agenda - bluewater health...agenda open session board meeting wednesday, june 27, 2018 lambton...
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AGENDA OPEN SESSION BOARD MEETING
Wednesday, June 27, 2018 Lambton College Event Centre
4:00 pm Directors:
Marg Dragan, Treasurer Anthony Iafrate Bill Gillam Jenny Greensmith
Louis Guimond Brian Knott Dr. Guy Kohlmeier Katherine Mantha
Bob McKinley Wayne Pease, Chair Fred Vanderheide Paul Wiersma, Vice-Chair
Ex-Officio Directors: Mike Lapaine Dr. Michel Haddad
Shannon Landry Dr. Sharon Rutledge
Dr. Nathan Taylor
Professional Staff/Staff: Dr. Kapil Kohli Samer Abou-Sweid
Laurie Zimmer Julia Oosterman
Paula Reaume-Zimmer
Recorder: Melissa Rondinelli *attached
NO. TOPIC ACTION TIME PRESENTER 1.0 CALL TO ORDER: WELCOME AND OPENING REMARKS 1 min Wayne Pease
1.1 Report on May and June In-Camera Board Meetings 1 min Wayne Pease
2.0 AGENDA APPROVAL
2.1 Approval of Agenda Decision 1 min Wayne Pease
2.2 Declaration of Conflict of Interest Decision 1 min Wayne Pease
3.0 CONSENT AGENDA
3.1 ITEMS FOR APPROVAL Wayne Pease
3.1.1 Open Session Board Minutes – May 23, 2018* Decision 1 min Wayne Pease
3.1.2 Broader Public Sector Accountability Act (BPSAA) Attestation*
Decision Marg Dragan
3.1.3 Board Policy Revisions* • Principles of Governance and Board
Accountability (5.10)* • Roles and Responsibilities of the Board of
Directors (5.15)* • Board Chair Position Description (5.45)* • Board Vice-Chair Position Description (5.50)* • Board Treasurer Position (5.55)* • Board Committee Chair Position Description
(5.60)* • Non-Director Committee Members (5.65)* • Code of Conduct (5.75)* • Board Committee Member Declaration
Decision Brian Knott
NO. TOPIC ACTION TIME PRESENTER (5.25)* – to replace Director Declaration (5.25) Non-Director Committee Member Declaration (5.27)
• Freedom Of Information – Delegation Of Authority And Oversight*
4.0 BOARD DECISIONS/OVERSIGHT
4.1 Strategic Plan Progress Report – Year 2* Discussion 10 mins Mike Lapaine
4.2 Governance and Nominating Committee Highlights* Information 2 mins Brian Knott
4.3 Quality Committee Highlights* Information 2 mins Paul Wiersma
4.4 Quality Committee Performance Scorecard* Discussion 5 mins Paul Wiersma
4.5 Resource Utilization & Audit Committee Highlights* Information 2 mins Marg Dragan
4.6 Financial Statement* Discussion 5 mins Marg Dragan
4.7 Resource Utilization and Audit Committee Performance Scorecard*
Discussion 5 mins Marg Dragan
4.8 Medical Advisory Committee Highlights* Information 2 mins Dr. M. Haddad
4.9 Board Work Plan* Information 3 mins Brian Knott
6.0 POLICY FORMATION – None
7.0 OPEN FORUM Opportunity for Directors to reflect on how patients, families and community were considered in discussions
Discussion 5 mins Wayne Pease
8.0 ADJOURNMENT: Next Meeting: September 26, 2018 Wayne Pease
MINUTES
OPEN SESSION BOARD MEETING Wednesday, May 23, 2018
Directors:
Marg Dragan, Treasurer √ Anthony Iafrate √ Bill Gillam √ Jenny Greensmith √
Louis Guimond √ Brian Knott √ Dr. Guy Kohlmeier √ Katherine Mantha √
Bob McKinley - R Wayne Pease, Chair - R Fred Vanderheide √ Paul Wiersma, Vice-Chair √
Ex-Officio Directors:
Mike Lapaine √ Dr. Michel Haddad √
Shannon Landry √ Dr. Sharon Rutledge √
Dr. Nathan Taylor √
Professional Staff, Staff and Guests:
Dr. Kapil Kohli – R Samer Abou-Sweid √
Laurie Zimmer √ Julia Oosterman √
Paula Reaume-Zimmer √
Recorder: Melissa Rondinelli (*attached in the minute record book)
1.0 CALL TO ORDER - Paul Wiersma called the meeting to order at 5:03 pm and welcomed the
Board and guests. 1.1 Report on February In-Camera Board Meeting
Paul reported on the items discussed at the April In-Camera Board meeting, which included professional staff appointments, audit plans, insurance coverage, property matters, compensation and executive performance evaluation.
2.0 AGENDA APPROVAL 2.1 Approval of Agenda*
Motion (K. Mantha/G. Kohlmeier): to approve the agenda as presented.
2.2 Declaration of Conflict of Interest Paul invited Directors to share any conflicts of interest. No conflicts were declared.
3.0 CONSENT AGENDA
3.1 ITEMS TO BE RECEIVED – REPORTS 3.1.1 Board Chair* 3.1.2 Professional Staff Association Report* 3.1.3 Quarterly Facilities Report* 3.1.4 Analysis of Loans and Investments* 3.1.5 Accreditation Self-Assessment Report and Action Plan* 3.1.6 Board Meeting Effectiveness Survey Results* 3.1.7 Board Attendance Records* 3.1.8 Board Education Record*
Bluewater Health – Open Meeting May 23, 2018 Page 2 ____________________________________________________________________________ 3.2 ITEMS FOR APPROVAL
3.2.1 Open Session Board Minutes – April 25, 2018* 3.2.2 Chief Financial Officer Certificate* 3.2.3 Revised Board Policy – 5.20 Roles and Responsibilities of an Elected and Ex-Officio
Director* 3.2.4 Delegation of Authority – Freedom of Information and Protection of Privacy Act
(FIPPA)* Motion (B. Knott/F. Vanderheide) and carried: to receive the reports presented and to approve the following items in the Consent Agenda: • Open Session Board Minutes of April 28, 2018 • Chief Financial Officer Certificate for the period ending March 31, 2018 • Revised Board Policy 5.20 – Roles and Responsibilities of an Elected and Ex-
Officio Director • Authorization for the Board Chair to sign the Delegation of Authority document
4.0 PRESIDENT AND CEO REPORT* Mike Lapaine presented his report and highlighted the new Indigenous Patient Navigator position at BWH, noting BWH is one of a few hospitals with this position. He then shared that Margaret Dragan will be recognized at the Sarnia Foundation’s 2018 Women of Excellence Awards on June 6, 2018. Mike congratulated Marg on this recognition and thanked her for her contribution to the BWH Board.
5.0 BOARD DECISIONS/OVERSIGHT
5.1 Resource Utilization and Audit Committee (RUAC) Highlights* Marg Dragan presented the RUAC Committee Highlights. She reported the Committee was updated on capital projects and the status of Health Infrastructure Renewal Funding (HIRF) and Hospital Energy Efficiency Program (HEEP) applications. She also noted Colleen Cook provided an update on union negotiations and Bill 148 implementation costs. Lastly, Marg reported the Committee reviewed financial risks. No questions or comments were raised.
5.2 Financial Statement* Marg presented the Financial Statement for the period ended March 31, 2018. She
commended staff for the hospital being in a $2M surplus position, and explained this was achieved through additional LHIN revenue - surge capacity and QBP (hip and knee replacements) funding, and utilities being $977K under budget.
Motion (M. Dragan/F. Vanderheide) and carried: to approve the Financial Statement for
the period ended March 31, 2018 as presented.
Bluewater Health – Open Meeting May 23, 2018 Page 3 ____________________________________________________________________________ 5.3 2018-19 Capital Budget* Marg presented the capital budget of $7,484,283. She reported RUAC received an overview
of how the Capital Budget Committee determined the recommended items, which includes mammography equipment, ultrasound machines, urology suite, new investment, replacement of equipment, etc.
Motion (M. Dragan/G. Kohlmeier) and carried: to approve the 2018-19 Capital Budget as presented.
The Board inquired about the hospital’s plan for the capital items not approved, the status
of the Chiller project, and whether the contingency and capital budget amounts were typical. Samer Abou-Sweid explained the items not approved will remain on the Five-Year Capital Plan and will continue to be assessed annually to determine which items must be purchased vs. deferred. Samer then reported the Chiller project was a three-year project and the remaining costs will be incurred this year.
In regards to the $500K contingency amount, Samer indicated the amount is based on the
requests that are denied, and it consistent with past practice. He added the hospital does not normally spend the full contingency amount. Mike then explained the capital budget would be funded through a combination of Health Infrastructure Renewal Funding, Foundation Funds and working capital.
The total capital budget amount was discussed next. Samer noted the budget was slightly
higher last year, and was even higher the year before. Mike explained the rule of thumb for calculating the capital budget is to consider amortization costs and add for inflation, unless extraordinary expenses are being considered. He noted BWH’s amortization is currently low. There were no further questions or comments.
5.4 Revised 2018-19 Operating Plan* Marg presented the revised operating plan. She explained Ministry funding was unknown
when the plan was first approved in January. Since then, BWH has learned its funding and has more information about expected expenses. BWH is now responsible for managing bundled payments, which is the rehabilitation portion of hip and knees replacements. The new Ministry funding received is expected to cover these bundled payments, which includes operating expenses estimated at $600K. In addition, the hospital is now anticipating expenses in the range of $700K to $1M to absorb the financial impact of Bill 148. It was noted the Ontario Hospital Association (OHA) has been advocating for hospital relief from the implications of this Bill without success.
It was noted the preliminary expenditure plan for 2018-19 was estimated at a $2.8M deficit
and is now $920,746. Although, the Board is being asked to approve a deficit plan similar to last year, there is confidence the hospital can manage to a balanced position by year-end. Mike pointed out the most important indicator for the hospital is its positive working
Bluewater Health – Open Meeting May 23, 2018 Page 4 ____________________________________________________________________________
capital, and even with the projected deficit, BWH will be able to fund the capital budget with its working capital.
Katherine Mantha asked why there is a reduction in CCO funding. It was explained there
was a reduction in cancer surgeries and the drugs associated with it this year, therefore, the funding was reduced. It was questioned if there were cases left untreated or fewer cases. BWH confirmed the hospital encouraged surgeries and the reduction was not due to resources, rather fewer cases. Louis commented that in principle he would not approve a deficit budget, but in light of the surplus this year and the conservative nature of the Chief Financial Officer, he would support the recommendation.
Marg clarified the hospital’s net new funding was $2.7M. She also noted some capital
spending could be delayed to be in a balanced position as well.
Motion (M. Dragan/G. Kohlmeier) and carried: to approve the 2018-19 Operating Plan as presented.
5.5 Community Accountability Planning Submission (CAPS)* Marg deferred presentation of this agenda item to Mike. He explained the submission
covers funding for community mental health programs including residential withdrawal management (RWMS). Mike advised the item was not discussed at RUAC due to timing issues. The ESC LHIN has requested Board approval of the submission by May 31, 2018. He noted the submission is the same as last year with the exception of RWMS. He also noted BWH has not received confirmation of funding for RWMS and does not expect it until after the election, although the ESC LHIN has provided verbal approval of the funding. There were no questions or concerns.
Motion (B. Knott/F. Vanderheide) and carried: to approve the CAPS as presented.
5.6 Resource Utilization and Audit Committee (RUAC) Performance Scorecard*
Marg noted the scorecard was updated since the RUAC meeting to include March data for the Emergency Department (ED) indicators. She then presented the scorecard and summarized the status of the following:
• 90th Percentile ED Length of Stay (LOS) for Complex Patients – Sarnia performing close to target of 8 hours at 8.4 hours, and Petrolia performing at 3.7 hours.
• 90th Percentile ED Wait Time for Admitted Patients – improvement over last month for both sites at 26 hours in Sarnia and 7.7 hours in Petrolia.
• ALC Rate% - on target • Cost per Weighted Case (CPWC) – Q4 data not available. • Mental Health Inpatient Cost per Patient Day – positive position • Surplus - $2.1M • Adjusted working capital – positive position • Capital budget – positive position with 78% of budget spent
Bluewater Health – Open Meeting May 23, 2018 Page 5 ____________________________________________________________________________
It was questioned if the current surplus will affect CPWC. Mike explained CPWC influences funding in a year or two from now, therefore, this year’s funding is not affected by the current CPWC. Jenny Greensmith then congratulated BWH on the improved ED length of stay indicator. She noted performance has been poor since last August and asked what other challenges have influenced the indicator besides the seasonal surge in the fall/winter. Mike explained the ED is pressured by patients attending for primary care concerns. He noted the hospital would be focusing heavily on improving wait time indicators this year. Dr. Kohlmeier noted the ALC rate has been positive and asked what the major cause of wait times is. He also questioned if the target was too aggressive. Mike indicated that even though the ALC rate has improved, the hospital has experience more admissions this year. The reduction in ALCs has opened up beds and improved patient flow. Laurie Zimmer added a lot of work has taken place within BWH and with its partners to reduce the number of acute ALC patients, such as education and the Intensive Hospital to Home program. Bill Gillam arrived for the meeting at 5:32 pm.
5.7 Medical Advisory Committee Highlights* Dr. Haddad presented the Committee Highlights and brought attention to quality improvement initiatives, recruitment and succession planning activities, and physician development and engagement strategies. He reported BWH has recruited two hospitalists and a new internist. Dr. Haddad also noted work is underway to arrange a session for the Professional Staff focused on leadership skills. He then provide a high-level overview of the Professional Staff Engagement Survey results which indicate positive changes. More details about the results will follow. Katherine Mantha asked about specific initiatives to support physician wellness and health. Dr. Haddad explained the work is being co-led by the Professional Staff Association and is in early development. Initiatives include Physician Wellness Committee, Professional Staff social events, and Professional Staff support group. He reported it is too early to measure whether the work is making a difference. It was questioned if other hospitals are involved in this work. Dr. Haddad suggested BWH is ahead of other hospitals on this issue. Jenny Greensmith asked for more information about the geriatrician business case. Dr. Haddad explained a business case for the position was presented to the Ministry of Health and Long-Term Care and has received support from the ESC LHIN. The intent is for the position to become part of the regional geriatric clinic and be supported by an interdisciplinary team at BWH. Anthony Iafrate arrived at 5:42 pm.
