summary of the qhc board of directors meeting march 26, 2013
TRANSCRIPT
Summary of the QHC Board of Directors Meeting
March 26, 2013 The following is a synopsis of some of the topics that will be discussed at the March 2013 QHC Board Meeting. Balanced Scorecard Mary Clare Egberts will review the results of the year-to-date 2012/13 third quarter QHC balanced scorecard (attached). 2012/13 Senior Leadership Performance Goals The Human Resources Committee is recommending that the Board approve that two of the 2013/14 Quality Improvement Plan goals be linked to Senior Leadership Team compensation. These are total margin and 90th percentile emergency department length-of-stay for admitted patients. The targets and remaining SLT goals linked to compensation will be brought to the Board for approval in June. 2013 – 2017 HR Strategic Plan The HR Committee is recommending approval of the QHC 2013-17 Human Resources Strategic Plan. The plan is linked to the QHC strategic plan and the following key HR performance areas: corporate culture, employee safety and wellness, workforce planning and stability, organizational learning and development, and leadership development. The plan was developed based on input from staff and physician feedback, surveys, QHC’s accreditation report, industry/legislative trends and labour market data. QHC Quality Improvement Plan The Board of Directors approved the 2013/14 Quality Improvement Plan (QIP) at the February board meeting. However, the performance targets were not available at that time. The attached QIP contains targets and baseline (historical) performance for all indicators except medication reconciliations and total margin, which will both be available in June 2013. All Ontario hospitals are mandated to submit an annual Quality Improvement Plan. Targets are set based on an extensive review of our internal data, external benchmarks and current performance. The Quality of Patient Care Committee is also submitting the attached 2012/13 QIP interim progress report and the Quality and Performance Improvement Quality Report. January 2013 Financial Update The year-to-date financial position shows a surplus of $112,000, compared to a budgeted surplus of $296,000, resulting in a negative variance of $184,000. QHC is essentially operating in a break-even position. Although 2013 started with heightened activity due to the impact of the seasonal flu, surge volumes declined during the month and QHC was operating within planned resources by the end of January. QHC is projecting a balanced year-end financial position before building related items.
2013/14 Operating & Capital Plans QHC continues the process of developing its 2013/14 operating budget. All of the proposed solutions that were developed by the planning teams and endorsed by the Board in February still leave a shortfall of about $3.8 million before there would be a balanced operating budget for QHC. There are currently a number of additional mitigation strategies being explored, including additional efficiencies in drugs, supplies and administrative areas and a tax recovery strategy. The Audit and Finance committee has directed Management to continue to work towards balancing the budget and management will table the 2013/14 operating budget at the April board meeting. The 2013/14 capital budget has now been completed, including medical capital equipment, plant renovations, non-medical and information technology. Internal planning teams have been meeting since November to prioritize the needs for next year. Management is currently sourcing financing availability from the Foundations and the 2013/14 capital budget will be tabled at the April Board meeting. Advisory Council and Board renewals In June the initial members of the QHC Advisory Council will have completed their first three-year term. The Nominations and Communications Sub-Committee is recommending to the Board 23 people for approval to the Advisory Council of QHC. These are a mix of new and reapplying members. If they are all approved, there will be 13 remaining vacancies on the 54-member Advisory Council. Additional members may come forward during the year and can be added at that time. Four members of the QHC Board of Directors have terms ending in June 2013 – Tricia Anderson, Steve Blakely, Doug McGregor and Brian Smith. The Nominations and Communications Sub-Committee received eight applications for these vacancies and will be interviewing six candidates in early April. The slate of candidates will go to the Board for approval in April. Next Meeting The next regular meeting of the QHC Board of Directors will be held on April 23 at QHC Belleville General Hospital.
QUNITE HEALTH CARE BOARD OF DIRECTORS Tuesday, March 26, 2013
Belleville General Hospital Inservice Classroom 5:45 to 7:00 p.m.
AGENDA
OUR VISION: QHC WILL PROVIDE EXCEPTIONAL AND
COMPASSIONATE CARE. WE WILL BE VALUED BY OUR COMMUNITIES AND INSPIRED BY THE PEOPLE WE SERVE.
