South West CCAC Board Leadership Team Value Proposition

South West CCAC
Board Leadership Team
Value Proposition
Who We Are
A transformative and diverse team of leaders, who are passionate about healthcare and serve the best interests of our
communities.
What We Do
We set the strategic direction, and oversee and evaluate the pursuit of that direction, to ensure responsiveness to the
needs of our communities.
How We Add Value
•
•
•
•
•
We
We
We
We
We
excel at governance.
live our belief in partnerships.
balance our future-orientation with evidence-informed decision-making.
ensure quality of care.
collaboratively challenge the status quo.
Where We Want To Be
At the cutting edge of transformative leadership to enable excellence in client-driven care.
Board Meeting Agenda
RECORDER:
Cate Patchett, Corporate Liaison
MEMBERS:
Pat Campbell, Board Secretary
Sandra Coleman, Chief Executive Officer
Tim Cronsberry, Board Member
Don Eby, Board Member
Brian Hadley, Board Vice Chair
Dr. Claude Lanfranconi, Board Treasurer
Mary Lapaine, Past Board Chair
Dr. Carol McWilliam, Board Member
Cynthia St. John, Board Member
GUESTS:
Hilary Anderson, Vice President, Corporate Services & CFO
Maureen Bedek, Vice President, Human Resources and Organizational Development
Nancy Dool-Kontio, Vice President, Patient Engagement & Integration
Donna Ladouceur, Vice President, Patient Care
Andria Appeldoorn, Communications Lead
Steven Carswell, Director of Quality
Time
Item
1.0
11:45
2.0
Topic
Call to Order
1.1
Opening and Welcome
1.2
Declaration of Conflict of Interest
Approval of Agendas
2.1
Approval of Consent Agenda
2.2
Approval of Agenda
Person
Reporting
L. Ballantyne
V-A-3
L. Ballantyne
L. Ballantyne
V-B-6
V-B-6
X
X
X
*PMF Strategic
Direction
Linda Ballantyne, Board Chair
Information/
Education
CHAIR:
Oversight/
Monitoring
PLACE:
1147 Dundas St., Unit 5, Woodstock
Policy
Formulation/
Decision-making
TIME:
11:45 a.m.
Policy Reference/
Strategic Direction
DATE:
Wednesday, March 30, 2016
11:55
12:00
12:05
4.0
5.0
6.0
Provide for Excellent Management
3.1
CEO Monthly Report for February/March 2016
S. Coleman
Ensure Board Effectiveness
4.1
Report From Governance Committee
Ensure Financial Viability
5.1
Report From Audit Committee
5.2
Report From Finance Committee of the Whole
B. Hadley
II-3
X
*PMF Strategic
Direction
3.0
Information/
Education
11:50
Person
Reporting
Topic
Oversight/
Monitoring
Item
Policy
Formulation/
Decision-making
Time
-2Policy Reference/
Strategic Direction
Board Meeting Agenda – March 30, 2016
All
V-A-1
X
All
T. Cronsberry
C. Lanfranconi
IV-1
IV-2
X
X
3
3
P. Campbell
P. Campbell
III-2
III-1
X
X
1
1
S. Carswell
Senior Leaders
III-1
III-1
L. Ballantyne
By-law
5.04
Ensure Program Quality and Effectiveness
6.1
Report From Quality of Care Committee
6.2
Report From Accreditation Committee
12:15 – 12:45 p.m. - LUNCH BREAK
12:45
7.0
Ensure Program Quality and Effectiveness
7.1
Patient Quality of Care Story
7.2
Health Equity to Enable Access to Quality Care
• Generative Discussion
2:00
8-10
In Camera Session
3:00
11.0
Adjournment and Next Meeting:
May 25, 2016 – 11:00 am - 3:00 pm
1415 First Avenue West, Suite 3009, Owen Sound
X
X
* 1. Work with Partners to Provide Safe, High Quality Client-Driven Care ▪ 2. Be a Great Place to Work ▪ 3. Use Resources Wisely
1
1
CONSENT AGENDA
March 30, 2016
A Consent Agenda is a list of items and appropriate attachments that are non-controversial, most likely do not require any
discussion, but require ratification of the Board. Examples of items that may be in the consent agenda include the minutes of
the previous meeting, a meeting schedule, standard reports from committees or other groups, and updating information.
The consent agenda is sent to all Directors in advance of the meeting. All items on the consent agenda are listed and the
appropriate reports attached. The first item on the consent agenda is a motion to accept the consent agenda. Any Director
wishing to discuss an item on the consent agenda can ask to have the item moved from the consent agenda to the Board
meeting agenda. All other consent agenda items are approved without further discussion.
A vote on the motion to approve the consent agenda is made prior to receiving a motion to accept the regular Board meeting
agenda.
I. It is recommended that the Consent Agenda for the March 30, 2016 Board meeting, consisting of the following
reports, be approved:
A. Minutes of February 3/16 Board of Directors Meeting
B. Policy Review: Policy III-6: Respect for Divesity
Board of Directors Meeting
Minutes
DATE:
Wednesday, February 3, 2016
TIME:
11:20 a.m.
PLACE:
356 Oxford St. W., London
CHAIR:
Linda Ballantyne, Board Chair
RECORDER:
Cate Patchett, Corporate Liaison
MEMBERS:
Pat Campbell, Board Secretary
Sandra Coleman, Chief Executive Officer
Don Eby, Board Member
Brian Hadley, Board Vice Chair
Dr. Claude Lanfranconi, Board Treasurer
Mary Lapaine, Past Board Chair
Cynthia St. John, Board Member
GUESTS:
Hilary Anderson, Vice President, Corporate Services & CFO
Nancy Dool-Kontio, Vice President, Patient Engagement & Integration
Maureen Bedek, Vice President, Human Resources and Organizational Development
Andria Appeldoorn, Communications Lead
Steven Carswell, Director of Quality
Professors Sandra Regan and Lorie Donelle, UWO Researchers
REGRETS:
Tim Cronsberry, Board Member
Dr. Carol McWilliam, Board Member
Donna Ladouceur, Vice President, Patient Care
[Teleconference]
AGENDA ITEM
1.
Call to Order
1.1 Opening and Welcome
L. Ballantyne opened the meeting at 11:20 a.m. and welcomed everyone.
ACTION/DECISION
South West CCAC Board of Directors Meeting – February 3, 2016
AGENDA ITEM
Page 2
ACTION/DECISION
Declaration of Conflict of Interest
2.
According to Bylaw No. 3, Articles 6.10-16 and Policy V-A-3, based on today’s Meeting Agenda and
the information in the agenda package received by the Board, there were no conflicts of interest
declared.
Approval of Agendas
2.1 Approval of Consent Agenda
The Consent Agenda of the February 3/16 meeting was approved on MOTION by C. St. John and
SECONDED by B. Hadley.
2.2
Approval of Agenda
The Agenda of the February 3/16 meeting was approved on MOTION by M. Lapaine and SECONDED
by D. Eby.
3.
Ensure Program Quality and Effectiveness
3.1 eShift Presentation & Discussion
The Board received for information an update report on the eShift Model of Care which enables a
single clinician to remotely care for multiple patients in their own home. An RN is connected by
technology to unregulated providers (technicians) who are at the bedside of each patient
(population includes Palliative/End-of-Life, Complex Children, and Chronic patients).
The RN directs the technician to observe and report signs/symptoms using the technology. The
robust data enables the nurse to assess, monitor or direct interventions including medication. The
model was invented at the South West CCAC and subsequently launched in the US, UK and France
as well as at five other CCACs.
•
MOTION CARRIED
2015/16-77
Some noteworthy outcomes to date include:
• South West CCAC Palliative
• Reduced readmissions in last 30 days from 50% to 2%
• >4000 distinct patients supported
• 1,000,000 hours of care
• Designated a Leading Practice by Accreditation Canada, 2012
• Named to Minister’s Medal Honour Roll, 2015
MOTION CARRIED
2015/16-78
South West CCAC Board of Directors Meeting – February 3, 2016
AGENDA ITEM
Page 3
ACTION/DECISION
S. Coleman introduced Professors S. Regan and L. Donelle from the University of Western Ontario
who were in attendance to dialogue with the Board and present on their investigation of the eShift
Model of Palliative Home Care. The Model is viewed as a unique, innovative, and important
approach to palliative home care, a partnering approach among the South West CCAC, Service
Provider organizations – VON and Care Partners – and Sensory Technologies.
