must maintain a balance between its revenues and expenses over the course of the fiscal year and must not incur a deficit at the end of the fiscal year.

For the year that ended March 31, 2019, the institution had a deficit of $927 399 and failed to meet its legal obligation to maintain a balanced budget. The deficit presented is fully covered by fund balances, which initially included surpluses on March 31, 2015. In fact, the sum of $927 399 comes from the amortization of the Dorval Campus’s capital assets and an internally generated allocation from the operating fund.

As such, the deficit before using the fund balances is $927 399 on March 31, 2019. The operating fund ended with a surplus of $103 274, while the capital fund shows a deficit of $1 030 673.

SERVICE CONTRACTS

Service Contracts involving expenditures of $25 000 or more, concluded between April 1, 2018, and March 31, 2019.

Number Value

Service contracts with an individual 1 6 $365 665

Service contracts with a contractor other than an individual 2

112 $12 217 862

TOTAL OF SERVICE CONTRACTS 118 $12 583 527

1 An individual, whether in business or not. 2 Includes private law corporations, partnerships, limited partnerships, or joint ventures.


SECTION 9—MONITORING OF STATE RESERVES, COMMENTS AND OBSERVATIONS ISSUED BY INDEPENDENT AUDITOR


SECTION 10—DISCLOSURE OF WRONGDOINGS

The process for establishing and emitting a procedure to facilitate the disclosure of wrongdoing by employees is currently being updated. In the interim, the institution has introduced a transitional measure: the Human Resources, Communications and Legal Affairs Directorate and the Financial Resources Directorate have been given the responsibility for receiving disclosures. No disclosures were received for the year 2018–2019.

Disclosure of Wrongdoing with respect to Public Bodies No. of Disclosures

No. of Grounds

Grounds

1. Number of disclosures received by the individual responsible for follow-up on disclosures 1 0 Not

applicable

2. Number of alleged grounds in disclosures received (Point 1)2

Not applicable 0

Not applicable 3. Number of grounds terminated pursuant to paragraph 3 of

Article 22 0

4. Number of disclosures received by the individual responsible for follow-up on disclosures: For the grounds alleged in the disclosures received (Point 2)—excluding those that were terminated (point 3)—identify which category of wrongdoing they relate to. � Contravention of a Québec provincial law, a federal law

applicable in Québec, or a regulation established under such a law

Not applicable

0 N/A

A serious breach in ethical standards and professional conduct

0 N/A

� Misuse of funds or property of a public body, including those it manages or holds for others

0 N/A

� Serious mismanagement within a public body, including abuse of authority

0 N/A

� Causing, through an act or an omission, serious injury or risk of serious injury to a person or the environment 0 N/A

� Ordering or counselling a person to commit a wrongdoing previously identified 0 N/A

5. Number of disclosures received by the individual responsible for follow-up on disclosures 0

Not applicable

6. Number of disclosures received by the individual responsible for follow-up on disclosures (Point 4) that were founded.

Not applicable

N/A

7. Total number of disclosures received (Point 1) that were determined to be founded, that is, that contained at least one disclosure that was determined to be founded

Not applicable

8. Number of times information was communicated in applying the first paragraph of Section 233 0 0 N/A

1. Number of declarations equals number of declarants. 2. A declaration may contain multiple grounds. For example, a declarant may mention in his declaration that his manager

used property of the State for personal gains and who contravened a provincial law by awarding a contract without a call for tenders.

3. List here the transfer of information to the Anti-Corruption Commissioner or any other organization whose duty is to prevent, detect, or suppress crime and legal infractions—such as a police force or a professional order—whether the disclosure is further investigated by the body responsible for follow-up or not.


APPENDIX 1: CODE OF ETHICS

CODE OF ETHICS AND PROFESSIONAL CONDUCT

FOR MEMBERS OF THE BOARD OF DIRECTORS

PURSUANT TO

THE ACT RESPECTING THE

MINISTÈRE DU CONSEIL EXÉCUTIF (Chapter M-30)

CENTRE INTÉGRÉ UNIVERSITAIRE DE

SANTÉ ET DE SERVICES SOCIAUX

DE L’OUEST-DE-L’ÎLE-DE-MONTRÉAL


TABLE OF CONTENTS

PREAMBLE ...................................................................................................................................... 62

SECTION 1 — GENERAL PROVISIONS ............................................................................................... 62

SECTION 2 — ETHICAL PRINCIPLES AND ........................................................................................... 65

RULES OF PROFESSIONAL CONDUCT ................................................................................................ 65

SECTION 3 – CONFLICT OF INTEREST ................................................................................................ 68

SECTION 4 – APPLICATION ............................................................................................................... 69

APPENDICES .................................................................................................................................... 73

APPENDIX I – MEMBER COMMITMENT AND AFFIRMATION ....................................................................... 74

APPENDIX II – NOTIFICATION OF A BREACH OF INDEPENDENT STATUS ...................................................... 75

APPENDIX III – MEMBER DECLARATION OF INTEREST ................................................................................ 76

APPENDIX IV – DECLARATION OF INTERESTS FOR THE EXECUTIVE DIRECTOR .............................................. 77

APPENDIX V – DECLARATION OF CONFLICT OF INTEREST ........................................................................... 78

APPENDIX VI – REPORTING A SITUATION OF CONFLICT OF INTEREST ......................................................... 79

APPENDIX VII – AFFIRMATION OF DISCRETION IN THE CONDUCT OF AN ENQUIRY ..................................... 80


PREAMBLE

The administration of a public health and social services establishment differs from that of a private organization. It must be based on a relationship of trust between the establishment and the population.