Bluewater Health – Open Meeting May 23, 2018 Page 6 ____________________________________________________________________________ 5.8 Quality Committee Highlights* Shannon Landry highlighted the report from the Rural Health and Inpatient Medicine
Programs, which focused on success at CEEH with the introduction of a Nurse Practitioner. She also brought attention to work underway to address falls. Next, Shannon noted the Committee received presentations about Workplace Violence and the no excuse for abuse campaign to begin in June, the ED Quality Revisit Program, annual privacy reporting, and the new approved Ethical Framework. Shannon indicated the Board would receive education for the Ethical Framework this fall. Brian commented the new Ethical Framework and education is timely given it is an Accreditation focus. Discussion about the Ethical Framework tool under development followed.
5.9 Quality Committee Performance Scorecard* Shannon presented the scorecard and discussed the indicators not reaching target
including: • Readmission within 30 days for COPD – currently at 21.6% and up from the previous
quarters. Shannon reported BWH investigated the patients and some are being readmitted for different diagnoses.
• Strengthen Patient and Family-Centre Care indicators - both indicators have been off target in the Inpatient area for the last four months. Shannon noted BWH is working hard on these indicators and will be considering new targets for the next scorecard given the hospital is performing better than its peers but not reaching targets.
• Was patient/family treated with kindness – It was noted kindness continues to be an organization wide focus and the Culture of Kindness Employee Council has been expanded to include more staff. Shannon also noted the Employee Engagement Survey results indicate the “kindness” score has improved. More details will follow in the fall.
There were no questions or comments. 5.10 Bluewater Health Foundation Report*
Brian Knott presented the report and highlighted the recent education event focused on Withdrawal Management. He then noted the Hoedown for Healthcare raised $7K for CEEH and brought attention to upcoming Foundation events: Golf fore Health (June 7, 2018) and the annual Gala (October).
5.11 Governance and Nominating Committee Highlights* Brian presented the Committee Highlights and brought attention to the education regarding Accreditation that will begin in the fall to prepare for the event in April 2019. He then noted members would receive an education tool/checklist to review prior to completing the OHA GCE Board Self-Assessment Tool. Next, Brian discussed timing for the June Board meetings and Annual General Meeting. Mike noted there were plans to share presentations with the Board about the Integrated
Bluewater Health – Open Meeting May 23, 2018 Page 7 ____________________________________________________________________________
Risk Management (IRM) framework and Staff and Professional Staff Engagement scores in June. However, given the importance of the items and the limited time available at the June meetings, he proposed they be reviewed at a fall Board Retreat instead. There was no objection to this idea. Mike also indicated it is best practice for a Board liaison to be involved in the IRM framework. He asked that anyone interested in participating in this work over the summer please contact Shannon.
5.12 Annual General Meeting (AGM) Brian brought forward a motion to hold the AGM at the Lambton College Event Centre to comply with the By-laws. There were no comments, questions or concerns raised.
Motion (B. Knott/K. Mantha) and carried: to approve the Annual General Meeting be held at the Lambton College Event Centre.
5.13 Board Education
Brian advised the Board a link to the OHA Governance Centre of Excellence (GCE) educational offerings was provided on the agenda. He noted several members recently attended the Advanced Board Governance conference and advised a reporting template had been prepared to assist members with reporting to the Board after attending a conference.
6.0 POLICY FORMATION – None.
7.0 OPEN FORUM
Brian indicated he has found the more frequent use of briefing notes to be very helpful when making decisions. Paul reminded the Board it is best practice for any significant decision to be supported with briefing notes. Katherine then shared that she attended the OHA GCE Advance Board program. She noted the speaker was very engaging, she learned one of eighteen patients are harmed in healthcare, and she was interested in investigating how risk can be addressed by the Board Sub-Committees with the introduction of the Integrated Risk Management framework.
8.0 IN-CAMERA AGENDA ITEMS Paul reported the Board would be meeting In-Camera following this meeting to discuss Board succession planning, Professional Staff credentialing, property matters, Board and executive expenses, risks, and performance evaluations.
9.0 ADJOURNMENT Motion (J. Greensmtih/A. Iafrate) and carried: to adjourn the meeting at 6:06 pm.
Bluewater Health – Open Meeting May 23, 2018 Page 8 ____________________________________________________________________________ ________________________ ____________________________ Paul Wiersma Mike Lapaine Vice-Chair Secretary Board of Bluewater Health Board of Bluewater Health
___________________________ Melissa Rondinelli Senior Executive Assistant Recorder
TO: The Board of Bluewater Health, (the “Board”)
FROM: Mike Lapaine, President and Chief Executive Officer
DATE: June 8, 2018
RE: April 1, 2017 to March 31, 2018 (“the Applicable Period”)
On behalf of Bluewater Health (the Hospital), I attest to:
• the completion and accuracy of reports required of the Hospital pursuant to Bill 122, section 6 of the Broader Public Sector Accountability Act, 2010 (BPSAA) on the use of consultants;
• the Hospital’s compliance with the prohibition in section 4 of the BPSAA on engaging lobbyist services using public funds;
• the Hospital’s compliance with any applicable expense claims directives issued under section 10 of the BPSAA by the Management Board of Cabinet;
• the Hospital’s compliance with any applicable perquisite directives issued under section 11.1 of the BPSAA by the Management Board of Cabinet; and
• the Hospital’s compliance with any applicable procurement directives issued under section
12 of the BPSAA by the Management Board of Cabinet, during the applicable period. In making this attestation, I have exercised care and diligence that would reasonably be expected of a President and Chief Executive Officer in these circumstances, including making due inquiries of Hospital staff and those of our procurement agency, TransForm Shared Service Organization that have knowledge of these matters.
I further certify that any material exceptions to this attestation are documented in the attached Schedule A.
Dated at Sarnia, Ontario this 8th day of June 2018.
Mike Lapaine President and Chief Executive Officer, Bluewater Health
I certify that this attestation has been approved by the Board of Bluewater Health on this 27th day of June, 2018.
Wayne L. Pease Chair of the Board, Bluewater Health Prepared in accordance with section 15 of the Broader Public Sector Accountability Act, 2010 (BPSAA)
SCHEDULE A to Attestation
1. Exceptions to the completion and accuracy of reports required in section 6 of the BPSAA on the use of consultants;
No known exceptions 2. Exceptions to the Hospital’s compliance with the prohibition in section 4 of the
BPSAA on engaging lobbyist services using public funds; No known exceptions
3. Exceptions to the Hospital’s compliance with the expense claims directive issued under section 10 of the BPSAA by the Management Board of Cabinet;
No known exceptions
4. Exceptions to the Hospital’s compliance with the perquisites directive issued under section 11.1 of the BPSAA by the Management Board of Cabinet; and
No known exceptions
5. Exceptions to the Hospital’s compliance with the procurement directive issued under section 12 of the BPSAA by the Management Board of Cabinet.
No known exceptions
1
Bluewater Health Briefing Note
Name of Committee: Board of Directors Date of Meeting: June 27, 2018 Submitted by: Julia Oosterman Subject: Board Policy Revisions Purpose of Report: Information Input Approval
Situation The Board follows a three-year review cycle for Board policies and requires all policies to be reviewed with the Accreditation cycle, which is taking place in April 2019.
Background Through recent governance review processes, a number of best practice opportunities have come to the Board’s attention. These opportunities and the majority of the Board’s policies will be reviewed over the summer months for potential revisions/adoption for presentation and approval to the Board in the fall. In the meantime, the following policies related to Board membership and new Committee member onboarding have been compared against other leading Board policy examples and Accreditation Standards, to ensure readiness for onboarding in September.
1. Principles of Governance and Board Accountability (5.10) 2. Roles and Responsibilities of the Board of Directors (5.15) 3. Board Chair Position Description (5.45) 4. Board Vice-Chair Position Description (5.50) 5. Board Treasurer Position (5.55) 6. Board Committee Chair Position Description (5.60) 7. Non-Director Committee Members (5.65) 8. Code of Conduct (5.75) 9. Board Committee Member Declaration (5.25) – to replace Director Declaration
(5.25) Non-Director Committee Member Declaration (5.27)
Analysis The recommended revisions simply language, and ensure policy alignment and compliance with Accreditation Standards. See draft revised policies attached.
Recommendation The Board approves the above noted Board policies as presented.
x
Page 1 of 4 Manual GOVERNANCE POLICY
POLICY Section 5.0 Board Effectiveness – Governance Policy Framework
Title PRINCIPLES OF GOVERNANCE & BOARD ACCOUNTABILITY
Issuing Body/ Prepared By
Governance and Nominating Committee
Approved by Board of Directors Number: GOV 5.10 Effective Date Revised Date
O: January 2009 R: June 2012 November 2015
June 2018
Version 34 File Name: S:\CHIEF EXECUTIVE OFFICER\BOARD AND BOARD COMMITTEES\BOARD BWH\BOARD POLICIES\5.10 - Principles Of Governance Board Accountability - November 2015.Docx
Controlled document. Any documents appearing in paper form must be used for reference purposes only. The on-line copy on the file server above must be considered the current documentation.
Purpose As part of its responsibility for ensuring Board effectiveness, the Board of Bluewater Health (BWH) will establish, approve and periodically review a statement of Principles of Governance and Board Accountability. This statement is an important requirement of effective governance and addresses the Board’s overarching philosophy and approach to its governance responsibilities, including its model of governance and accountabilities. This policy sets out the Principles of Governance and Board Accountability as developed and approved by the Board of BWH. Policy 1. The Board of Directors governs BWH through the direction and supervision of the
business and affairs of the corporation in accordance with its articles of incorporation, its by-laws, vision, mission and values, governance policies and other laws and regulations.
2. The Board adheres to the Modified Pointer and Orlikoff Governance Model, (as referenced in the Roles and Responsibilities of the Board of Directors policy (GOV-5.15) a model of governance through which it provides strategic leadership and direction.
3. The Board acts at all times in the best interests of BWH, having regard for its accountabilities to its patients and the communities served, the Ministry of Health
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PRINCIPLES OF GOVERNANCE & BOARD ACCOUNTABILITY
Number: GOV 5.10 Page 2 of 5
and Long-Term Care (MOHLTC) and the Erie St Clair Local Health Integration Network (ESC LHIN) and its relationship with other service providers.
3. 4. The Board maintains a culture of honesty and integrity, open debate, ethical
decision making, forthright examination of all issues and strives for a consensual approach to decision-making based on evidence-informed, best practice.
5. The Board, through the strategic planning process, defines values for BWH which will be reflected in the Board’s decision making processes, recognizing that decisions and actions taken must be consistent with the approved values.
6. The Board maintains at all times a clear distinction between Board and management roles, while recognizing the interdependencies between them.
7. The Board is accountable to: BWH’s patients and its communities served to:
• engage the communities served when developing plans and setting priorities for the delivery of health care;
• advocate for and seek resources to provide appropriate health care;
• utilize its resources effectively to fulfill BWH’s mission and mandate;
• ensure the quality and safety of patient care and service delivery • ensure the appropriate use of community contributions and
resources; • consider the diversity of needs and interests in its policy
formulation and decision-making; • work within its resources, monitoring their efficient and effective
use consistent with BWH’s mission and mandate; • measure and report on BWH performance against accepted
standards and best practices in comparable hospitals and in accordance with requirements of the Excellent Care for All Act (ECFAA), Broader Public Sector Accountability Act (BPSAA) and other all applicable legislation;
• inform the MOHLTC/ESC LHIN of any gaps between needs of the communities served and scope of services provided, based on resources allocated by the Ministry and the ESC LHIN to fulfill the BWH’s mission and mandate; and
• apprise the MOHLTC/ESC LHIN and the communities served of Board policies and decisions related to the BWH’s mandate that might be required to operate within its resources.
• identify and undertake integration opportunities (separately and in conjunction with the ESC LHIN) and other health service providers to provide appropriate, co-ordinated, effective and efficient services and that are consistent with the mission, vision, values and strategic plan of BWH and in the best interests of the community.
Formatted: List Paragraph
Commented [MR1]: This is not best practice
PRINCIPLES OF GOVERNANCE & BOARD ACCOUNTABILITY
Number: GOV 5.10 Page 3 of 5
• disclose information about BWH’s governance processes, decision-
making and performance in an open and transparent manner.
PRINCIPLES OF GOVERNANCE & BOARD ACCOUNTABILITY
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the Ministry of Health and Long-Term Care (MOHLTC) and/or the Erie St.
Clair LHIN (ESC LHIN) to: • comply with applicable government legislation, regulations,
directives policies and directions; • ensure that BWH operates within:
• the MOHLTC’s provincial strategic plan; • the ESC LHIN’s integrated health service plan; • the service accountability agreements with the ESC LHIN
• work within its resources, monitoring their efficient and effective use consistent with BWH’s mission and mandate;
• measure and report on BWH performance against accepted standards and best practices in comparable hospitals;
• inform the MOHLTC/ESC LHIN of any gaps between needs of the communities served and scope of services provided, based on resources allocated by the MOHLTC/ESC LHIN to fulfill the BWH’s mission and mandate; and
• apprise the MOHLTC/ ESC LHIN and the communities served of Board policies and decisions related to the BWH’s mandate that might be required to operate within its resources.
• identify and undertake integration opportunities (separately and in conjunction with the ESC LHIN) and other health service providers to provide appropriate, co-ordinated, effective and efficient services and that are consistent with the mission, vision, values and strategic plan of BWH and in the best interests of the community.
• disclose information about BWH’s governance processes, decision-making and performance in an open and transparent manner.