Professors Regan and Donelle provided the Board with a report on the Key Messages and Executive
Summary and presented on the highlights of the research findings from Year 1 of the three-year
study along with an outline of next steps for Years 2 and 3. Highlights included the following:
•
•
•
•
The eShift model supported the patient to die in their place of choice, whether that be their
home or hospice.
The respite care enabled by the eShift model supported the informal caregivers to maintain
their wellbeing in order to better manage the care of their loved one.
The innovative use of health human resources, a hallmark of the eShift model, has improved
access to palliative/respite care within the home setting.
The continuity of care and education provided by the directing registered nurse and the personal
support worker in the Technician role, supported informal caregivers to manage care and this
reduced unnecessary hospitalization, ambulance calls, and emergency room visits.
4.-5. In Camera Session
It was MOVED by B. Hadley and SECONDED by C. Lanfranconi that the Board move into an In
Camera session as per Policy V-B-7 to discuss matters related to litigation and personnel. The
open session resumed at 3:15 p.m.
6.
Establish Program Quality and Effectiveness
6.1 Patient Quality of Care Story
In its role to ensure quality care, the Board received an account from S. Carswell of a palliative
patient and their end of life experience that was not as the family expected. The Board discussed
how a culture of quality and patient safety within the CCAC can be led, supported and sustained
by the Board.
MOTION CARRIED
2015/16-79
South West CCAC Board of Directors Meeting – February 3, 2016
AGENDA ITEM
7.
Page 4
ACTION/DECISION
Provide for Excellent Management
7.1 CEO Monthly Report for January 2016
The Board received for information the Monthly CEO Report for January 2016 from S. Coleman
providing an update in each area of the Board’s Performance Measurement Framework Goal
Statements as well as an update on communications, LHIN and Board initiatives, and provincial
work. S. Coleman pointed out the highlights and elaborated on queries from Board Members. Also
provided for the Board’s information was the quarterly Adjunct Programs Report for the third
quarter period October 1/15 to December 31/15 updating the Board on the following initiatives:
8.
9.
• Partnering for Quality
• South West Self-Management Program
• Grey Bruce Falls Prevention
• Connecting South Western Ontario (cSWO)
• Health Links
• eHomecare
• thehealthline.ca
Ensure Financial Viability
8.1 Report From Finance Committee of the Whole
C. Lanfranconi reported from the Finance Committee of the Whole having received a report from
Senior Leaders advising of the Q3 results to December 31st, updating on new information and
trends relevant to the oversight of resources, and updating on year-end forecasts which continue
to predict a balanced budget within current funding. The Committee received the Enterprise Risk
Management report for Q3 where high risk areas were identified along with mitigation strategies.
Adjournment and Next Meeting
The meeting was adjourned at 3:20 p.m. on MOTION by B. Hadley and SECONDED by M. Lapaine.
Next regular meeting:
Wednesday, March 30, 2016, 11:00 a.m. – 3:00 p.m.
1147 Dundas Street, Unit 5, Woodstock
MOTION CARRIED
2015/16-83
CONFIRMED: ______________________________ CHAIR
GOVERNANCE
RESPONSIBILITY:
Ensure Program Quality and Effectiveness
SUBJECT:
RESPECT FOR DIVERSITY
NUMBER:
III-6
ISSUE DATE:
April 2009
Definition: Diversity is defined as including “race, ancestry, place of origin, colour, ethnic origin,
citizenship, creed, sex, sexual orientation, age, marital status, family status or handicap” 2.
The Community Care Access Centre recognizes the dignity and worth of every person and will
provide for equal rights and opportunities without discrimination.
The Community Care Access Centre, as represented by the Board of Directors, staff, and
volunteers value and respect the diversity of its patients, the community and each other. In
addition to abiding by all relevant legislation, the CCAC will:
 Promote a climate of understanding and mutual respect for the dignity and worth of every
person;
 Be courteous and tactful in all interactions;
 Respect the customs and beliefs of individuals consistent with the mission of the
Community Care Access Centre;
 Strive towards equity and fairness and will work with honesty, integrity, respect and good
faith;
 Promote harmonious relationships with health care partners and community stakeholders;
and
 Support the above through organizational policies and education.
No person affiliated with the CCAC will participate in acts of harassment or discrimination
towards any other person.
2
Ontario Human Rights Code Part I Section 1.
http://www.elaws.gov.on.ca/DBLaws/Statutes/English/90h19_e.htm#BK0
Board of Directors Policy Manual
Page 45
Agenda Item: 3.1
CEO Monthly Report
February/March, 2016
1. Work with Partners to provide safe, high quality, Client Driven Care
1.1 Patient centered experience
-the Patient Experience team continues to interview patients, caregivers, physicians, staff and others to drive forward the Board approved strategy. Recruitment of
Patient Advisors to begin soon, with onboarding expected in May/June.
1.2 Safe, high quality care
-QIP developed for Board to consider for approval, with submission March 31st. PMF and Quality Plan under development, for Board approval through May and
June 2016.
-protocols in place to support physician assisted death.
-Patient Care and Finance teams working closely to support updated OBRA/best practice benchmarks to ensure quality and sustainability heading into the new
fiscal year.
1.3 Access to community based care at the right time
-CCAC/CSSA collaborative work to streamline processes and ensure CCAC supporting high/moderate needs patients, with CSS supporting low needs patients.
1.4 Partnerships result in integrated solutions
-all contracts with our providers being extended for one year on current rates
-Donna is coleading an initiative with LHSC and others for care and shelter supports for homeless people in London. We now have a dedicated Care Coodinator
supporting the three London homeless shelters and a designed expert within our Care Coordination team at LHSC.
-the Oxford and Elgin palliative outreach team is now up and running with daily huddles, education and training for partners, and a much more integrated approach
to supporting palliative patients with team based care.
2. Great Place to Work
2.1 Engaged Employees
-management team and QILT meetings to engage with staff on our input into Patients First, the work of the Recruitment and Retention Task team, as well as other
quality improvement initiatives.
-working with ONA and CUPE on pay equity maintenance.
-staff led Wellness initiative relaunched, doing very positive work.
-revised scheduling processes to automate and lean, freeing up manager time for staff and patients, more improvements to come.
2.2 Healthy and Safe Workplace
-workplace safety survey sent to staff, results will be part of the PMF report to the Board in June.
-revising policies and procedures to support Employee Attendance.
-launched Halogen in March, which is a software program to support the performance evaluation process.
3. Use Resources Wisely
3.1 Value for Money
-15/16 budget – continue to forecast balanced budget. Year end audit process has begun.
-16/17 budget – forecasting a deficit assuming no new funding, see report from Finance Committee on operational assumptions and recommendations for April 1,
2016.
-moved to provincial Vendor of Record for cell phones and cellular, with significant savings.
3.2 Increasing Productivity through innovation and technology
-eforms –Hilary’s team has now launched a suite of electronic forms that enable staff to now populate information once in forms or CHRIS and then ensure
automatic population where necessary, including in the patient chart, to eliminate double entry resulting in substantial efficiencies. This was requested by our QILT
teams last fall and now the forms are rolling out. Ultimately more than 80 of these “forms” will be automated. Other CCACs are wanting to duplicate this work.
4 Communication/Awareness
-South West CCAC response to Patients First submitted to government, South West LHIN, and shared with partners and staff.
-Staff Blog and tweeting continues.
5 LHIN Initiatives
-Feb 5th LHIN/Hospital/CCAC Leadership forum
-Feb 24th and March 23rd Health System Leadership Council meeting
-Health Links team transitioning to HPHA to support LHIN’s work on Patients First transition.
6
Board Initiatives
-Feb 10th and 17th Executive Committee meetings – with process on CEO evaluation for spring 2016.