The administration of a public health and social services establishment differs from that of a private organization. It must be based on a relationship of trust between the establishment and the population. This Code thus establishes the ethical principles and obligations of professional conduct for members. Professional conduct refers mainly to the totality of a member’s duties and obligations, whereas ethics involves examining the broad principles of conduct to be followed by all board members, and establishing the consequences of each of the possible options in response to situations that they may face. These choices must be based, among other things, on a commitment to sound governance, which implies accountability commensurate to the responsibilities that are assigned to the establishment.

SECTION 1—GENERAL PROVISIONS GENERAL OBJECTIVES

The objectives of the present document are to prescribe rules of conduct for members of the Board of Directors in matters of integrity, impartiality, loyalty, competence, and respect, and to render them accountable by establishing the ethical principles and rules of conduct that are applicable to them. This Code begins by stating the general duties and obligations of each administrator.

The Administrators’ Code of Ethics and Professional Conduct:

a) establishes preventive measures, in particular rules concerning declaration of interests;

b) deals with the identification of situations of conflict of interest;

c) regulates or prohibits practices related to member remuneration;

d) specifies the duties and obligations of members even after they leave office;

e) includes enforcement mechanisms, including the designation of persons responsible for enforcing the code, and provides for sanctions.

In the exercise of their duties, all members shall respect the ethical principles and rules of conduct provided in the present Administrators’ Code of Ethics and Professional Conduct, as well as in the applicable laws. In case of divergence, rules shall apply according to the hierarchy of the laws involved.

1. LEGAL BASIS

The Administrators’ Code of Ethics and Professional Conduct is based mainly on the following provisions:

• The preliminary provision and articles 6, 7, 321 to 330 of the Civil Code of Québec.

• Articles 3.0.4, 3.0.5 and 3.0.6 of the Regulation respecting the ethics and professional conduct of public office holders, of the Act respecting the Ministère du Conseil exécutif (CQLR, chapter M-30, r. 1).

• Articles 131, 132.3, 154, 155, 174, 181.0.0.1, 235, 274 of the Act respecting health services and social services (CQLR, chapter S-4.2).

• Articles 57, 58 and 59 of the Act to modify the organization and governance of the health and social services network, in particular by abolishing the regional agencies (CQLR, chapter O-7.2).


• Act respecting contracting by public bodies (CQLR, chapter C-65.1).

• Lobbying Transparency and Ethics Act (CQLR, chapter T-11.011).

• Charter of Rights and Freedoms, CQLR, c C-12.

2. DEFINITIONS

For the purpose of these rules, the following words mean:

Ad hoc review committee: A committee constituted by the Board of Directors to handle potential faults or omissions or to resolve an issue submitted to it and propose a new rule.

ARHSSS: Act Respecting Health Services and Social Services.

AMHSN: The Act to modify the organization and governance of the health and social services network, in particular by abolishing the regional agencies.

Board: Board of Directors of the establishment, as defined by articles 9 and 10 of the Act to modify the organization and governance of the health and social services network, in particular by abolishing the regional agencies.

Code: A code of ethics and professional conduct for members, established by the Governance and Ethics Committee and adopted by the Board of Directors.

Confidential information: Data or information whose access and use are restricted to designated and authorized persons or entities. This information includes any personal, strategic, financial, commercial, technological, or scientific information belonging to the establishment, and any information whose disclosure could harm a user or a person working within the establishment. Any information, of a strategic nature or other, that is not known to the public and that, were it known to a person who is not a member of the Board of Directors, would be likely to procure an advantage or to compromise the realization of a project of the establishment.

Conflict of interest: Refers chiefly, without being limited to, any apparent, real or potential situation in which members might risk compromising the objective fulfilment of their duties, due to their judgment being influenced or their independence being affected by the existence of a direct or indirect interest. Situations of conflict of interest may concern, for example, money, information, influence, or power.

Enterprise: Any form of organization of the production of goods and services, or any other business of a commercial, industrial, financial, or philanthropic nature, or any group aiming to promote values, interests, or opinions, or to exercise influence.

Immediate family: For the purposes of article 131 of the Act respecting health services and social services, is considered an immediate family member of a president and executive director, assistant president and executive director, or senior manager of the establishment, their spouse, their child and the child of their spouse, their mother and father, the spouse of their mother or father, as well as the spouse of their child or of their spouse’s child.

Independent person: As defined by article 131 of the Act respecting health services and social services, a person qualifies as independent if the person has no direct or indirect relation or interest, for example of a financial, commercial, professional or philanthropic nature, likely to interfere with the quality of the person’s decisions as regards the interests of the establishment.

Interest: Refers to any interest of a material, financial, emotional, professional, or philanthropic nature.

Member: A member of the Board of Directors, whether independent, designated or appointed.


Reasonable person: Process by which an individual engages in critical reflection and considers the elements of a situation to reach the most reasonable decision possible in the circumstances1.

Serious misconduct: The outcome of a fact or a set of facts attributable to a member that constitute a serious violation of his or her obligations and duties, resulting in a breach of faith with the board members.

Spouse: A person related by marriage or civil union, or a common-law partner within the meaning of article 61.1 of the Interpretation Act (CQLR, chapter I-16).

3. SCOPE OF APPLICATION

All members of the Board of Directors are subject to the rules of the present Code.

4. ENTRY INTO EFFECT

The present document comes into effect the moment it is adopted by the Board of Directors. The Governance and Ethics Committee of the Board of Directors is responsible for ensuring the present Code is applied. The Code must be revised by the Governance and Ethics Committee every three years, or as required by legislative or regulatory changes, and must be amended or rescinded by the Board during one of its regular sessions.

