Santé Pontiac

Transcription

Santé Pontiac

P
Annual Management Report 2013-2014
The CSSS du
in the
www.santepontiac.qc.ca
ontiac
of its community
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2013-2014
The CSSS du Pontiac, in the
of its community
Adopted by the Board of Directors on June 9, 2014
Presented at the Annual meeting on June 19, 2014
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P
In this period of severe worldwide economic difficulties, all of the CSSS du
Pontiac employees are striving not only to provide high-quality services to the
people of Pontiac but also to optimize and improve the services provided. The
population of Pontiac has every reason to be proud of its health services.
Le Journal du Pontiac, July 2013
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Table of contents
Message from the President and the Executive director
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_____________________________________________________________________________________________________________________________ ______________
Statements and list of acronyms
7
Reliability of the data
Code of ethics and deontology of the directors
_____________________________________________________________________________________________________________________________ ______________
Picture of our organization
8
Our mission, our vision, our values
Our installations
Interesting data
Characteristics of our population and overall health
Members of the board of directors, Organizational plan and Administrative Management
_____________________________________________________________________________________________________________________________ ______________
Our priorities
12
The challenges related to the strategic plan
_____________________________________________________________________________________________________________________________ ______________
Highlights
16
Optimization
Bill 100 and LEAN Concept
Safety of Care and services
Qualified human resources and well-being at work
_____________________________________________________________________________________________________________________________ ______________
Accomplishments and activities 2013-14
18
_____________________________________________________________________________________________________________________________ ______________
Future perspectives and challenges to overcome in 2014-2015
21
_____________________________________________________________________________________________________________________________ ______________
User satisfaction and quality of service
22
Accreditation
Service quality and complaints Commissioner
Report of the examining physician on medical complaints
_____________________________________________________________________________________________________________________________ ______________
Councils and Committees
24
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Financial statements and Analysis of results of operations
28
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Administrators’ code of ethics and professional conduct
32
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Results pertaining to commitments 2013-2014
Annexe
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Message of the President and the Executive director
On behalf of the Board of Directors, we
are very pleased to present the 2013-2014
management annual report.
The year was filled with challenges, both
on an administrative level and in terms of
the services provided. First of all, in May
2013, the new CHLSD in Shawville
opened its doors to the residents of the
former Pontiac Reception Center (CAP).
The transition was completed successfully as a result of the exceptional work done by the management team for the
sector, the employees and our valuable volunteers. The second challenge involved
giving a third vocation to the former CHLSD, namely the Shawville CLSC, which
was accomplished in only two months! This Centre, which is now a multi-service
Centre, will further promote the collaboration with our network partners, which
share the facility with us.
In terms of human resources, we must mention the remarkable work done by the
human resources team with respect to recruiting and, above all, the college-level
nursing training project in Pontiac. Once again, the work with our partners was
exceptional: Heritage College, Local Employment centre (CLE), Agence des services de santé et de services sociaux de l’Outaouais (ASSSO), Club de recherche
d’emploi du Pontiac (CREP) and Western Québec School board. The medical
team was mobilized to facilitate the arrival of the new doctors. The recruiting
committee was reactivated in cooperation with the MRC and the Agence de santé
et des services sociaux de l’Outaouais. The future seems very promising already.
The clear and determined objective of the Board of Directors: to maintain the current services at the CLSC Mansfield-et-Pontefract.
In closing, the 2014-2015 challenges for the CSSS du Pontiac are:
Hemodialysis;
2015-2020 strategic plan;
Recruitment of new doctors and employees;
Balanced budget, despite decreased financing;
Maintaining all of our services (increasingly precarious as
a result of budget cuts).
Special thanks to the members of the Board, managers, staff members, the
medical team and the volunteers without whom we would be unable to offer
high-quality and safe services.
Preisdent
Executive director
The Board of Directors has implemented a management tool to ensure rigorous
quarterly tracking of performance in terms of accountability, satisfaction, safety
and quality.
The facility attained and surpassed most of the objectives set, in keeping with the
strategic plan.
In terms of quality, the Health and social services ministry visited us to examine
the practises in two of our CHSLD and our evaluation was very positive. Special
thanks to all CHSLD staff members who provide comfort and excellent care for
our residents, day after day.
We were also visited by Accreditation Canada and, once again, the results were
very positive and remarkable. The highlights: the bond between the community
and our facility, a strong, well-articulated local network.
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STATEMENTS
Data reliability
It is my responsibility, as Executive director, to ensure the reliability of the data contained in this Annual management report and the related control measures.
The results and the data provided in the 2013-2014 management report for the CSSS du Pontiac provide a faithful portrait of the facility’s mission, mandates,
responsibilities, activities and strategic guidelines. The report also presents the objectives, indicators, goals to be attained and the results.
The data is accurate and reliable.
I declare that the data contained in this annual management report and the control mechanisms pertaining to the data are reliable and that the data corresponds
to the situation as at March 31, 2014.
By law, board members of public facilities must implement a code of ethics and professional conduct covering their duties and obligations.
ARHSSS: Act respecting health services
ARLA: Age-related loss of autonomy and social services
ASD: Autism spectrum disorders
BFI: Baby-friendly initiative
BoD: Board of directors
CAP: Pontiac Reception Centre
CBM: Comparative balance sheet of medication
CHSLD: Long-term care facility
CJO: Outaouais Youth Center
CSSS: Centre de santé et de services sociaux
CSSSP: Centre de santé et de services sociaux du Pontiac
CVA: Cerebral vascular accident
DGM: Department of general medicine
DP: Physical disability
DPS: Director of Professional Services
DSQ: Dossier santé Québec
FMG: Family medicine group
HC: Hospital Centre
HCS: Home care services
HRP: Human Resources Plan
ID: Intellectual disability
List of acronyms
For 2013-2014, no violations of the code of ethics and professional conduct were reported or noted.
The code of ethics and professional conduct for the CSSS du Pontiac board is provided on page 30 of this annual report.
ID-ASD: Intellectual disability – Autism spectrum disorder
IPECS: Integrated prenatal and early childhood services
LEAN: System intended to increase efficiency, essentially by eliminating all actions
that have no added value
LTC: Long-term care
MORE: Managing Obstetrical Risk Efficiently program
MSC: Manoir Sacré-Cœur (Sacred-Heart Manor)
MSSS: Ministry of Health and Services
ND: Nursing Director
NIR: Non-institutional resources
NPHP: National Public Health Plan
OIIAQ: Order of Nurses of Quebec
OIIQ: Order of Nurses Assistants of Quebec
PFCAP: Personal, family and community aid program
PMI-HC: Personalized multi factorial intervention - home care
RCUO: Grouping of the Users Committees of the Outaouais
RS: Residences for seniors
RSIPA: Network of integrated services for elderly people)
SNP: Specialized nursing practitioner
SS: Services for seniors
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Portrait de notre organisation
The Centre de santé et de services sociaux du Pontiac
includes the hospital, the residences and the CLSCs in
the territory. We have nine (9) service installations.
The CSSS du Pontiac fulfils its clinical mission by offering a complete range of
services adapted to the needs of the people living in the territory. The services,
based on the client groups in the various facilities, fulfil our mission.
We are:
A rural, bilingual community located in the Outaouais
region, north-west of the Gatineau urban region, “HullAylmer” sector.
Approximately 15,500 km 2 including 19 municipalities,
most of which have fewer than 1,000 residents.
In 2011: 20,817 residents
$36 million approximate budget
Close to 500 employees
3 surgeons, 1 anesthetist, 1 internist, 1 radiologist, 2 GP-anesthetists, 1 GPgastroenterologist, 13 general practitioners (GP) and 1 pharmacist
364 volunteers
39 short-term hospital beds including 2 in obstetrics, 3 in intensive care and
3 in palliative care for 1,436 admissions
115 long-term care beds: 50 at the CAP, 40 at the MSC and 25 at the hospital
2 emergency rooms, with approximately 26,000 visits per year, with about 32%
of these visitors coming from outside our territory
1,573 different home-care users
To promote maintenance and improvement of the general
health of the entire population of the Pontiac.
general and specialized services, including in particular:
*Our MISSION
health promotion and disease prevention, assessments, ditreatment,
rehabilitation,
social
integration,
autonomy support, long-term residential care and end-oflife services.
To coordinate the services provided by other local network
professionals, to meet the needs of the population of our
territory.
at the Hospital
Emergency room acknowledged as a trauma centre, out-patient services, 39
short-term beds, diagnostic services, rehabilitation, oncology, inhalotherapy,
mental health, nutritional services, facilities for FMG. We also offer general
surgery and specialized surgery for cataracts, ENT (ear, nose, throat), and orthopedics. Out-patient services include: internal medicine, ENT, ophthalmology,
gynecology, gastroenterology and, several GP perform minor surgery.
in Residential living
The 115 residents receive all of the necessary services, including those provided
under the CSSS integrated programs.
at the CLSCs
Home support, public health, community services, childhood/adolescence/
family services, placement in the community, day centre, mental health and
routine health care services. The Mansfield-et-Pontefract service outlet has an
emergency clinic and also offers diagnostic services and obstetrical clinics. The
vision for 2014-2015 is to add bone density to the diagnostic services already
offered.
Acquisitions and renovations
To this end, the CSSS du Pontiac offers a continuum of
agnoses,
Our SERVICES are :
Buildings:
The renovation of one of our installation was the
highlight of the year. The Bryson service center was
relocated to the vacant premises of the former CAP.
No change was made to the existing service offer
and all of the services remained accessible and available to the people of
Pontiac.
Technologies: From among several computer projects, we would like to highlight the new digital dictation system and the Dossier Santé Québec project,
which have been added to the line of services and now ensure regional and provincial access to information.
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To maintain a strategic position with regard to our
responsibility towards the population.
To actively contribute to the local services network in
close collaboration with our partners, with the objective
of working together to maintain,
improve and restore
the health and well-being of the population of our ter-
As a facility that is affiliated with McGill University, our centre takes in several
trainees and medical residents from several teaching institutions each year, working
in several disciplines.
The employees’ code of ethics and professional conduct was revised, updated and
distributed in order to guide conduct and implement standards that promote good relations among the users and those who work with them. Likewise, the harassment policy was revised and redistributed during the course of the year.
Our installations
ritory. We aim for a very high level of service quality
*Our VISION
and client satisfaction, within the bounds of regional
and national orientations and the resources allocated
Mansfield-et-Pontefract
CLSC Main office + Emergency clinic
to us.
Manoir Sacré-Cœur (CHSLD)
Shawville
We are working in cooperation with the medical clinics, the drug stores and
all of the organizations in the territory to facilitate access to care and services.
The CSSS du Pontiac wants to develop a continuous improvement culture
through innovation and best practises in order to offer safe, high-quality care
and services.