-Feb 10th Audit Committee meeting – launching 15/16 audit, report due to Board at your June Board meeting.
-Feb 17th and March 9th Quality Committee meetings – to develop QIP, as well as consider MSAA, coming to Board at March meeting for approvals.
-Mar 8th Governance Committee meeting – recommendations on work plan changes and priorities for the Board.
-Mar 23rd Accreditation Committee meeting – recommending extension for site visit given upcoming transformation.
7 Provincial Work
-Roadmap Implementation and Advisory Committee meetings – several meetings to engage on Self Directed Funding, Levels of Care and Contract rate
harmonization.
-Feb 23 and Mar 22nd CCAC CEO meetings, as well as weekly teleconferences.
-Nancy continues provincial meetings regarding hospital ehealth/information systems.
-Donna attended a two day workshop launching the Ontario Palliative Care Network
Agenda Item: 4.1
REPORT TO BOARD OF DIRECTORS
Governance Committee Report
March 30, 2016
Submitted By: B. Hadley
The Governance Committee met on March 8th and conducted the following business:
RECOMMENDATION
•
2016/17 Annual Committee Work Plan
It is recommended that the Board approve the Governance Committee’s annual 2016/17 Work Plan noting it is a work
in progress and some adaptation in topics and timing may be necessary from time to time as issues arise.
Given the transition period will not be business as usual, the Committee is recommending not pursuing some activities, as
highlighted in yellow in the attached chart below. The Committee’s work will focus on mission critical work ensuring the
continuity of patient care.
Of the deliverables for 3.0 Evaluation, Board Meeting Effectiveness surveys will be conducted going forward. Of the deliverables
under 5.0 Succession Planning, the Committee is putting forth for the Board’s consideration that post the June 29th Annual
Meeting, the current Board Officers and Committee Membership continue, pending Members are willing to continue on with
their term.
From previous discussions at Committee and Board meetings whereby it was determined that the Committee’s responsibilities
for 4.0 Recruitment and Nomination will not proceed, these items have also been highlighted in yellow to be removed from the
Work Plan.
•
2016 Board Goals for Itself
In view of the Minister’s Patients First proposal, it is recommended that the Board goal be as follows:
The Board is committed to supporting staff and the organization during the transition period and
striving to continue to focus on patients with no disruption to home care services, and the
Board’s responsibility to provide strategic leadership and direction to the CCAC having
regard for its accountabilities to the LHIN, to the Ministry, and to its patients and the
communities served.
At the June 24/15 meeting, the Board approved three goals for itself for the year of which were assigned to the Governance
Committee to implement and lead the action plan as described below.
Governance Opportunity for
Excellence Objective
‘Booster shot’ back to Generative
Governance basics
Enhance the Board’s education plan
Implement Accreditation Action Plan
from Governance Functioning Survey
Action Plan
Consider variety of techniques from
Dr. Cathy Trower’s ‘The Practitioner’s
Guide to Governance as Leadership –
Building High-Performing Nonprofit
Boards’
Consider the option to include
governance certification and other
details to be determined, including a
partnering approach with other health
care Boards.
Timing
Who Leads
Progress
Fall
Governance
Committee
Ongoing
Fall/Spring
Governance
Committee
Fall
Governance
Committee
TBD
FOR INFORMATION
Evaluation Processes
The Committee reviewed results of the December 9/15 and the February 3/16 Board meeting effectiveness surveys noting no
concerns and will ensure comments and suggestions from Board Members are taken into consideration in future planning.
Governance Committee Members:
Brian Hadley, Chair
Tim Cronsberry
Cynthia St. John
Sandra Coleman
Linda Ballantyne
Assisted by Cate Patchett
Agenda Item: 5.1
REPORT TO BOARD OF DIRECTORS
Audit Committee Report
March 30, 2016
Submitted By: T. Cronsberry
The Audit Committee met on February 10th and conducted the following business for the Board’s endorsement:
RECOMMENDATION
It is recommended the Board endorse the 2015/16 Audit Service Plan as presented to the Audit Committee by
Chris Dowding of Deloitte and accepted by the Audit Committee.
The following key elements were included in the presentation:
•
•
•
•
•
•
Audit Scope and Terms of Engagement
Fraud risk
Complete engagement reporting
Significant Audit Risks - Dashboard
Communication Requirements under Canadian Generally Accepted Auditing Standards (GAAS)
Audit fees
It is anticipated the draft 2015/16 Audited Financial Statements will be presented to the Committee on June 22nd in
preparation for recommending Board approval at the June 29/16 Board meeting followed by acceptance by the Members at the
Annual Meeting also on June 29/16.
2015/16 Supplemental Audit
It is recommended that the Board endorse the focus of the 2015/16 Supplemental Audit be on financial controls
incorporating three complex internal processes for a fee of up to $10K, subject to availability of funds.
Over the past few years the Board has engaged the Auditors to complete a supplemental audit with the purpose to provide
additional assurance, above and beyond the assurance provided by the financial audit, in areas considered to be qualitatively
high risk.
Audit Committee Members:
Tim Cronsberry, Chair
Brian Hadley
Linda Ballantyne
Assisted by Sandra Coleman, Hilary Halliday, Cathy Burgoyne
Agenda Item: 5.2
REPORT TO BOARD OF DIRECTORS
Report From Finance Committee of the Whole
March 30/16
Submitted By: C. Lanfranconi
RECOMMENDATION
It is recommended that the South West CCAC operationalize April 1, 2016 for the new fiscal 16/17 year
assuming a 0% increase in funding for fiscal 16/17 and implement a cost containment strategy as
presented in order to pursue a balanced budget by March 31, 2017.
Implementation to be carried out in phases by the Senior Team as they learn about funding for this fiscal and
monitor results. We will keep the Board apprised as needed and all to be revisited with the Board in June, and upon
any new material information.
Agenda Item: 6.1
REPORT TO BOARD OF DIRECTORS
Report from Quality of Care Committee
March 30/16
Submitted By: P. Campbell
The Quality of Care Committee met on February 17th and March 9th and conducted the following business:
RECOMMENDATIONS
2016/17 Quality Improvement Plan Targets, Narrative and Measures
It is recommended that the Board approve the 2016/17 Quality Improvement Plan (QIP) Narrative and Measures
and Targets for South West CCAC as presented for submission to Health Quality Ontario (HQO) and the LHIN, and
for posting publicly on our website by March 31st.
The following information is provided to the Board on the South West CCAC’s 2016-17 Quality Improvement Plan (QIP),
attached below in two parts:
1. 2016-17
o
2. 2016-17
o
Quality Improvement Plan “Narrative”
An overview of performance on last year’s QIP and forward to next year’s QIP
Quality Improvement Plan “Work Plan”
Detailed information on the measures and specific actions that the organization will take to improve in each area.
Members discussed and agreed to the measures for the South West CCAC’s 2016-17 QIP. A decision was made for the following
measures to be included:
Measure
Description
Falls for Long Stay Clients (Safety)
Percentage of Adult, Long-Stay home care patients who record a fall on their follow-up RAI-HC assessment.
Avoidable ED Visits (Effectiveness)
Avoidable emergency department visits by CCAC patients
Avoidable Hospital Readmissions (Effectiveness)
Avoidable hospitalizations and readmissions of CCAC patients
Five Day Wait Time – Nursing Services (Access)
Percentage of patients requiring nursing services that are seen within 5 days of service authorization.
Five Day Wait Time – Complex PSW (Access)
Percentage of complex patients requiring PSW services that are seen within 5 days of service authorization.
Client Experience (Patient Centred)
Percentage of home care clients who responded positively on their rating of overall service
Dying in Place of Choice (Patient Centred) (new)
Percentage of patients dying in their preferred place of death.
After establishing the measures to be included on the QIP, the Quality of Care committee approved appropriate targets for
each of the measures. Appendix A (attached) provides the Board with an overview of the organization’s most recent
performance, the current target, the revised target (if applicable), and a rationale for the change in target (if applicable).