5. PUBLICATION

The institution must make the present Code available to the public, notably by publishing it on its Internet site. It must also publish it in its annual management report, stating the number of cases dealt with and the follow-up thereupon, and setting out of any breaches determined during the year by the ad hoc review committee, the determination thereof, any penalties imposed by the Board of Directors, and the names of any persons revoked or suspended during the year or whose mandate has been revoked.

1 BOISVERT, Yves, Georges A. LEGAULT, Louis C. CÔTÉ, Allison MARCHILDON and Magalie JUTRAS (2003). Raisonnement éthique dans un contexte de marge de manœuvre accrue : clarification conceptuelle et aide à la décision – Rapport de recherche, Centre d’expertise en gestion des ressources humaines, Secrétariat du Conseil du trésor, p. 51.


SECTION 2—ETHICAL PRINCIPLES AND RULES OF PROFESSIONAL CONDUCT

6. ETHICAL PRINCIPLES

Ethics refer to the values (i.e. integrity, impartiality, respect, competence and loyalty) needed to safeguard the public interest. For administrators, it means respecting the right to rely on, among other things, one’s judgment, honesty, responsibility, loyalty, equity, and dialogue when exercising choice and making decisions. Ethics are thus useful in uncertain situations, when there is absence of rules, when the rules are not clear, or when following the rules leads to undesirable consequences.

In addition to observing principles of ethics and professional conduct, members of the Board of Directors must:

• Exercise, within the scope of the powers conferred on them, the care, prudence, diligence and skill that a reasonable person would exercise in similar circumstances; they must also act with honesty, loyalty and in the interest of the establishment and of the population served.

• Fulfil their general duties and obligations holding to the requirements of good faith above all else.

• Display a constant concern for the respect of life, of human dignity, and the right of every person to receive health and social services, within applicable limits.

• Be sensitive to the needs of the population and ensure that fundamental human rights are taken into account.

• Endorse current priorities and objectives, notably accessibility, continuity, quality and safety of car and services, with the ultimate goal of improving the population’s health and well-being

• Exercise their responsibilities while respecting recognized standards of accessibility, integration, quality, relevance, efficacy and efficiency, as well as available resources.

• Participate, actively and in a spirit of collaboration, in implementing the establishment’s overall priorities.

• Contribute, through the performance of their duties, to fulfil the mission, to respecting the values set forth in this Code, by drawing on their aptitudes, knowledge, experience, and rigour.

• Ensure that rules concerning confidentiality and discretion are respected at all times.

7. RULES OF PROFESSIONAL CONDUCT

Rules of professional conduct are a set of legal rules of conduct whose violation can lead to sanctions. They can be found in various laws and regulations cited in Section 2. These duties and professional rules of conduct thus establish what is prescribed and what is prohibited.

In addition to observing principles of ethics and professional conduct, members of the Board of Directors must:

8.1 Availability and Competence

• Be available to fulfil their functions by regularly attending Board of Directors meetings, according to the terms specified in the Règlement sur la régie interne du conseil d’administration de l’établissement.

• Acquaint themselves with the issues and actively take part in deliberations and decisions.

• Promote mutual cooperation.

• Fulfil their functions by putting their knowledge, abilities, and experience to work for the benefit of their colleagues and of the population.


8.2 Respect and Loyalty

• Respect the provisions of applicable laws, regulations, standards, policies, and procedures, as well as the general duties and obligations related to their office in accordance with the standards of good faith.

• Maintain courteous behaviour and relationships based on respect, cooperation, professionalism and an absence of any form of discrimination. Respect the rules of procedure governing Board of Directors meetings, especially those concerning the allocation of speaking time, decision-making, and the diversity of views, which should be considered as necessary for sound decision-making, as well as any decision reached, regardless of dissent.

•

• Respect all Board of Directors decisions, regardless of dissent, by showing reserve when offering public comment regarding decisions taken.

8.3 Impartiality

• Declare themselves on proposals by exercising their right to vote in the most objective manner possible. To this end, they cannot make any commitment with respect to a third party, nor provide such a party with any guarantee regarding their vote or any decision.

• Place the interests of the establishment before any personal or professional interest.

8.4 Transparency

• Exercise their responsibilities transparently, notably by basing their recommendations on objective and sufficient information.

• Share with members of the Board of Directors any information that is useful or relevant in the decision-making process.

8.5 Discretion and Confidentiality

• Subject to the provisions of the law, show discretion concerning matters of which they gain knowledge in or during the performance of their duties.

• Display prudence and restraint in handling any information whose disclosure or use could harm the interests of the establishment, prejudice the private life of an individual, or confer any undue advantage upon a natural or legal person.

• Maintain the confidentiality of private deliberations among members of the Board of Directors, as well as the positions held, members’ votes, and any other information that requires confidentiality, whether by virtue of law or pursuant to a decision by the Board of Directors.

• Refrain from using confidential information obtained in or during the performance of their duties for their own benefit, or that of any natural or legal person, or of any other interest group. This obligation does not have the effect of preventing a member who represents or is linked to a particular group from reporting back, except when information is confidential according to law or if the Board of Directors requires that confidentiality be respected.

8.6 Political Considerations

• Make their decisions independently of all partisan political considerations.


8.7 Public Relations

• Respect applicable rules within the establishment concerning information, communication, use of social media, and relationships with the media, among others, by not expressing themselves to the media or on social media if not authorized by the rules.

8.8 Public Office

• Notify the Board of Directors of their intention to run for election to an elective public office.