8. Consistent with the Board’s commitment to good governance practices, timely access to information, appropriate protection of personal privacy, and appropriate protection of other information that is exempt or excluded from disclosure under the Freedom of Information and Protection of Privacy Act, the Board will make available to the public information about its governance processes, decision making and organizational performance including, but not limited to: the statement of Board and Director roles, responsibilities and
accountabilities; a list and biographies of elected and ex-officio Directors and their
participation on Board committees; the Board policies addressing governance structures and processes,
including those which address how the Board functions independently of management;
the terms of reference governing Board standing committees; the results of BWH’s participation in the voluntary national accreditation
process through Accreditation Canada; the Hospital and Multi-Sectoral Service Accountability Agreements with
the MOHLTC and ESC LHIN; the Open Board meeting information package with the CEO report and
Board meeting highlights;
PRINCIPLES OF GOVERNANCE & BOARD ACCOUNTABILITY
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an annual report, including audited financial statements, outlining BWH’s
accomplishments and performance; performance reporting information in compliance with the requirements of
ECFAA, BPSAA, and the FIPPA and other applicable government legislation or directives; and
a summary of the processes through which BWH demonstrates accountability, transparency and engagement.
Monitoring Method and Frequency: 1) Accreditation Canada Survey and report (timing
aligned with Accreditation cycleevery three years) 2) Board Evaluation (as per Policy 5.86)
3) Review of Global Communications and Community Engagement Plan/Status Report (every three years, aligned with Strategic Planning cycle)
4) CAP and RHAP reports and evaluations (annually) 5) Review of the Policy (every three years)
Page 1 of 4 Manual GOVERNANCE POLICY
POLICY Section 5.0 Board Effectiveness – Governance Policy Framework
Title ROLES AND RESPONSIBILITIES OF THE BOARD OF DIRECTORS
Issuing Body/ Prepared By
Governance and Nominating Committee
Approved by Board of Directors Number: GOV 5.15 Effective Date Revised Date
O: January 2009 R: June 2012 January 2016
June 2018
Version 34 File Name:
Controlled document. Any documents appearing in paper form must be used for reference purposes only. The on-line copy on the file server above must be considered the current documentation.
Purpose As part of its responsibility for ensuring Board effectiveness, the Board of Bluewater Health (BWH) will establish, approve and periodically review a description of the Roles and Responsibilities of the Board of Directors. This description is an important requirement of effective governance. It addresses the Board’s expectations for itself and provides the foundation upon which the Board’s performance can be evaluated. This policy sets out the Roles and Responsibilities of the Board of Directors as developed and approved by the Board of BWH. Policy The Board governs by fulfilling the following roles: 1.0 Policy Formulation Establish policies to provide guidance to those empowered with the responsibility to lead and manage BWH operations. 2.0 Decision-Making On matters that specifically require Board approval, choose from alternatives that are consistent with Board policies and that advance the goals of BWHDirectors will ensure the ethical framework/principle based decision making approach is applied in Board decision making processes. 3.0 Oversight Monitor and assess organizational processes and outcomes. Responsibilities of the Board A) Establish Strategic Direction
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ROLES AND RESPONSIBILITIES OF THE BOARD OF DIRECTORS
Number: GOV 5.15 Page 2 of 4
• Consider key healthcare needs and stakeholders, and engage the
community of diverse persons and entities when developing plans and setting priorities for the delivery of healthcare
• Establish and periodically review BWH’s mission, vision and values • Contribute to the development of and approve the strategic plan of BWH,
ensuring . Ensure that it is alignedalignment with the provincial strategic plan and the LHIN integrated health services plan. Conduct a review of the strategic plan as part of a regular annual planning cycle
• Ensure that Board decisions are consistent with BWH’s mission, vision, values and strategic plan
• Monitor corporate performance regularly against the strategic plan and performance indicators
B) Provide for Excellent Management
• Select and appoint the President and Chief Executive Officer (“CEO”) • Establish measurable annual performance expectations in co-operation with
the President/CEO, assess the President/CEO performance annually and determine compensation
• Delegate responsibility and authority to the President/CEO for the management and operation of BWH and require accountability to the Board
• Select and appoint the Chief of Professional Staff (COPS) • Establish measurable annual performance expectations in co-operation with
the Chief of Professional StaffCOPS, assess Chief of Professional Staff COPS performance annually and determine compensation
• Delegate responsibility and authority to the Chief of Professional Staff COPS for the supervision of the practice of medicine, dentistry and midwifery, and extended class nurses with privileges, within BWH and require accountability to the Board
• Provide for President/CEO and Chief of Professional Staff COPS succession
• Ensure that the President/CEO and the Chief of Professional Staff COPS establish an appropriate succession plan for senior management and Professional Staff and a human resource plan, with review of such plans annually
• Appoint Medical Directors and other medical leadership positions, on the recommendation of the Chief of Professional StaffCOPS, as required under Bluewater Health’s by-laws and the Public Hospitals Act
• Establish and monitor implementation of policies to provide the framework for the management and operation of BWH, in compliance with applicable laws and regulations
C) Ensure Program Quality and Effectiveness • Ensure the effectiveness and fairness of the annual credentialing process
for the Professional Staff • Review and approve appointments, reappointments and privileges for
Professional Staff as recommended by the Medical Advisory Committee, in consideration of BWH’s resources and the community’s needs
• Provide oversight of the credentialed Professional Staff through the Chief of Professional Staff COPS and the Medical Advisory Committee and, if necessary or advisable, effect the restriction, suspension or revocation of privileges of any credentialed professional staff member as provided under
ROLES AND RESPONSIBILITIES OF THE BOARD OF DIRECTORS
Number: GOV 5.15 Page 3 of 4
the Public Hospitals Act, following recommendation by the Medical Advisory Committee
• Review and approve the Quality Improvement Plan , quality goals and performance indicators (using best practices and benchmarks) and monitor indicators of clinical outcomes, quality of care and service delivery, patient safety, satisfaction and organizational risk
• Ensure the development of a process for identifying, managing and monitoring organizational risks
• Ensure that policies and processes to manage resource utilization and patient safety are in place and operating effectively
• Ensure that policies are in place to provide a framework for addressing ethical issues arising from clinical care, education and research
• Ensure that management has plans in place to address variances from performance standards, including management of critical incidents , systemic or recurring quality of care issues, and complaints and concerns, and oversee implementation of the remediation plans
D) Ensure Financial Viability
• Approve the annual operating and capital budget, and monitor financial performance periodically against the budget and agreed-upon indicators
• Ensure that management undertakes multi-year financial planning, optimizes the use of resources, operates within the resource envelope, adheres to the Hospital (H-SAA) and Multi-Sectoral (M-SAA) Service Accountability Agreements and manages to acceptable levels of risk
• Ensure policies are in place on asset protection, procurement, borrowing, signing authority, resource planning, financial condition, expense reimbursement and perquisites
• Approve an investment policy and monitor compliance • Ensure that management has measures in place to ensure the integrity of
internal accounting controls and reporting processes and the effectiveness of management information systems
• Ensure that the Members appoint qualified auditors, and examine, consider and approve the Corporation’s financial statements and the report of the auditors at least annually
E) Ensure Board Effectiveness
• Recruit Directors who are skilled, experienced and committed to BWH, and plan for the succession of Directors and Officers
• Establish comprehensive Board orientation and ongoing Board development and education programs
• Establish and monitor implementation of Board goals and annual work plans for the Board and its standing committees
• Ensure that the Board receives timely, appropriate information to support informed policy formulation, decision-making and oversight
• Establish and periodically review policies concerning governance structures and processes to maximize the effective functioning of the Board
• Establish a policy and process for evaluating the performance of the Board as a whole and individual Directors that fosters continuous improvement
• Ensure decision-making processes are transparent • Ensure that effective mechanisms are in place for reporting on BWH
performance
ROLES AND RESPONSIBILITIES OF THE BOARD OF DIRECTORS
Number: GOV 5.15 Page 4 of 4
• Ensure that the Board adheres to the Principles of Governance and
Accountability statement and demonstrates accountability to its stakeholders
• Ensure that the Board fulfills all of its responsibilities as set forth by the Public Hospitals Act, the Excellent Care for All Act, the Broader Public Sector Accountability Act and all other applicable legislation.
F) Foster Relationships
• Ensure that BWH builds and maintains positive relationships with the ESC LHIN in fulfilling BWH’s service accountability agreements with the ESC LHIN and its obligations under provincial policies established by the Ministry of Health and Long-Term Care
• Ensure that BWH is fulfilling its role within the ESC LHIN region by fostering effective coordination and integration of patient care and health service delivery and positive working relationships with other community health service providers
• Ensure that mechanisms are in place to build and maintain positive relationships and effective two-way communication within BWH with Professional Staff, staff, volunteers, the Foundations and with the community served.
Monitoring Method and Frequency: 1. Accreditation Canada Survey and report (timing
aligned with Accreditation cycleevery three years) 2. Review of Global Communications and Community
Engagement Plan/Status Report (every three years, aligned with Strategic Planning cycle)
3. Board Evaluation (as per Policy 5.86) 4. Individual Director Evaluation (as per Policy 5.86) 5. Review of the Policy (every three years)
Page 1 of 4 Manual GOVERNANCE POLICY
POLICY
Section 5.0 Board Effectiveness – Governance Policy Framework
Title BOARD CHAIR POSITION DESCRIPTION Issuing Body/ Prepared By
Governance and Nominating Committee
Approved by Board of Directors Number: GOV 5.45 Effective Date Revised Date
O: January 2005 R: March 2007 October 2007 January 2009 June 2012 October 2015 June 2018
Version 67 File Name: S:\CHIEF EXECUTIVE OFFICER\BOARD AND BOARD COMMITTEES\BOARD BWH\BOARD POLICIES\5.45 - Board Chair Position Description - October 2015.Docx
Controlled document. Any documents appearing in paper form must be used for reference purposes only. The on-line copy on the file server above must be considered the current documentation.
Purpose As part of its responsibility for ensuring Board effectiveness, the Board of Bluewater Health (BWH) will establish, approve and periodically review a position description for Board Chair. This description is an important requirement of effective governance as it provides the Chair and all Directors and Non-Director Committee Members (NDCMs) with a clear understanding of what is expected of this position and serves as a benchmark against which the performance of the Chair can be assessed. This policy sets out the position description of the Board Chair as developed and approved by the Board of BWH. Policy Role Statement The Board Chair, working collaboratively with the President/CEO and the Chief of Professional Staff, provides leadership to the Board, ensures the integrity and effectiveness of the Board’s governance role and processes and represents the Board within the hospital and to outside parties. The Board Chair co-ordinates the activities of the Board in fulfilling its governance responsibilities and facilitates co-operative relationships among Board and NDCMs, between the Board and President/CEO and the Board and Chief of Professional Staff and with internal and external stakeholders. The Board Chair ensures that all matters relating to the Board’s mandate are brought to the attention of, and discussed by, the Board.
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BOARD CHAIR POSITION DESCRIPTION Number: GOV 5.45 Page 2 of 5
Responsibilities Board Governance: Through the work of the Governance and Nominating Committee, overseeensures the quality of the Board’s governance processes including that: • the Board’s governance structures and processes are reviewed, evaluated and revised,
as required • Ensuring that the Board performs a governance role that respects and understands the
role of management; • Ensuring that the Board develops and implements annual goals and a work plan that are
aligned with the hospital’s mission, vision and values and strategic priorities and embrace continuous improvement;
• Ensuring that the work of the Board committees is aligned with the Board’s role and annual work plan and that the Board respects and understands the role of Board committees;
• Ensuring Board succession planning through processes to recruit, select and educate Directors and NDCMs with the skills, experience, background and personal qualities required for effective governance;
• Ensuring that the Board , individual Directors and NDCMsmembers have have access to appropriate orientation and education;
• Overseeing the Board orientation and education processes • and providing cConstructive feedback is provided to to Committee Chairs, Directors
and NDCMs, as required, to foster continuous improvement; and • Ensuring that the Board’s governance structures and processes are reviewed, evaluated
and revised, as required.
Board Meetings: • Ensure that a schedule of Board meetings is prepared annually and is reflective of
current Board issues, needs and/or interests. • Establish agendas for board meetings in collaboration with the President/CEO that are
aligned with the Board’s roles, annual goals, work plan and current issues. • Preside over meetings of the Board and Executive Committee. • Ensure that meetings are conducted according to applicable legislation, the by-laws,
and the Board’s governance policies and Rules of Order. • Facilitate and advance the business of the Board, ensuring that meetings are effective
and efficient for the performance of governance work. • Utilize a practice of referencing BWH’s Strategic Priorities, Board goals and Board
policies in guiding discussions in order to support the decision-making processes of the Board.
• Encourage input and ensure that the Board hears all sides of a debate or discussion. • Encourage all Directors to participate in the discussions. • Facilitate the Board in reaching consensus and decisions. • Ensure relevant information is made available to the Board in a timely manner, and that
external advisors are available to assist the Board as required.
Direction: • Serve as the Board’s central point of official communication with the President/CEO and
Chief of Professional Staff.
BOARD CHAIR POSITION DESCRIPTION Number: GOV 5.45 Page 3 of 5
• Guide and counsel the President/CEO and Chief of Professional Staff regarding the
Board’s expectations and concerns. • Serve as a resource to the President/CEO and Chief of Professional Staff at his/her
request. • In collaboration with the President/CEO, develop standards for Board decision-support
packages. This documents that includes formats for reporting to the Board and the with level of detail provided to ensure that BWH management strategies and planning and performance information are appropriately presented to the Board.
Performance Evaluation: • Lead the Board in monitoring and evaluating the performance of the President/CEO and
Chief of Professional Staff through an annual process as outlined in Board policies (GOV 2.30 – CEO and COPS Performance Management and Evaluation).