2016 Accreditation Survey Deferral
It is recommended that the Board approve that the South West CCAC formally submit an application to
Accreditation Canada to postpone the October 2016 on-site Accreditation survey for a period of eighteen months.
2016/17 Annual MSAA Performance Targets & Measures
In accordance with Policy IV-3, it is recommended that the Board approve the indicators for the Multi-Sector
Service Accountability Agreement with the South West LHIN for the term 2016-17 for signing by the Board Chair
and CEO to be submitted to the LHIN after the March 30th Board Meeting.
The Local Health System Integration Act, 2006 requires that the LHIN and Health Service Providers (HSP) enter into a service
accountability agreement. There are three main parts to the MSAA:
1) the contractual provisions re accountability;
2) the budget called the Community Accountability Planning Submission or (CAPS); and,
3) the performance indicators with targets.
Our current MSAA is in place for 2014 to 2017. The main part of the MSAA, the contractual accountability provisions, remain
the same, and each year we update the 2nd and 3rd parts, the CAPS and Performance Indicators. The second part, the CAPS
portion of this agreement was approved at our December 9/15 meeting and was submitted to the LHIN in January 2016. The
third part, Performance Indicators are provided in the table below.
It should be noted that at the time of the Committee meeting, the confirmed schedules had not been received from the LHIN.
However, they were subsequently received and reviewed by staff and are exactly as discussed verbally with the LHIN and in
turn with the Committee.
The agreement supports a collaborative relationship between the LHIN and the HSP to improve the health of Ontarians through
better access to high quality services, to coordinate health care in local health systems and to manage the health system at
the local level effectively and efficiently.
Performance Indicators
N/A
2016-2017
Performance
Target
Standard
$0
>=0
6.3-9.4
N/A
8.40%
<=10.1%
0.00%
>=0%
N/A
0.00%
>=0%
9.46%
<10.41%
9.46%
<10.41%
Target
1 Balanced Budget - Fund Type 2
2 Proportion of Budget spent on Administration
$0
7.90%
3 Percentage Total Margin
4 Percentage of Alternate Level of Care (ALC) Days (closed cases)
0
5 Variance Forecast to Actual Expenditures
0
6 Variance Forecast to Actual Units of Service
Access: Wait time from Hospital Discharge to Service Initiation (Hospital
New
7 Clients) (50th percentile)
N/A
Access: Wait time from Hospital Discharge to Service Initiation (Hospital
6.44 days
8 Clients) (90th percentile)
Access: Wait time Home Care Services - Application to First Service (50th
N/A
New
9 percentile)
Access: Wait time Home Care Services - Application to First Service (90th
10 percentile)
2015-2016
Performance
Standard
>=0
Q1
8.1%
Actuals
N/A
N/A
<5%
N/A
0
<5%
<5%
N/A
0
<5%
N/A
<=7.08 days
N/A
Q1
1 days
Q1
6 days
Q1
5 days
N/A
N/A
1 day
1 day
N/A
N/A
6 days
<=7 days
N/A
N/A
5 days
<=6 days
Q1
20 days
N/A
N/A
21 days
<=22 days
Q1
92%
Q1
8.15%
Q1
13.09%
Q2
92%
Q2
9.7%
Q2
14.1%
Q3
93%
90%
>=85%
N/A
N/A
N/A
N/A
N/A
N/A
24 days
<=26.4 days
90%
>=81%
8.41%
<=9.25%
11.43%
<=12.58%
N/A
N/A
N/A
N/A
N/A
12.70%
<=14%
5 day wait time - Nursing visits (does not take into account patient
New
15 choice)
N/A
N/A
Q1
93.0%
Q2
93.8%
Q3
92.7%
95%
TBD
5 day wait time - Personal Support Complex patients (does not take into
New
16 account patient choice)
N/A
N/A
Q1
87.9%
Q2
92.5%
Q3
87.6%
95%
TBD
N/A
N/A
Q1
53%
Q2
59%
Q3
57%
68%
>=63%
N/A
N/A
Q1
81%
Q2
80%
Q3
81%
82%
>=77%
11 ADP Occupancy Rate
12 ALC Acute Rate
13 ALC Post Acute Rate
14 ALC Rate
New
17 % of eligible patients in complex continuing care beds
18 % of eligible patients in rehabilitation beds
New
New
2016/17 Committee Work Plan
It is recommended that the Board approve the Quality of Care Committee’s annual 2016/17 Work Plan noting it is a
work in progress and some adaptation in topics and timing may be necessary from time to time as issues arise.
FOR INFORMATION
Performance Reporting for South West CCAC
•
2015/16 Q3 Performance Measurement Framework Results
The Committee received the available results for 2015/16 third quarter noting targets are being met on all quarterly indicators
(Goals 1.2, 1.3 and 3.2) except for Goal 1.1 which is a lagging indicator close to target for Q2 as shown below:
Goal Statement
1.1
We ensure a Patient
Centered experience.
1.2
We ensure Safe, high
quality care.
1.3
We ensure Access to the
right community-based
care at the right time.
3.2
We are increasing
productivity through
innovation & technology.
Performance Indicator(s)
Patient/Caregiver overall
rating of South West CCAC
services (KPI 1)
Percentage and Number of
Adverse Events
Percentage of Adult Day
Program occupancy
Percentage of Purchased
Services budget spent on
Chronic/Complex patients
(in home)
Q3 Result
Target
93.1%*
>94%
.77%/34
≤1.0%/29
93%
90%
72.04%
>70%
*Q2 - Lagging indicator as data reliant on external source
•
2015/16 Q3 Quality Plan Results
The Committee received the available indicator results for the third quarter Quality Plan and the Fact Sheets related to
indicators where the target is not being met. Members were satisfied with the progress being made, what is being done to
improve each indicator, and the variance explanations, noting there are no concerning trends to alert the Board to.
•
2015/16 Enterprise Risk Management Results
Further to presentation at the February 3rd Finance Committee of the Whole meeting, the results for the third quarter Enterprise
Risk Management Report were received for information and further discussion. Staff will report more often if necessary in the
upcoming year. The Committee was in agreement to include additional risk indicators pertaining to Staffing and to Patient
Flow.
•
2016/17 PMF/QP Performance Planning
Having received a Briefing Note from Senior Leaders, the Committee agreed that the planning approach for the 2016/17
PMF/Quality Plan utilize the existing measures from 2015/16 for 2016/17. The Committee will be establishing recommended
targets for the PMF/Quality Plan. The Senior Leader team is in the process of reviewing the historical performance trends and
action plans for the upcoming year and will provide recommended targets for 2016/17 for the Committee’s consideration at
its next meeting on May 4th to put forward for Board approval on May 25th.
•
Patient/Family Engagement – Update on Action Plan
The Committee received an update on the Action Plan of the multi-year Patient/Family Engagement Plan whereby the proposed
Patient Advisor role and Patient Advisor selection and recruitment strategy were presented along with timelines and work plan.
The Committee provided feedback on the material prepared by staff - Recruitment and Selection of Patient Advisors and the
Patient Advisor Handbook - and determined it would support the organization going forward with next steps to recruit and
select Patient Advisors in phases scaled to a defined number of individuals with a purpose targeted.
•
Patient Satisfaction – Value and Results of the Client/Caregiver Experience Evaluation (CCEE)
The Committee received an update on Patient Satisfaction: Value and Results of the CCEE with information on background for
survey inclusion/exclusion criteria, value of survey, selected results, and future of the survey.
The 2016/17 Action Plan will include:
o
o
o
o
Provide Patient Care with team specific information to drive specific improvements
Focus on improving “% Excellent” and “% Very Good”
Further utilize information during Service Provider Performance Reviews
Integrate CCEE measures into project/program evaluations
South West LHIN Q2 Report on Performance Scorecard – South West CCAC’s Contributions
The Committee reviewed the South West LHIN Q2 Report on Performance Scorecard which shows the system progress against
three outcomes, twelve metrics, and four key drivers and were satisfied that the South West CCAC’s strategic plan and
performance measurements within the Performance Measurement Framework and Quality Plan align and support those of the
LHIN.