Our users are our primary concern. The institution's
human resources represent the cornerstone of our service
supply.
Confidentiality can never, in any circumstances, be
overlooked in our organization.
Continuous service quality improvement depends on a
rigorous commitment on everyone's part.
The values of respect and professionalism are called for
in all interventions that are taken
or
far,
who
are
involved
CLSC: Isle-aux-Allumettes, Rapides des Joachims, Quyon and Otter Lake
Interesting data
in
the
care
services provided.
and
2013-14
2012-13
CLSC:
1 600
394
503
1 573
405
482
HOSPITAL:
Number of ADMISSIONS
% OCCUPANCY RATE/39 beds
Number of NEWBORNS including C-Sections
Visits in EXTERNAL CLINICS
SURGERIES including scopes
Visits and users in ONCOLOGY
Number of SCANS
1 436
94%
148
13 539
1 512
1 225 v/139 u
2 883
1 523
100%
153
12 660
1 483
852 v 125 u
2 757
99%
100%
3 465
3 959
25 796
4 652
3 014
4 122
27 359
5 248
CHSLD
% OCCUPANCY RATE/115 beds
with users, their family members and all people,
near
Hospital, CAP, CLSC
Different HOME-CARE users
YOUTHS seen in «Youths in difficulty»
Users seen in MENTAL HEALTH, youths and adults
Maintaining our manpower skills is a priority.
*Our VALUES
Main office
Number of FLU SHOTS AND PNEUMOVAX
Primary clinical care visits
Visits in BOTH EMERGENCIES
Treatment days in REHABILITATION
of its community
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Characteristics of our population
Main challenges
Declining, aging population;
Low density population spread over a large territory;
Availability of qualified human resources;
In 2008, all of the forest product processing plants in the territory closed, namely in
both the pulp and paper and, lumber sectors. To date, none of the plants has started
back up and no plant was created to remedy Pontiac’s economy. According to data
from the Institut de la statistique du Québec, the MRC du Pontiac is the one with the
lowest disposable income in all of Québec.
Characteristics
The population in our territory is divided approximately 40-60 between francophones
and anglophones. The francophones are essentially located in Fort-Coulonge, Mansfield-et-Pontefract and Ile-du-Grand-Calumet. The anglophones are found in larger
numbers in Shawville and the surrounding areas as well as on Isle-aux-Allumettes and
in the neighbouring villages;
The regions of Campbell’s Bay, Otter Lake and the municipality of Pontiac are more
bilingual, with an Anglophone predominance;
The people in the western portion of the territory, which is located along the Ontario
border, tend to make more of their purchases in Pembroke and Renfrew than in the
Outaouais area.
Members of the
Overall health
Various indicators reveal a greater frequency
of problems pertaining to a loss of autonomy.
Life-expectancy in good health, outside an institution, is 60 years
compared to 63.9 for the Outaouais region and 67.3 for Québec.
The increase in chronic diseases, obesity and diabetes are examples of problems
that must also be considered through prevention. Various indicators reveal an
increased frequency of problems related to a loss of autonomy, which will result
in a greater need for services.
It should be noted that the proportion of smokers is greater here (28.4%) than for
Quebec (24.2%).
The level of education has an impact on the use of the
health and social services (37% of the population have a post-secondary diploma
and 9% have university degrees). The fight to prevent students from dropping out
and to encourage them to stay in school is important in our territory.
Comments by Dr. Courteau concluding his analysis of the state of health of the
population in our territory: “This data indicates significant medical and social
costs and important economic losses for the population of the territory. While
socioeconomic level is a good indicator of the state of the health of a population, the opposite is also true since premature death has a destabilizing effect
on employment, productivity, individual well-being and families and the development of young people.”
Board of Directors
On March 31st, 2014
From left:
Mr. Jean-Guy Patenaude, president
Mr. Richard Grimard, Executive director
Mrs. Lucille Bélair
Mrs. Amanda Bérubé
Mrs. Hélène Boulet, vice-president
Mrs. Manon Francoeur
Mr. Pierre Fréchette
Dr. Isabelle Gagnon
Mr. Edward J. McCann
Dr. Maurice Lamarche
Mr. Gaëtan Lance
Mrs. Sylvie Landriault
Mrs. Geneviève O’Brien
Mrs. Anne Paquin
Mr. Jacques Piché
Mrs. Sylvia Poisson-Hodgins
Mrs. Claudette Rainville-Stanton
Mr. Georges Robitaille
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BOARD OF DIRECTORS
Committees
Committees
Quality Improvement
Clinical Ethic
GENERAL
ADMINISTRATION
Local Complaint and
Quality of
service
Commissioner
Administration of
PROFESSIONAL
SERVICES
Risk Management
Medical Complaint Revision
Richard Grimard
Users - Residents (3)
Council of Nurses
Multidisciplinary Council
Responsible of
Performance
Accountability
Committees
CPDP
Dr .John Wootton
Administrative
Antibiotic Utilization
Review
Pharmacology
Chronic Illness
Fight against cancer
Palliative Care
Trauma
Medical services and
Pharmacy*
Executive Director’s
Evaluation
Audit
Vigilance and Quality
Evaluation of the local
Complaint and Quality of
service Commissioner
Clinical Ethic
Trevor Tanguay
Administration of
ADMINISTRATIVE AND SUPPORT services
FINANCIAL and
TECHNICAL
services
Joanne
Dubois
Leanne Gray
Administration of
PHYSICAL HEALTH and
NURSING CARE
AUTONOMY
SUPPORT
COMMUNITY services
and PUBLIC HEALTH
Ann
Rondeau
Gail
Ryan
Pharmacy
HUMAN RESOURCES
Administration of
Administration of
Guylaine
Marcil
Daniel Hébert
Mélanie
Francoeur
MEDICAL RECORDS/
RECEPTION/
SECRETARIAL services
Gilbert
Daoust
Caroline
Beaudet
Alain
Gillet
Linda
Malenfant
Nicole Boucher
Sophie Bonin
-Larivière
Christine
Alie
Paulette Boucher
CLINICAL services - DPS and DON
* Fight against cancer *Palliative Care
* Chronic Illness
Ambulatory
services
General
Care
Diagnostic
services
Risk Management and
Infection
Prevention
InfantYouth Family
services
0-17 ans
SocioCommunity Interven- Mental and
tion
Social
services
Health
Home-Care
services
Residential
services
CAP
Residential
services
MSC and
Long Term
18 ans et +
Dr. John Wootton and Gail Ryan
Functional link (consultative)
Organizational plan and Administrative Management Team, on March 31st, 2014
Hierarchic link (under the autority of)
of its community
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The CSSSP is the gateway to health and social services throughout the territory of Pontiac. Our services are intended to satisfy the ob-
Our priorities
jectives of the 2012-2015 strategic plan, while respecting our philosophy.
We offer services in French and in English, with the same guarantee of quality. We support the family and promote the maintenance of a natural environment for elderly people, adults and children, and we respect the rights of the clients to be clearly
informed about the services.
We are committed to guaranteeing the users’ confidentiality.
The emphasis is on development in order to maintain the skills and expertise of our human resources.
We maintain a service organization based on a philosophy of integrated services, adapted to the clients’ needs and we highlight
our cooperation and involvement with the community organizations.
On our way to 2015 - The challenges related to the strategic plan
The availability of
QUALIFIED HUMAN ROUSOURCES
in sufficient numbers and motivated to
take action
Education: We promote education within our territory
and the nursing training provided in our territory
demonstrates our commitment;
Ongoing training in the sectors of activities;
Investment of 1.12% of the payroll in personnel
training;
Human resource plan: Has been updated.
CHALLENGES:
Goal:
4,40%
We are still experiencing recruiting diffi-
Work organization project: Is implemented in the living environments;
macist, speech therapist, nurses and
Jeunes explorateurs d’un jour (Day students): Participation and development of contacts to increase the participation of young people;
Revision of the orientation program in the critical care
sectors;
2012-13:
11,34%
Result:
10,01%
2012-2013:
4,37%
Result:
4,49%
culties in the following professions: phar-
RETENTION rate of new employees
Goal: 68,97% 2012-13: 62,12%
Result: 63,37%
beneficiary attendants.
% hours worked by PRIVATE AGENCY:
In the residences, there are still too many
contractual workers.
Goal: 6,81%
Employment insurance is a major issue.
Student project for the summer;
Preceptorship project: Is maintained in critical and
short-term care;
Goal:
11,28%
% of OVERTIME hours by network PERSONNEL
Trainees: The regular presence of trainees, while giving precedence to candidates from the territory;
Medical recruiting: We are continuing our partnership
with McGill University;
% of OVERTIME hours by NURSES
Ratio between the number of hours on SALARYINSURANCE and the hours worked
Goal:
6,47%
2012-13:
6,63%
Result:
7,91%
NURSES:
2012-13: 7,81% Result: 6,12%
NURSING ASSISTANTS and
BENEFICIARY ATTENDANTS:
Goal: 0% 2012-13: 0%
Result: 0,2%
INHALOTHERAPISTS:
Goal: 7,32% 2012-13: 4,63% Result: 0%
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Integrated prenatal and early childhood:
assume our
RESPONSIBILITY to the population
Unintentional trauma: Regional and local programs as
part of the service continuum for cerebral vascular accidents (CVA);
Reactivation of the regional and local trauma committees, with a systematic review of the file;
Preventive clinic: Implementation of a preventive
clinical practice intervention in partnership with public
health;
Appropriation of the Alleyn-Cawood sector: This sector was always handled, by tacit agreement, by the
CSSS de la Vallée Gatineau. Since September 2013,
the CSSS de Pontiac has assumed responsibility for
these clients, for which we are responsible. All community services are provided, as required;
Vaccination of children: Efforts are made to reach the
goals. The following measures were implemented:
A pamphlet indicating the benefits of vaccination was
prepared and given to parents;
Vaccinations were offered individually;
We have noted an improvement with respect to vaccination against Meningitis C;
Weekly home-care visits to women in IPECS
(Prenatal):
Goal:
0,31%
DTaP vaccine:
2012-13: 89,9%
Result: 89,3%
Meningococcal C conjugate:
2012-13: 55,7%
Result: 63,3%
Smokers: Number of smokers given counselling to
help them stop smoking (intensive or brief):
Goal: 25
2012-13: 36
Result: 28
Result:
0,32%
Telemedicine pilot project by the Pierre Janet Hospital
and the CSSSP, for pediatric psychiatry;
NEGLIGENCE intervention plan: The plan has been
consolidated and all the care-givers have been trained;
2012-13:
N/A
Result:
0,72%
Hours of service to be offered in long term home
care: We offered 27,587 hours and had a result of
30,318 hours;
Result:
0,12%
HCS-ARLA: The goal of offering 17,343 hours was
attained and we offered 22,676 hours;
Number of places in NIR: 21 places, temporary closing of 2 residences, currently recruiting;
7th week to 12th month:
Goal:
0,28%
2012-13:
N/A
13th to the 60th month:
Goal:
0,15%
2012-13:
N/A
Result:
0,10%
Fall prevention: A fall prevention program was developed for the home care services, the CHSLD, the Hospital and the NIR (Non-institutional resources);
Approach adapted to the elderly person: We are continuing to implement the plan.