Time Item Topic
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5:45
3.0 Approval of Minutes 3.1 Minutes from Board meeting February 26, 2013
B. Smith
X
5:50 4.0 4.1 Report of the Chair
B. Smith V-A-8 X
5:55
5.0 Building Relationships 5.1 Report of the President & CEO- Balanced Scorecard
M.C. Egberts
VI-1
X
6:00
6.0 Provide for Excellent Leadership & Management Human Resources Committee 6.1 2013/14 SLT Performance Based Compensation Plan 6.2 2013-2017 Human Resources Strategic Plan
T. Anderson T. Anderson
II-4
II-5
X
X
6:10 6:25 6:30
7.0 Ensure Program Quality and Effectiveness Quality of Patient Care Committee 7.1 2013/14 Quality Improvement Plan 7.2 Quality Quarterly Report Medical Advisory Committee 7.3 Report of the Medical Advisory Committee Professional Staff Association 7.4 Report of the Professional Staff Association
J. Petrie
J. Petrie
Dr. Zoutman
Dr. Tromp
III-1
III-1
Bylaw 8.04
Bylaw 7.03
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X
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X
2Time Item Topic
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6:35
8.0 Ensure Financial & Organizational Viability Audit and Finance Committee 8.1 January 2013 Financial Statements 8.2 2013/14 Operating & Capital Plans 8.3 Insurance Renewal
J. Embregts
J. Embregts J. Embregts
IV-2
IV-1
IV-3
X
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6:50
9.0 Ensure Board Effectiveness Nominations and Communications Sub-Committee 9.1 Advisory Council 2013-2016 9.2 Applications for the Board of Directors
L. Hanbury
L. Hanbury
V-B-1.1
V-B-1
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7:00
10.0 Adjournment Next Board Meeting: Tuesday, April 23, 2013 Location: Belleville General Hospital
B. Smith X
Quinte Health Care DRAFT 3.1 Board of Directors Meeting Minutes
February 26, 2013 A meeting of the Board of Directors of Quinte Health Care was held on Tuesday, February 26, 2013 at the Belleville General Hospital, In-service Classroom and Conference Room. Mr. Brian Smith chaired the meeting. Present: Mrs. Tricia Anderson Mr. Steve Blakely Mrs. Mary Clare Egberts
Mr. John Embregts Mr. Les Hanbury Mr. Doug McGregor
Mrs. Darlene O’Farrell Mr. John Petrie Mr. Nick Pfeiffer
Mr. Brian Smith, Chair Mrs. Katherine Stansfield Dr. Margaret Tromp Mr. Stuart Wright Dr. Dick Zoutman
Regrets: There were regrets from Ms. Karen Baker, Dr. Norma Charrière and Mr. David MacKinnon
Staff Present: Mr. Brad Harrington Mrs. Jan Richardson Mrs. Susan Rowe
Ms. Kathryn Noxon, Recording Secretary 1.0 Call to Order Mr. Smith welcomed everyone and called the meeting to order at 4:30 p.m. 1.1 Approval of Agenda Motion: To approve the open session February 26, 2013 agenda. Moved by: Mr. Petrie Seconded by: Mr. Hanbury Carried 1.2 Declaration of Conflict of Interest There were no declarations of conflict of interest for open session. 2.0 Closed Session Motion: To go into closed session. Moved by: Mr. McGregor Seconded by: Mrs. O’Farrell Carried
Quinte Health Care Board of Directors Meeting Minutes February 26, 2013
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3.0 Board Minutes 3.1 Minutes from the Board meeting held on January 22, 2013. Motion: To approve the minutes from the Board meeting held on Tuesday, January
22, 2013 Moved by: Mr. Blakely Seconded by: Mr. Pfeiffer Carried 4.0 Education Session 4.1 Credentialing An education session on physician credentialing at QHC was given by Dr. Dick Zoutman, Chief of Staff. 5.0 Report of the Chair Mr. Smith presented his report to the Board which summarized the Committee meetings and events he attended since the last Board meeting. Of particular interest was the presentation to the OHA made by Mr. Smith and Mrs. Rowe in Toronto Conducting Board Business Under Severe Media and Public Scrutiny. The OHA webcast featured Quinte Health Care, which is considered to be an Ontario hospital with significant media and public attention to the open Board meetings. The moderator was Doug Mepham of MacDonald & Co. The session was held in conjunction with the OHA’s Effective Communication in Open Board Meetings scheduled to take place March 25th. 6.0 Building Relationships 6.1 Report of the President and CEO Mrs. Rowe was asked to present a summary of the consultation process on the proposed solutions to address the QHC funding gap. Concerns were expressed around the decision process regarding the solutions and the bed closures and community supports. Mrs. Egberts met recently with Jackie Redmond, CEO of the South East Community Care Access Centre (CCAC). The CCAC is aware of the concerns within the community and of the challenges they have ahead of them. They believe they are ready to meet those challenges. It was noted that QHC’s collaboration with the CCAC is going very well. 7.0 Ensure Financial & Organizational Viability Audit and Finance Committee 7.1 2013/14 Operating and Capital Plan Development Mr. Embregts stated that as previously reported the financial gap between expected revenues and expenses could be as high as $10 million for its fiscal year that starts April 1, 2013 and could climb by an additional $5 million in future years. Last fall, planning teams within QHC were formed and challenged to find $10M in savings. Each team was given a formal efficiency target to work towards.