The key performance contributions made by the South West CCAC were highlighted and it was noted that in provincial
comparisons overall, the South West is performing well. The South West will continue to support and collaborate on projects
aimed at improving the performance of the South West LHIN. Further collaboration opportunities are commencing including
participation on the Health Links Learning Collaborative, the Regional Stroke Phase 2 Community Stroke Rehab Project Team,
amongst many others.
South West LHIN Quality Symposium
The Committee received information on the annual South West LHIN Quality Symposium to be held on Thursday, June 2nd at
the Stratford Rotary Complex. Further discussion to occur with the full Board. (See agenda below.)
HQO Report – Impressions and Observations (2015/16 QIPs) [Click here to view Report]
The Committee received for information the Health Quality Ontario report on CCACs – Impressions and Observations 2015/16
Quality Improvement Plans largely concentrating on the lessons CCACs learned over the past year and demonstrating CCACs’
commitment to continuous improvement and large-scale system change. The South West CCAC was ‘spotlighted’ for its ‘always
events’ on the Patient Experience indicator where specific aspects of care that are essential are performed consistently for
every patient, every time.
Quality of Care Committee Members:
Pat Campbell, Chair
Carol McWilliam
Mary Lapaine
Don Eby
Claude Lanfranconi
Linda Ballantyne
Sandra Coleman
Assisted by: Steven Carswell, Hilary Halliday, Donna Ladouceur, Nancy Dool-Kontio, Shirley Koch, Cate Patchett
Quality Improvement Plan (QIP)
Narrative for Health Care Organizations in
Ontario
3/31/2016
This document is intended to provide health care organizations in Ontario with guidance as to how they can develop a Quality Improvement
Plan. While much effort and care has gone into preparing this document, this document should not be relied on as legal advice and organizations
should consult with their legal, governance and other relevant advisors as appropriate in preparing their quality improvement plans. Furthermore,
organizations are free to design their own public quality improvement plans using alternative formats and contents, provided that they submit a
version of their quality improvement plan to Health Quality Ontario (if required) in the format described herein.
1
Click here to enter text.Overview
The South West Community Care Access Centre (CCAC) is committed to our vision of 'outstanding care - every
person, every day'. Through our culture of Client Driven Care and a commitment to continuous quality improvement,
we seek to achieve our mission: "To deliver a seamless experience through the health system for people in our
diverse communities, providing equitable access, individualized care coordination and quality health care."
In 2016-17 the South West CCAC will be further advancing our quality improvement priorities, with a focus on the
following areas:
- reducing falls;
- reducing unplanned visits to the emergency department;
- reducing unnecessary hospital admissions;
- improving access to care (5 Day wait times);
- improving the experience of care for patients and their families; and
- improving the number of patients that die in their preferred place of death.
The areas highlighted in this Quality Improvement Plan are aligned with our broader internal and external
accountability structures, including our:
-
Strategic Direction (including “Work with Partners to provide safe, high quality client driven care”; be a
"Great place to work" and to “Use resources wisely”) ;
The South West Local Health Integration Network's Integrated Services Plan (2016-19);
The South West CCAC's annual operating plan ; and
Our Multi-Sector Service Accountability Agreement (M-SAA).
QI Achievements from the Past Year
The South West CCAC, through its Quality Improvement Plan, has had many successful projects and initiatives
implemented over the last year. Our goal of continuous improvement has allowed us and our partners to deliver
significant and meaningful improvements to patients and to the healthcare system. Some of the highlights include:
Falls Prevention:
A Falls Prevention working group was established in 2015-16 with representation from community teams across
the South West. Falls prevention training was delivered to all Care Coordinators in 2015-16. Learning objectives
included:
•
Defining the nature and scope of falling
•
Identify causes and risk factors for falls
•
How to educate patients, caregivers and families
•
Where to access resources
Falls prevention will continue to be a focus for Care Coordinators as they do assessments and reassessments to
identify at risk patients and provide resources to mitigate risks.
Reducing Emergency Department and Hospital Readmissions/Visits:
The successful implementation of the Intensive Hospital to Home program by the CCAC has contributed greatly to
the successful reduction of Alternate Level of Care (ALC) rates across the region. A refresh of the Home First
approach was completed in 2015-16 for all Hospital Care Coordinators and Hospital staff. Other contributing factors
include our Access to Care program, which has positioned CCAC Care Coordinators to support assessment and
coordinated access for Rehabilitation, Transitional Care, Restorative Care, and Complex Continuing Care beds in
hospitals as well as Adult Day Programs, supportive housing and assisted living.
2
Another key strategy has been the leadership role that the South West CCAC plays in the various Health Links
within the region. Integration with primary care in combination with Rapid Response Nurses creates a critical linkage
to improve continuity during hospital transitions and prevent unnecessary emergency department visits.
Our promotion and use of technology is another key enabler. Innovations such as e-notification have been initiated
with our hospital partners and is having a positive impact on the avoidable emergency department visits and hospital
admissions. The CCAC has also partnered with a key regional hospital on a Post-Acute project focused on reducing
length of hospital stay and readmission for those with Chronic Obstructive Pulmonary Disease (COPD).
A Telehomecare program was implemented in 2015-16 with a focus on patients with COPD. This initiative is a key
support for patients to be supported at home often negating a visit to the emergency room visit.
5 Day Wait Times:
For 2014-15 the South West CCAC worked collaboratively with our contracted Service Provider partners to develop
and implement a Service Initiation Tool (SIT) to improve the prioritization of a patient's first visit for care. Utilization
of the tool has improved our internal and external communications and allowed for more appropriate service
prioritization.
Additional work is needed at a provincial level to ensure the measure reflects patient choice and to understand the
root causes (and remedies) when care is not delivered within timeline parameters.
In 2015-16, additional work was completed which should lead to additional improvements. A LEAN Kaizen event
for our service initiation processes was conducted. In collaboration with our Service Providers and Patient Care
staff, many significant process improvements were found that should improve performance.
Patient Experience:
Patients receiving care from the South West CCAC and our contracted Service Providers have consistently reported
a very high level of satisfaction with their care experience. As the South West CCAC continues to advance quality
improvement initiatives, we will continue to look for opportunities to improve the patient experience. This year, the
organization continues with its Patient Experience Strategy, with a goal of recruiting and utilizing a team of Patient
Advisors which should help to support the identification and success of our improvement activities. As patients
share their experiences we continue to incorporate these learnings into “always events”.
In addition, with generally high organizational level performance on this measure, our focus shifts to working closely
with our individual patient care teams on improvement activities related to patient experience.
Palliative Preferred Place of Death:
In 2016-17, we will integrate a measure on palliative patient’s dying in their preferred place of choice. In the past
year, the South West CCAC has had many successes in this area, including launching a second palliative care
outreach team for the Oxford and Elgin area. This team will enable more patients to die in their place of choice. We
have also developed 24/7 centralized phone numbers for patients to access palliative care physicians in
London/Middlesex, Oxford, Elgin and Grey Bruce with intent to minimize unplanned hospital visits.
In addition, we have developed Coordinated Access for the Parkwood Palliative Care Unit and Hospice beds and
maintain a centralized wait list for all palliative bedded supports in London. This is supported by daily bed huddles
to prioritize and triage all patients requiring bedded supports.
Integration and Continuity of Care
The South West CCAC believes that integration and continuity of care are essential, and are required in order for
us to meet our commitment to the people in our region. Our Strategic Direction to “Work with Partners to provide
3
safe, high quality client driven care”, supported by the Excellent Care for All Act, has consistently provided us with
a strong foundation for our improvement efforts.
We have a strong history of working collaboratively with our health system partners and have seen those
relationships as a critical success factor in improving outcomes and patient experience. We will continue to build
on these existing relationships and hope to create new relationships to further enhance our performance.
Engagement of Leadership, Clinicians and Staff
The creation, implementation and the success of the South West CCAC's Quality Improvement Plan requires
dedication, commitment and effort from all facets of our organization (both clinical and non-clinical). The direction
and planning for our annual Quality Improvement Plan is the responsibility of Board Quality of Care Committee and
our Senior Leadership Team.