CHALLENGE:
We are aware of the need to diversify the
non-institutional resources and the development work that remains to be done.
Number of young people with Mental health disorders:
Number of persons who benefitted from a personalized
multifactor Fall prevention intervention:
PIED program (Fall prevention):
Goal: 25
Proportion of children receiving in CSSS, 1 st dose of
vaccine against:
Goal: 85%
2012-13:
N/A
Birth to 6th week :
Goal
0,87%
“Capsules AGIR” project implemented in the living
environments;
Goal: 2 groups
2012-13: 24
2012-13: 1
Result: 18
Result: 0 group
SERVICES
that are close to the clients’ environment
Transitional clinic: Treatment of +30% of the patients
who came to the transitional clinic (orphans);
Specialized nursing practitioner (SNP): Treatment and
follow-up of 320 patients;
Training environment: The facility wants to become a
training environment for future SNP candidates;
Mental Health and Dependency
To be able to
of its community
Goal:
69
2012-13:
93
Result:
76
Number of adults with Mental health disorders:
Goal:
290
2012-13:
389
Result:
427
Number of variable intensity support places in the
community for adults 18 years and over:
Goal:
11
2012-13:
10
Result:
12
Number of young people who received services
pertaining to Dependency
Goal:
15
2012-13:
6
Result:
24
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Reasonable ACCES TIMES for the
specific services provided to
a vulnerable clientele
Waiting lists: Management and revision of waiting lists for
surgery, various specialities in outpatient clinics and medical imaging. As a result of government expectations, this is
a constant concern;
Waiting times: Waiting times are respected for oncological surgery and follow-up by the patient designated nurse;
Access: No waiting list where “urgent” cases are concerned. Maximum access of a few weeks is acknowledged
for “semi-urgent” cases. For the ID-ASD-PD access plan,
no waiting time surpassed the limits set by the MSSS, for
both urgent cases and cases with a high or moderate priority. The CSSSP drafted its local report on the access plan
for these clienteles, as required;
Availability of beds: Implementation of systematic followup with the Agency in terms of emergencies and the availability of short-term beds;
CVA patients: Steps taken on the regional and local levels
to reduce the time between the presence of symptoms and
treatment for patients who have suffered a CVA;
Pathology samples: Implementation of systematic followup of pathology samples to ensure medical and/or surgical
follow-up without delay;
Waiting in short-term beds: We attained 6/7 goals . We
have been asked to ensure that the number of patients waiting is 3 people. In terms of assessment/direction to longterm care, we have an average of 4 people waiting, as a
result of the aging population in the territory;
Surgery: All waiting times prescribed were respected.
CHALLENGES:
Recruiting difficulties encountered with re-
spect to rehabilitation, specifically in speech
therapy for children aged 0-5, make access
times, a concern;
respect to the accessibility of psychiatric ser-
Number of surgeries waiting in excess of 1 year:
Goal: 0
Cataract surgery: 0
Day surgery: 0
Surgery with hospitalization: 0
Access to the various specializations is a re-
% of persons treated within 28 days for an
oncology surgery:
Goal: 80% Result: 91%
We are still experiencing difficulty with
vices, which is limited to 1 day per week;
gional concern. Steps have been taken to
create a regional appointment centre. We
would like to have the number of specialists
in Pontiac increased in keeping with the
Access to Medical Imaging:
% of read tests in a delay of 7 days or less:
Goal: 100%
Result: 100%
demand for services;
% of requests done for elective patients within the expected delays:
Goal: 90%
Result: 100%
We reduced access to the emergency clinic of
% of transcribed reports, completed and transmitted in
a delay of 7 days or less:
Goal: 100%
Result: 99%
the CLSC de Mansfield-et-Pontefract from
June 24, 2013 to September 2, 2014, as a result of a shortage of medical staff.
network
Access to EMERGENCY ROOMS:
% of time on
gurneys in
excess of 24
hours :
Goal:
20%
in excess to 48
hours:
Goal:
1%
2012-13:
0,3%
Result:
0,8%
Goal:
12 h
2012-13:
14,41 h
Result:
14,17h
Average stay
on gurneys:
2012-13:
11,24%
A DEVELOPED and INTEGRATED
Result:
9,53%
Treated within
normal wait times for SURGERY :
Goal: 90%
% of patients registered in the central scheduling mechanism treated within normal wait times for:
Cataract surgery: 100%
Day surgery: 96,1%
With hospitalization excluding cataract: 100%
A local service network built on a solid foundation. We
are determined to ensure the well-being of our population;
Strategic plan in the community: Our leadership is
recognized by the various authorities of the network;
Nine programs are the object of a specific undertaking:
Public health, General services, Physical health, Mental
health, Age-related to loss of autonomy, Physical disability, Intellectual deficiency and Autism spectrum
disorder, Youths in difficulty and dependencies. Each
of these projects has a clinical project;
The presence of nine facilities in our territory demonstrates our commitment to and respect for the community;
The action plans for the following clinical projects are
updated annually with the partners: ARLA and IDASD-PD.
14
An EXEMPLARY PERFORMANCE
focused on well-being, quality,
safety and innovation
Accreditation Canada: Obtained four-year accreditation in February 2014
Evaluations: We were the object of several quality
assessments: Accreditation Canada, MSSS visits to the
CHSLD and evaluations of the physical conditions in
the CHSLD by CQA;
Surveys of user satisfaction, personnel motivation and
client safety;
Numerous reports to the Agency and professional orders;
Infection prevention: We have a full-time nurse
assigned to infection prevention and we have several
internal, permanent committees: risk management,
vigilance, continuous quality improvement committees,
users’ committees and residents’ committees;
We have continued to publish the internal risk management and infection prevention newsletter;
Treatment of ST-segment elevation myocardial infarction: We have accessible, continuous and quality services, as required;
Safety: The theme of the facility’s calendar is safety;
Transfer of a resource: We have transferred an information resource to the Regional technology centre;
Videoconference: We have migrated the videoconference environments and the videoconferencing stations
to the new department, including the inventory update;
human resources;
nity;
The solid partnership with our intersectorial
Nosocomial Infections:
% of hospitals General and speciality Care, with rates
of nosocomial infections less than or
equal to the thresholds set
Goal: 95%
C-Difficile : Result: 100%
MRSA:
Result: 100%
partners, the community organizations;
The Agence de la santé et des services sociaux de
l’Outaouais and the MSSS;
The presence and involvement of the FMG;
Personalized services offered by teams with a
“local flavour”;
The firm commitment to offer services close to
REALITY OF THE PONTIAC, being located
on the Ontario border
The FMG, which is a unique model;
The Emergency clinic located in Mansfield-etPontefract;
The specialized medical services offered on an outpatient basis at the Shawville hospital;
And, nine facilities in the territory;
Networking between the Deep River hospital (Ontario)
and the CSSS Pontiac for better services to the population of Rapides des Joachims;
Criticall: “Criticall” for Ontario users who use our
centre.
the living environment of our users;
Without a doubt, a Board of Directors and a
management team that are determined to offer
Ontario services: We have significantly reduced the
number of users who used Ontario services. Four (4)
factors are behind this success:
Double identification: We have implemented a policy
concerning double identification of users and double
verification of medication;
Digital dictation system: We have continued with the
implementation and we started the voice recognition
project;
The fact of being able to rely on qualified
The strategic position we hold in the commu-
Three-party agreement with the CSSS de Gatineau and
the CHEO for more specialized services in
neonatology;
Everyone is on board
Winning conditions
high-quality and safe services.
The scoreboard
was implemented
during the year. It
is prepared for the
Board of Directors
and the Managers.
It was given a
special mention
by Accreditation
Canada.
It is published on our
Web site.
of its community
TABLEAUX DE BORD
DE GESTION
Année financière
2013-2014
Périodes 1 à 11
15
Highlights
OPTIMIZATION
Safety of care and services
Volunteers: More structured volunteer program implemented to optimize recruiting and make the service more available and sustained;
A survey on client safety was administered in Spring 2013; it also served to raise
the awareness of all of CSSSP personnel, doctors and volunteers;
Efficiency: Implementation of efficient occupation projects to adapt the former facilities of the CAP, including our network partners’ need for space.
Declarations of accidents and incidents: The risk management team analyzed
551 accident and incident declarations;
Laboratory: Local laboratory service optimization project underway, specifically with respect to re-organizing the facilities, receiving and sample analysis
procedures as well as in terms of the equipment used for transporting samples
both internally and externally;
NIR Individual and personalized meetings were held with each owner of an NIR,
concerning the incident-accident reports, to explain the necessity, the meaning, the
importance and the utility;
Access to diagnostic services outside the
regular hours, for the doctors in the Pontiac
FMG;
Hygiene and cleanness: Route and work
hour re-organization plan;
Work organization: Pharmacy project,
namely the remote digitization of prescriptions;
Important challenge:
Increase hours in order to
maintain the elderly persons with handicaps at
home. It is a great challenge, where human and
financial resources are
concerned.
The cumulative budget cuts imposed with
respect to optimization until 2013-14 are $637,000. In the future, we are
planning on savings from two major energy projects including one project
already in place in the new CAP residence and soon a second project for the
hospital. These projects will reduce the costs associated with energy consumption;
The cumulative budget cuts imposed until 2013-2014 as a result of Bill 100
are $553,000.
This bill, introduced in 2010 was implemented by the provincial government
to ensure a balanced budget in
2013-2014. The measures
Bill 100 Balanced Budget
taken by our facility should
not in any manner affect the direct services provided to the population. You
may find the measures taken on page 31 of this report.
Tel-Ami program for our volunteers working with clients at home;
Safety kits given to IPECS clientele;
Car seats: Verification and training clinic for partners to ensure adequate installation;
Risk management: Training at time of hiring and ongoing training;
Telecommunication system was deployed for the emergency team (“terramessaging” pager system);
Move: Construction of the new CAP completed and residents moved in complete
safety in May 2013;
Coroner’s investigations: No recommendation pertaining to our establishment;
Acquisition of equipment: Acquisition of several pieces of equipment to ensure
the safety of clients and personnel: rail levers, fall carpets, preventive mattresses,
benches, Nocospray (disinfection system);
Occupational health and safety: No “dangerous” situation was declared;
CSST: We have 13 active CSST cases;
Employees’ vaccination:
Follow-up of restraints: The policy on the
approximately 52% of our
application and, above all, the reduction in the
employees were vaccinated with
use of restraints was completely revised;
the Flu shot
Quarterly reports given to the Board;
Significant and sustained reduction;
Reminders and training to continue;
Relocation of the oncology department (outpatient service) within the hospital so as to facilitate access, increase the safety of the interventions, further promote the presence of the pharmacist in the department and reduce the handling of oncological products.