• Representation: • Ensure that the Board is appropriately represented at BWH functions, other official
functions and to the community and public at large. • Serve as the Board’s exclusive official spokesperson and contact with the media, unless
otherwise delegated. Relationships and Mentorship: • Facilitate relationships with, and communication among Directors and NDCMs and
between Directors, NDCMs and the President/CEO and Chief of Professional Staff • Provide assistance and advice to committee Chairs to ensure they understand Board
expectations and have resources required to fulfill their Terms of reference • Serve as a mentor to other Directors and NDCMs to ensure that each is supported and
contributes his/her special skills and expertise effectively in the performance of their roles
• Provide feedback to individual Directors and NDCMs on performance, including addressing issues associated with underperformance, in order to facilitate continuous improvement
• Maintain a constructive working relationship with the President/CEO and Chief of Professional Staff providing advice, counsel and an understanding of Board expectations
Reporting: • Report regularly and promptly to the Board regarding issues that are relevant to its
governance responsibilities. • Report to the annual meeting of the members concerning the operations of BWH. Board Conduct: • Set a high standard for Board conduct and enforce by-laws and policies regarding
Director and NDCM conduct. Succession Planning: • Ensure succession planning occurs for the President/CEO, Chief of Professional Staff
and the Board and its Standing Committees.
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BOARD CHAIR POSITION DESCRIPTION Number: GOV 5.45 Page 4 of 5
BOARD CHAIR POSITION DESCRIPTION Number: GOV 5.45 Page 5 of 5
Committee Membership: • Serve as an ex-officio member of all Board standing committees, sub-committees and
special committees (but not generally be expected to participate in their work and deliberations). •
Skills, Attributes and Experience The Board Chair will possess the following personal qualities, skills and experience: • All of the personal attributes required of a Director; • Substantial governance experience in the hospital, not-for profit or broader public sector,
preferably as a Board Chair; • Demonstrated leadership skills; • Strategic and facilitation skills; • Tact and diplomacy skills; • Ability to effectively influence and build consensus within the Board; • Ability to establish trusted advisor relationship with the President/CEO, Chief of
Professional Staff and other Directors and NDCMs; • Ability to make the necessary time commitment and required flexibility in work schedule
to meet the requirements of this leadership role; • Ability to communicate effectively with the Board, Senior Management, the Ministry of
Health and Long-Term Care, the Erie St. Clair Local Health Integration Network and the community;
• Demonstrated commitment to continuous learning and self-development in areas of skills and expertise required by the Board and that will enhance Board effectiveness;
• Demonstrated commitment to the Principles of Governance and Board Accountability.
Term The Board Chair shall be elected by the Board to serve a two-year term. Following completion of the two-year term, the individual may be re-elected for a further one-year term. Monitoring: Method and Frequency 1. Board Evaluation (as per Policy 5.86)
2. Individual Director and NDCM Evaluation (as per Policy 5.86) 32. Review of the Policy (every three years) 3. Accreditation Canada Survey and Report (timing aliged with
Accreditation cycle)
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Page 1 of 2 Manual GOVERNANCE POLICY
POLICY
Section 5.0 Board Effectiveness - Governance Policy Framework
Title BOARD VICE-CHAIR POSITION DESCRIPTION
Issuing Body/ Prepared By
Governance and Nominating Committee
Approved by Board of Directors Number: GOV 5.50 Effective Date Revised Date
O: January 2009 R: June 2012 October 2015
June 2018
Version 34 File Name: S:\CHIEF EXECUTIVE OFFICER\BOARD AND BOARD COMMITTEES\BOARD BWH\BOARD POLICIES\5.50 - Board Vice-Chair Position Description - October 2015.Docx
Controlled document. Any documents appearing in paper form must be used for reference purposes only. The on-line copy on the file server above must be considered the current documentation.
Purpose As part of its responsibility for ensuring Board effectiveness, the Board of Bluewater Health (BWH) will establish, approve and periodically review a position description for the Board Vice-Chair. This description is an important requirement of effective governance as it provides the Vice-Chair and all Directors and Non-Director Committee Members (NDCMs) with a clear understanding of what is expected of this position and serves as a benchmark against which the performance of the Vice-Chair can be assessed. This policy sets out the position description of the Board Vice-Chair as developed and approved by the Board of BWH. Policy Role Statement The Vice Chair works collaboratively with the Board Chair and . He or she supports the Board Chair in fulfilling his/ or her responsibilities. Responsibilities Board Chair Substitute: Assume the duties of the Board Chair in his or /her absence, as requested by the Chair, including representing the Board and the Hospital at official functions and to the public at large. Board Conduct: Maintain a high standard for Board conduct and enforce by-laws and policies regarding Director and NDCM conduct. Mentorship:
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BOARD VICE-CHAIR POSITION DESCRIPTION Number: GOV 5.50 Page 2 of 3
Serve as a mentor to other Directors and NDCMs.
BOARD VICE-CHAIR POSITION DESCRIPTION Number: GOV 5.50 Page 3 of 3
Committee Membership: Serve as a member of the Executive Committee and at least one additional standing committee of the Board. Skills, Attributes and Experience The Vice-Chair will possess the following personal qualities, skills and experience: • Hospital Board experience • All of the personal attributes required of a Director and Committee Chair; • Demonstrated management Leadership skills; • Strategic and facilitation skills; • Tact and diplomacy skills; • Ability to effectively influence and build consensus within the Board; • Ability to establish trusted advisor relationship with the President/CEO, Chief of
Professional Staff, other Directors and NDCMs; • Ability to make the necessary time commitment and required flexibility in work schedule
to meet the requirements of this leadership role; • Ability to communicate effectively with the Board, Senior Management, the Ministry of
Health and Long-Term Care, the Erie St Clair Local Health Integration Network and the community;
• Demonstrated commitment to continuous learning and self-development in areas of skills and expertise required by the Board and that will enhance Board effectiveness;
• Demonstrated commitment to the Principles of Governance and Board Accountability.
Term The Vice-Chair shall be elected annually by the Board. An individual may serve a maximum of three (3) consecutive annual terms as Vice-Chair provided that the Board may approve extensions in exceptional circumstances. Monitoring Method and Frequency 1. Board Evaluation (as per Policy 5.86)
2. Individual Director and NDCM Evaluation (as per Policy 5.86)
32. Review of the Policy (every three years) 3. Accreditation Canada Survey and report (timing aligned with
Accreditation cycle)
Page 1 of 2 Manual GOVERNANCE POLICY
POLICY
Section 5.0 Board Effectiveness – Governance Policy Framework
Title BOARD TREASURER POSITION DESCRIPTION
Issuing Body/ Prepared By
Governance and Nominating Committee
Approved by Board of Directors Number: GOV 5.55 Effective Date Revised Date
O: January 2009 R: June 2012 October 2015
June 2018
Version 34 File Name: S:\CHIEF EXECUTIVE OFFICER\BOARD AND BOARD COMMITTEES\BOARD BWH\BOARD POLICIES\5.55 - Board Treasurer Position Description - October 2015.Docx
Controlled document. Any documents appearing in paper form must be used for reference purposes only. The on-line copy on the file server above must be considered the current documentation.
Purpose As part of its responsibility for ensuring Board effectiveness, the Board of Bluewater Health (BWH) will establish, approve and periodically review a position description for Board Treasurer. This description is an important requirement of effective governance as it provides the Chair and all Directors and Non-Director Committee Members (NDCMs) with a clear understanding of what is expected of this position and serves as a benchmark against which the performance of the Treasurer can be assessed. This policy sets out the position description of the Board Treasurer as developed and approved by the Board of BWH. Policy Role Statement The Treasurer works collaboratively with the Board Chair and President/CEO to support the Board in fulfilling its fiduciary responsibilities. Responsibilities Board Conduct: Maintain a high standard for Board conduct and uphold by-laws and policies regarding Director and NDCM conduct, with particular emphasis on fiduciary responsibilities. Mentorship: Serve as a mentor to other Directors and NDCMs.
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BOARD TREASURER POSITION DESCRIPTION Number: GOV 5.55 Page 2 of 2
Committee Membership: Serve as a member of the Executive Committee and chair the Resource Utilization and Audit Committee. Audited Financial Statement: Present to the annual general meeting as part of the annual report, an audited financial statement of BWH and the report thereon of the independent auditors. Skills, Attributes and Experience The Treasurer will possess the following personal qualities, skills and experience: • All of the personal attributes required of a Director and Committee Chair; • Strong financial management literacy, preferably with education and work experience in
the professional accounting and/or finance fields; • Ability to make the necessary time commitment and required flexibility in work schedule
to meet the requirements of this leadership role; • Ability to communicate effectively and efficiently; • Demonstrated commitment to continuous learning and self-development in areas of
skills and expertise required by the Board and that will enhance Board effectiveness; • Demonstrated commitment to the Principles of Governance and Board Accountability.
Term The Treasurer shall be elected annually by the Board. An individual may serve a maximum of three (3) consecutive annual terms as Treasurer provided that the Board may approve extensions in exceptional circumstances. Monitoring Method and Frequency 1. Board Evaluation (as per Policy 5.86)
2. Individual Director and NDCM Evaluation (as per Policy 5.86) 3. Review of the Policy (every three years) 4. Accreditation Canada Survey and report (timing aligned with
Accreditation cycle)
Page 1 of 3 Manual GOVERNANCE POLICY
POLICY
Section 5.0 Board Effectiveness – Governance Policy Framework
Title BOARD COMMITTEE CHAIR POSITION DESCRIPTION
Issuing Body/ Prepared By
Governance and Nominating Committee
Approved by Board of Directors Number: GOV 5.60 Effective Date Revised Date
O. January 2009 R: June 2012 October 2015
June 2018
Version 34 File Name: S:\CHIEF EXECUTIVE OFFICER\BOARD AND BOARD COMMITTEES\BOARD BWH\BOARD POLICIES\5.60 - Board Committee Chair Position Description - October 2015.Docx
Controlled document. Any documents appearing in paper form must be used for reference purposes only. The on-line copy on the file server above must be considered the current documentation.
Purpose As part of its responsibility for ensuring Board effectiveness, the Board of Bluewater Health (BWH) will establish, approve and periodically review a position description for Board Committee Chair. This description is an important requirement of effective governance as it provides the Committee Chair, all Directors and Non-Director Committee Members (NDCMs) with a clear understanding of what is expected of this position and serves as a benchmark against which the performance of the Committee Chair can be assessed. This policy sets out the position description of the Committee Chair as developed and approved by the Board of BWH. Policy Role Statement A Committee Chair, working collaboratively with assigned staff support, provides leadership to the committee. He or she ensures that the terms of reference of the committee are followed. He or she effectively manages issues to promote effective dialogue. He or/ she respects that the committee has no direct management role with Hospital staff. Responsibilities Agendas: Establish agendas, consistent with the Board approved committee work plan, in collaboration with staff support and preside over meetings of the committee.
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BOARD COMMITTEE CHAIR POSITION DESCRIPTION
Number: GOV 5.60 Page 2 of 3
Leadership: Effectively leadfacilitate each committee meeting in a manner that encourages thoughtful participation and promotes understanding of complex issues. Ensure a fair discussion, especially when differences and conflicting opinions arise. Expertise: Serve as a leader within the Board on the matters addressed in the committee’s terms of reference. Advise Board Chair: AdviseLiaise with the Board Chair on the key issues and recommendations addressed by the committee. Report to the Board: After each committee meeting, with the assistance of executive staff support, prepare a report and where appropriate, decision-support recommendations summaries, as applicable, for consideration by submission to the Board. Work Plan: With the assistance of executive staff support, develop an annual work plan that fulfills the responsibilities of the committee and is consistent with the Board work plan. Mentorship: Serve as a mentor to committee members and with the Board Chair develop a succession plan for the chair. Skills, attributes and experience: A Committee Chair will possess the following personal qualities, skills and experience:
• All of the personal attributes required of a Director; • Interest and experience related to the work of the Committee; • Ability to chair a meeting such that decisions are made in a manner that is respectful and
efficient; • Willingness and ability to commit time to the responsibilities of the Committee Chair; • Demonstrated commitment to continuous learning and self-development in areas of
skills and expertise required by the Board and that will enhance Board effectiveness;
• Demonstrated commitment to the Principles of Governance and Board Accountability.
Term A Committee Chair shall be elected by the Board for a one (1) year term. An individual may be re-elected to chair the same committee or may be elected to chair a different committee following completion of his/her term.
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BOARD COMMITTEE CHAIR POSITION DESCRIPTION
Number: GOV 5.60 Page 3 of 3
Monitoring Method and Frequency: 1. Board Evaluation (as per Policy 5.86)
2. Committee Evaluation (as per policy 5.86) 3. Individual Director and NDCM Evaluation (as per policy 5.86) 4. Review of the policy (every three years) 5. Accreditation Canada Survey and Report (timing aligned with
Accreditation cycle)
Page 1 of 3 Manual GOVERNANCE POLICY
POLICY Section 5.0 Board Effectiveness - Governance Policy Framework
Title NON-DIRECTOR COMMITTEE MEMBERS Issuing Body/ Prepared By
Governance and Nominating Committee
Approved by Board of Directors Number: GOV 5.65 Effective Date Revised Date
O: January 2006 R: January 2009 June 2012 June 2015
June 2018
Version 45 File Name: J:\Departmental\Admin\CHIEF EXECUTIVE OFFICER\BOARD AND BOARD COMMITTEES\BOARD BWH\BOARD POLICIES\5.65 - Non Director Committee Members - April 2015 (XREF 570).Docx
Controlled document. Any documents appearing in paper form must be used for reference purposes only. The on-line copy on the file server above must be considered the current documentation.