In addition to the above, a broad engagement strategy was required to develop the QIP that reflects the input and
priorities of the entire organization. This engagement involved many exercises, including consultation with:
-
Quality Improvement Leadership Team: Our internal staff quality committee is responsible for improving
the quality of care provided by the organization and improving internal CCAC processes (in alignment with
our strategic plan).
-
Inter-Agency Leadership Team: A committee comprised of leaders from of our contract Service Providers
and Vendors, tasked with co-creating solutions to improve the quality and consistency of care and to
promote innovation.
-
South West CCAC's Management Team: The leaders across the organization with accountabilities for
Patient Care, Patient Engagement and Integration and Corporate Services (HR/OD, Finance, Information
Technology etc.)
-
Patient Care Management Team: The front line leaders of our clinical teams provided expertise on
process, barriers and opportunities.
In addition to consultation, our quality and safety objectives will be cascaded through our team’s annual work plans
and our leaders’ performance objectives. This will ensure alignment of our efforts and that QIP objectives are clear.
Client, Patient, Resident Engagement
The South West CCAC has many methods in which we engage with our patients on a daily basis. From our Parent
Advisory Council to our Client & Caregiver Experience and Evaluation survey, our quality journey is informed by the
wishes and needs of our patients.
Moving forward, through our multi-year Patient Engagement Strategy, we will have further opportunities to engage
directly with patients, including Patient Advisors, Mentors and an Advisory Council in the development of our Quality
Improvement Plan.
4
Other
The organization has a consistent and established track record of quality improvement, but certain challenges and
risks are present. Through the "Patients First: A Proposal to Strengthen Patient-Centred Health Care in Ontario",
Ontario's health care system is undergoing a significant transformation. During this transformation, the South West
CCAC will remain committed to quality improvement but we recognize that emerging priorities may impact our ability
to complete our entire improvement plan.
In addition, all of the indicators on our QIP are dependent on the collaborative work with our health system partners
which can also be impacted by unknown and emerging issues and trends. For all of our quality improvement work,
there are clear accountabilities and project measures that are utilized to proactively understand any challenges that
may impact our ability to achieve our targets.
The South West CCAC is also dependent on the work of our contracted service providers. With the increasing
demands for CCAC-funded services for more and more complex patients, we will need to continue to work closely
with our contract service providers to ensure that the 'right care is delivered to the right patient at the right time'.
To best manage our QIP, a most responsible person (MRP) will be assigned to each QIP indicator. These individuals
will be accountable for ensuring that the improvement initiatives and change ideas are implemented and that any
barriers to implementation are addressed. The Quality team will provide oversight for the QIP and will work with the
MRPs and those who are leading the initiatives to facilitate the improvements.
Sign-off
I have reviewed and approved our organization’s Quality Improvement Plan:
Linda Ballantyne
Chair , Board of Directors
Pat Campbell
Chair , Board Quality of Care Committee
Sandra Coleman
Chief Executive Officer
5
South West CCAC Quality Improvement Plan
2016-17 Work Plan
AIM
Quality dimension
Measure
Objective
To reduce avoidable hospital
admissions among home care
patients
Measure/Indicator
Percentage of home care clients
who experienced an unplanned
readmission to hospital within 30
days of discharge from hospital
Unit /
Population
% / Home Care
Clients
Change
Current
performance
16.7
Target
16.5
Effective
To reduce the number of
unplanned ED visits among home
care patients
Patient Centred
To improve patient experience
Percentage of home care clients
with an unplanned, less-urgent ED
visit within the first 30 days of
discharge from hospital.
Percent of home care clients who
responded "Good", "Very Good",
or "Excellent" on a five-point scale
to any of the client experience
survey questions: i) Overall rating
of CCAC services ii) Overall rating
of management/handling of care
by Care Coordinator iii) Overall
rating of service provided by
service provider
Improve % of End of Life and
Palliative patients who passed
away in their preferred place of
death
% / Home Care
Clients
% / Home Care
Clients
% / Palliative
patients
9.2
93.1
9.0
94.0
Collecting Baseline Collecting Baseline
(Provincial)
(Provincial)
Planned improvement Initiatives
Methods
Process measures
Goal for change ideas
To improve the awareness of the Home First program amongst our
hospital partners to ensure patients are receiving the appropriate
care
1)Home First Refresher
Additional training for hospital staff on the value and process
of the Home First Program
# of hospital staff trained
2)Continued utilization of the Rapid
Response Nurses
Ensure RR Nurses are deployed to patients post-discharge.
% of RRN patients seen within 24 hours of hospital Utilize RRNs to support patients living at home and to avoid
discharge
unneccesary ED visits and re-admissions.
1)Increase utilization of the
Coordinated Care Plans (CCPs) for
high needs patients (Health Links)
Ensure appropriate patients have a CCP conducted.
# of Coordinated Care Plans in each Health Links
To ensure high needs patients have an individualize and coordinated
plan; have care providers who ensure the plan is being followed ;
have support for medication management with a goal of reduced ED
visits and hospital admissions.
2)Develop and enhance Care
Coordinator skills and expertise
required to lead Coordinated Care
Planning activities
Training and education resources for staff to developed skills
and engagement in leading CCPs.
# of staff members educated
Ensure Care Coordinators have skills necessary to lead Coordinated
Care Plans with system partners. Support spreading of knowledge
and best practice among care coordinators.
1)Patient Engagement Strategy
The second year of our four year strategy will ensure the
patient voice is a central part of our organization's planning.
# of Patient Advisors Recruited
Year 2 is focused on recruiting and utilizing Patient Advisors in # of connections with Patient Advisors
select areas of the organization.
Patient Advisors should support the South West CCAC's Client
Centred Care approach and allow the organization to better plan,
execute and improve care delivery.
2)CCEE Results Sharing
Share team results with individual clinical teams and
managers.
# of teams that have received results and created
an action plan
Promote awareness of the survey tool, questions and areas for
individual team improvement
3)Promote the use of Always Events
Integrate language on key forms and in key process
documents.
TBD
Promote the use of always events to increase patient experience,
engagement and satisfaction.
4)Review qualitative CCEE comments Develop sustainable method of reviewing and responding to
to identify areas for improvement
patient comments from the CCEE servey.
N/A
Trend, collate and share results with clinical and management teams
so that they may better understand the patient experience (both
positive and negative).
Refine and roll-out revised processes for patients to provide
5)Improve Patient Relations processes feedback and for staff to manage patient complaints and risk
events.
TBD
To improve the ability of patients to provide their feedback to the
CCAC, and develop standardized, efficient and timely responses.
Under Development
TBD
TBD
TBD
South West CCAC Quality Improvement Plan
2016-17 Work Plan
AIM
Quality dimension
Safe
Measure
Objective
To reduce falls among long-stay
home care patients
Measure/Indicator
Percentage of adult long-stay
home care clients that have a fall
on their follow-up RAI-HC
Assessment
5 Day Wait Time - Nursing Visits: %
of patients who received their first
nursing visit within 5 days of the
service authorization date.
Timely
To reduce service wait times
5 Day Wait Time - Personal
Support for Complex Patients: % of
complex patients who received
their first personal support service
within 5 days of the service
authorization date.
Unit /
Population
% / Adult long
stay home care
clients
% / Home Care
Clients
% / Home Care
Clients
Change
Current
performance
36.9
93.1
90.0
Target
34.0
95.0
95.0
Planned improvement Initiatives
Methods
Process measures
Goal for change ideas
Further develop formal and sustainable linkages with the
1)Continue to implement, spread and SWLHIN Falls Prevention Strategy Network; Promote Falls
sustain activities from the South West Prevention during Falls Prevention Month (November);
CCAC's Falls Prevention Strategy.
Develop education plans for Care Coordinators and Service
Provider Organizations
TBD
The goal of the project is to further integrate the South West Local
Health Integration Network (SWLHIN) Falls Prevention Strategy into
operations at the SW CCAC and to collaborate with our system
partners to ensure falls prevention information and interventions are
readily accessible to SW CCAC patients.
2)Focus on population based
approaches to falls prevention.