LEAN Concept
Publication:
PHYSICAL RESTRAINT
A better understanding
For a better choice ...
16
Qualified human resources and well-being at work
Challenges: Our principal challenges in terms of human resources concern recruiting, attraction and retention of employees;
Human resource estimate: We are continuing to update the estimate and the staffing plan will be developed at the end of September 2014. The titles of positions for which there are shortages are identified on a
national, regional and local level so as to concentrate on the means to be implemented to recruit future
employees;
The impact of the shortage of qualified human resources includes several elements. Among other things,
the employees for the positions concerned (nurse, auxiliary nurse, inhalotherapist) are required to work a
lot of overtime and occasionally, they have to work with reduced staff;
The student project has been maintained. We are receiving more and more CVs and we have to determine
priorities and criteria for the students we accept; our retention rate for the students hired over 3 years is
68%;
In 2013-2014, through the student project, we hired a radiodiagnostic technician, 3 candidates for the nursing profession, 7 nurses, one social worker and an inhalotherapist. The student project remains our best
means for attracting and retaining personnel. It should be noted that word of mouth is also very effective!
Recruiting: We use all of the means available to recruit professionals. We took part in “Skype” recruiting
with the firm TLS inc. Two candidates from the Philippines were retained and will start in the hospital’s
emergency department;
We are working with the firm EPSE (human resource management evaluation and consultation services);
they provide tools for interview questionnaires and psychometric tests for professional positions;
The welcome and migration agent for the MRC du Pontiac ensures adequate integration and acts as a
resource person;
Web posting and position attribution is developed through our LOGIBEC system, which is an efficient
and profitable tool;
Training offered to personnel and doctors:
Five days training in intensive care for two nurses;
Motivational approach
Rural region trauma team development course
Call button training
Interdisciplinary Intensive Care Workshop
MORE
Oxygen therapy prescribed at home
Hand hygiene
Infection prevention and risk management training
Treating wounds
Adapted approach for elderly people
Best practises in endoscopy
CPR and advanced CPR
Neonatal resuscitation
Suicide prevention
Volumetric pumps
Prevention of elder abuse
RSIPA, OEMC evaluation
Retirement planning
Use of restraints
Transfusion medicine
STD prevention
Promotion-Prevention - school context
Charlie
Dependency
Will and declaration of unfitness
IPECS
Administering epinephrine Verification of car seats
Approach and behaviour at work
Cognitive therapy
ISO-SMAF profiles
Cross-training
Managing NIR
Pairing in certain positions to ensure better succession planning for strategic work positions
On a medical level, 18 student trainees
and 10 second-year residents were welcomed
In the other sectors, we accepted 129 summer students
9 Secondary V students as part of the
Jeunes explorateurs program
Several trainees
Participation at the employment fair at the
Sieur de Coulonge secondary school
Participation of the DSI in the internship management committee
Salary insurance: An external consultant and a doctor designated by the health office joined us to facilitate the revision of the file processing process;
Regionally, with the Comité patronal de Négociation
(CPNSSS), the salary insurance file was given priority.
A request was submitted to an expert physician to transmit
the information and raise awareness through the Direction
régionale de médecine générale (DRMG) with respect to the
impact of issuing a doctor’s note on the level of financial
and human resources;
We are particularly proud of the implement of the DEC in
nursing program at Shawville in partnership with the Heritage College. Seven (7) of our employees are registered
in the program and there is a possibility of 12 new employees once they obtain their diplomas. We have already
welcomed these students for their internships.
Our human resources
2012-13
Managers
Full time
Part-time
Employees
Full time
Part-time
Occasional
Equivalent to full time
2013-14
17
2
17
2
284
83
283
77
54
61
Full time equivalent is calculated as follows:
Number of hours worked according to the contract of employment
Divided by: number of worked hours of a full time
employee with same job title.
Full time equivalent is calculated as follows for Occasional :
Number of hours divided by: 1826 hours.
of its community
17
Accomplishments and activities—2013-2014
0-5-30 program: With the school partners, the CSSS
de la Vallée de Gatineau and Pontiac involved with
“Entrez en saine”, we developed a contest that ran
from February 25 to May 26, 2013, for the employees of the CSSSP intended to make improvements in
three respects: diet, physical activity and stopping
smoking. We also
developed a calendar of activities
for nutrition
month, in partnership with
Program 0-5-30
our school
Per day:
partners.
0 cigarette
5 fruits and vegetables
50 minutes of physical activities
91 regional teams, of which: 14 local teams
We have 62 active participants
at the Day Centre!
Dependency: Training has been completed and
screening started using the checklists;
Chronic diseases: Chronic disease activities continued in partnership with the Pontiac FMG;
Support to students is a collaborative committee
with the organizations involved with young people at
school in order to better respond to their specific
needs. The committee is coordinated by a CSSSP
social worker;
Baby-friendly initiative: To continue efforts to obtain recognition for;
Promote training and information for the community
through breastfeeding booths;
Implement the breastfeeding route and the internal
communication campaign on breastfeeding;
Healthy school: Implementation of the program in all
of the schools in the territory, with coordination ensured by the school nurse;
Infection prevention: Purchase of a new technology,
“Nocospray” to reduce the presence of pathogens in
the environment;
Several awareness-raising sessions held for various
contagious diseases, such as MRSA, VRE, C. Difficile, as well as on washing hands in all service outlets;
Training concerning the seals of the N-95 masks for
personnel and first responders.
Implementation of a follow-up clinic for multiresistant bacteria in infection prevention, in partnership with the CSSS de Gatineau;
Addition of a hand hygiene control audit;
Addition of a hygiene and cleanness control audit;
CAMI (Access to injection material): The school nurse
takes part in the program;
Reactivation of the regional and local trauma committees, with a systematic revision of the file;
PFCAP: We offer the program, conducted by a CSSS
staff member and a CJO worker, at the Maison de la
famille du Pontiac;
Implementation of systematic follow-up with the
Agency with respect to emergencies and the availability of short-term beds;
Quality culture: Implementation of a quality culture
in the laboratory and renewal of closer partnerships
with the consulting specialists;
Fight against cancer: Revision of the oncology service offer and reactivation of the local and regional
committees;
IPECS: Addition of an intervener to the program;
Participation of the DPS at the Campus Santé and project of the Satellite family medicine unit;
Baby-friendly initiative:
CSSS du Pontiac: en route to the Babyfriendly initiative
As part of the 2013 World Breastfeeding
Week, the CSSS du Pontiac is proud to announce the adoption of its breastfeeding policy.
This is a big step toward the certification of the Babyfriendly initiative.
Recognized worldwide, the Baby-friendly initiative
serves to implement exemplary practises to promote the
success of breastfeeding. The adoption of the breastfeeding policy will allow the CSSS to continue its work toward certification.
For more information, please
call the nurse at the CLSC, nearest your residence:
CLSC Mansfield:
CLSC Shawville:
CLSC Chapeau:
CLSC Quyon:
Quebec trisomy 21 screening system implemented;
Doreen Dionne - 819 683-3000
Nicole Gatien - 819 647-3553
Lorraine Fleury - 819 689-5080
Chantal Graveline - 819 458-2848
18
Comparative balance sheet of medications: The balance sheets are applied 100% in all our sectors;
Surgery: To continue negotiations for a dentistry
agreement in Pontiac;
MORE: To continue ongoing training for this project;
Infectious diseases: Training of school nurses and
prenatal nurses for the screening of blood-borne and
sexually transmitted infections;
Renovation and adaptation of the former CAP for the
personnel of the Bryson installation, including changing the mission of the building for the Shawville
CLSC;
Computer resources: Repatriation to the Agence de la
santé et des services sociaux de l’Outaouais of a
CSSSP employee for the activities of the project management office;
The “Sentinelles” are adults who wish to act as volunteers and serve as relays between suicidal individuals and the resources available in the community. We
are in the final stage of training and have trained two
professionals who will transmit the training in the
territory, starting in Fall 2014;
Bereavement group: We held two (2) groups during
the year;
Suicide prevention: Awareness raising from February
2-8, 2014, suicide prevention week. Yellow ribbons
were distributed to the personnel. The ribbons were
worn throughout the week; the theme was that used by
the Quebec suicide prevention association: “You are
important for us, suicide is not an option.”
Mental health week: We offered muffins and coffee
to the employees; Blitz in several Pontiac businesses;
Information and public consultation:
Table of partners for the seniors which is revising the
senior services and ID-ASD-PD clinical projects; this is
an exceptional and essential network;
Collaboration with setting up the local section of the
TCARO, namely the Table for the seniors of the Pontiac;
Complete revision of the collective agreements concerning the NIR: Training given, upgrading of the financial
and information services provided to the resources;
Collaboration in the provincial revision of protocols to be
signed by the CSSS and the RS;
Satisfaction surveys of the clients using community, hospital and residence services;
Various types of information provided by the users’ committee: Le Phare newsletter, promotional items and
calendars.
Creation a team composed of 4 doctors, who will follow up on the hospitalizations of a group of patients.
The doctors take turns on a weekly basis;
Exemplary performance
Communication: CHSLD newsletter, good initiative,
good work!
in Pontiac
Principal computer projects:
Reconstruction of our WEB site, medical WEB and
Extranet;
Message from the Academic Dean of Heritage College
CHSLD Newsletter
Now implementing Dossier Santé Québec;
Implementation of the “Omnitech” compliance software in the laboratory;
The 20 students in the program have just crossed the mid
-term mark. The preliminary results indicate that the
students are doing well. Based on the information we
receive regularly, everyone (students and faculty) is very
motivated and appreciates the program.
Geri-Active
Implementation of the Canamex tera messsaging paging system;
Purchase and implementation of a new Wifi network;
Replacement of workstations and migration from
Windows XP to Windows 7 on all workstations (in
progress);
Upgrade of SoftLab software;
Nursing program
In this number…
Shared roles and responsabilities of the care team
“Agir” project and work organization plan project
Capsule from the health and safety partnership committee
We would like to thank all of our partners in Shawville
and to highlight the contribution made by the Pontiac
Hospital which provided the laboratory equipment. We
will keep you informed about the progress made by
our future nurses.