Purpose As part of its responsibility for ensuring Board effectiveness, the Board of Bluewater Health (BWH) has determined that the participation of Non-Directors from the community as members of certain Board Committees is beneficial to obtain a broad range of perspectives, to provide additional expertise and to identify and assess individuals’ interest and aptitude to be Directors in the future. This policy sets out selection process and responsibilities of Non-Director Committee Members (NDCMs). Policy Selection The Governance & Nominating Committee is responsible for recommending individuals to the Board to serve as Non-Director Committee Members NDCMsfor in accordance with the Nominations Process pPolicy (GOV-5.70). Non-Director Committee Members NDCMs shall meet the qualifications for Directors as set out in this Policy and in the in s.5.03 of the Corporate By-laws of BWH. Non-Director Committee Members NDCMs shall have one (1) year renewable terms. No individual shall serve more than five (5) consecutive one-year terms as a Non-Director Committee MemberNDCM, except as otherwise permitted from time to time by resolution of the Board. Professional Staff Association (PSA) The PSA annually elects Professional Staff members to its Executive Committee. These PSA members are then appointed to Board Standing Committees through processes established by the Chief Executive Officer (CEO) and Chief of Professional Staff (CoPS). For the purposes of role clarity at Board Standing Committee meetings, the Vice-President Sarnia and Secretary/Treasurer should be considered NDCMs once appointed.
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NON-DIRECTOR COMMITTEE MEMBERS Number: GOV 5.65 Page 2 of 4
Other NDCM Positions The Quality Committee of the Board membership includes two Patient Experience Partners (PEPs), one Professional Staff Association member (non-executive) and one hospital employee member other than a physician or nurse. The PEPs are selected by the BWH Patient Experience Partner Council. The Professional Staff and hospital employee positions are selected through processes established by the CEO and CoPS respectively. For the purposes of role clarity at Quality Committee of the Board meetings, these positions should be considered NDCMs once appointed. Responsibilities 1.0 Accountability and Fiduciary Duties A Non-Director Committee Member NDCM acts ethically, honestly, in good faith and in the best interests of Bluewater Health and in so doing, supports Bluewater Health in fulfilling its mission and mandate, and discharging its accountabilities. A Non-Director Committee Member NDCM exercises the care, diligence and skill that a reasonably prudent person would exercise in comparable circumstances. Non-Director Committee Members NDCMs with special skill and knowledge are expected to apply that skill and knowledge to matters that come before the Committee. A Non-Director Committee Member NDCM does not represent the specific interests of any constituency. A Non-Director Committee Member NDCM acts and makes decisions that are in the best interest of Bluewater Health as a whole. A Non-Director Committee Member NDCM adheres to the vision, mission and values of Bluewater Health and complies with the Public Hospitals Act, the Corporations Act, by-laws, applicable laws and regulations and Board policies. A Non-Director Committee Member NDCM adheres to the Principles of Governance and Board Accountabilities policy (GOV-5.10). 2.0 Exercise of Authority A Non-Director Committee Member NDCM carries out the powers of office only when acting as a voting member during a duly constituted meeting of the Committee. A Non-Director Committee Member NDCM respects the responsibilities delegated by the Board to the President/Chief Executive Officer and Chief of Professional Staff, avoiding interference with their duties but insisting upon accountability to the Committee and reporting mechanisms for assessing organizational performance. 3.0 Conflict of Interest A Non-Director Committee Member NDCM does not place him/herself in a position where his/her personal interests conflict with those of Bluewater Health. A Non-Director Committee Member NDCM complies with the Conflict of Interest provisions in the by-laws and Board policy. 4.0 Team Work A Non-Director Committee Member NDCM works positively, cooperatively and respectfully with others in the performance of his or her duties while exercising independence in decision making. 5.0 Participation A Non-Director Committee Member NDCM reviews pre-circulated material and comes prepared to Committee meetings and educational activities, asks informed questions, and makes a constructive contribution to discussions. A Non-Director Committee Member NDCM considers the need for independent advice to the Committee on major corporate actions.
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NON-DIRECTOR COMMITTEE MEMBERS Number: GOV 5.65 Page 3 of 4
6.0 Formal Dissent A Non-Director Committee Member NDCM reviews the minutes of the previous meeting on receipt and insists that they record any Non-Director Committee MemberNDCM’s disclosure of an actual or potential conflict of interest, abstention or dissent. A Non-Director Committee Member NDCM who is absent from a Committee meeting is deemed to have supported the decisions taken and policies approved by the Committee in his or her absence unless he or she formally records a dissenting view with the Committee secretary. 7.0 Board Solidarity The official spokesperson for the Board and its committees is the Chair or the Chair’s designate. A Non-Director Committee MemberNDCM supports the decisions and policies of the Committee in discussions with outsiders, even if the Non-Director Committee Member NDCM holds another view or voiced another view during a Committee discussion or was absent from the Committee meeting. A Non-Director Committee Member NDCM refers requests for comments on behalf of the Committee to the Committee Chair. 8.0 Confidentiality A Non-Director Committee MemberNDCM respects the confidentiality of Committee discussions and information. 9.0 Time and Commitment A Non-Director Committee Member NDCM is expected to commit the time required to fulfill Committee responsibilities. A Non-Director Committee Member NDCM is expected to attend a minimum of 85% of the meetings of the Committees of which he/she is a member. Non-Director Committee Members NDCMs who fail to meet the attendance requirements are subject to review by the Committee Chair and may be asked to step down from the Committee. 10.0 Competencies A Non-Director Committee Member NDCM actively contributes specific expertise, skills and other attributes that are needed on the Committee. 11.0 Education A Non-Director Committee Member NDCM seeks opportunities to be educated and informed about the Committee, the Board and the key issues at Bluewater Health and in the broader health care system through participation in Board and Committee orientation and education programs, maximizing use of information and resources on the Board website, participation in strategic planning processes, Board retreats and other mechanisms, as appropriate. 12.0 Self-Evaluation and Continuous Improvement A Non-Director Committee Member NDCM is committed to a process of continuous self-improvement as a Committee member. All Non-Director Committee Member NDCMs participate in the evaluation of the Committee and in individual Non-Director Committee Member NDCM evaluations and act upon results in a positive and constructive manner. 13.0 Fundraising Activity A Non-Director Committee Member NDCM supports the efforts of the Bluewater Health Foundation and Charlotte Eleanor Englehart Hospital Foundation. Monitoring Method and Frequency: 1. Non-Director Committee Member evaluation (as per Policy
5.86)
NON-DIRECTOR COMMITTEE MEMBERS Number: GOV 5.65 Page 4 of 4
2. Committee Evaluation (as per Policy 5.86) 3. Board Evaluation (as per Policy 5.86) 4.. Review of the Policy (every three years) 3. Accreditation Survey and Report (timing aligned with
Accreditation cycle)
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Page 1 of 3 Manual GOVERNANCE POLICY
POLICY Section 5.0 Board Effectiveness – Governance Process Title CODE OF CONDUCT Issuing Body/ Prepared By
Governance and Nominating Committee
Approved by Board of Directors Number: GOV 5.75 Effective Date Revised Date
O: January 2005 R: May 2006 January 2013 February 2016
June 2018
Version 45 File Name: S:\CHIEF EXECUTIVE OFFICER\BOARD AND BOARD COMMITTEES\BOARD BWH\BOARD POLICIES\5.75 - Code of Conduct.rtf
Controlled document. Any documents appearing in paper form must be used for reference purposes only. The on-line copy on the file server above must be considered the current documentation.
Purpose As part of its responsibility for ensuring Board effectiveness, the Board of Bluewater Health (BWH) will establish, approve and periodically review a Code of Conduct for Elected and Ex-Officio Directors and Non-Director Committee Members (NDCMs). This Code is an important requirement of effective governance as it provides Directors and NDCMs with a clear understanding of the conduct which is expected of them and supports the Board’s commitment to the highest standards for public trust, honesty and integrity in all aspects of its affairs. This policy sets out the Code of Conduct as developed and approved by the Board of BWH. Directors and NDCMs are also required to comply with the Hospital’s Code of Conduct Policy (COR-HR-A-3.80) which applies to all employees and volunteers.. Policy The Board, its Directors and NDCMs will demonstrate ethical, respectful, businesslike, and lawful conduct, including proper use of authority and appropriate decorum in carrying out their responsibilities. Fiduciary Duties Directors and NDCMs stand in a fiduciary relationship to BWH. As fiduciaries, Directors and NDCMs must act ethically, honestly, in good faith, and solely in the best interests of BWH. Directors and NDCMs will be held to strict standards of honesty, integrity and loyalty. Conflict of Interest Directors and NDCMs will not place themselves in positions in which their personal interests will conflict with the interests of BWH. Directors and NDCMs must also avoid situations in which their duties to BWH may conflict with duties owed elsewhere. Where conflicts of interest arise, Directors and NDCMs will comply with the Conflict of Interest provisions of the by-laws.
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CODE OF CONDUCT Number: GOV 5.75 Page 2 of 4
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Confidentiality Directors and NDCMs will respect the confidentiality of matters brought before the Board and its Committees or coming to their attention through the course of their duties. Specifically, they will respect the confidentiality of in camera Board discussions and information and such other Board discussions and information as deemed to be confidential by the Board, and comply with the Confidentiality provisions of the by-laws. Directors and NDCMs owe a duty to the corporation to respect the confidentiality of information about the corporation whether that information is received in a meeting of the Board or a committee or is otherwise provided to or obtained by the Director or committee member. Directors and NDCMs shall not disclose or use for their own purpose confidential information concerning the business and affairs of the corporation unless otherwise authorized by the board. Media Relations As outlined in the Hospital’s Media Relations Policy (COR-COMPA-A-5.120), media requests are facilitated by Communications and Public Affairs. Any Director or NDCM who is questioned by media representatives will refer such individuals to Communications and Public Affairs to ensure that the most applicable spokesperson is speaking on behalf of the organization. A representative from Communications & Public Affairs will be at all Board meetings to facilitate media requests. The Board Chair will be the designated spokesperson for issues pertaining to the Board /governance, the President/CEO or Chief, Communications and Public Affairs for corporate/organizational issues and the Chief of Professional Staff (COPS) for Professional Staff issues, unless otherwise directed by Communications & Public Affairs. Board Solidarity and Spokesperson Directors and NDCMs will support the decisions and policies of the Board in discussions with outsiders, even if the Director holds another view or voiced another view during a Board or Committee discussion or was absent from the meeting. With the official spokesperson for the Board being the Chair, Directors and NDCMs will refer requests for statements on behalf of the Board to the Chair. The Board Chair may delegate his/her responsibility for representing and acting as spokesperson for the Board to other Directors, as required. When so authorized, the Director’s or NDCM’s representations will be consistent with decisions and policies of the Board. Directors will be held to strict standards of honesty, integrity and loyalty. A director shall not put personal interests ahead of the best interests of the corporation. Respectful Conduct It is recognized that Directors and NDCMs bring to the Board and its Committees diverse backgrounds, skills, experience and opinions. Directors and NDCMs will not always agree with one another on issues. All discussions and interactions will take place in an atmosphere of mutual respect and courtesy, with all striving for a consensual approach to decision-making. The authority of the Board and Committee Chairs will be respected by all Directors and NDCMs. All Directors and NDCMs must be in compliance with all municipal, provincial and federal laws and conduct themselves in a respectful, lawful manner.
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CODE OF CONDUCT Number: GOV 5.75 Page 3 of 4
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Director - Management Interactions In all interactions with the President/CEO and COPS, Directors and NDCMs will do so within the scope of the Board’s authority, recognizing the lack of authority vested in the individuals except when explicitly Board authorized. Directors and NDCMs will respect the responsibilities delegated by the Board to the President/CEO and COPS, avoiding interference with their duties. Attendance Directors and NDCMs are expected to commit the time required to fulfill Board and Committee responsibilities. Those who fail to meet the attendance and participation requirements as outlined in the Roles and Responsibilities as an Elected and Ex-Officio Director Policy (GOV 5.20) or the Non-Director Committee Member Policy (GOV 5.65) will be subject to review by the Board Chair and may be asked to step down from the Board or Committee.
CODE OF CONDUCT Number: GOV 5.75 Page 4 of 4
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Obtaining Advice of Counsel Requests to obtain outside opinions or advice regarding matters before the Board will be made through the Board Chair. Breach of the Code of Conduct In the event of a breach of this Code of Conduct by a Director or NDCM, the issue will be referred to the Executive Committee for review, to take appropriate action, up to and including recommending to the Board removal of the Director or NDCM from the Board or Committee(s). All Directors have an obligation to report a breach of the code of conduct or any illegal behavior. Monitoring Method and Frequency: 1. Board ,Evaluation Individual Director, NDCM,
Committee and Meeting Evaluations (as per Policy 5.86) 2. Review of the Policy (every three years)
3. Accreditation Report and Survey (timing aligned with Accreditation Cycle)
Manual GOVERNANCE POLICY POLICY
Section 5.0 Board Effectiveness – Governance Policy Framework
Title BOARD COMMITTEE MEMBER DECLARATION
Issuing Body/ Prepared By
Governance and Nominating Committee
Approved by Board of Directors Number: GOV 5.25 Effective Date Revised Date
O: January 2005 R: June 2018
Version 8 File Name:
Controlled document. Any documents appearing in paper form must be used for reference purposes only. The on-line copy on the file server above must be considered the current documentation.
I _______________________________________, consent to act as a: ☐ Director/Ex-officio Director of Bluewater Health (BWH) ☐ Non-Director Committee Member of BWH ☐ Patient Experience Partner of BWH ☐ Professional Staff Association Member of BWH ☐ I acknowledge and accept the accountabilities as outlined in the appended Principles of
Governance and Board Accountability Policy. ☐ I agree to comply with the performance expectations as stated in the appended Roles
and Responsibilities as an Elected and Ex-officio Director Policy/Non-Director Committee Members Policy, as applicable.
☐ I confirm that I have read, understand and will comply with the Code of Conduct Policy
as appended. ☐ I confirm that as a Committee Member, I am bound to adhere to and respect these and
all other Board policies and I undertake to do so. ☐ I confirm that I have read, understand and will comply with the specific provisions as
outlined in “Conflict of Interest” and “Confidentiality” sections of the Corporate By-law of BWH, as appended.