Utilize a Falls Risk Screener for Long-Stay patients; Develop
and utilize performance measures that drill down into local
and population based results.
TBD
Ensure falls prevention tools and resources align with our population
based model (in both intensity and design).
3)Continue to focus and understand
the correlation between patient
acuity/complexity and falls risk.
Utilize data and information to further understand falls risks
% of patients who experience a fall, stratified by
Population/Risk Level
Adding new prioritization levels for improved triaging of
Performance of each of our Contract Service
1)Implement recommendations from
urgent orders; Improved communication processes related to Providers Performance of each of our internal
the Kaizen Event
"Patient Availability Date"
CCAC nursing providers.
Promote and manage performance of all of our PSS providers to
ensure organizations are consistently meeting the target.
2)Reduce errors in service offers
process through education for Care
Coordinators
Ensure service offers are delivered in a timely manner without errors
in order to avoid delays that could impact 5 day wait time.
Education and training for our care coordinators
TBD
Adding new prioritization levels for improved triaging of
Performance of each of our contracted service
1)Implement recommendations from
urgent orders; Improved communication processes related to
providers
the LEAN Kaizen Event
"Patient Availability Date"
Promote and manage performance of all of our PSS providers to
ensure organizations are consistently meeting the target.
2)Introduce Service Provider
Performance New Indicator 5 Day
Wait Time Indicator
Ensure all Service Providers are aware of their current performance
related to 5-day wait time and to ensure CCAC has a contractual
target and process to ensure performance.
5 Day Wait for Nursing and Personals Support for Complex
patient will be introduced as one of the new contract
performance indicators for 2016/17 .
Performance of each individual Service Provider
Appendix A – QIP Indicators and Targets
Measure
Falls for Long Stay Clients
(Safety)
Last Available
Performance
Revised
2016-17
36.9 %
34%
34%
Maintain stretch target despite
increasingly complexity of patients.
9.2%*
9.0%
9.0%
Target adequately reflects objectives.
16.7%*
18.2%
16.5%
Sustained quarter over quarter results
below previous target.
92.7 %
95%
95%
Target adequately reflects objectives and
aligns to MSAA.
87.6 %
95%
95%
Target adequately reflects objectives and
aligns to MSAA.
93.1 %
94%
94%
Target adequately reflects objectives.
91%
N/A
Q3 2014-15:
Avoidable Hospital Readmissions
(Effectiveness)
Q3 2014-15
Five Day Wait Time – Nursing
Services (Access)
Q3 2015-16
Five Day Wait Time – Complex PSW
(Access)
Q2 2015-16
Client Experience
(Client Centred)
Q2 2015-16
(Patient Centred)
Rationale
Current
2015-16
Avoidable ED Visits
(Effectiveness)
Dying in Place of Choice (new)
Target
Measured differently by OACCAC. Work
Establishing Baseline underway to align process provincially.
2016 Quality Symposium
REGISTRATION IS NOW OPEN
Please register by Wednesday, May 18.
We are pleased to announce a great lineup of speakers for the 2016 Quality Symposium. The
Quality Symposium brings together more than 400 health service providers, governors and
partners for a day of education and inspiration around quality improvement best practices. This
event is accessible and free of charge.
Plan to join us on Thursday, June 2nd, 2016 at the Stratford Rotary Complex.
AGENDA
9:00 – 9:20
Opening Comments – Michael Barrett, CEO, South West LHIN
9:20 – 9:25
Success Story Video
9:30 – 10:00
Hearing the Patient Voice: Judith John
Former hospital communications executive, cancer survivor, and caregiver
10:20 – 10:25
Success Story Video
10:25 – 10:45 BREAK
10:45 – 11:40
KEYNOTE: Andrew Coyne
Political Journalist
11:40 – 11:45
Success Story Video
11:45 - 12:00
Quality Awards Presentation
12:00 – 1:00 LUNCH
1:00 – 2:00
Presentation: George Smitherman
Political figure, community activist, and consultant
2:00 - 2:05
Success Story Video
2:05 - 2:30
Provincial Quality Improvement Update: Dr. Joshua Tepper
President and CEO, Health Quality Ontario
2:30 – 3:10
Panel
Judith John, George Smitherman, Andrew Coyne
Moderated by Dr. Josh Tepper
3:10 - 3:15
Closing Comments
Agenda Item: 6.2
REPORT TO BOARD OF DIRECTORS
Accreditation Committee Report
March 30/16
Reported by: P. Campbell
The Board Accreditation Committee met on March 23rd and conducted the following business:
SUPPORT OF RECOMMENDATION
Having received and discussed the recommendation from the Quality of Care Committee at its March 9th meeting, the
Accreditation Committee is in support of the recommendation to the Board to submit an application to postpone the October
2016 Accreditation on-site survey for a period of eighteen months – see separate Report from Quality of Care Committee.
The Committee received further information since March 9th that Accreditation Canada has communicated that it will implement
a consistent approach in approving postponement requests from CCACs, and that it will be for a period of no more than twelve
months, i.e. to October 2017 for South West.
The Committee recognized that the receiving organization will need to be conscious of the postponed timeline for Accreditation
and ensure that the knowledge and skills related to Accreditation are identified and brought forth.
Board Accreditation Committee Members:
Pat Campbell, Chair
Linda Ballantyne, Board Chair
Tim Cronsberry, Board Member
Brian Hadley, Governance Committee Chair
Sandra Coleman, CEO
Assisted by: Steven Carswell, Director of Quality and Cate Patchett, Corporate Liaison
Agenda Item: 7.2
REPORT TO BOARD OF DIRECTORS
Health Equity to Enable Access to Quality Care
March 30/16
Reported by: Senior Leaders
The Ministry of Health and Long-Term Care emphasizes health equity as a foundational requirement for health system change.
Disadvantaged populations end up sicker and in need of care resulting in poor health outcomes and increased costs to the
system. They may experience disparities in their health status, access to service and the quality of care they receive. It is
important for all health system partners to address inequitable access to quality care to prevent further widening of health
disparities.
Health equity is the basis of the Minister’s speech on November 4/15 and his Patients First proposal. It is a requirement in the
CCAC Sector Multi-Sector Service Accountability Agreement, and a strategic focus of the South West LHIN. Equity is also a
keystone commitment in the South West CCAC’s Mission statement,
“To deliver a seamless experience through the health system for people in our diverse communities,
providing equitable access, individualized care coordination and quality health care.”
The South West CCAC is dedicated to ensuring that all patients achieve the best possible health outcomes regardless of
language, race, religion, disability, gender, gender identity, sexual orientation, income or any other individual characteristic.
We are committed to identifying inequities, and putting strategies in place to address them to enable access to quality care.
Equity and population health is central throughout our Board and operational policies and practices.
It is important for the South West CCAC Board to understand what health equity is and to be aware of the work the CCAC is
doing in this area. In addition to the Patient Quality of Care Story agenda item about a patient from a disadvantaged
population and his experience with accessing health services, this report consists of the following four elements:
1.
2.
3.
4.
Educational presentation on health equity in Ontario in general and more specifically in the South West;
Snapshot of what the South West CCAC does now to support several populations;
Demonstration to profile County Reports through the lens of what we know about our populations and geographies;
A generative discussion on how to continue to ensure we are improving equitable access to quality care.
Health Equity
March 30, 2016
What is Health Equity?
“Health Equity enables all people to reach their full health
potential, that people should not be disadvantaged because of
their race, ethnicity, religion, gender, age, social class, [where
they live], socioeconomic status or other socially determined
circumstance.”
Modified from Whitehead M, Dahlgren G. 2006. Concepts and principles for tackling social
inequities in health: Levelling up part 1. Geneva: World Health Organization. (p. 5).
http://news.bbc.co.uk/2/hi/7584056.stm
Health Equity vs. Equality
Provincial Commitments
Excellent Care for All Act:
“The ‘For All’ in Ontario’s Excellent Care For All legislation is a
deliberate recognition that we can only improve the health of
the population if everyone receives the recommended standard
of care”.