• Immediately resign from their functions if elected to a full-time public office. They must resign if the public office is part-time and is likely to interfere with their duty of confidentiality and/or place them in a conflict of interest.

8.9 Goods and Services of the Institution

• Use establishment goods, resources, and services in the manner established by the Board of Directors. They cannot commingle the establishment’s goods and their own. They cannot use these goods for their own profit or to profit a third party, unless they are duly authorized to do so. The same applies to resources and services put at their disposal by the organization, in accordance with recognized modes of use, applicable to all.

• Not receive any remuneration other than that provided for by law for the performance of their duties. However, members are entitled to a reimbursement of expenses incurred in the performance of their duties, within the conditions and to the extent set by the government.

8.10 Benefits and Gifts

• Do not solicit, accept, or require, on behalf of themselves or of a third party, nor pay or commit to pay to a third party, directly or indirectly, a gift, a token of hospitality, or any other advantage or consideration that is likely to influence them in the performance of their duties or to create expectations to that effect. All gifts and tokens of hospitality must be returned to the giver.

8.11 Inappropriate Interventions

• Avoid intervening in the process of hiring personnel.

• Avoid any move to favour family or friends or any other natural or legal person.


SECTION 3—CONFLICT OF INTEREST

9. Members cannot perform their duties for their own interest or for that of a third party. They must prevent all conflicts of interest and any appearance of conflict of interest and avoid placing themselves in a situation that renders them unfit to perform their duties. A member is notably in a conflict of interest when the interests involved are such that he might prefer some of them at the expense of the establishment or obtain from them an advantage, whether direct or indirect, current or eventual, personal or in favour of a third party.

10. Within a reasonable time of starting their functions, members must organize their personal affairs so that they may not interfere with the performance of their duties, by avoiding incompatible interests. The same applies when an interest devolves to an administrator by succession or by gift. The same applies when an interest devolves to an administrator by succession or by gift. They must not exercise any form of influence on other members.

11. Members must abstain from participating in deliberations when their objectivity, judgment or independence might be compromised due to personal, family, social, professional or business relationships. Moreover, the following situations, in particular, can represent a conflict of interest:

a) having a direct or indirect interest in a deliberation by the Board of Directors;

b) having a direct or indirect interest in a contract or a project of the establishment;

c) obtaining or being about to obtain a personal advantage as a result of a decision of the Board of Directors;

d) being engaged in a lawsuit against the establishment;

e) letting oneself be influenced by external considerations, such as the possibility of an appointment, or employment prospects or offers.

12. Members must submit and declare in writing to the Board of Directors any pecuniary interests they have, other than minority shares held in a company that do not represent a controlling stake, in any legal person, partnership or commercial enterprise that have a service contract with the establishment, or are likely to enter into one, using the form Member Declaration of Interest (see Appendix III). Moreover, they must abstain from sitting on the Board of Directors or participating in any deliberation or decision-making when a question concerning this interest is being discussed.

13. Members with a direct or indirect interest in a legal person or with a natural person that results in a conflict between their personal interest, that of the Board of Directors or of the establishment governed must, on pain of forfeiture from office, disclose such interests in writing to the Board of Directors using the form Declaration of conflict of interest in Appendix V.

14. Members who are in a real, potential or apparent situation of conflict of interest with respect to an issue raised during a session must declare the situation at once, and it shall be recorded in the minutes. They must retire during deliberations and decision-making concerning the issue. They must recuse themselves from deliberations and decision-making concerning the issue.

15. A donation or a bequest made to a member who is neither the spouse nor a close family member of the donor or testator is void, in the case of a donation, or without effect, in the case of a bequest, if the act takes place while the donor or testator is being treated or receiving services from the establishment.


SECTION 4—APPLICATION

16. THE ADMINISTRATORS’ CODE OF ETHICS AND PROFESSIONAL CONDUCT:

All members commit to acknowledging and fulfil their responsibilities and functions to the best of their knowledge and to respecting the present document as well as the applicable laws. Within sixty (60) days of the adoption of the present Administrators’ Code of Ethics and Professional Conduct by the Board of Directors, each member must submit the completed Member commitment and affirmation form from Appendix I of the present document.

All new members must also do this within sixty (60) days of joining the Board. In case of doubt about the applicability or scope of the present Code, it is the member’s responsibility to consult the Governance and Ethics Committee.

17. GOVERNANCE AND ETHICS COMMITTEE

In matters of ethics and professional conduct, the Governance and Ethics Committee’s functions, among other things, are to:

a) develop an Administrators’ Code of Ethics and Professional Conduct in compliance with article 3.1.4 of the Act respecting the Ministère du Conseil exécutif;

b) ensure the present Code is shared and promoted among the members of the Board of Directors;

c) inform members of the content and the implementing measures of the present Code;

d) advise the members on any question concerning application of the present Code;

e) handle declarations of conflict of interest and provide any members who so request an opinion on these declarations;

f) revise the present Code as required and submit any modifications for adoption by the Board of Directors;

g) periodically evaluate the application of the present Code and make recommendations to the Board of Directors as appropriate;

h) retain the services of external resources, if required, to review any issue that it receives from the Board of Directors;

i) conduct an analysis of any situations of breach of the law or of the present Code and report on it to the Board of Directors.

As it is the members of the Governance and Ethics Committee who set the rules of conduct, they should not be called on to interpret them, in a disciplinary context. Doing so could taint the disciplinary process by introducing a bias potentially unfavourable to the member in question. For this reason, it is proposed that an ad hoc review committee be set up to resolve the problem or to propose a rule, at the discretion of the Board of Directors.