Quinte Health Care Board of Directors Meeting Minutes February 26, 2013
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The Audit and Finance Committee received the preliminary projections of the 2013/14 operating budget and the committee will receive the first full draft of the budget in March. It is not believed that any additional clinical reductions incremental to what has been proposed could be implemented at the present time. The change management required for the existing solutions is at or beyond capacity of what can be feasibly executed in one fiscal year. The motion being brought forward to the Board allows management to move forward with the final planning steps in developing the 2013/14 Operating Budget. Motion: The Audit and Finance Committee recommends that the Board of Directors
endorse in principal the proposed solutions to solve the 2013/14 funding gap and enable management to make final changes arising from the stakeholder consultation including the staff planning process and prepare the final draft of the 2013/14 Operating Budget.
Moved by: Mr. Embregts Seconded by: Mr. Petrie Carried 7.2 December 2012 Financial Statements The December 2012 financial results show a deficit of $113K versus a budgeted deficit of $11K, resulting in a negative variance of $102K. YTD financial results show a $33K deficit which is basically a breakeven position. As previously noted, QHC has been impacted by an earlier and more intense flu season than was experienced in the prior year. This resulted in an increase in both inpatient and outpatient activity that was particularly heavy through the holiday period and extended into the new year. The expected impact on labour costs as well as supply and drug costs was mitigated by the seasonal reductions and slowdowns in some areas of service and increased vacation utilization during the holiday season. We may also be seeing early positive impacts of the material usage project (Project Apollo) work focusing on supply utilization and efficiencies. Project Apollo was one of the balancing strategies that were introduced to help QHC achieve a year-end balanced position and focused on three main areas in its initial launch: Diagnostic Imaging, Operating Room and Emergency Department. Motion: To approve the December 2012 Financial Statements. Moved by: Mr. Embregts Seconded by: Mrs. Anderson Carried 7.3 Diabetes Program Budget Submission 2013/14 The Diabetes Program of the Ministry of Health and Long-Term Care (MOHLTC) requires that the 2013/14 budget submission is reviewed and approved by the Board of Directors. The funding is consistent with the amount received in fiscal 2012/13 and there have been no changes in the delivery of services. Motion: The Audit and Finance Committee recommends to the Board of Directors
approval of the 2013-14 budget submission for the Diabetes Program. Moved by: Mr. Embregts Seconded by: Mr. Hanbury Carried
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8.0 Ensure Program Quality and Effectiveness Quality of Patient Care Committee 8.1 2013/14 Quality Improvement Plan Mr. Petrie reported that Quinte Health Care is mandated through the Excellent Care for All Act (ECFAA) to submit an annual Quality Improvement Plan (QIP). In compliance with the requirements under the ECFAA, the 2013/14 QIP must have Board approval by March 31, 2013. This plan is then submitted to Health Quality Ontario by April 1, 2013. The QIP must include the following: Annual performance improvement targets and justification for those targets; and Information concerning the manner in and extent to which, executive compensation is
linked to the achievement of targets The following quality objectives and measures are being recommended for inclusion in the 2013/14 QIP.
Quality Dimension
Objective Measure/Indicator
Safety
Increase proportion of patients receiving medication reconciliation upon admission
The total number of patients with medications reconciled as a proportion of the total number of patients admitted to the hospital
Effectiveness
Improve organizational financial health
Percent by which total corporate revenues exceed or fall short of total corporate expenses, excluding the impact of facility amortization
Access
Reduce wait times in the ED 90th percentile ER length of stay for Admitted Patients
Integrated
Reduce unnecessary time spent in acute care
Percentage Alternative Level of Care (ALC)
Reduce unnecessary hospital readmission
Readmission within 30 days of discharge for the following CMGs: Chronic Obstructive Pulmonary Disease and Congestive Heart Failure
It was recommended that the words ‘and performance targets’ be removed from the motion because they were not included in the information provided. The targets will be presented to the Quality of Patient Care Committee at their next meeting. Motion: That the Quality of Patient Care Committee recommend to the Board of
Directors approval of the 2013/14 Quality Improvement Plan submission to Health Quality Ontario, indicating the priorities for quality improvement.