Minister’s Speech, OHA, November 4, 2015:
“We must reorganize our system in a bold and transformational
way so that we can deliver on our promise of health equity – of
equitable access. We must build a system that best meets the
needs of Ontarians, that closes gaps, and brings services to the
people who need them most.”
South West LHIN IHSP 2016-2019
• IHSP Implementation strategy focused on health
equity
• Health Equity – consistently apply a health equity
lens to enable access to quality care
• Request use of Health Equity Impact Assessment
for programs & initiatives
MSAA Indicator
• French Language Services
• Aboriginal - Support staff to complete Indigenous
Cultural Competency Training (ICCT)
• Reportable MSAA indicators
HEIA
What is HEIA?
• HEIA is a decision support tool which walks users through the steps of
identifying how a program, policy or similar initiative will impact population
groups in different ways. HEIA surfaces unintended potential impacts. The
end goal is to maximize positive impacts and reduce negative impacts that
could potentially widen health disparities between population groups—in
short, more equitable delivery of the program, service, policy etc.
Why use HEIA?
The HEIA tool that has been developed by MOHLTC has four key objectives:
• Help identify unintended potential health equity impacts of decision-making
(positive and negative) on specific population groups
• Support equity-based improvements in policy, planning, program or service
design
• Embed equity in an organization’s decision-making processes
• Build capacity and raise awareness about health equity throughout the
organization
Health Equity Impact Assessment (HEIA) Tool
• HEIA leverages existing work and creates greater consistency
and transparency in the way that equity is being considered
across the health system.
• HEIA is a proven method to assess initiatives and investments to
ensure that potential unintended health impacts on populations
are considered/addressed to reduce health disparities across
vulnerable/marginalized population groups.
• Access and quality barriers sustain or even widen serious health
disparities, resulting in increased future cost burden and poor
health outcomes for vulnerable populations.
Steps to Completing the HEIA
1. Scoping
– Population - Using evidence, identify which populations may experience
significant unintended health impacts (positive or negative) as a result of
the planned policy, program or initiative.
– Determinants of Health - Identify determinants and health inequities to be
considered alongside the populations you identify
2.
Identify Potential Impacts – Unintended Positive Impacts, Unintended
Negative Impacts
3.
Mitigation - Identify ways to reduce potential negative impacts and
amplify the positive impacts.
4.
Monitoring - Identify ways to measure success for each mitigation
strategy identified.
5.
Dissemination - Identify ways to share results and
recommendations to address equity.
Health Equity In Action
at South West CCAC
-Board Policies
-CCAC Staffing
-Populations: Aboriginal, Mennonite, LGBTQ, Health
Links, Self Management Program
-Data
South West CCAC Board policies
Foundational policies in good shape:
• Mission statement and Credo make a commitment
to equity
• Policy I-3 – community engagement of diverse
populations
• Policy II-2- CEO direction includes equity
• Polices II-10 and 11 – French and AODA
• Policy V-A-5 Guidelines for selection of Directors
Recommendation add “equity” explicitly to:
• Policy III-6 Respect for Diversity
• Policy V-A-1 Principles of Governance and Board
Accountability
CCAC staff support and training
• Daryl Nancekivell is a Regional Manager who is our
lead contact for our partnership with the Aboriginal
community
• He works closely with the Aboriginal community
including the lead from the LHIN
• Staff are also completing the Indigenous Cultural
Competency training (leadership, Care
Coordinators)
Care Coordination support to First Nations
• 5 First Nation communities in South West
• Dedicated Care Coordinator to support each of
these communities
• Regular meetings with the Health Center staff for
each community
• Proactively look at what might be the right service
plans for the patients, PSW is shared between the
Federal government and CCAC
• CC connected to SOHACC as well which supports
the urban residents
• CC works closely with SPOs to ensure cultural
awareness for patients and families
Hospital Care Coordination
• Aboriginal navigators are in place at LHSC and
GBHS
• They often focus on the more complex discharges
to the community
• The CCAC CC work closely with this team to ensure
there is a collaborative approach to the discharge
process and care plan development
• These navigators do support other patients in other
hospitals but they are based out of the 2 hospitals
Oneida LTCH
• The Oneida First Nation community is one of only 4
in the community to have a Long-Term Care Home
• The home opened in February of 2012
• It is a 64 bed facility which operates consistently at
over 97% occupancy
• the CCAC team worked with the Band in the early
days pre opening and it was determined that CCAC
would manage admissions and the waitlist
• There is a separate wait list for this home which is
a 3A and that indicates and aboriginal applicant
who would get priority for an admission
• Crisis and spousal reunification would
take precedent
Mennonite Population
• The Health Unit in Perth is a leader in working with
this population
• The NP for this area has been connected in and
made visits to patients
• We ensure Care Coordination supports for this
population across the South West
• The Majority of the members of this community do
not have a Health Card so if services accessed
varied methods of payment occur
LGBTQ
Why Does this Matter?
SW QILT Discussion
Current State
Opportunity?
LGBTQ Employees identified
feeling invisible
Rainbow Corner on Intranet to
promote awareness and
inclusivity
No engagement with LGBTQ
Community
Building partnerships with Public
Health Unit, Rainbow Health and
London InterCommunity Health
LGBTQ invisible in strategic plans
LGBTQ Patient Advisor
opportunity to assist with
strategic planning
LGBTQ invisible in patient
complaints
Visibility of LGBTQ specific
barriers to care in complaints
No focus on LGBTQ in Education
Orientation, PD session
opportunities
Deliverables and Timelines
Deliverable
Date
Prepare staff and partners to partner with patients
and families at the organizational level
Summer 2016
Onboard and Orient LGBTQ Patient Advisor
Summer 2016
Roll-out education initiatives and orientation plan
Fall 2016
Develop communication plan
Fall 2016
Join Community Standards of Practice (directory of
organizations and service providers who have
committed to specific Community Standards of
Practice related to serving LGBT2Q+ communities)
Fall 2016
Evaluation
Ongoing
SW Health Links Approach to the HEIA
• Each Health Link area will complete the HEIA as part of their
implementation planning process
• Training completed with SW LHIN Aboriginal Lead
• Identified priority populations based on work group discussions
and input from Health Link Leadership Collaborative
• SW Health Link project manager met with representatives from
specific priority populations (e.g. French Language Services,
Mennonite Community Services, SOAHAC)
South West Self Management Program
• Completed the Health Equity Impact Assessment
• Engaged with communities to modify programs in response to identified
needs from assessment
• Stanford Chronic Disease Programs available in English, French, Spanish and
Arabic
• Peer Leader Volunteers who speak English, French, Spanish & Arabic and
identify as Aboriginal and LGTBQ
• Workshops hosted across all communities and diverse locations including at
First Nation communities and Homeless Shelter
• Partnership agreements in place with organizations that link with diverse
populations
• Getting the Most Out of Your Health Care Appointment – in English, French &
Spanish
• Focus on Health Literacy – support for everyone to understand information
• Choices and Changes program materials modified to train HSP and individuals
living with low vision
Data
• County Reports now available
• Enables a picture by geography of each County
• Hilary will do a demonstration and overview
• Sub populations other than geography are not yet
identified for a variety of reasons Hilary will speak
to
– Should that be on our action plan for the coming year?
Generative Discussion
What do we know?
•
•
What do we
already know
about the effect of
social determinants
of health on health
equity?
What stood out for
you or was new
information?
Triple-Helix
Thinking
How should we focus?
•
•
Are we on the
right track with
focusing on
equity for the
Aboriginal,
Mennonite, and
LGBTZ
Communities?
Are there other
populations we
should consider?
What are some options?
•
•
Where are the
•
opportunities for
creative thinking
to invent new
solutions for
health equity in all
of this?
How can we create
•
a better patient
experience for
these populations?
What can we commit to?
Given the
influence of health
equity, what
should the
collective health
care community
consider doing to
effect change?
What more could
the SW CCAC be
doing?
Agenda Item: 11.0
BOARD OF DIRECTORS
Adjournment and Next Meeting
Wednesday, May 25, 2016
11:00 a.m. – 3:00 p.m.
1415 First Avenue West, Suite 3009
Owen Sound