Michael J. Randall
Academic Dean / Directeur des études
of its community
19
Fight against cancer
Results of activities
Number of users seen in Palliative
home-care services
Goal: 92 Average Interv: 14,0
2012-13: 78 -16,79
Results: 78 - 18,40
Commitment not
met however, we
have no one on
the waiting list
% of people receiving a diagnosis of cancer who
are assigned a patient designated nurse within
48 hours
Goal: 70%
2012-13: 77% Result: 75%
% of patients treated through oncological
surgery within less than 28 calendar days
Goal: 90%
2012-13: 85,7%
Result: 91%
Residential living
Average hours worked per day-presence in
Nursing Care
Goal: 3,0 hours
2012-13: 3,25 h Result: 3,22 h
Age-related Loss of Autonomy
People with loss of independence who received homecare services
Number of users and average interventions
Goal: 751 Average Interv.: 23,0
2012-13: 781 - 25,30
Results: 678 - 31,26
Goals: 252 Average Interv.: 4,0
2012-13: 261 - 3,23
Results: 302 - 3,13
Number of groups in the Fall prevention program
Goal: 3 groups /2 years
Result: 0
Nosocomial infection prevention
Next year, we will create 3 groups and the commitment will be
attained.
Obtaining the recommended ratio of nurses (FTE) assigned to nosocomial infection prevention
Goal: 100% Result: 100%
Surgeries
Number of cataracts surgeries:
2012-13: 283 Result: 233
Number of Day surgeries:
2012-13: 412 Result: 413
Number of surgeries with hospitalization:
2012-13: 227 Result: 252
Number of places in nearby residential resources in
physical disability
Goal: 1 place
2012-13: 2 places
Result: 2
Physical disabilities, cognitive impairment and Autism Spectrum disorders (ASD)
Number of users with physical disabilities who receive
home-care services
Average hours worked per day-presence in
Professional services
Goals: 206 Average Interv.: 21,47
2012-13: 216 - 21,5 Results: 158 - 29,2
Goal: 0,20 hours
2012-13: 0,183 h Result: 0,19 h
We have no one on the waiting list
Physical Health
Psychosocial services
Direct allowances: Physical disability
Goal : 29
2012-2013: 36
Result: 32
Direct allowances: CI-ASD
Number of users in CI et ASD who received
home-care services
Goal: 48
2012-2013: 67
Result: 62
Goals: 63 Average Interv: 9,4
2012-2013: 87 - 9,91
Results: 99 - 12,11
Establishment of 3 of 4 prerequisites for implementation of the adapted approach to seniors in hospital settings
Use of an identification system in the emergency
Installation and application of the follow-up mechanisms required for positive identification
Presence of a key or liaison professional in the emergency dedicated to vulnerable senior clients and
ensuring inter-institution links
2012-2013: Yes
Yes
2012-2013:
In progress
Yes
Goal: 3 of 4
Application of a walking program in the Emergency and/or in the hospitalization units
20
The great challenges for 2014-15
Hemodialysis
See program update;
Medical recruiting
To ensure a medical changing of the guard; recruiting of doctors for the obstetrics
department and to guarantee full coverage of the two emergency departments;
Balanced budget
Achieving a balanced budget is becoming more and more difficult, with budget
cuts over a period of 4 years, for a total of $1.2 million;
Service offer
In addition to budget cuts of $1.2 million, we have to face other major budget
cuts for 2014-2015, which have to be confirmed and will certainly result in difficult
decisions concerning the level of the service offer;
Telephone system
Upgrade the telephone system for the entire organization;
Energy saving
Geothermic at the Hospital;
Socio-economic context
The capacity of our social services to fulfil their role, considering the socio-
economic context;
Considering the economic and social difficulties of the territory, the Table of social
development of the Pontiac will work closely with the MRC du Pontiac to find ways
to improve the social health of our community;
Recruiting qualified human resources
Recruiting pharmacists and several other professions need to maintain
services in Pontiac;
In 2014-15, we wish to...
In terms of care and services:
To start our bone density project: Project that will start in mid-summer 2014
and will be located in the CSSS de Mansfield-et-Pontefract;
Organize the dentistry project;
Increase services in the operating room;
To integrate the Centralized appointment centre gradually; appointments for
specialized clinics and medical imaging will be regional;
Increase the presence of specialists in the out-patient clinic;
Hemodialysis
With respect to hemodialysis, we have hired a clinical consultant to prepare a
service offer to be presented to the Board of directors and the Agency for
April 2014; project to be undertaken with determination;
In terms of Human resources:
Qualified human resources: To implement an Attestation of professional studies program in hygiene and cleanness with the Professional Education Center of
the Pontiac. This training will be offered to our employees in order to raise their
awareness within the context of their work. The same will be done with respect
to training for institutional cooks that we would like to implement throughout
the territory;
Presence at work: A major challenge for our organization. We are using policies, meetings, information and all of the means needed to deal with this important challenge;
Continue nursing training in Pontiac;
Recruiting and retention: An action plan must be developed by 2015. To do
this, we will reinforce our group by adding personnel management agents. The
plan will cover the best approach, from welcoming to integrating new
employees. The hiring process is being revised.
Our close tie with the community network
is a major and valuable asset.
of its community
21
User satisfaction and Quality of services
Accreditation Canada
The complete report is available on our WEB site
Since the CSSS has been accredited for a very long, since well before this was required by law, the Accreditation Canada process is
part of the notion of continuous quality improvement that we
strongly believe in.
The 2014 visit gave the entire CSSS team an opportunity to note
our own progress. As a result, the report mentions great accomplishments (ex.: laboratory), our continued strengths (ex.: knowlAnn Rondeau edge of the needs of our population and our solid partnerships) and
the identification of areas for possible improvements (maintaining the current services despite a shortage of resources).
The observations reflect the reality of our CSSS. Our success is most certainly the
result of employees who are competent and proud, a dynamic management team, the
strong leadership of management and a very committed board of directors.
Certain measures have already been implemented and others will implemented on a
medium-term basis, depending on the current issues and the resources available.
However, quality and safety remain priorities for our organization and we will be do
everything possible to ensure that, on a daily basis, this culture is embedded in each
individual: user, manager, care-giver, employees, doctor and volunteer.
Results of the User satisfaction survey
RELATIONSHIP– Hospital and CLSC
Dimension
2010
2011
2013
Relationship with the client
89,38
90,09
89,74
90,10
91,52
91,62
89,59
89,41
89,81
88,43
89,29
87,46
Respect / dignity
Confidentiality
Empathy
PROFESSIONAL CONTRIBUTION - Hospital and CLSC
Dimension
2010
2011
2013
Professional contribution
86,01
87,69
85,53
Reliability
86,39
89,05
86,22
Responsabilization
84,00
83,48
83,01
Soothing
88,31
89,25
87,30
84,47
86,83
83,15
Solidarity
Special thanks to the team of visitors that evaluated us, as always, in a constructive
and stimulating manner.
The CSSS received its accreditation. The results deserve mention even though they
are presented very briefly:
1. Of all of the organization practises required (31), only one did not comply with
the main test. This situation will be corrected before July 14, 2014. This is the only
recommendation required for 2014;
2. We complied with the minimum number required as the response rate for the
evaluation tools (safety).
3. We complied with a proportion of 94.8% for all of the priority criteria raised and
91.8% for all of the other criteria.
4. Not only did we not have any red indicators for the client satisfaction survey but
we even had green criteria(!);
5. Our results were rated “yellow” with respect to employee motivation, but we have
nevertheless noted an improvement since 2011.
It is important to congratulate all the employees,
employees, managers and doctors for the excellence of their care and services. We can also take
pride in the fact that the efforts that have been
made to respond to our users’ needs were recognized by the population through a survey conducted in 2013.
ORGANIZATION OF SERVICES (CHSLD)
Our objective is not only to congratulate ourselves,
Dimension
2010
2011
2013
although it is important to do so when it is merited,
Organization of services
but also to remind the people in charge of the ac84,32 87,64
87,67
creditation teams that they should also use these
Simplicity
83,27 93,61
89,83
results to underline future interventions as part of
Continuity
the continuous quality improvement program.
82,12 81,84
86,81
The CSSS du Pontiac is, as usual, proud of the
Accessibility
90,08 97,33
92,46
results obtained and, above all, to see that all of the
Rapidity
efforts made by each and every one of us make a
84,69 88,96
85,77
difference and have a great deal of influence.
Comfort
82,18 89,10
88,76
Thanks to the clients for their cooperation and to
RELATIONSHIP (CHSLD)
DEGRÉ the users’ committee for their valuable time.
Dimension
2010
2011
2013
PROFESIONAL CONTRIBUTION (CHSLD)
Relationship
86,84 90,42
90,71
Dimension
2010
2011
2013
With the client
Professional contribution
Respect / dignity
85,02 89,83 87,24
80,87 91,25
91,91
Reliability
83,70 91,00 88,31
Confidentiality
Responsabilization
84,59 89,27 83,29
89,56 94,83
94,66
Soothing
85,28 89,79 88,69
Empathy
82,27 86,77
85,45
Solidarity
88,74 86,00 84,21
All in all, the thoroughness
and commitment of all had
resulted in this success!
22
Service quality and complaints Commissioner
Actions for improvement by the Complaints Commissioner:
The annual report of the Commissioner is accessible via our WEB site at:
www.santepontiac.qc.ca
Benoit Paré
All the information in the report was addressed and analyzed during
three (3) meetings of the Monitoring Committee and, 2 reports were
submitted to the members of the Board of Directors.
In 2012-2013: the Commissioner received 40 cases::
18 complaints, 1 dual-component complaint, 13 medical complaints et
8 assistances/interventions.
The majority including 65% of the cases involved the Hospital, and 33% of the cases
involved the CLSC (physical health component), 1% in accomodation and
1% in home-care.
Making appointments: Revision and updating of the procedure;
Calibration of diagnostic instruments: Implementation of a management system;
Memo board developed for replacement personnel (laboratory);
Interventions and reminders concerning the involvement of the first-line manager;
Communications: Interventions and analyses given to the doctors concerned with
respect to the importance of maintaining good communication with the users; General reminders also given to the personnel about communication;
Adaptation of the social media policy and use of texting in an intervention context;
Handicapped access: Washroom renovated on the first floor at the Hospital;
Access to information: Revision of control measures;
Hygiene and cleanness: Revision and reminders of the process for taking samples.