Moved by: Mr. Petrie Seconded by: Mrs. Anderson Carried
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Medical Advisory Committee (MAC) 8.2 Report of the Medical Advisory Committee Dr. Zoutman provided his report to the Board. Physician engagement concerning the QHC funding gap has been ongoing and Dr. Zoutman was pleased to report that the Medical and Professional Staff credentials portal has been completed. Dr. Zoutman acknowledged the many staff members who have assisted with this project. 8.2.1 Recommendations Report Dr. Zoutman requested approval of the following recommendation: Motion: That the QHC Board of Directors appoint Dr. Scott Morrison as Department
Chief of Anaesthesia as recommended by the Medical Advisory Committee on February 12, 2013.
Moved by: Mr. Wright Seconded by: Mr. Embregts Carried Professional Staff Association (PSA) 8.3 Report of the Professional Staff Association Dr. Tromp reported on initiatives being discussed by the PSA including online renewal of credentials which may open up a way for physicians to pay their PSA fees as part of the credentials renewal process. Discussions are also ongoing regarding patients with responsive behaviours, ALC patients and the proposed solutions for closing the funding gap. 9.0 Provide for Excellent Leadership & Management Human Resources Committee 9.1 2012/13 Performance Goals (SLT, CEO, COS) Mrs. Anderson reported that the Human Resources Committee has reviewed the CEO and COS annual performance goals as well as SLT performance goals linked to compensation. A progress report was provided for review and it was acknowledged that most of the 2012/13 performance goals for the CEO, COS and SLT are tracking to be on target for achievement at fiscal year-end. 10.0 Ensure Board Effectiveness Governance Committee 10.1 Board Policies Mr. Pfeiffer reported that the Governance Committee has completed its annual review of the governance related policies as identified in the Committee’s work plan. The majority of the changes identified were minor housekeeping ones, aligning wording with existing usage and changes in title or position. However, the following recommended changes require additional explanation. The Board’s Officers, Chair, Vice-Chair, and Treasurer are selected according to Policy V-B-2 and have their respective positions described in policies V-A-8, V-A-9, and V-A-10. These policies have been
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simplified so that all reference to terms of service are consolidated in policy V-B-2. Policy V-B-2 has been changed so that the same process is used to select all Board Officers and the terms of service are now consistent: appointed by the Board annually for a one year term, expected to serve a minimum of two sequential terms, and a maximum limit of three sequential terms. Motion: To approve changes to Board policies as follows:
Establish Strategic Direction: I-2, I-3 Governance Policy Framework: V-A-2, V-A-3, V-A-4, V-A-5, V-A-7, V-A-8, V-
A-9, V-A-10, V-A-12 Governance Process: V-B-1.1, V-B-2, V-B-3, V-B-5, V-B-7, V-B-8, V-B-9, V-B-
12 Build Relationships: VI-4
Moved by: Mr. Pfeiffer Seconded by: Mr. Hanbury Carried 11.0 Adjournment Motion: To adjourn at 7:10 p.m. Moved by: Mr. Embregts Seconded by: Mr. Hanbury Carried _____________________________ __________________________ Brian Smith, Chair Mary Clare Egberts Board of Directors President and CEO and Board Secretary
1
4.1 Report of the Board Chair
March 26, 2013 Events and Meetings Attended: March 5 – attended the Audit and Finance Committee meeting. March 14 – attended the regular meeting with Dr. Zoutman and Mrs. Egberts. March 19 – attended the Nominations and Communications Sub-Committee meeting. March 22 – met with Donna Segal, new Chair of the SE LHIN and Mrs. Egberts. Respectfully submitted, Brian Smith, Chair For your information, here is the list of OHA Educational Sessions.