☐ I confirm I do not have a conflict of interest which would prevent me from serving as a
Committee Member of BWH, pursuant to the Corporate By-law of BWH. ☐ I consent to holding meetings of the Board of Directors or of any Committee of the Board
of Directors by means of such telephone, electronic or other communication facilities as permit all persons participating in the meeting to communicate with each other
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BOARD COMMITTEE MEMBER DECLARATION Number: GOV 5.25 Page 2 of 2
simultaneously and instantaneously. These consents will continue in effect from year to year so long as I am a Committee Member of the BWH Board pursuant to the Corporate By-law of BWH.
☐ I confirm I have a criminal record check, including vulnerable sector screen, on record
with BWH Administration and confirm that there have been no changes since I filed this information with BWH.
☐ I confirm that I have provided BWH Administration with a secure e-mail address/account
to receive board information and communications which may be considered confidential and I undertake to advise the Hospital in writing of any change of address/account as soon as possible after such change.
☐ I declare the above information to be true and accurate as of the date hereof.
_______________________________ _______________________________ Signature Date ______________________________ _______________________________ Chair Date Attachments: 1) Principles of Governance and Board Accountability Policy (5.10) 2) Roles and Responsibilities as an Elected and Ex-officio Director Policy (5.20) 3) Non-Director Committee Members Policy (5.65) 4) BWH Corporate By-law 5) Code of Conduct Policy (5.75)
Monitoring Method and Frequency: 1) Review by Board Chair 2) Review of the Policy (annually)
3) Accreditation Canada Survey and report (timing aligned with Accreditation cycle)
Page 1 of 1
Manual GOVERNANCE POLICY POLICY
Section 5.0 Board Effectiveness – Governance Policy Framework
Title DIRECTOR BOARD COMMITTEE MEMBER DECLARATION
Issuing Body/ Prepared By
Governance and Nominating Committee
Approved by Board of Directors Number: GOV 5.25 Effective Date Revised Date
O: January 2005 R: March 2007 October 2007 January 2009 June 2012 May 2014 June 2017June 2018
Version 78 File Name: S:\Chief Executive Officer\Board\Policies\5.25 - Director Declaration - June 2017.docx
Controlled document. Any documents appearing in paper form must be used for reference purposes only. The on-line copy on the file server above must be considered the current documentation.
As a Director, I _______________________________________, consent to act as a: ☐ Director/Ex-officio Director of Bluewater Health (BWH). ☐ Non-Director Committee Member of BWH ☐ Patient Experience Partner of BWH ☐ Professional Staff Association Member of BWH
•
☐ I acknowledge and accept the accountabilities as outlined in the appended “Principles of Governance and Board Accountability” pPolicy. (GOV 5.10)
☐ I and agree to comply with the performance expectations as stated in the
appended “Roles and Responsibilities as an Elected and Ex-officio Director” pPolicy/Non-Director Committee Members Policy, as applicable. (GOV 5.20).
☐ I confirm that I have read, understand and will comply with the Code of Conduct
Policy as appended. ☐ I confirm that as a DirectorCommittee Member, I am bound to adhere to and
respect these and all other Board policies and I undertake to do so..
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BOARD COMMITTEE MEMBER DIRECTOR DECLARATION
Number: GOV 5.25 Page 2 of 3
• ☐ I • confirm that I have read, understand and will comply with the specific provisions as outlined in Article 5.09 “Conflict of Interest” and Article 5.10 “Confidentiality”, sections of the BWH Corporate By-law of BWHs, as appended. ☐ I • confirm that I do not have a conflict of interest which would prevent me from serving as a
Committee Member Director of BWH, pursuant to Article 5.09 “Conflict of Interest”, of the BWH Corporate By-law of BWHs. .
☐ I c consent , pursuant to the provisions of the Article 1.02 (a) of the BWH By-laws, as
appended, to holding meetings of the Board of Directors or of any Committee of the Board of Directors by means of such telephone, electronic or other communication facilities as permit all persons participating in the meeting to communicate with each other simultaneously and instantaneously. These consents will continue in effect from year to year so long as I am a Committee Member Director onf the BWH Board pursuant to the Corporate By-law of BWH.
• ☐ I confirm I
have a criminal record check, including vulnerable sector screen, on record with BWH Administration and confirm that there have been no changes since I filed this information with BWH.*
• ☐ I confirm that I have provided BWH Administration with a secure e-mail address/account
to receive board information and communications which may be considered confidential and I undertake to advise the Hospital in writing of any change of address/account as soon as possible after such change.
• ☐ I • declare the above information to be true and accurate as of the date hereof.
_______________________________ _______________________________ Signature Date
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BOARD COMMITTEE MEMBER DIRECTOR DECLARATION
Number: GOV 5.25 Page 3 of 3
______________________________ _______________________________ Chair Date Attachments: 1) “Principles of Governance and Board Accountability” pPolicy (GOV 5.10) 2) “Roles and Responsibilities as an Elected and Ex-officio Director” pPolicy (GOV 5.20) 3) Non-Director Committee Members Policy (5.65) 2) 3) Articles 1.02 (a), 5.09 and 5.10 of the BWH Corporate By-law By-laws 4) 5) Code of Conduct Policy (5.75)
Monitoring Method and Frequency: 1) Review by Board Chair 2) Review of the Policy (every three yearsannually)
3) Accreditation Canada Survey and report (timing aligned with Accreditation cycle)
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Page 1 of 2 Manual GOVERNANCE POLICY
Policy Section 6.0 Fostering Relationships
Title FREEDOM OF INFORMATION – DELEGATION OF AUTHORITY AND OVERSIGHT
Issuing Body/ Prepared By
Governance and Nominating Committee Quality Committee of the Board
Approved by Board of Directors Number: GOV 6.50 Effective Date Revised Date
O: November 2011 R: September 2015
May 2018
Version 23 File Name: S:\Admin\Chief Executive Officer\Board\Policies\6.50 Freedom of Information FOI Delegation of Authority and Oversight.doc
Controlled document. Any documents appearing in paper form must be used for reference purposes only. The on-line copy on the file server above must be considered the current documentation.
Purpose As part of its responsibility for fostering relationships and pursuant to the requirements of the Freedom of Information and Protection of Privacy Act (“FIPPA”), the Board of Bluewater Health is responsible for ensuring that the Hospital’s policies and processes comply with FIPPA. This policy sets out processes to support the Board in fulfilling this responsibility. Policy The Board hereby authorizes and directs the CEO to implement appropriate and effective processes to ensure that the Hospital is in compliance with FIPPA. In particular, the Board directs adequate personnel and resources to permit the Hospital to fulfill its obligations in respect of access to information and protection of privacy. FIPPA designates the Chair of the Board as the “Head” of the Hospital. The Board hereby directs the Chair to consult with the CEO to identify appropriate Hospital personnel to whom the Head’s powers and duties should be delegated, and to take all necessary steps to effect such delegation. The CEO shall: • annually report to the Board on FIPPA compliance • advise the Board of FIPPA-related activities which are particularly significant • ensure that the Hospital meets its reporting obligations to the Information and Privacy
Commission (IPC)
APPROVED
FREEDOM OF INFORMATION – DELEGATION OF AUTHORITY AND OVERSIGHT
Number: GOV 6.50 Page 2 of 2
:
Monitoring Method and Frequency: 1. Review of policy (every 3 years)
2. Review of Delegation of Authority of ‘Head’ (annually) 3. CEO Performance Evaluation (annually) 4. Accreditation Canada Survey and report (timing aligned with accreditation cycle)
References: Freedom of Information and Protection of Privacy Act: https://www.ontario.ca/laws/statute/90f31
Successes Completed Quality and Patient Safety Plan Embedded “just culture” education into orientation program Identified patient safety champions for each program Initiated Good Catch Program Launched Red Rule – requirement for two patient identifiers Developed Integrated Risk Management System Increased supervision and security on Mental Health Inpatient Unit specifically in Child and Youth and
Residential Withdrawal Management Services areas Revised Surgical Safety Checklist – requirement for two signatures Implemented bedside reporting in Surgery Program Completed monthly hospital-wide Morbidity and Mortality patient case reviews, with department
reviews held at least semi annually Challenges Fear of “speaking up” Trust in organization Influenza vaccination rate Limitations of documentation system
Key Priorities for 2018/19 Readiness for Accreditation Canada Survey – April 2019 Fall Reduction Strategy Illicit drug strategy to improve patient experience, ensure consistent practice and minimize risk (ED,
ICU, and medicine) Additional strategies to increase influenza vaccination rate
Goal Initiative Indicator
Ingrain patient safety
Implement a Quality and Patient Safety Plan
It is difficult to speak up if I perceive a problem with patient care
Strategic Plan Progress Report
April 1, 2017 to March 31, 2018
Bluewater Health Strategic Plan Progress Report 2018
2
Successes Reconfigured beds and standardized model of care in Medicine unit, to allow for greater flexibility
during surge periods and to accommodate patients with contact precautions Holiday and Influenza “Surge Planning” Dedicated pharmacy technicians in ED to improve quality of medication histories, support outpatients
with COPD, and to collaborate closely with community partners Developed and implemented Geriatric Care Pathway in the ED Introduced Nurse Practitioner Role at CEEH site Increased patient access to Cardiac Clinic to ensure timely access to diagnostics and consultation for
patients with chest pain and to reduce inpatient admission rates Patient Flow/ALC Avoidance Improvements Mental Health and Addiction Integration in ED to support community resources and access
o Addition of Psychiatric Assessment Nurse and greater CMHA after-hours coverage o Improved response for psychiatry consultations in ED o Ongoing engagement and expansion of Child and Youth Collaborative between BWH and St.
Clair Child and Youth Services o Implementation of BSharp for all Mental Health and Addictions patients, which includes use of
interRAI, a standard assessment systems that better flags risk, and triggers Clinical Assessment Protocols
o Child and Youth Mental Health Inpatient Improvement Initiative Exceptional wait time results for many other priority indicators (CT, MRI, Hip/Knee/Cancer Surgeries,
lab tests, etc.) Other Access to Care Improvements Launched Critical Care Outreach Team (ICU and Respiratory Therapy with Intensivist support) Developed and implemented In-House Code Stroke Process Implemented 24/7 access to CT/CTA improving more timely access for endovascular therapy Introduced Iron Infusion Clinic in Dialysis Unit Expanded Palliative Care Services for Dialysis patients to improve quality of life Implemented anterior and SuperPATH hip replacements reducing the length of stay for these
procedures Expanded Cancer Care Program with the addition of a second oncologist funded through Cancer Care
Ontario
Improve access to care
Improve Emergency Department (ED) wait
times 90th percentile length of stay for admitted patients
Bluewater Health Strategic Plan Progress Report 2018
3
Established Electroconvulsive Therapy Program Introduced Transesophageal echocardiogram services
Challenges Limited primary care access Appropriate resources and capacity to support specialized marginalized populations i.e. homelessness Mental Health & Addictions demand on the ED and patient flow Long-Term Care repatriation/admission processes when facilities are in outbreak Limited access to Interprofessional Community Based services/Outpatient Rehabilitation Limited physician coverage i.e. Rehab or psychiatric support on CCOG unit Consistent practices/processes with “Estimated Date of Discharge” (EDD)
Key Priorities for 2018/19 No One Waits (NOW) initiative to improve time to inpatient bed and align with best practices in bed
management/patient flow o Improve collaboration between Department of Psychiatry and ED to identify and implement
opportunities to discharge patients to the community for follow-up as an alternative to admission to the Mental Health unit
o Discharge Strategy – including real time reporting from Oculys Stay-Track boards, EDD practices, Patient Oriented Discharge Strategy (PODS)
o Improve workflow in the ED to decrease left without being seen (LWBS) patients, improve wait times and patient experience, improve triage practices and minimize risk in the waiting room
o Development of Pharmacist Discharge Facilitator Program to reduce afterhours backlog and ensure medication history is available in a more timely manner
o Psychiatry Primary Care Collaboration/Outreach to decrease Form 1 and 2 patients presenting from Primary Care to the ED
Implementation of Mobilization of Vulnerable Elders (MOVE) Program
Bluewater Health Strategic Plan Progress Report 2018
4
Successes Five-year strategic capital plan finalized Submission of Stage 1 Parts A and B of the CEEH Capital Redevelopment Plan Opening of temporary Residential Withdrawal Management Services beds Real-time Location Service (RTLS) commissioned and fully installed
Challenges Dealing with end of life on equipment and substandard inpatient facilities at CEEH Managing public expectations on capital development projects
Key Priorities for 2018/19 Continued development at CEEH Ongoing planning for permanent Residential Withdrawal Management Services and CEEH Capital
Redevelopment Projects Ongoing participation in Regional Hospital Information System (HIS) project Further expansion of Pharmacy Retail Store Redesign and separate Child and Youth Mental Health Physical Space
Goal Initiative Indicator
Ensure continuous investment in strategic infrastructure
Implement a sustainable plan for services, facilities, capital equipment and technology
Status of plan
Bluewater Health Strategic Plan Progress Report 2018
5
Successes
3M Audit to identify weighted case opportunities Increased volume of hip and knee replacement surgeries Ongoing implementation and adoption of Choosing Wisely initiatives Improved collaboration with partners to repatriate ICU patients earlier Implementation of Oculys Stay-Track interactive boards on inpatient units Deployed Key Performance Indicator Boards across the organization to increase knowledge and align
quality/performance indicators with strategic plan Successful expansion of Pharmacy Retail Store Fully implemented work order system
Challenges Decrease in non-elective weighted cases Recruitment challenges
Key Priorities for 2018/19 Introduction of Clinical Documentation Specialist to ensure comprehensive documentation Introduction of Hip and Knee Bundled Quality Based Procedures (QBP)- an extension of the existing
surgical QBP into a bundled model. Expansion of the Clinical Reserve Unit to broader the number of individuals able to work in multiple
areas to address sick calls and vacation time Development of supply and parts inventory system Refinement of scorecard reporting using case costing data Optimization of Material Handler Cart to include pricing Implementation of MModal – front end voice recognition technology Continued focus with Professional Staff to ensure all diagnoses, comorbidities and procedures are
documented to capture to accurate weighted case information
Goal Initiative Indicator
Demonstrate accountability and efficiency
Increase awareness and understanding of resource decisions Cost per weighted case
Bluewater Health Strategic Plan Progress Report 2018
6
Successes Culture of Kindness Employee Council established, with principles and action plan developed Established Well Being Advisory Team with representation from the Healthy Living Team, Culture of
Kindness Employee Council and Employee Engagement team, with formalized aims and priorities for each team
Dedicated focus on Professional Staff Wellness Creation of the Workplace Violence Prevention Committee with “No Excuse for Abuse” campaign to
begin in June Resilience training embedded in leadership training and other workplace education sessions
Challenges
Complexity of transformational culture change in a 24/7 - 365 environment Inspiring staff during surge periods or when staffing resources are stretched
Key Priorities for 2018/19: Solidify a Wellbeing Strategy by aligning current practices and expanding support for resilience
education and prevention and or management of compassion fatigue Planning for ED redesign to improve workflow Development of workplace violence prevention metrics and increased staff training in workplace
violence prevention Development of Staff Duress System with full deployment of staff duress buttons and
policies/procedures to support usage Creation of action plan from Employee Engagement Results 2018 Rollout of Kindness Plan
Goal Initiative Indicator
Focus on the experience of care and caring
Strengthen our culture of kindness
Patient: Treated with kindness
BWH: Is a culture of kindness promoted at BWH?
