Santé Pontiac
Transcription
Santé Pontiac
P Annual Management Report 2013-2014 The CSSS du in the www.santepontiac.qc.ca ontiac of its community 2 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 3 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 4 Table of contents Message from the President and the Executive director 6 _____________________________________________________________________________________________________________________________ ______________ 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 5 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. 6 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. Administrators’ code of ethics and professional conduct 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 7 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. Annual Management Report 2013-2014 8 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. The CSSS du Pontiac, in the 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 9 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 Annual Management Report 2013-2014 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 10 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) The CSSS du Pontiac, in the of its community 11 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% Annual Management Report 2013-2014 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% 12 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; The CSSS du Pontiac, in the 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 13 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% Annual Management Report 2013-2014 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 CSSS du Pontiac, in the 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 Annual Management Report 2013-2014 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 The CSSS du Pontiac, in the 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; Annual Management Report 2013-2014 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 The CSSS du Pontiac, in the 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 Annual Management Report 2013-2014 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; The CSSS du Pontiac, in the 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! Annual Management Report 2013-2014 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 The CSSS du Pontiac, in the 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. Annual Management Report 2013-2014 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 The CSSS du Pontiac, in the 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. Annual Management Report 2013-2014 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 The CSSS du Pontiac, in the 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 Annual Management Report 2013-2014 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 The CSSS du Pontiac, in the 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 No measures were taken to resolve the problem. NR The charges of activity center (7600) Laundry were all in the activity center 7604 (Laundry). 20112012 O No measures were taken to resolve the 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 Annual Management Report 2013-2014 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. The CSSS du Pontiac, in the 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. Administrators’ code of ethics and professional conduct 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; Annual Management Report 2013-2014 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; Administrators’ code of ethics and professional conduct 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; The CSSS du Pontiac, in the 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