Risk Governance for Health Care Boards and Senior Management Attending: Nick Pfeiffer, Doug McGregor and Cathy O’Oneill April 8, Toronto
Maximizing Governing Purpose and Value in Turbulent Times April 12, Toronto
Good Governance for Health Care Organizations April 22, Toronto
Conference for Board Finance Committee Members Attending: Karen Baker and Brad Harrington April 26, Toronto
Rural and Northern Health Care Governance Workshop May 7, Toronto
Conferences
Courses
Broadcast
CEO Report to the Board 5.1 March 26, 2013 Balanced Scorecard Attached to my report is the QHC Balanced Scorecard report for 2012/13 year-to-date Q3. Recent Communications Activities Over the past month, I have focused considerable time on communication and relationship-building activities related to the health system funding reform and upcoming changes at QHC. This has included meetings and phone calls with key physicians, partners, formal and informal leaders, both internal to QHC and in the community. My goals have been building understanding of the provincial health system reform, “myth-busting” around QHC’s proposals and ensuring we continue to have the partnerships needed to successfully implement these proposals. I have been very pleased to have Jackie Redmond, CEO of the CCAC, start to partner with us in these activities and commit to further involvement in our communications. For example, she joined me for separate meetings with the Mayor of Quinte West and the Mayor of Prince Edward County to discuss the increases to home care support and the CCAC has distributed a newspaper insert throughout the region on the CCAC services and how home care support is being enhanced. Paul Huras has also been doing speeches and media interviews. Over the coming months, we will need to be even more proactive in our communications efforts. Process Improvement We continue to make important strides in implementing a culture of continuous process improvement at QHC, which will support many of the solutions to the funding gap. For example, the unit managers or team leaders at BGH are now participating in a 10 minute “bed scrum” every morning where they compare a census of patients, determine shared solutions where a unit is short-staffed or over-capacity with patients and ensure an efficient flow of patients between units. One week in March we had some impressive and concrete examples of how this culture of quality improvement can have a significant and measurable impact. In that week, QHC hit a new low of 8.1% ALC patients, or 23 patients. A total of 8 ALC patients who had been at QHC more than 25 days were discharged to more appropriate care settings; there were free beds available for new admissions at all four of QHC’s hospitals consistently all week; and on one day there were no patients waiting in any of our ERs. This was all while the volume of patients seeking care through the emergency departments had not dropped from the expected numbers. My congratulations to the entire inter-professional team who have been working so diligently to make these improvements at QHC. Health Links The two Health Links in the QHC region have now worked with all their partner organizations to determine their initial priorities and submit their plans to the MOHLTC.
The Quinte Health Link, which includes providers in Prince Edward County, Quinte West, Brighton and Belleville, will initially focus on the Hospital at Home project, palliative care, cardiac rehab and patients with congestive heart failure. The Rural Hastings Health Link, which includes providers in Hastings County, has four priority initiatives looking at: chronic disease prevention and management; care coordination; end of life/palliative care; and diverting non-urgent patients from the Bancroft emergency department. These initiatives will support our plans to close the funding gap and our strategic directions of providing effective care transitions and creating an exceptional patient experience. Update on the PECMH Business Case Process Following our last meeting on January 21 with the LHIN, Paul Huras has invited Katherine Stansfield and me to a follow-up meeting to discuss the next steps on the PECMH business case proposal. We will be attending the meeting with Dr. Greg Higgins from the Prince Edward Family Health Team (PEFHT); Mary Camp, PEFHT interim ED; and Sandy Latchford, Chair of the Prince Edward Health Alliance. QHC and the Prince Edward Family Health Team first provided the LHIN with the pre-capital submission in June 2012 and we must continue to strongly advocate for the business case to be formally submitted to the Ministry of Health and Long-Term Care. VP Vacancy We are in the early stages of the recruitment process for filling the vacancy that will be created when Jan Richardson retires at the end of March. A search firm has been retained and we have re-defined the role for the position. The new job description is based on a reorganization of portfolios among the three VPs that will ensure all three have responsibility for at least one clinical area and create a more equitable distribution of the portfolios. Depending on the skills of the successful candidate, there could be minor adjustments to this new organizational structure once they are hired. Until the new VP begins in the role, I have divided the areas of Jan’s current portfolio among other members of the Senior Leadership Team. Brad Harrington will assume oversight of Diagnostic Services, Susan Rowe for Human Resources and Dick Zoutman for Medical Affairs, with the support of Miranda Germani. I will express my appreciation once again to Jan for her immeasurable contributions to QHC and to the local communities for 36 years. It has been a true pleasure to work with her over the past three years and she will be missed by all. 3SO award Congratulations to 3SO for being the first Canadian recipient of the GHX Best 50 award. To select the Best 50, GHX looked at more than 4,000 hospitals and shared services in the U.S. and Canada and identified leaders in supply chain excellence, streamlined operations and cost reduction.
QHC Balanced Scorecard – Q3 2012/13 YTD
Direction Enhance the Quality and
Safety of Care
Create an Exceptional
Patient Experience
Provide Effective Care Transitions
Be an Exceptional Workplace
Improve Strategic Enablers
Goal Reduce number of inpatient falls
Reduce ED length of stay for
admitted patients
Reduce alternate level of care patient days
Under development for 2013/14
Balance budget before building amortization
Target Falls per 1,000 patient days
≤ 5.7
90th percentile length of stay ≤ 21 hours
ALC patient days ≤ 17%
Margin ≥ 0
Q3 2012/13 Performance
5.66
20.8
14.7
‐0.2
6.1
QHC SLT 2013-14 PERFORMANCE-BASED COMPENSATION PLAN
1. Senior Leadership Team positions to which performance-based compensation applies & percentage of salary at risk:
President and CEO – 5% of salary; Chief of Staff – 5% of salary; Vice Presidents – 3% of salary; and Directors (Communication, Strategic Planning/Projects) – 1% of salary
Performance payouts to be determined upon evaluation of year-end performance and will be within the performance improvement envelope paid in 2012. All parameters of the compensation plan remain unchanged from prior years.