Bluewater Health Strategic Plan Progress Report 2018
7
Successes Introduction of Personal Support Workers Talent development activities embedded in Human Resource and Organizational Development
planning Fully implemented Knowledge Management Council, a multi-disciplinary team that shares education
plans and collaborates on the organization calendar of development opportunities Training opportunities with Schulich School of Medicine & Dentistry for physicians to become Adjunct
Professors Successful recruitments of new Professional Staff specialists Invited community partners to thought leadership and educational events 2017 leadership development opportunities
2nd cohort - Leading in the Middle Wave 4 - Innovative Management 3rd program - Board of Governors Certificate Lambton College Leadership Retreats – September 2017 and March 2017
Challenge Recruitment demands – high volume areas, specialty positions
Key Priorities for 2018/19: Continued development of Succession Planning Model Increase number of composite positions and expand Clinical Reserve Unit Create fourth development program for individuals expressing interest in future management careers Education on the LEADS leadership capabilities framework Train midwives to full scope Physician Management Institute (PMI) physician leadership educational session Partnering with Schulich School of Medicine & Dentistry at Western University to expand training
opportunities, for example CCFP- EM (3rd year in Family Medicine – Emergency Medicine training position at Sarnia Emergency Department)
Goal Initiative Indicator
Promote individual, team and professional development
Enhance an environment of continuous learning
Supervisor helps access training and development
Bluewater Health Strategic Plan Progress Report 2018
8
Successes Lambton Health Quality Partners collaborative work focused on care transitions Created shared Health Links/Patient Flow Coordinator position between BWH and the Lambton County
Lake Huron Health Link Implemented Community Paramedic Program Enhanced relationships with community partners
weekly ALC reviews enhanced discharge plans with Intensive Hospital to Home Program (IHH) review of ALC leading strategies to identify gaps in practice
Strengthened relations between Pharmacy team and community pharmacies Implemented Admission Family Conferences for patients admitted to CCOG unit Increased Social Work services dedicated to Mental Health Inpatient and Child and Youth programs Strengthened relationships between BWH Medical Affairs and health care providers not affiliated with
BWH Challenges
Inconsistent messaging to patients/families around transition planning (Home First) when dealing with
the myriad community agencies Community capacity for patients with behavioural issues Housing for marginalized populations
Key Priorities for 2018/19 Ongoing advocacy with the ESC LHIN for continued support in the Intensive Hospital to Home program Lambton Health Quality Partners collaborative projects Improved flow of information between BWH and Primary Care Providers Improved coordination between Mental Health and Addiction Services to Community
Goal Initiative Indicator
Build sustainable partnerships and collaborations
Provide a seamless patient journey across the continuum of care
Alternate level of care (ALC) rate
Bluewater Health Strategic Plan Progress Report 2018
9
Successes Created Indigenous Patient Navigator position Improved Transitions of Care and Discharge Planning Implemented Collaborative Model of Care across all units Launched paediatric, surgical pre-admit and MIC video tour on BWH website Opened Indigenous Birthing Room on Maternal and Infant Care Unit Initiated Anxiety and Fears Rounding with Patient Experience Partners (PEPs) Participation of PEPs in Skills Day to educate staff on role of PEPs Expanded Hospital Elder Life Program (HELP) to CEEH site Developed patient watch policy to ensure right level of service for supporting high-risk patients
Challenges Timeliness and subjectivity of data obtained through patient experience surveys to drive changes at
the point of care
Key Priorities for 2018-19 Staff education on anxiety and fears for patients Introduction of Patient Orientated Discharge Strategy (PODS) to improve communication and the
overall experience Provision of Palliative Care services at CEEH site
Goal Initiative Indicator
Strengthen Patient & Family-Centred Care (PFCC)
Ingrain the four principles of Patient & Family-Centred Care
Overall rating of experience
Goal Initiative Indicator PerformanceJune 2016
TargetYear 1 - 2017
PerformanceYear 1 - May 2017
Target Year 2 - 2018
PerformanceYear 2 - March 2018
Target Year 3 - 2019
Ingrain patient safety Implement a Quality and Patient Safety Plan
It is difficult to speak up if I perceive a problem with patient care
Collecting Baseline Data
To be determined Jan - Mar 2017 41.9%
49.6% April 2017 - Mar 201846.9%
50%
Improve access to care Improve Emergency Department wait times
90th percentile length of stay for admitted patients
22 hours 20 hours Sarnia - 24.6 hours CEEH - 6.8 hours
Sarnia - <=20 hoursCEEH - <= 8 hours
Jan - Dec 2017 Sarnia - 24.9 hours
CEEH - 8 hours
Sarnia - <=20 hoursCEEH - <= 8 hours
Build sustainable partnerships & collaborations
Provide a seamless patient journey across the continuum of care
Alternate level of care (ALC) rate 27.40% 25.00% 21.40% 21.00% April 2017 - Mar 201815.00%
17.20%
ED - 49.1% Apr 2017 - Mar 2018 ED - 49.7%
ED - 50.6%
Inpt - 75.9% Apr 2017 - Mar 2018 Inpt. 68.6% Inpt. 72.0%
Supervisor helps access training and development
63.30% 65.30% December 201666.3%
67.30% Apr 2017 to Mar 201869.4%
NA
NEW INDICATOR- The organization promotes staff health and wellness.
49.40% 51.60% 55.7%
ED - 64.5% Apr 2017 to Mar 2018ED - 66.8%
68.6%
Inpt - 80.4%Apr 2017 to Mar 2018
Inpt - 78.2%81.4%
BWH: Is a culture of kindness promoted at BWH?
Employees -61.9% Prof Staff -56.1%
Volunteers -80.1%
Employees -63.9% Prof Staff -58.1
Volunteers -82.1%
December 2016Employees -58.9% Prof Staff -56.1%
Volunteers -88.6%
Employees -65.9%Prof Staff -60.1%
Volunteers - 84.1%
Apr 2017 - Mar 2018 Employees - 69.9%Prof Staff - 69.1%
Employees - 71.9%Prof Staff - 71.1%
Demonstrate accountability and efficiency
Increase awareness and understanding of resource decisions
Cost per weighted case 2015/16 Q3 $5,537 $5,361 2016/17 Q3$5,669
$5,366 Apr 2017 - Mar 2018$5,788
$5,800
Ensure continuous investment in strategic infrastructure
Implement a sustainable plan for services, facilities, capital equipment and technology
Status of plan - Yr 1 No plan Plan Developed Under development Plan Updated Plan Updated Plan Updated
Strategic Plan: Kaleidoscope of Care Monitoring Tool
Outstanding PerformanceOptimize roles, resources, revenues, technology and innovation
Focus on the experience of care and caring
Patient: Treated with kindness Q2 2016/1766.7%
To be determined April - Sept. 201676.8%
Strengthen our culture of kindness
To be determined Collecting baseline data
Quality CareAssure the right care, in the right place, at the right time, by the right provider
Exceptional RelationshipsExpand innovative partnerships and collaborations to improve experiences, services, transitions and community health
Inspired PeopleAdvance our culture of kindness with an intention to learn, lead, collaborate and celebrate
Strengthen Patient & Family-Centred Care
Ingrain the four principles of Patient & Family-Centred Care
Overall rating of experience Q2 2016/1771.10 %
Enhance an environment of continuous learning
Promote individual, team and professional development
Revised: May 2018 Next Update: September 2018 Page 5 of 44
Indicator Name: It is difficult to speak up if perceive a problem with patient care
Alignment: Quality and Patient Experience Committee (QPEC)/Quality Committee of the Board (QCB)
Strategic Goal: Ingrain Patient Safety
Definition: This is a custom employee survey question that asks employees to respond to the statement “in this unit it is difficult to speak up if I perceive a problem with patient care”. The top box responses request respondents to “strongly disagree” and “disagree” with the proposed statement. A higher percentage of employees disagreeing or strongly disagreeing with this statement is preferred.
Rationale: “It is difficult to speak up if I perceive a problem with patient care” is a measure that comes from a reliable and valid survey through patient safety research. To ensure we can track and measure this indicator we will assess a baseline and target by sending staff surveys thorough a Survey Monkey process. This indicator is a measure indicative of patient safety culture throughout the organization and will identify how safe the inter-professional team feels to report patient safety incidents. The development, dissemination, education and implementation of a Quality and Patient Safety Plan will enable a culture of safety by enhancing knowledge transfer of the importance of reporting patient safety incidents to improve quality and safety of the patients we serve.
Additional Specifications:
This indicator was released in December 2016. Responses to this question are collected routinely in a Strategic Engagement survey.
Target for 17/18: 49.6%
Bluewater Health Target 49.6%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Q3 16/17 Q4 16/17 Q1 17/18 Q2 17/18 Q3 17/18
Dif
ficu
lt
to s
pe
ak u
p
Difficult to Speak up if Perceive a Problem with Patient Care
Pre
ferre
d Tre
nd
ing
Our Status
Revised: May 2018 Next Update: September 2018 Page 11 of 44
Indicator Name: 90th Percentile Emergency Department Length of Stay (LOS) for Admitted Patients
Alignment: Performance & Utilization Committee (PUC)/Resource Utilization & Audit Committee (RUAC)
Strategic Goal: Improve access to care
Definition: ED length of stay for admitted visits is defined as the time from triage or registration, whichever comes first, to the time the patient leaves the ED to an inpatient bed. It is measured in hours. The 90th percentile is the maximum length of time in which 9 of 10 of admitted patients have completed their ED visit and have been moved to an inpatient unit. A small number is desirable.
Rationale: Time is crucial to the effectiveness and outcome of patient care, especially for emergency patients. In conjunction with other indicators, this can be used to monitor the total length of time admitted patients spend in the ED in an effort to improve the efficiency and, ultimately, the outcome of patient care. This measure remains one of Bluewater Health’s top priorities in our Quality Improvement Plan (QIP) and Strategic Plan.
Additional Specifications:
Inclusions:
1. Admitted unscheduled emergency visits2. ED visits with a valid and known registration date/time or triage date/time
and a valid and known date/time the patient left the ED
Exclusions:
1. Scheduled emergency visits2. Non-admitted unscheduled emergency visits3. Visits with both unknown/invalid registration and triage date/time OR with
unknown/invalid patient left ED date/time
Peer Comparator: Ontario high-volume community hospitals, Sarnia Site only
Sarnia Site
Petrolia Site
Target
Ontario high-volume community hospitals 16/17
0
5
10
15
20
25
30
35
Apr
16
May
16
Jun
16
Jul
16
Aug
16
Sep
16
Oct
16
Nov
16
Dec
16
Jan
17
Feb
17
Mar
17
Apr
17
May
17
Jun
17
July
17
Aug
17
Sep
17
Oct
17
Nov
17
Dec
17
Jan
18
Feb
18
Mar
18
Q1 16/17 Q2 16/17 Q3 16/17 Q4 16/17 Q1 17/18 Q2 17/18 Q3 17/18 Q4 17/18
ED
LO
S (
ho
urs
)
90th Percentile ED LOS(Admitted Patients)
Pre
ferr
ed
Tre
nd
ing
Sarnia
Status
CEEH
Status
Revised: May 2018 Next Update: September 2018 Page 19 of 44
Indicator Name: Alternate Level of Care (ALC) Rate %-All Inpatient Services
Alignment: Quality and Patient Experience Committee (QPEC), Quality Committee of the Board (QCB), Performance & Utilization Committee (PUC), Resource Utilization & Audit Committee (RUAC)
Strategic Goal: Build sustainable partnerships and collaborations
Definition: The rate at which patients who have been designated ALC occupy inpatient beds.
Rationale: Ensuring that each patient receives the appropriate level of care at all times during their healthcare journey is a priority at Bluewater Health. Our goal is for Emily to receive the right care, given at the right time, in the right place, always. The ALC rate represents an opportunity for inpatients to be transitioned to the next level of care, where their care needs and the services provided are better matched. Multiple factors can influence ALC rate, including overall hospital occupancy, and availability of resources both internal and external to the hospital.