7
2
In 2013-2014:
Report of the examining physician on
18
8
medical complaints
18 complaints + 7 medical complaints +
2 dual-component complaint + 8 Assistances/interventions = 35 cases
Complaint subjects
Accessibility and continuity
Care and services
Interpersonal relationships and
communication
Environment and material resources
Financial/Organizational
Programs
Physical health and nursing care
Autonomy support
Medical sector
Intervention domains
Information/explanation
Conciliation
Improvement of practices
Reminder/procedures
Recognition/error
Modification of procedures
Adaptation of environment
2012-13
17%
28%
27%
15%
13%
2013-14
19%
30%
40%
4%
7%
Fields:
71%:
Hospital
14%:
CLSC,
physical health
12%: Home-care
3% Accommodation
47% Reception/secretarial services
13% Technical services
24%
15%
35%
18%
14%
7%
7%
4%
13%
3%
Delays in conclusions:
0-30 days: 50%
31-45 days: 11%
+45 days: 39%
Filing methods:
40% written 17% e-mail
23% written– meetings
20% verbal
Authors of the complaint:
71% users 29% representatives
During the year, the examining physician responded to12 complaints of a medical nature. Two (2) of these complaints were hanDr John
dled by the DPS outside the system. One of the complaints was reWootton
ferred to the review committee which made a decision without having to change the conclusions of the examining physician.
One complaint, which did not concern any particular doctor, but which included a
medical component, was handled directly by the local complaints commissioner for
a response.
Complaint subjects:
Frustration concerning the treatment or test given, which was not the one wanted or
requested;
Inappropriate service expectations;
Waiting time for emergency services or during observation, at the hospital;
Lack of understanding of coverage provided by the Quebec Medical Health card.
The most important complaints concerned adequate communication in a context of
serious illness, when several doctors and even several facilities may be involved.
Delays were experienced in certain cases, despite the best efforts made to analyze
them;
During the course of the year, the Board of Directors renewed the mandate of the
examining physician for another three (3) years. Since no other candidate is interested, I will remain responsible for this mandate.
of its community
23
Conseils et comités
CONTINUOUS QUALITY IMPROVEMENT Committee
Ann Rondeau
Alain Gillet
Michel Pigeon
Lucille Bélair
Benoit Paré
Sophie Bonin
Gail Ryan
Paulette Boucher
Dr. John Wootton
USERS’ Committee
Robert Ladouceur, president
Gaëtan Lance, vice-president
Michel Pigeon
Angela Lance
Keith Nadeau
Claudette Rainville-Stanton
JoAnne Hobbs-Nimchuk
Fernand Roy, resource-person and treasurer
Resource-person who has left:
Mrs. Elaine Denault (December 2013)
We held four (4) meetings this years and handled the following matters:
Revision of the continuous quality improvement program;
Preparation for the 2014 visit from Accreditation Canada, through the analysis of the surveys on user satisfaction, personnel motivation and client safety;
Analysis of the status of the organization practises required (ROP) by Accreditation Canada;
Discussion of the results of the flu vaccination program;
Addition of a systematic point on the agenda, pertaining to the recommendations made following government visits concerning the improvement of the quality of the living environments;
Discussion of the values of the facility versus its guidelines;
Discussion and questioning with respect to “re-merging” the committee with the risk management
committee;
Sharing of information about the service corridors and the agreements among the trauma facilities, concerning people who have spinal cord injuries and people who have had strokes;
Participation in the development of plans and frameworks in keeping with the 2011 recommendations of
Accreditation Canada;
Discussion concerning practises and procedures in the event of an external disaster;
Highlighting of the prospective analyses made by the CSSS;
Other topics discussed: collective prescriptions, surgical morbidity, disinfection device, post-complaint
survey, hand washing, campaign against elder abuse.
The members of the users’ committee meet six (6) times or more during the year, namely once every second
month, with a break during the summer period. At the request of the committee, the manager of the autonomy support program chairs the committee and takes part in the meetings.
Special promotion activities:
Took part in organizing a family meal at Christmas. We made the most of this occasion to promote the committee by distributing promotional items with the committee name on them to all visitors, and those helping
to serve the meal. Three activities were organized, one at the Manoir Sacré-Cœur (MSC), one at the Pontiac
Reception Centre (CAP) and one in long-term care;
Took part, in cooperation with the living environment leisure activity group, in organizing a BBQ in each of
the three (3) living environments, in order to promote users’ rights;
Took part in the visit by Accreditation Canada in February 2014, on site and during the preparations for the
visit, in Spring 2013, by contributing to the residents’ satisfaction survey;
Took part in the MSSS quality improvement visit to the CAP and long-term care;
Provided support to three (3) residents’ committees with their promotion and information activities for residents and their families.
Our accomplishments: The principal accomplishments of the users’ committee in 2013-2014 concerned:
Participation in the RCUO annual meeting;
Participation in training provided by the RCUO;
Promotion of the users’ committee;
Ongoing reflection about the development of a annual activity promotion plan .
All the members of the CSSS du Pontiac users’ committee remain committed and dedicated to their clientele, their residents and their users. Cooperation with the CSSS personnel is close, constant and pleasant.
24
CLINICAL ETHIC
GOUVERNANCE and ETHIC
VIGILANCE and QUALITY
Committee
Committee
Committee
The committee meet three (3) times in 2013-2014.
The Committee met only once but was active
with respect to the implementation of a conceptual framework for ethics. The following four points
were discussed and developed:
Code of ethics and conduct for administrators;
Ethical terms for any research project;
Code of ethics and conduct;
Reference guide for clinical ethical situations to support
our care-givers.
The committee met once
during the course of the year to develop two (2) governance practises for the CSSS du Pontiac.
First, the governance and ethics committee established
its internal procedures for governing its work.
Second, the committee developed a code of ethics and
conduct for the members of the Board of Directors of the
CSSS du Pontiac. This code was adopted by the Board
of Directors on February 25, 2013.
This last point was the one that took most of the committee’s energy. In fact, we clarified and identified several elements that make it easier for us to identify a
situation with an ethical component. The committee met
on an “ad hoc” basis another time as a result of an ethical dilemma concerning the mental health of a patient
and respect for his choices.
Jean-Guy Patenaude, president
Anne Paquin, vice-presidente
Richard Grimard, secretary
Gaëtan Lance
Jacques Piché
In keeping with its mandate, the committee is responsible for the measures implemented with respect to the
quality and safety of its services and its personnel/
volunteers.
For this reason, the committee systematically and rigorously examines each of the complaints handled by the
Complaints Commissioner and the quality of the services in order to improve quality and ensure safe care
and services.
The committee was also made aware of processes and
results:
The Accreditation Canada evaluation, the visit by the
Quebec Health and social services ministry to the
CHSLD, and the visit by Quebec Accreditation to the
CHSLD.
The volume of complaints is stable. The committee submitted a recommendation to the Board of Directors with
respect to reviewing our out-patient appointment system
and the impact of the regional appointment centre project.
Richard Grimard, president
Claudette Rainville-Stanton, president
and member of the BoD
Daniel Hébert, vice-president
Dr Anthanassios Karabatsos
Philippe Morin
Ali-John Chaudhary
Jean-Guy Patenaude
Gilbert Daoust
Richard Grimard, secretary
Benoit Paré
Hélène Boulet
Gaëtan Lance
Alain Gillet
of its community
25
RISK MANAGEMENT Commitee
Gilbert Daoust, president
Claudette Rainville-Stanton, vice-president
Alain Gillet
Richard Grimard
Gail Ryan
Mélanie Francoeur
Sophie Bonin
Dr. Athanassios Karabatsos
Colleen Larivière
Benoit Paré
Ann Rondeau
Others
Incidents/Accidents
We held four (4) meetings and discussed:
Scoreboard for follow-up on reports;
Analysis of sentinel events;
Preparation for the 2014 accreditation;
Follow-up on the implementation of the CBM;
Emergency measures and fire drills;
Prevention of infections, reports and follow-up
on nosocomial infections;
Coroner’s report:
With respect to following up on the coroner’s
report, we did not make any recommendations
concerning our facility.
MORE - Maintained the training for the nurses
in the concern of obstetrical risk management
Our objectives for 2013-2014 are to:
Medications
Falls
47% of the reports pertain to falls
including 208 patients
for a total of 7 fractures.
In 2012-13: 57% of the reports pertained to falls, touching 264 patients,
nice improvement!
The Fall prevention program is proving to be a major tool. Despite the number of falls, the reporting culture is well established
because, by reporting, the person doing the reporting stops to
think about the incidents in order to reflect and make corrections
for preventing accidental repeats.
37% of the reports are related to medication errors.
At the monthly meetings of the Board of Directors, we
inform the members of the situation
regarding nosocomial infections.
We received 551 declarations of accidents/incidents:
42% in residential living, 56% hospital
and 2% in CLSC and home-care.
Continue to be vigilant with respect to the analysis of accidents/incidents and to try to identify
solutions;
Ensure transparent disclosure;
Implement, with respect to the Accreditation
Canada recommendation, to implement and
follow up on hand hygiene accreditation and the
quality control audits in hygiene and cleanness;
Continue publishing a newsletter on risk management and infection prevention.
Risk management measures taken:
New binder and new policy on the managing the
risk of falls implemented and accessible;
Identification of users at risk of falling by means
of a yellow bracelet
Revision of the medication circuit;
Clearing of corridors in all facilities;
Additional preventive means to maximize the
control of nosocomial infections through the use
of the Nocospray disinfection system.
During the year, we treated :
15 cases of MRSA ((Methicillin-resistant
Staphylococcus aureus)
5 known VRE and 10 new cases
(Vancomycin-resistant Enterococcus)
6 C-difficile (Clostridium Difficile)
All cases that are related to nosocomial infections
are followed strictly according to the guidelines of
the Public health Department. Infection control
and prevention consists of 6 components including:
Surveillance and monitoring of the emerging infectious problems,
Policy, procedure and measures of support,
Education and training,
Evaluation,
Communication and information and Management
of outbreaks.
The local register of incidents and accidents was put in place on April 1, 2004.
The committee was approved by the Board
of Directors and established on
November 2, 2004.
Adoption by the Board of Directors on
May 17, 2005, of the bylaw on the rules
governing the disclosure of all necessary
information in the event of an accident;
support measures including appropriate
care and measures
in preventing the recurrence of such an
accident.
Most of the time, disclosure rules are
respected, analysis is carried out to assess
the root causes of accidents with consequences, and solutions are
then applied in order
to prevent a recurrence.
At all times, the disclosure rules
are applied.
.
26
Council of PHYSICIANS,
MULTIDISCIPLINARY Council
DENTISTS and PHARMACISTS
We held two (2) general meetings and the executive
committee met nine (9) times. Committee elections took
place in 2013.
Several files are in progress, specifically the recruiting
file, which is handled jointly with the Agence de la santé
de l’Outaouais and the community.