Pay at risk is linked to the achievement of QIP performance goals and strategic and/or system goals
2. Process for selection of indicators: Priority indicators identified by Board Quality of Patient Care Committee. Senior Leadership reviews priority indicators, strategic and system goals and makes recommendation to HR Committee
Quality Dimension
Objective Outcome Measure/Indicator Weighting Current 2012-13
performance
2013-14 Target
Effectiveness Improve organizational health
Total Margin: Percentage by which total corporate (consolidated) revenues exceed or fall short of total corporate (consolidated) expenses, excluding the impact of facility amortization in a given year
tbd
Tbd at year
end
Tbd by June
Access Reduce wait times in the ED
ER Wait times: 90th Percentile ER length of stay for admitted patients at all four hospitals
tbd 21.4 hours
(Q4 11/12 to Q3 12/13)
< 20 hours*
STRATEGIC LEADERSHIP AND SYSTEM PLANNING GOALS
Arise from strategic planning and system planning initiatives – To be determined
*this metric is being recommended by the Quality of Patient Care Committee at the March Board meeting
Enhance the Quality and
Safety of Care
Be an Exceptional Workplace
Create an Exceptional
Patient Experience
Provide Effective Care Transitions
ImproveStrategic Enablers
Our Mission: We are an integrated system of four hospitals working with our partners to provide exceptional care to the people of our communities.
Our Vision: QHC will provide exceptional and compassionate care. We will be valued by our communities and inspired by the people we serve.
Our Values Imagine it’s you Respect everyone Take ownership We all help provide care
Always strive to improve
DRAFT QHC 2013-17 Human Resources Strategic Plan Exceptional care, inspired by you
QHC Strategic Directions
This means….
Leadership Development
Build QHC leadership capacity through the support and development of
current & future leaders
Create a QHC workplace culture
where staff & physicians feel
valued
Workplace Culture
Create QHC sustainability by
recruiting, selecting & retaining the right people in the right job at the right time
Human Resources Planning
Provide effective training &
development for staff at QHC
Learning
Enhance organizational focus on a being a safe & healthy workplace
Safe & Healthy Workplace
HR Strategic Directions
• Staff are supported to manage their daily work pressures
• All staff & physicians exhibit organizational values in interactions with patients, families & colleagues
• Recognition is provided for achievement of goals & accomplishments
• QHC has a 3 year Human Resource plan
• HR planning is data-driven with monthly dashboard reports available to managers
• Staff are selected for values and talent, supported for success and held accountable for team & individual results
• QHC has a culture of staff safety & wellness where all staff & physicians understand and meet their safety accountabilities
• QHC has an effective and valued wellness program
• Safety issues are identified & addressed from an improvement and learning perspective
• QHC has incorporated the OHA leadership competency model & developed talent management and succession planning methodologies
• QHC provides an ongoing and effective leadership and management development program
• Management standard work practices are utilized
• QHC’s education framework and policies support ongoing investments for multidisciplinary staff development
• Staff complete mandatory training and incorporate into their daily work
• Change initiatives are supported with appropriate educational strategies
Balanced Scorecard Metric
Quality Framework Patient & Family First Framework Interprofessional Care Framework Education Framework
metric metric metric metric metric
QHC 2013-2014 - Quality Improvement Plan Version Date: March 15, 2013
Quality Dimension
Objective Measure/IndicatorCurrent
PerformanceTarget
2013/14Target Justification
Priority Level
Planned improvement
initiatives (Change Ideas)
Methods and
process measures
Goal for change ideas
(2013/14)
Effectiveness Improve organizational financial health.
Total Margin (consolidated): percent by which total corporate (consolidated) revenues exceed or fall short of total corporate (consolidated) expense, excluding the impact of facility amortization, in a given year.
-0.2 (Q3 12/13)
TBD
Our target will be based on the approved 13/14 budget.
1
Access Reduce wait times in the Emergency Department
Emergency Department (ED) Wait Times: 90th Percentile ED Length of Stay (LOS) for Admitted Patients
21.4 hours (Q4 11/12- Q3
12/13)
< 20 hours
Our target is an internal QHC benchmark based on current performance.