18. AD HOC REVIEW COMMITTEE

18.1 The Governance and Ethics Committee sets up, as required, an ad hoc review committee composed of at least three (3) persons. One of these persons must have practical competencies in the domain of professional conduct and ethical reflection. The committee may be composed of members of the Board of Directors or of external resources with specific competencies, particularly in legal matters.

18.2 A member of the ad hoc review committee cannot serve on the committee if he is directly or indirectly involved in a matter that has been submitted to the committee.

18.3 The ad hoc review committee’s functions are to:

a) conduct enquiries, at the request of the Governance and Ethics Committee, into any situation involving a presumed breach, by a member of the Board of Directors, of the rules of ethics and professional conduct set out in the present Code;

b) determine, following such an enquiry, whether a member of the Board of Directors has breached the present Code or not;

c) make recommendations to the Board of Directors on measures that should be imposed on an offending member.

18.4 The start date, the duration of the mandate, and the terms of reference of the ad hoc review committee are set by the Governance and Ethics Committee.

18.5 If the ad hoc review committee is unable to make its recommendations to the Governance and Ethics Committee before its members’ terms of office of expire, the Governance and Ethics Committee may extend their terms of office for the time needed to fulfil the aforementioned requirement. The individual being investigated must be informed in writing.

19. DISCIPLINARY PROCESS

19.1 Any breach or dereliction of a duty or obligation under the Code constitutes a derogation and may result in a sanction.

19.2 When a person has substantial grounds to believe that a member may have breached the present document, the Governance and Ethics Committee will submit the matter to the ad hoc review committee by forwarding the Reporting a situation of conflict of interest form from Appendix VI completed by the person in question.

19.3 The ad hoc review committee determines, after analysis, whether an enquiry is warranted. If so, it notifies the member concerned of the alleged breach(es), referring to the relevant provisions of the Code. The notification advises the member that he may, within thirty (30) days, provide his observations in writing to the ad hoc review committee and, on request, be heard by the committee regarding the alleged breach(es). He must at all times respond diligently to any communication or request from the ad hoc review committee.

19.4 The member will be informed that the review concerning him will be conducted in a confidential manner, to protect the anonymity of the person making the allegation as much as possible. In case of a breach of confidentiality, the person who is the subject of the review must not communicate with the person who requested it. The persons responsible for conducting the enquiry must fill out the form Affirmation of discretion in the conduct of an enquiry in Appendix VII.

19.5 All members of the ad hoc review committee must act with respect for the principles of fundamental justice and with concern for confidentiality, discretion, objectivity and impartiality. They must be independent-minded and act with rigour and prudence.


19.6 The ad hoc review committee must respect the rules of procedural fairness by providing the member concerned a reasonable opportunity to know the nature of the allegation, to become acquainted with the documents in the ad hoc review committee’s file, to prepare and make his written or verbal submissions. If, upon request, the member is heard by the ad hoc review committee, he may be accompanied by a person of his choosing. However, this person cannot take part in the deliberations, nor in the decision of the Board of Directors.

19.7 Persons or authorities charged with examining or enquiring into alleged or actual conduct that may be contrary to standards of ethics or professional conduct, or charged with determining or imposing appropriate penalties, may not be prosecuted by reason of acts performed in good faith in the performance of their duties.

19.8 The ad hoc review committee forwards its report to the Governance and Ethics Committee, at the latest sixty (60) days following the start of its enquiry. This report is confidential and must contain:

a) A description of the facts surrounding the allegation;

b) A summary of the testimony and the documents consulted, including the point of view of the member concerned;

c) A reasoned conclusion on the merit of the allegation regarding a breach of the Code;

d) A reasoned recommendation on the measure to be imposed, if applicable.

19.9 On recommendation of the Governance and Ethics Committee, the Board of Directors shall meet, in camera, to decide on the measure to be imposed on the member in question. Before deciding to apply a measure, the Board must notify the member and offer him an opportunity to be heard.

19.10 The Board of Directors may temporarily relieve of his functions any member accused of a breach, to allow for an appropriate decision to be made in the case of an urgent situation requiring rapid intervention, or in an alleged case of serious misconduct. If the member in question is the president and executive director, the chairman of the Board of Directors must immediately notify the Minister of Health and Social Services.

19.11 Any measure taken by the Board of Directors must be communicated to the member concerned. Any measure imposed upon him, as well as the decision to relieve him of his functions, must be in writing and reasoned. Where there has been a breach, the chairperson of the Board of Directors will inform the president and executive director or the Minister, depending on the severity of the breach.

19.12 This measure may be, depending on the nature and severity of the breach, a call to order, a reprimand, a suspension of a maximum duration of three (3) months or a revocation of the member’s mandate. If the measure is to revoke the mandate, the chairperson of the Board of Directors shall inform the Minister of Health and Social Services.

19.13 The secretary of the Board of Directors retains all files related to the application of the Administrators’ Code of Ethics and Professional Conduct, in a confidential manner, for the entire duration prescribed by the establishment’s retention schedule and in accordance with the Archives Act (CQLR, chapter A-21.1).

20. NOTION OF INDEPENDENCE

Members of the Board of Directors, whether independent, designated, or appointed, must disclose to the Board of Directors in writing, at the earliest opportunity, any situation likely to affect their status. They must submit to the Board of Directors the form Notification of a breach of independent status from Appendix II of the present Code, at the latest thirty (30) days following the advent of such a situation.


21. OBLIGATIONS AT THE END OF A TERM

With respect to the present document, members of the Board of Directors must, after their term ends:

• Respect the confidentiality of any information, debate, exchange or discussion that they witnessed in or during the performance of their duties.