The human resources files are as follows:
Departure of a doctor as an active member to become an
associate member (Dr. N. Gomez);
Resignations: -A member of the executive committee;
- Dr. L. Côté as the person responsible for long-term
care (replaced by: Dr. M. Lamarche);
- Consulting biochemist (replaced by Dr. Alain);
Hiring of 2 doctors: Dr. Rivero Lopez and Dr. J. Forget
as a pharmacist and as an active member of the DGM
and the anesthesia department;
Absence of Dr. Keith MacLellan (returned part-time);
Sponsorship of Dr. H. Boret, French anesthetist and end
of sponsorship of Dr. Kayumba;
Changes in status as associate member (Dr. M. Benfey),
temporary status (Dr. T. O’Neill), privileges (Dr. E. Potvin) and extension of privileges (Dr. M. Soultan);
Interested in working us: Dr. Maria Kungurov;
Training of the recruiting committee and activities;
Four (4) scholarship recipients accepted;
The executive committee is handling several files:
Pager system; Intensive care management; Modification of the rules for the DMG; Training for the endoscopy service within the Internal Medicine department;
Reduction in the hours of the emergency department at
the CLSC Mansfield during the Summer.
Dr Freydoun Homayounfar, president
Dr John Wootton, DPS
Dr Luis Rivero Pinelo, vice-president
Dr Majed Soultan
Dr Kaveh Roustaian
Dr. Sevag Zaroukian and
The current executive committee was
elected during the annual meeting held on
April 19, 2013 for a term of three (3)
years and has met
four (4) times since then.
During the meetings of the executive committee, we
discussed several matters or an organizational nature
concerning the facility: New CHSLD, Accreditation,
budget situation, recruiting and retention of personnel
and other practical matters.
Furthermore, a dinner meeting was held. This information session concerned the 211 service which is a centralized information and referral service that rapidly directs people to the resources in their region.
This year was marked by the Accreditation evaluation of
the services provided to the population. The results were
excellent. For years, we have been working hard to
create a facility that responds to the needs of the population and, since most of the objectives have been attained,
it seems clear to me that we have made the right decisions in this respect. Needless to say, when it is a matter
of human beings, services must evolve over time and the
work pertaining to service quality must be ongoing. We
all understand this. Thus, I would like to acknowledge
all of our managers and professionals who have invested
so much in developing our programs and services. These
results indicate how much attention we pay to the needs
of our population and we will continue
our efforts.
Mr Richard Grimard
Georges Robitaille, president
Richard Grimard, executive director
Sophie Bonin, vice-president
Chantal Lair, secretary
Serena Larivière
Anne Mageau
Joanne Dubois
Council of
NURSES
Four (4) meetings were held in
2012-13. The following topics were
discussed:
Follow-up: Accreditation, social media policy, coroner’s
report, Regional Nurses Committee (Agence de l’Outaouais ) + report, CBM, specialized nurse practitioner
(SNP);
Therapeutic nursing plan (TNP);
Portfolio on ongoing nursing training (20 hrs/year) and
OIIAQ training (10 hrs/year);
Management of antibiotics; Code of ethics;
Feedback on the results of professional exams;
Training - ACS in nursing, Pontiac;
Baby-friendly initiative: Breastfeeding policy;
Protocol on care/collective prescriptions: Adjustments to
basal insulin, intensive therapy and pre-mixed insulin;
Introduction to clinical follow-up and frequency of blood
sampling for diabetic or pre-diabetic patients.
Presentations: Management of influenza, outbreak of
infectious gastro-enteritis in care facilities, infection prevention and organ donation.
Our objectives for 2014-2015:
The general appreciation of the quality of the nursing
care in the centre (OIIQ and OIIAQ follow-up, TNP consolidation);
Evaluation and maintenance of nursing skills (contribute
to the organization of nursing care);
Continue to be the spokesperson for sectors of activity;
Encourage the nursing personnel to take part in CIIa;
Develop an awareness raising strategy wit respect to
confidentiality and the social media.
Lucille Bélair, president
Gilbert Daoust, vice-president
Gail Ryan, secretary
Richard Grimard, executive director
Sylvie Chartrand, Mélanie Francoeur,
Paula Keon
Chantal Lefebvre, Chantal St-Aubin,
Nurses assistants: Lyne Jolicoeur and Lina Lacroix
of its community
27
Financial statements and Financial analysis
To the members of the Board of Directors of the Pontiac CSSS, June 9, 2014
The summarized financial statements were drawn from the annual financial statements of the Pontiac CSSS for financial year
ending March 31, 2014.
We expressed a guarded opinion regarding the rental contracts. Our guarded opinion indicates that the financial statements
Leanne Gray
give, in all significant aspects, an accurate picture of the financial standing of the Pontiac CSSS as at March 31, 2014, as well
as the results of its activities, the change in its net debt and its cash flow for the fiscal year ending on that date, in accordance
with the Canadian public sector accounting standards.
Deloitte & Touche s.e.n.c.r.l. - CPA auditor, CA,
public accountancy permit no A108268
MANAGEMENT REPORT
The financial statements of the CSSS du Pontiac were completed by Management, which is responsible for their preparation and faithful presentation, including estimates and important judgments. This responsibility includes the choice of appropriate accounting conventions that comply with the standards of the financial management manual stipulated in section 477 of the AHSSS. The financial information contained in the rest of the annual management report is in agreement with the information provided in the financial statements.
To carry out its responsibilities, management maintains a system of internal controls which it considers necessary. This system provides reasonable assurance that assets
are protected, operations adequately entered at the right time, duly approved and enabling production of reliable financial statements.
The CSSS du Pontiac management recognizes that it is responsible for managing its affairs in compliance with the Acts and regulations that govern it.
The Board of Directors oversees the manner in which management carries out the responsibilities incumbent on it in the matter of financial information, and has approved the financial statements. It is assisted in its responsibilities by the auditing committee. This committee meets with management and the auditor, examines the
financial statements and recommends their approval by the Board of Directors.
The financial statements were audited by Samson Bélair/Deloitte & Touche s.e.n.c.r.l. duly mandated to do so, in compliance with recognized Canadian auditing standards. Their report shows the nature and extent of this audit, as well as the expression of their opinion. The firm without restriction, meet with the auditing committee to
discuss any element concerning their audit.
Leanne Gray,
Director of Financial services
Richard Grimard,
Executive director
28
SUMMARY STATEMENT of financial position
Statements of EARNINGS
REVENUES
2013-2014
2012-2013
Agency and Ministry
Users fees
Sale of services
37 870 722$
2 382 666$
100 876$
36 144 657$
2 505 036$
111 271$
Recoveries
Other contributions and donations
Others
193 473$
151 985$
363 492$
41 063 214$
214 928$
185 966$
64 066$
39 225 924$
EXPENSES
Salaries, social benefits and fringe benefits
Drugs
Blood products
Medical and surgical supplies
Food
Amortization of capital assets
Others
Deficiency of revenues over expenses
FINANCIAL ASSETS
2013-2014
2012-2013
589 234$
1 068 004$
1 319 947$
1 321 343$
602 457$
645 119$
5 102 450$
4 471 859$
Deferred charges
26 540$
25 113$
Deferred pay for leave of absence
66 085$
40 778$
7 706 713$
7 572 216$
5 011 699$
4 752 509$
678 566$
953 589$
6 008 241$
6 453 147$
235 392$
181 728$
14 252$
7 936$
1 043 537$
785 717$
28 188 838$
27 877 372$
41 180 525$
41 011 998$
(33 473 812)$
(33 439 782)$
Prepaid expenses
275 735$
241 024$
Inventories
469 189$
450 293$
32 134 230$
32 208 308$
32 879 154$
32 899 625$
(594 658)$
(540 157)$
Cash
Receivables – Agency and Ministry
Other receivables
Grant received in advance –
Accounting reform
27 376 100$
1 033 129$
543 313$
1 211 464$
26 531 596$
967 955$
544 584$
1 221 607$
451 357$
1 956 456$
8 545 896$
493 145$
1 589 301$
7 881 255$
Advances of funds from the Agency
41 117 715$
(54 501)$
39 229 443$
(3 519)$
Deferred pay for leave of absence
LIABILITIES
Temporary loans
Other payables
Accrued interest payable
Deferred revenues
Long-term debt
SUMMURY STATEMENT of Accumulated deficits
OPENING deficit
Deficiency of revenues over expenses
BALANCE, END OF YEAR
(540 157)$
(536 638)$
(54 501)$
(3 519)$
(594 658)$
(540 157)$
NET DEBT
NON FINANCIAL ASSETS
Capital assets
FUNDS BALANCE
of its community
29
Comments and observations made by the independent auditors
Legend for column 3 : R= Reserve O= Observation C=Comment
Columns 5, 6 and 7 : R= Resolved PR= partially resolved NR= Not resolved
Description
Year
Nature
1
2
3
Measures taken to resolve the problem
On March 31,
2014
5
6
7
In regards to financial statements
Leases of immovable property concluded between the establishment and the
Société immobilière du Québec are accounted for as operating lease contracts
while they are capital lease contracts
20112012
R
No measures were taken to resolve the
problem, as per directive from the MSSS
The statistics pertaining to activity center Respiratory therapy (6350), were not
calculated.
20112012
O
The statistics are now being calculated.
The statistics of the activity center (6390) Clergy, were not gathered.
20112012
O
problem.
NR
The charges of activity center (7600) Laundry were all in the activity center 7604
(Laundry).
20112012
O
problem.
NR
The statistics of activity center 6322 were not calculated.
20132014
O
Measures were taken to solve the situation
for the year 2014-2015.
NR
In regards to statistics and the worked and paid hours
R
PR
30
Questionnaire to be filled by the auditor independent (external auditor)
The establishment did not respect the Bill 100 on budgetary balance because
they end fiscal year with a deficit.
2012-2013
NOTES to the financial statements
1. Accounting principles: Management is responsible for the preparation
of the summary financial statements.
O
The establishment watches closely all costs in
order to reach the budgetary balance.
NR
Measures taken in 2012-2013
to reach Budgetary Balance
2. Financial analysis: The Establishment as not received the financial
analysis for 2012-2013.
3. Related parties transactions: The following donations were received for
the purchase of medical
equipment and other supplies:
2014
Fondation de l’hôpital communautaire
du Pontiac, Inc.
60 458$
Fondation du CLSC Pontiac
19 771$
Fondation du CAP
41 010$
121 239$
2013
7 051$
7 575$
-_____
14 626$
REDUCTION OF:
Travel expenses,
Costs of training,
Professional fees,
Independent labor,
Advertisement fees,
Downsizing at the level of administrative support including 1 full time
and no replacement during leaves.
We have reached the results "required" under this Act.
of its community
31
Objectifs généraux et champ d’application
Rules of professional conduct
This code is not intended to replace the legislation and
regulations in effect or establish a comprehensive list of
standards to be met by and behaviour expected of the BoD
members of the Pontiac CSSS, In fact, it:
Covers preventive measures, including rules pertaining to the
expression of interest;
Covers the identification of conflict of interest situations;
Governs or bans practices pertaining to directors’ compensation;
Covers directors’ duties and obligations, even after they have
stopped performing their duties;
Sets out mechanisms for enforcing the Code including
designating people responsible for enforcing it and the possibility of penalties.