1
Reduce unnecessary time spent in acute care
Percentage Alternate Level of Care Days (% ALC): total number of inpatient days designated as ALC, divided by the total number of inpatient days
15.9% (Q4 11/12 - Q3 12/13)
< 15.1%
Our target is an internal QHC benchmark based on current performance.
2
Reduce unnecessary hospital readmissions
Readmission within 30 days: number of patients with Chronic Obstructive Pulmonary Disease and Congestive Heart Failure readmitted to any facility for non-elective inpatient care within 30 days of discharge for any reason, compared to the number of expected non-elective readmissions
21.4% (Q3 11/12 - Q2 12/13)
< 19.3%
Our target is an internal QHC benchmark based on current performance.
2
TBD
There is no provincial benchmark for medication reconciliation on admission. Our target will be an internal QHC benchmark based on current performance.
1
Part B: Improvement Targets and Initiatives
Integrated
Improvement initiatives include clinical pathways, reduction in ALC patients and decrease length of stay for complex patients. The methods, process measures and goals for change are under development. The initiatives support our commitment to improving patient flow.
Improvement initiatives include clinical pathways and a comprehensive seniors' strategy with early identification of complex patients with the potential to be designated ALC, targeted care plans and discharge planning including community partners. The methods, process measures and goals for change are under development.
Improvement initiatives include clinical pathways, medication reconciliation and improved discharge planning processes. The methods, process measures and goals for change are under development. The initiatives support our commitment to preventing readmissions.
Safety Improvement initiatives to increase medication reconciliation on admission targeting inpatient medical patients, including methods, process measures and goals are under development for initiation April 1.
Improvement initiatives include clinical efficiencies to decrease lengths of stay, decrease numbers of alternate level of care for palliative care patients and cognitively/behaviorally challenged patients, and manage material usage.
AIM MEASURE CHANGE
Increase proportion of patients receiving medication reconciliation upon admission
Medication reconciliation at admission: definition to be determined
TBD
1
Excellent Care for All Quinte Health Care Quality Improvement Plan: Interim Progress on Year Two (2012/13) The following template provides an interim progress report on the Priority 1 indicators that we set out in our year 2 (2012/13) Quality improvement Plan (QIP). A final progress report will be made available June 25, 2013.
Priority Indicator
Historical
Performance as stated in the 2012-13 QIP
Performance
Goal as stated in the 2012-13 QIP
Progress to
date
Comments
Falls: number of falls per 1000 patient days (excludes critical harm falls)
5.6 </= 5.7
6.15 (Q3 12/13)
5.66
(12/13 YTD)
Reducing patient falls has been a corporate priority for QHC. Year to date data indicates that QHC is meeting the target for falls. A greater focus on reducing and reporting falls has likely lead to the sustained falls rate from April 2012. Due to the potential risks for our patients, falls will continue to be a priority for QHC.
Total Margin (consolidated): Percent by which total corporate (consolidated) revenues exceed or fall short of total corporate (consolidated) expenses, excluding the impact of facility amortization, in a given year.
1.9% ≥ 0
-0.2
(Q3 12/13)
QHC is tracking very close to the Margin target and we project to meet this target by year end.
ER Wait times: 90th Percentile ER length of stay for admitted patients at all four hospitals
23.2 hours </= 21 hours
22.7
(Q3 12/13)
20.8 (12/13 YTD)
ER lengths of stay are measured from the time the patient is triaged until they arrive at the inpatient unit. Extended lengths of stay in the ER is a common and significant issue for most hospitals that will require multiple years of work to significantly impact. To date QHC is achieving the target of a 10% reduction in ER wait times from 23.2 hours to less than or equal to
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21 hours. QHC will continue to implement focused improvement projects led by ER and inpatient staff and physicians to further reduce ER wait times.
Percentage ALC days: % of ALC days (total number of inpatient days designated as alternate level of care divided by the total number of all inpatient days)
19.6% </= 17%
14 (Q3 12/13)
14.7
(12/13 YTD)
Patients are designated as Alternate Level of Care (ALC) when they no longer require an acute care hospital bed. To ensure patients are receiving their care in the most appropriate place for their needs, QHC is committed to ensuring appropriate and timely discharge plans are in place. Since April 2012, QHC has shown a greater than 20% improvement in the %ALC from 19.6% to 15%. Quarter four data will be used to calculate our final performance. Further reducing ALC patients will continue to be a priority for QHC in 2013-2014.