• Behave in such a way as to not obtain any undue advantage, on their personal behalf or on behalf of another, from their former position as administrator.

• Not act on their personal behalf or on behalf of another, with respect to a procedure, negotiation, or any other situation in which they have participated and concerning which they have information not available to the public.

• Abstain from seeking employment with the establishment during their term and in the year following their term, unless they are already employed by the establishment. Potential cases for exception shall be submitted to the Board of Directors.


APPENDICES


APPENDIX I—MEMBER COMMITMENT AND AFFIRMATION

ELECTION OFFICE CONTACT DETAILS

I, _____________________________________________ [printed name and surname], member of the Board of Directors of the ____________________________________, declare that I have read and understood the Administrators’ Code of Ethics and Professional Conduct, adopted by the Board of Directors on ______________________, that I understand its meaning and scope, and declare that I am bound by each of its provisions as if it were a contractual engagement on my part with respect to the __________________________________.

With that in mind, I solemnly affirm that I will fulfil all the duties of my position, and exercise its powers, faithfully, impartially, and honestly, to the best of my ability and knowledge.

I solemnly affirm that I will not accept any sum of money or any consideration for what I will have achieved in the performance of my duties, other than the remuneration and reimbursement of my expenses allocated in accordance with the law. I commit to not disclosing or allowing to be known, without being so authorized by law, any information or document of a confidential nature of which I gain knowledge in or during the performance of my duties.

In witness whereof, I ___________________________________, have read and understood the Administrators’ Code of Ethics and Professional Conduct of the __________________________________ and I commit to complying with it.

Signature

Date (YYYY/MM/DD)

Location

Name of the Commissioner of Oaths

Signature


APPENDIX II—NOTIFICATION OF A BREACH OF INDEPENDENT STATUS

SIGNED NOTIFICATION

I, the undersigned, _____________________________________________ [printed name and surname], hereby declare that I believe I am in a situation likely to affect my status as an independent member within the Board of Directors of the ___________________________________ due to the following acts:

_________________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________

Signature

Date (YYYY/MM/DD)

Location


APPENDIX III—MEMBER DECLARATION OF INTEREST

I, _____________________________________________ [printed name and surname], member of the Board of Directors of the ____________________________________, declare the following:

1. Pecuniary Interests

� I do not have any pecuniary interests in a legal person, partnership or commercial enterprise.

� I have pecuniary interests, other than minority shares held in a company that do not represent a controlling stake, in the legal persons, partnerships, or commercial enterprises identified below [name the legal persons, companies or enterprises concerned]:

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________

2. Administrator Role

� I am not acting as the director of a corporation, organization, business, for-profit or non-profit organization, other than my mandate as a member of _______________________________.

� I am acting as the director of a corporation, organization, and business, for-profit or non-profit organization, identified below, aside from my mandate as a member of _______________________________. [Name the legal persons, companies, enterprises, or organizations concerned]:

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________

3. Employment

I am employed as follows:

Occupation Employer

I declare that I am under obligation to update this declaration as soon as my situation warrants, and I commit to adopting a conduct that complies with the Administrators’ Code of Ethics and Professional Conduct of the __________________________________.

In witness whereof, I have read and understood the Administrators’ Code of Ethics and Professional Conduct of the ______________________________ and commit to complying with it.

Signature

Date (YYYY/MM/DD)

Location


APPENDIX IV—DECLARATION OF INTERESTS FOR THE EXECUTIVE DIRECTOR

I, _____________________________________________ [printed name and surname], President and Executive Director and ex-officio member of the ___________________________________, declare the following:

1. Pecuniary Interests

� I do not have any pecuniary interests in a legal person, partnership or commercial enterprise.

� I have pecuniary interests, other than minority shares held in a company that do not represent a controlling stake, in the legal persons, partnerships, or commercial enterprises identified below [name the legal persons, companies or enterprises concerned]:

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________

2. Administrator Role

� I am not acting as the director of a corporation, organization, business, for-profit or non-profit organization, other than my mandate as a member of _______________________________.

� I am acting as the director of a corporation, organization, and business, for-profit or non-profit organization, identified below, aside from my mandate as a member of _______________________________. [Name the legal persons, companies, enterprises, or organizations concerned]:

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________

3. Employment

“The president and executive director and the assistant president and executive director of an integrated health and social services centre or an unamalgamated institution must devote themselves exclusively to the work of the institution and the duties of their office.

However, with the Minister’s consent, they may engage in other professional activities, whether remunerated or not. They may also carry out any mandate the Minister entrusts to them.” (art. 37, CQLR, chapter O-7.2).

In witness whereof, I have read and understood the Administrators’ Code of Ethics and Professional Conduct of the ______________________________ and commit to complying with it.

Signature

Date (YYYY/MM/DD)

Location


APPENDIX V—DECLARATION OF CONFLICT OF INTEREST

I, the undersigned, _____________________________________________ [printed name and surname], member of the Board of Directors of the ____________________________________, believe that I am in a situation of conflict of interest, given the following facts:

_________________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________

Signature

Date (YYYY/MM/DD)

Location


APPENDIX VI—REPORTING A SITUATION OF CONFLICT OF INTEREST

I, the undersigned, _____________________________________________ [printed name and surname], consider that the following member: ______________________, is in an apparent, real, or potential situation of conflict of interest give the following acts:

_________________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________

I ask that the Board of Directors forward this report to the Governance and Ethics Committee for analysis and a recommendation, and I understand that certain information provided in this form constitutes personal information protected by the Act respecting Access to documents held by public bodies and the Protection of personal information (CQLR, chapter A-2.1).