Availability and active participation: make themselves available by regularly attending BoD meetings, becoming aware of
matters and participating in decision-making. They encourage co-operation and contribute to deliberations;
Compliance: comply with legislation, regulations, standards,
policies and procedures. Act courteously and maintain relationships based on respect, co-operation and professionalism.
Also follow the rules governing the running of BoD meetings,
respect diversity of viewpoints and all BoD decision, even if
they disagree;
Care and competence: Act within the limits of the powers
assigned to them and in the interest of the Institution;
Institution’s goods and services: Uses the goods, resources
and services in accordance with the terms. They may not
merge the CSSS’s goods with their own. They may not use
them to their own or anyone else’s advantage unless authorized to do so by the BoD. Do not receive a salary. They are
entitled to be reimbursed for expenses made in performing
their duties as per the terms and to the extent determined by
the government;
Benefits and gifts: Must not request, accept, demand, give or
commit to give, directly or indirectly, a gift, hospitality or
consideration when it is intended to influence or generate
expectations in that regard. If they receive a benefit, they are
accountable to the Institution for the value of the benefit;
Inappropriate interventions: Refrain from getting involved in
the staff hiring process, as per the LSSS. They refrain from
manipulating in order to favour relatives or any other individual or corporate entity.
Ethical principles - Directors:
Act within the limits of the powers assigned to them. They
fulfill their duties and obligations in accordance with the requirements of good faith;
Neutrality: Express their opinion on proposals by voting.
Cannot make commitments to third parties or guarantee them
a vote or on any decision whatsoever. They must put the
Institution’s interests above any personal or
professional
interest;
Must exhibit constant concern for respecting human life and
every individual’s right to receive health care services and
social services;
Transparency: Support their recommendations with sufficient
objective information. Share with BoD members any information that is useful for decision-making;
Are required to abide by the ethical principles and rules of
professional conduct set out in this Code;
Discretion and confidentiality: Exhibit discretion, wisdom
and reserve with any information that could adversely affect
the Institution’s interests, jeopardize privacy or confer an
advantage on an individual or corporate entity. They maintain
the confidentiality of deliberations, defended positions, members’ votes and any information involving a decision by the
Institution. Refrain from using confidential information to
their own advantage, to the advantage of other individuals or
corporate entities or of an interest group;
Are sensitive to the public’s needs and take basic human
rights into consideration;
Adhere to the principles of relevance, continuity, accessibility, quality, safety and efficiency of the services provided;
Carry out their responsibilities in keeping with local, regional
and national directions, in consideration of the Institution’s
human, physical, informational, technological and financial
resources;
Take an active and team-based role in developing and
and implementing general policies;
Help fulfill the mission, while respecting the Institution’s
values and vision by using their skills, knowledge, experience
and thoroughness.
Public relations: Adhere to the media relations policy;
Public office: Inform the BoD of their intention to seek nomination for elective public office. Must resign immediately if
elected to public office full time. They must also resign if
elected part time and if that responsibility is likely to place
them in a conflict of interest situation;
Independent directors
Directors who are elected, appointed or co-opted as independent directors must disclose to the BoD in writing, as soon as
possible, any situation likely to affect their status. They must
submit that written disclosure no later than 20 days following
the existence of such a situation.
Conflict of interest - Directors:
Must prevent any conflict of interest and avoid putting themselves in a situation that would make them incapable of performing their duties. It is a conflict of interest when the
interests are such that they may be led to prefer certain ones to
the detriment of the Institution or see in it a benefit that is
direct or indirect, current or potential, personal or in favour of
a third party;
Must arrange their personal affairs so that they cannot jeopardize the performing of their duties;
Must refrain from taking part in deliberations and decisions
when their objectivity, judgment or independence could be
compromised by personal, family, social, professional or business relationships.
Must state in writing to the BoD the interest they have in corporate entities, corporations or companies that have entered
into or may enter into service contracts with the Institution;
32
Directors who put themselves, the BoD or the Institution in a
conflict of interest must disclose their interest to the BoD in
writing;
Being a minority shareholder in a corporate entity that runs
such a company does not constitute a conflict of interest if
the shares are traded in a recognized stock exchange and is
not an insider of that corporate entity;
Must disclose to the BoD any potential or apparent conflict
of interest situation regarding an issue raised during a BoD
meeting. That disclosure must be entered into the minutes.
They must withdraw from all deliberations and decisionmaking on the issue;
Any individual must notify to the Chair of the BoD in writing about any director who could be in a conflict of interest.
That written notification is submitted to the Governance and
Ethics Committee. That committee may recommend implementing preventive measures or that an inquiry be held by
Enforcement of the code
All directors undertake to recognize and discharge their
responsibilities and duties to the best of their knowledge and
to comply with this Code and legislation;
Within 60 days of the BoD adopting this Code, directors must
produce a covenant. Every new director must also do so
within 60 days;
When in doubt about the scope or application of this Code, it
devolves to directors to consult the Institution’s Governance
and Ethic Committee..
Disciplinary process
Any breach or omission regarding a duty or obligation constitutes a corrupt practice and may result in action;
The Discipline Committee’s report is conveyed to the BoD no
later than 45 days after the start of the inquiry;
The BoD meets in private to decide on the action to take with
the director. Before taking any action with the director, the
BoD must inform him/her and give him/her the chance to be
heard. He/she may be accompanied by an individual of his/
her choosing. That individual cannot be involved in the
BoD’s deliberations or decision;
To enable an appropriate decision to be made, in an urgent
situation or presumed serious offence, the BoD may temporarily remove the director from his/her duties;
Any action taken must be communicated by the BoD to the
director in question. It must be in writing and justified;
That action may be informal disciplinary action, a reprimand,
a suspension for a maximum of 3 months, a cancellation of
mandate, depending on the nature and seriousness of the
breach;
the discipline committee. A donation or legacy given to an
administrator who is neither a spouse nor relative is void in
the case of a donation or invalid in the case of a legacy, if
that action occurs at a time when the donator or testator is
cared for or receiving services;
End of term - Directors:
Must remain on duty until they are replaced or elected, designated or co-opted again;
Respect the confidentiality of any information obtained in
the performance of their duties;
Must conduct themselves in such a way as to not derive any
undue advantage;
Must not act on their own behalf, with respect to a procedure, a negotiation or any other of the Institution’s situations
for which they participated;
Refrain, if not already employed by the Institution, from
applying for a position with the Institution;
In view of the shortage context and recruiting difficulties, the
BoD agreed, through resolution 2012-09-17, to make it possible for a resigned member’s application to be admissible
with respect to clear rules.
The Governance and Ethics Committee refers the matter to
the discipline committee when there is a well-motivated reason to believe that a director has contravened the Code;
After analysis, the Discipline Committee determines whether
there is reason for an inquiry. If yes, it informs the director of
the breaches in question and the reference. He/she may,
within 20 days, provide his/her observations in writing and be
heard by the Discipline Committee;
A director who is informed that an inquiry is to be held about
him/her must not contact the individual who asked for the
inquiry to be held;
The Discipline Committee may assign individuals responsible
for conducting the inquiry. The inquiry must be confidential
and must protect, if possible, the anonymity of the individual
who generated the allegation. The inquiry officer must be
discrete, objective and unbiased;
The Discipline Committee must adhere to the rules of natural
justice by providing the director with an opportunity to read
the charge, the documents, and to prepare and make written
or spoken representations. The director can be accompanied
by a person of his/her choosing;
The BoD secretary keeps and maintains the confidentiality of
all files pertaining to enforcement of the Code throughout the timeframe set by the Institution’s retention
schedule, in accordance with the Archives Act.
Dissemination of the code
The Institution must make this Code available to the public
and publish it in its annual report;
The Institution’s annual management report must state the
number of cases handled and the follow-up to them, any
breaches seen during the year by the Discipline Committee,
any decisions made, as well as the name of directors suspended during the year or whose mandate has been cancelled.
Final provisions
This Code is in effect as of the day it is adopted by the Institution’s Board of Directors;
This Code must be reviewed by the Institution’s Governance
and Ethic Committee every 3 years or when legislative or
regulatory changes require it.
Those who cannot be charged before the law due to acts carried out in good faith while performing their duties are individuals and authorities who are responsible for conducting
the inquiry as well as those responsible for determining or
imposing the sanctions;
of its community
33
Tribute to our volunteers
... May 16, 2013
Recognition of years of service
... May 30, 2013
Employees annual BBQ
… September 12, 2013
The awards were based on
organizational values and the
challenges identified in the multi-annual strategic plan 2012-2015.
Winning Group for Excellency
We had the pleasure to offer 7 prizes: 5 awards
of Individual distinction and 2 Group achievement award.
Achievement award winners for
groups (all categories)
(Received a plaque to be installed in winning activity
center)
Prize for EXCELLENCY:
Multidisciplinary approach on risk management in obstetrics (AMPRO)
Winning Group: Coup de coeur
Prize of EXCELLENCY
In the context of the annual evening of
'Recognition of employees' which took place on
30 may 2013, we decided to emphasize the commitment, the contribution
and achievements of individuals and groups of individuals for the year 2012-13.
Winners for Individual distinction
(received an I-PAD)
Category 1: Nurses, Nurse assistants and
inhalotherapists
Michel Fortin, nurse, General Care
Nurses: Natalie Romain, Caroline Presseau,
Emilie Robert and Gilbert Daoust (manager)
Category 2: Paratechnics,Trades and
Photo: Gilbert Daoust, manager and the executive
director, Mr. Richard Grimard
Sandra Bastien, house cleaning
Prize: COUP DE COEUR
Clerical support, department of Emergency
Administrative agents: Glenda Beauregard,
Tammie Bérard, Léane Kenney, Danielle
Labine and Paulette Boucher (manager)
Photo, left to right: Gail Ryan (director of Physical
health), Paulette Boucher, Danielle Labine, Tammie
Bérard and the executive director,
Mr. Richard Grimard
auxiliary services
Category 3: Office personnel, technicians
and professionals of the administration,
unionized and non-unionized staff
Lucie Dubé, administrative secretary
Category 4: Professionals
Josée Godin, dietetic technician
Category 5: Pharmacist, physicians
Dr. Donna Courchesne (absent)
34
The 2013-2014 Annual Management Report is published, in limited quantity,
by the CSSS du Pontiac,
and accessible on our web site at: www.santepontiac.qc.ca
The masculine form is used throughout this document and can designate women as well as men.
Sometimes the feminine form is used, but it also designates men.
The production of this report is the fruit of the work of many contributors from the Administrative Management team
and different councils and committees of the CSSS du Pontiac.
We would like to thank the Agence de santé et des services sociaux de l’Outaouais for the translation.
Presentation and layout by Paulette Boucher.
35

Santé Pontiac

Transcription

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