To: QHC Board of DirectorsFrom: John Petrie, Chair of the Quality of Patient Care CommitteeSubject: Quality and Performance Improvement Quarterly ReportDate of Meeting : March 26, 2013
For: Monitoring
Indicators Current Status
Enhance the Quality and Safety of Care
Falls per 1000 Patient Days*
HSMRCreate an Exceptional Patient Experience
90th Percentile ED LOS for Admitted patients*
Overall Inpatient Satisfaction
Overall Emergency Department Patient SatisfactionProvide Effective Care Transitions
Percent ALC Days*
90th Percentile Cancer Surgery Wait Times
90th Percentile ED LOS for CTAS I-III Non Admitted Patients
90th Percentile ED LOS for CTAS IV-V Non Admitted Patients
90th Percentile Wait Time - CT Scan - Belleville
90th Percentile Wait Time - CT Scan - Trenton
90th Percentile Wait Time - MRI Scan
90th Percentile Wait Time Cataract Surgery
90th Percentile Wait Time Hip Replacement
90th Percentile Wait Time Knee Replacement
Readmission rate within 30 days for Selected CMGs to any Facility
* Quality Improvement Plan and Strategic Priority
To: Board of Directors 7.3 From: Dr. Dick Zoutman, Chief of Staff Re: Report of the Medical Advisory Committee Date: March 26, 2013 Medical Staff Leadership There have not been any formal changes in medical staff leadership this past month but my office is planning a workshop meeting with all of the Department Chiefs and Division Heads to review their roles and functions and how we can create an even more synergistic team of medical leaders. We enjoy a high level of overall medical and professional staff engagement and want to optimize how we use the precious resource that is our medical and professional leadership. Quality of Care and Process Improvement There are 16 process improvement initiatives that are flowing from our extensive community, staff and medical staff engagement process. These were reviewed with the medical and professional staff at the MAC meeting and we are looking forward to having considerable medical and professional staff input into the execution of these projects. We had a very good conversation at the MAC about strategies to get this vital input. The QHC Code of Conduct was brought to the MAC for discussion. This very important document is based upon QHC’s 5 core values as the underlying principles for how we all work together at QHC to deliver exceptional care. It is important to note that the Code of Conduct applies the EVERYONE who is associated with QHC regardless of role. It holds each of us accountable for our behavior and how we work together. I am most grateful to Mitch Birken and the Human Resources team that developed the Code. We had input from experts within the Ontario Medical Association as well. The Medical Staff resoundingly endorsed the Code of Conduct at the MAC. Medical And Professional Staff Human Resources The medical and professional staff human resources plan has been completed for 2013-14. Many thanks to Breanne Ricketts-Gaber for her hard work to assemble the data. We will bring this forward to the next MAC and then to the Board. We continue to aggressively recruit for pediatricians and psychiatrists. We had several days at QHC in March without specialist pediatrician coverage, but again Dr. John Coady in Family Medicine and Dr. Don Clarke in Obstetrics and Gynecology and our colleagues in Anesthesia all helped provide urgent coverage for neonates and other emergencies. This is an example of the team work and dedication that QHC enjoys. Dr. Michael de la Roche is working very hard as our Interim Chief of Pediatrics. We have acquired a new psychiatrist thanks to the never ending recruitment efforts of our medical recruitment team and Dr. Colin McPherson. QHC and CBC’s The Fifth Estate Documentary I was contacted by CBC’s award winning and long running (30 years!) investigative journalism program The Fifth Estate to assist them in an investigation they were doing concerning how hospitals use infection control surveillance data to improve the quality of care. They wanted me to come to Toronto for an on camera interview. I said nothing doing, you need to come to QHC to see how we do this the “Quinte way”. So they did! On Friday March 15 a CBC film crew came to QHC. The show’s host Mark Kelley interviewed (grilled) me about infection surveillance but was especially fascinated when I told him how QHC is adopting leading practices in using data to drive quality improvement. In the middle of the interview on Sills 4 the overhead announces there will be a huddle at the performance improvement board in 5 minutes. There were many surprised looks at the huddle when a CBC camera crew and Mark Kelley showed up! Thanks to Miranda Germani, Kristen Ricketts, Pam Melanson and the many staff who participated, including our own Mary Clare. They are all stars! The episode called
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“Vital Signs: Inside Canadian Hospitals” airs on CBC Friday April 12 at 9 pm, Saturday April 13 at 2 pm, and Sunday April 14 at 1130 pm. Huge Thanks! Finally I wish to express my deepest gratitude to Jan Richardson upon her up coming retirement. Jan’s wisdom, guidance, patience, and good humor (and great stories!) were indispensible to me during my first year 16 months as Chief of Staff. Thank you Jan! Respectfully Submitted,
Dick Zoutman, MD, FRCPC Chief of Staff