I consent to this information being used for the sole purpose of determining whether or not there exists a situation of apparent, real or potential conflict of interest.

Signature

Date (YYYY/MM/DD)

Location


APPENDIX VII—AFFIRMATION OF DISCRETION IN THE CONDUCT OF AN ENQUIRY

I, the undersigned, _____________________________________________ [printed name and surname], solemnly declare that I will not reveal or make known, unless authorized by law, any confidential information coming to my knowledge in the exercise of my duties.

Signature

Date (YYYY/MM/DD)

Location


APPENDIX 2: MALTREATMENT IN A FEW STATISTICS—YOUTH PROTECTION DIRECTORATE

SIGNALEMENTS PROCESSED DURING THE YEAR

SIGNALEMENTS RETAINED BY PRESENTING PROBLEM

2016-2017 2017-2018 2018-2019

0-5 6-12 13-15 16-17 Unknown Total % 0-5 6-12 13-15 16-17 Unknown Total % 0-5 6-12 13-15 16-17 Unknown Total % % aug.

Signalements not retained Girl 193 289 185 136 6 809 47.5% 188 273 190 152 5 808 49.6% 233 332 245 184 5 999 48.0%

Boy 192 362 205 117 12 888 52.1% 194 368 147 96 4 809 49.7% 250 490 212 122 2 1 076 51.7%

Unknown 5 1 0 0 0 6 0.4% 5 5 0 1 0 11 0.7% 4 1 0 0 0 5 0.2%

Total 390 652 390 253 18 1 703 49.9% 387 646 337 249 9 1 628 45.1% 487 823 457 306 7 2 080 51.7% 27.8%

Signalements retained Girl 313 305 135 72 0 825 48.2% 348 387 157 99 1 992 50.1% 319 354 201 101 3 978 50.3%

Boy 322 391 125 48 0 886 51.8% 347 448 120 61 9 985 49.8% 370 422 112 54 8 966 49.7%

Unknown 0 0 0 0 0 0 0.0% 2 0 0 0 0 2 0.1% 1 0 0 0 0 1 0.1%

Total 635 696 260 120 0 1 711 50.1% 697 835 277 160 10 1 979 54.9% 690 776 313 155 11 1 945 48.3% -1.7%

Signalements processed Girl 506 594 320 208 6 1 634 47.9% 536 660 347 251 6 1 800 49.9% 552 686 446 285 8 1 977 49.1%

Boy 514 753 330 165 12 1 774 52.0% 541 816 267 157 13 1 794 49.7% 620 912 324 176 10 2 042 50.7%

Unknown 5 1 0 0 0 6 0.2% 7 5 0 1 0 13 0.4% 5 1 0 0 0 6 0.1%

Total 1 025 1 348 650 373 18 3 414 100.0% 1 084 1 481 614 409 19 3 607 100.0% 1 177 1 599 770 461 18 4 025 100.0% 11.6%

2016-2017 2017-2018 2018-2019

Presenting Problem 0-5 6-12 13-15 16-17 Unknown Total % 0-5 6-12 13-15 16-17 Unknown Total % 0-5 6-12 13-15 16-17 Unknown Total %

Abandonment Girl 1 1 20.0% 1 1 20.0% 1 1 3 5 62.5%

Boy 1 2 1 4 2.6% 1 2 1 4 2.2% 3 3 1.5%

Unknown

Total Abandonment 1 3 1 5 0.3% 2 2 1 5 0.3% 1 4 3 8 0.4%

Physical Abuse Girl 43 63 31 14 151 40.6% 34 93 42 16 185 44.5% 30 94 50 24 1 199 48.4%

Boy 55 127 26 13 221 59.4% 43 149 21 14 3 230 55.3% 52 127 24 8 1 212 51.6%

Unknown 1 1 0.2%

Total Physical Abuse 98 190 57 27 372 21.7% 78 242 63 30 3 416 21.0% 82 221 74 32 2 411 21.1%

Risk of Serious Physical Abuse Girl 19 15 3 1 38 56.7% 21 16 5 4 46 50.5% 33 20 5 1 59 54.6%

Boy 17 11 1 29 43.3% 23 17 2 2 1 45 49.5% 26 20 1 2 49 45.4%

Unknown

Total Risk of Serious Physical Abuse 36 26 4 1 67 3.9% 44 33 7 6 1 91 4.6% 59 40 6 3 108 5.5%

Sexual Abuse Girl 7 15 16 6 44 66.7% 9 25 17 12 63 74.1% 11 15 10 8 44 83.0%

Boy 6 13 2 1 22 33.3% 6 9 4 3 22 25.9% 4 3 2 9 17.0%

Unknown

Total Sexual Abuse 13 28 18 7 66 3.9% 15 34 21 15 85 4.3% 15 18 10 10 53 2.7%

Risk of Serious Sexual Abuse Girl 2 8 10 2 22 45.8% 13 13 8 6 40 54.8% 7 10 3 1 21 46.7%

Boy 6 16 1 3 26 54.2% 13 14 5 1 33 45.2% 11 11 1 1 24 53.3%

Unknown

Total Risk of Serious Sexual Abuse 8 24 11 5 48 2.8% 26 27 13 7 73 3.7% 18 21 3 2 1 45 2.3%

Psychological Abuse Girl 137 111 23 15 286 52.9% 147 127 32 19 325 54.0% 128 121 41 21 1 312 48.1%

Boy 119 116 17 3 255 47.1% 136 110 25 4 2 277 46.0% 167 134 23 10 2 336 51.8%

Unknown 1 1 0.2%

Total Psychological Abuse 256 227 40 18 541 31.6% 283 237 57 23 2 602 30.4% 296 255 64 31 3 649 33.4%

Negligence Girl 34 59 16 4 113 48.9% 42 45 11 7 105 42.3% 43 40 26 10 1 120 47.1%

Boy 51 49 16 2 118 51.1% 48 77 14 3 1 143 57.7% 43 72 14 5 1 135 52.9%

Unknown

Total Negligence 85 108 32 6 231 13.5% 90 122 25 10 1 248 12.5% 86 112 40 15 2 255 13.1%

Serious Risk of Neglect Girl 71 27 8 4 110 48.2% 81 61 11 9 1 163 51.7% 67 47 19 6 139 55.4%

Boy 67 39 11 1 118 51.8% 77 58 10 4 2 151 47.9% 67 36 5 1 3 112 44.6%

Unknown 1 1 0.3%

Total Serious Risk of Neglect 138 66 19 5 228 13.3% 159 119 21 13 3 315 15.9% 134 83 24 7 3 251 12.9%

Serious Behavioural Issues Girl 6 28 26 60 39.2% 7 31 26 64 44.4% 6 46 27 79 47.9%

Boy 18 50 25 93 60.8% 12 38 30 80 55.6% 19 42 25 86 52.1%

Unknown

Total Serious Behavioural Issues 24 78 51 153 8.9% 19 69 56 144 7.3% 25 88 52 165 8.5%

Total Girl 313 305 135 72 825 48.2% 348 387 157 99 1 992 50.1% 319 354 201 101 3 978 50.3%

Boy 322 391 125 48 886 51.8% 347 448 120 61 9 985 49.8% 370 422 112 54 8 966 49.7%

Unknown 2 2 0.1% 1 1 0.1%

TOTAL 635 696 260 120 1 711 100.0% 697 835 277 160 10 1 979 100.0% 690 776 313 155 11 1 945 100.0%


ORIGIN OF SIGNALEMENTS

CHILDREN SUBJECT OF A SIGNALEMENT

NUMBER OF EVALUATIONS/ORIENTATIONS AND DECISIONS FROM THE PROVINCIAL DIRECTOR

2016-2017 2017-2018 2018-2019

Signalements

Not

retained Retained Total %

Not


Not


Family Environment

Parent 159 74 233 6.4% 149 90 239 6.2% 180 74 254 5.8%

Sibling 39 47 86 2.4% 44 59 103 2.7% 39 46 85 1.9%

Child itself 9 1 10 0.3% 2 6 8 0.2% 6 3 9 0.2%

Parent's partner 6 3 9 0.2% 5 1 6 0.2% 7 2 9 0.2%

Total Family Environment 213 125 338 9.2% 200 156 356 9.2% 232 125 357 8.1%

Employees of different organizations

Employee of a CJ 120 207 327 8.9% 139 239 378 9.7% 37 68 105 2.4%

Employee of a CSSS 107 154 261 7.1% 112 139 251 6.5% 44 40 84 1.9%

Employee of a hospital or a physician 112 158 270 7.4% 150 172 322 8.3% 163 170 333 7.6%

Employee of a residential / foster care 8 8 16 0.4% 11 7 18 0.5% 8 10 18 0.4%

Employee of an organization 160 112 272 7.4% 120 137 257 6.6% 262 231 493 11.2%

Foster Family 2 4 6 0.2% 1 3 4 0.1% 0 0 0 0.0%

Other Professions 18 17 35 1.0% 17 9 26 0.7% 36 8 44 1.0%

Unknown

Employee of a CI 0 0 0 0.0% 0 0 0 0.0% 160 193 353 8.0%

Total Employees of different organizations 527 660 1 187 32.4% 550 706 1 256 32.4% 710 720 1 430 32.6%

School Environment 308 383 691 18.9% 307 480 787 20.3% 482 436 918 20.9%

Law Enforcement 578 600 1 178 32.2% 532 709 1 241 32.0% 699 745 1 444 32.9%

Community

Neighbours 159 86 245 6.7% 130 75 205 5.3% 115 82 197 4.5%

Others 14 5 19 0.5% 23 12 35 0.9% 25 15 40 0.9%

Total Community 173 91 264 7.2% 153 87 240 6.2% 140 97 237 5.4%

Total 1 799 1 859 3 658 100.0% 1 742 2 138 3 880 100.0% 2 263 2 123 4 386 100.0%

2016-2017 2017-2018 2018-2019

0-5 6-12 13-15 16-17 Unknown Total 0-5 6-12 13-15 16-17 Unknown Total % aug. 0-5 6-12 13-15 16-17 Unknown Total % aug.

Children subject of at least one Signalement 847 1 091 490 294 22 2 744 852 1 147 470 304 17 2 790 1.7% 946 1 238 564 349 16 3 113 11.6%

Children subject of at least one retained Signalement 549 607 227 105 12 1 500 591 696 235 131 9 1 662 10.8% 563 614 248 121 10 1 556 -6.4%

2017-2018 2018-2019

Orientations and Decisions Number % Number %

End an intervention 1 1% 0 0%

Refer the youth to Crown Prosecutor 36 24% 24 16%

Apply extrajudicial sanctions 115 76% 130 84%

Total 152 100% 154 100%


Annual Management Report 2018–2019

Centre intégré universitaire de santé et de services sociaux de l’Ouest-de-l’Île-de-Montréal

160 Stillview Ave.

Pointe-Claire, QC

H9R 2Y2

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