Additional Specifications:
ALC Rate = Total number of ALC Days in a given period
Total number of inpatient days in the same time period ×100%
Peer Comparator: Ontario hospital value
ALC Rate
Bluewater HealthTarget
Provincial Target FY 17/18
ALC Days
0
200
400
600
800
1000
1200
1400
1600
1800
2000
0
5
10
15
20
25
30
35
40
45
50
Apr
16
May
16
Jun
16
Jul
16
Aug
16
Sep
16
Oct
16
Nov
16
Dec
16
Jan
17
Feb
17
Mar
17
Apr
17
May
17
Jun
17
July
17
Aug
17
Sep
17
Oct
17
Nov
17
Dec
17
Jan
18
Feb
18
Mar
18
Q1 16/17 Q2 16/17 Q3 16/17 Q4 16/17 Q1 17/18 Q2 17/18 Q3 17/18 Q4 17/18
AL
C D
ay
s In
pa
tie
nt
Se
rvic
es
AL
C R
ate
%
ALC Rate % -All Inpatient Services (Sarnia and Petrolia)
Pre
ferr
ed
Tre
nd
ing
Our Status
Revised: May 2018 Next Update: September 2018 Page 25 of 44
Indicator Name: Overall Rating of Experience
Alignment: Quality and Patient Experience Committee (QPEC)/Quality Committee of the Board (QCB)
Strategic Goal: Strengthen Patient and Family-Centered Care
Definition: Overall Rating of Experience: Inpatient (IP) and Emergency Department (ED), patients are asked to rate their hospital experience on a scale from 0 to 10, with 0 being I had very poor experience and 10 being I had a very good experience.
Rationale: Patient experience measurement is an industry best practice and hospitals are required to survey patients at least once every fiscal year, according to Ontario’s Excellent Care for All Act (ECFAA), 2010. “We create exemplary healthcare experiences with patients and families every time”, is the mission of Bluewater Health. These questions reflect how well the hospital is achieving its overall mission. The patient experience is what we strive to excel at. Measurement of patient experience is important because it provides an opportunity to improve care, enhance strategic decision making, meet patients’ expectations, effectively manage and monitor healthcare performance, and document benchmarks for the organization.
Additional Specifications:
Scores are calculated using the following measure recommended by the National Research Corporation Canada (NRCC): Positive - Positive measure type is calculated by counting “Positive” response (i.e., 9-10 or Yes, Definitely or Always) and dividing by the total number of responses.
Inclusion Criteria: - Patients who have received active treatment at Bluewater Health
- 18 years or older at the time of admission- Alive at the time of discharge
Exclusion Criteria: - Patients who have notified Bluewater Health they wish to be excluded from
the mailing list- Patients who are stillborn or deceased while in the hospital- Patients with no fixed address
- Psychiatric patients (unless being specifically surveyed using the MentalHealth inpatient or outpatient survey tool)
- Patients who present with evidence of sexual assault or with sensitiveissues (e.g., miscarriage)
Peer Comparator: The Ontario Hospital Association Patient Reported Performance Management (OHA PRPM) benchmark includes OHA member hospitals. The Ontario Inpatient (IP) Community Hospital (Hosp) Average compares hospitals of the same size within the province. Peer comparators are updated quarterly.
Inpatient OHA-PRPM – 68.2% Ontario IP Community Hosp Average – 65.0%
Emergency Department (ED) There is no peer comparator as this is a Bluewater Health custom question for the Emergency Department Patient Experience of Care Survey (EDPEC)
Target for 2017/2018:
ED - 49.1% Inpatient – 75.9%
ED Target 49.1%
Inpatient Target 75.9%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Apr16
May16
Jun16
Jul16
Aug16
Sep16
Oct16
Nov16
Dec16
Jan17
Feb17
Mar17
Apr17
May17
Jun17
Jul17
Aug16
Sep16
Oct17
Nov17
Dec17
Jan18
Feb18
Mar18
Q1 16/17 Q2 16/17 Q3 16/17 Q4 16/17 Q1 17/18 Q2 17/18 Q3 17/18 Q4 17/18
Ov
era
ll R
ati
ng
of
Exp
eri
en
ce
Overall Rating of Experience
ED Inpatient
Pre
ferre
d T
ren
din
g
ED
StatusInpatient
Status
Revised: May 2018 Next Update: September 2018 Page 28 of 44
Indicator Name: Supervisor helps access training and development
Alignment: Quality and Patient Experience Committee (QPEC)/Quality Committee of the Board (QCB)
Strategic Goal: Focus on the experience of care and caring
Definition: This is a custom employee survey question that will ask “My Supervisor helps me to access training and development?” The top box responses request respondents to “Agree” and “Strongly Agree” with the proposed statement. A higher percentage of employees agreeing or strongly agreeing with this statement is preferred.
Rationale: Ensuring that each patient receives the best care possible begins with exceptional care providers. Bluewater Health is committed to strengthening the skills and education of our employees. This commitment to education promotes inspired people who will advance our culture of kindness with an intention to learn, lead, collaborate and celebrate. Evidence suggests that investment in employee training and development leads to employees feeling more valued and willing and able to invest in their work. Employee training and development supports efficiencies and standardized procedures, risk reduction, patient safety and quality of patient care. Research links high levels of employee engagement with increased patient satisfaction when an organization focuses on processes and people. This reflects on the organization’s ability to provide opportunities for personal development to stay up to date with latest techniques and technologies and recognize employees for acquiring additional skills and knowledge sets.
Additional Specifications:
This indicator was released in December 2016. Responses to this question are collected routinely in a Strategic Engagement survey.
Target for 2017/2018:
67.3%
Bluewater Health Target 67.3%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Q3 16/17 Q4 16/17 Q1 17/18 Q2 17/18 Q3 17/18
Su
pe
rvis
or
he
lps a
cce
ss t
rain
ing
&
de
ve
lop
me
nt
Supervisor Helps Access Training and Development
Pre
ferre
d T
ren
din
g
Our Status
Revised: May 2018 Next Update: September 2018 Page 29 of 44
Indicator Name: Was Patient/Family Treated with Kindness
Alignment: Quality and Patient Experience Committee (QPEC)/Quality Committee of the Board (QCB)
Strategic Goal: Focus on the experience of care and caring
Definition: This is a new, custom question for Bluewater Health’s patient experience surveys which are mailed to a random selection of patients after they are discharged. Our aim is that the culture of kindness at Bluewater Health will be increasingly felt by our patients and families over time. This question asks Emily to reflect and respond to the statement “Were you and your family treated with kindness by employees, volunteers and physicians at Bluewater Health?” Responses available for this question are as follows: No/ Yes, somewhat/ Yes, mostly/ Yes definitely
Rationale: Exemplary healthcare experiences begin with kindness. We understand that patients expect courtesy, respect and dignity, beginning with an expression and attitude of kindness and caring. We understand that having highly skilled and competent staff isn’t enough. Ensuring that you and your family are treated with kindness is a key focus of Bluewater Health’s commitment to Patient & Family-Centered Care. Patient experience measurement is an industry best practice and hospitals are required to survey patients at least once every fiscal year, according to Ontario’s Excellent Care for All Act (ECFAA), 2010.
Additional Specifications:
Scores are calculated using the following measure recommended by the National Research Corporation Canada (NRCC): Positive - Positive measure type is calculated by counting “Positive” response (i.e., 9-10 or Yes, Definitely or Always) and dividing by the total number of responses. Inclusion Criteria: - Patients who have received active treatment at Bluewater Health
Exclusion Criteria: - Patients who have notified Bluewater Health they wish to be excluded from
the mailing list- Patients who are stillborn or deceased while in the hospital- Patients with no fixed address
- Psychiatric patients (unless being specifically surveyed using the MentalHealth inpatient or outpatient survey tool)
- Patients who present with evidence of sexual assault or with sensitiveissues (e.g., miscarriage)
Peer Comparator: This is a Bluewater Health custom question and no peer comparator data is available. NRC Health establishes benchmarks/peer comparators based on the following requirements:
- Made up of one year of data- Questions must be used by at least five facilities
Must have at least 1000 responses for the question
Target for 2017/18: ED - 64.5% Inpatient - 80.4%
ED Target 64.5%
IP Target 80.4%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Apr16
May16
Jun16
Jul16
Aug16
Sep16
Oct16
Nov16
Dec16
Jan17
Feb17
Mar17
Apr17
May17
Jun17
Jul17
Aug16
Sep16
Oct17
Nov17
Dec17
Jan18
Feb18
Mar18
Q1 16/17 Q2 16/17 Q3 16/17 Q4 16/17 Q1 17/18 Q2 17/18 Q3 17/18 Q4 17/18
Wa
s P
atie
nt/
Fa
mily
Tre
ate
d w
ith
K
ind
ne
ss
Was Patient/Family Treated with KindnessED Inpatient
Pre
ferre
d T
ren
din
g
Inpatient
Status
ED
Status
Revised: May 2018 Next Update: September 2018 Page 30 of 44
Indicator Name: Is a Culture of Kindness Promoted at Bluewater Health Alignment: Quality and Patient Experience Committee (QPEC)/Quality Committee of the Board
(QCB)
Strategic Goal: Focus on the experience of care and caring
Definition: This is a custom survey question that will ask “Is a culture of kindness promoted at BWH?” Top Box responses from Employees, Professional Staff and Volunteers are displayed. The top box responses request respondents to “Agree” and “Strongly Agree” with the proposed statement. A higher percentage of employees agreeing or strongly agreeing with this statement is preferred.
Rationale: Bluewater health is committed to strengthening our culture of kindness while we deliver Quality Care to Emily. Creating a kindness culture in the workplace reduces stress, fosters relationships, increases psychological wellness and health and leads to increased engagement, energy and resiliency at work. Evidence suggests that high engagement influences human resource goals of increased retention and recruitment, high job performance and lower absenteeism. Research links high levels of employee engagement with increased patient satisfaction when an organization focuses on processes and people. Caring for people creates a workforce with physical energy, mental focus and the emotional drive necessary to provide exemplary care to Emily every day. The culture of kindness has been measured in the “joy” people bring to work; it is palpable throughout the organization and referred to as measuring “humanity”.
Additional Specifications:
This indicator was released in December 2016. Responses to this question are collected routinely in a Strategic Engagement survey.
Target for 2017/2018:
Employees – 65.9% Professional Staff - 60.1% Volunteers - 84.1%
Employee Target 65.9%
Professional Staff Target 60.1%
Volunteer Target 84.1%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Q3 16/17 Q4 16/17 Q1 17/18 Q2 17/18 Q3 17/18Is a
Culture
of Kin
dness
Pro
mote
d a
t BW
H
Is a Culture of Kindness Promoted at Bluewater Health
Employees Prof. Staff Volunteers
Pre
ferre
d Tre
nd
ing
Our Status
Revised: May 2018 Next Update: September 2018 Page 32 of 44
Indicator Name: Acute Cost per Weighted Case
Alignment: Resource Utilization and Audit Committee (RUAC)/Performance Utilization Committee (PUC)
Strategic Goal: Demonstrate accountability and efficiency
Definition: Acute Cost per Weighted Case is an indicator that measures the cost associated with caring for a standard acute patient. It is calculated as total acute inpatient and newborn expenses (both direct and indirect) divided by acute inpatient weighted cases. The direct costs are the expenses incurred in the departments providing service to our acute patients (e.g., Medicine, Surgery, and Obstetrics). The indirect costs are an allocation of Administration and Support expenses (e.g., Housekeeping, Lab, Pharmacy, etc.). A weighted case is a case with an assigned Resource Intensity Weight (RIW).
Rationale: This is an important indicator as it tracks how an organization is utilizing its resources. It combines the financial spending with the activity that drives the spending. By focusing on weighted cases, comparability is enhanced as differences in acuity, severity and complexity of cases are taken into consideration.
Additional Specifications:
Peer Comparator: No established peer comparator data
Target
5000
5100
5200
5300
5400
5500
5600
5700
5800
5900
6000
Q1 16/17 Q2 16/17 Q3 16/17 Q4 16/17 Q1 17/18 Q2 17/18 Q3 17/18 Q4 17/18
Co
st
pe
r W
eig
hte
d C
ase
Cost per Weighted Case: Acute Inpatient & Day Surgery (53% of overall activity)
Pre
ferr
ed
Tre
nd
ing
Our StatusOur Status
1
Governance and Nominating Committee Highlights
June 13, 2018
Board Evaluation Members were requested to complete a Committee evaluation survey and reviewed the Exit Survey to be distributed to members leaving the Board. Special note was made of the Committee’s accomplishments and appreciation was shared for the work of all involved. Board Education/Orientation/Team Building The Committee received an overview of orientation/education plans for new and existing Board members to begin this summer and continue into next spring. The plan includes general governance orientation, committee specific orientation, a fall Board Retreat focused on Accreditation, the new Ethical and Integrated Risk Management Frameworks, and more. The Committee also discussed governance best practice information learned through recent Ontario Hospital Association (OHA) conferences, with plans to address the recommendations in the fall. Review of Board Policies The Committee learned a full review of the Board’s policies would take place over the summer months to ensure readiness for Accreditation in April 2019. Members also reviewed a number of policies recommended for Board approval in the Consent Agenda. Submitted by: Brian Knott
Quality Committee of the Board Highlights
June 18, 2018
Program Report: Best Practice, Director Quality & Patient Experience and Interprofessional Practice, Dave Remy • Successes: implementation of Red Rule where BWH is required to use two approved patient
identifiers before provision of patient care; Choosing Wisely Committee employing several communication strategies to reduce the amount of rib and spine x-rays – this initiative is aimed at reducing unnecessary tests
• Challenges: fear of reporting breaches to the Red Rule due to performance management; ensuring Choosing Wisely communication strategies are clear and sustainable as well as education of new physicians is occurring
• Next Steps: continue Red Rule Fridays, promotion of the Good Catch Program and Rounding; continue reporting and auditing for Choosing Wisely initiative
Patient Experience Concerns and Compliments Report and Patient Family-Centred Care Action Plan, Dave Remy • January 1 to March 31, 2018 concerns and compliments data was reviewed • Lisa Hawthornthwaite has been hired as the new Patient Experience Specialist • BWH has hired an Indigenous Patient Navigator, Nikki George, a media announcement and contact
information are available on the BWH website • Patient Experience Partners (PEPs) have been rounding to the units with Shannon Landry to meet
with staff and patients regarding anxiety and fears Quality and Patient Safety Program Report, Dave Remy • a review and current state of patient falls has been conducted and training is being completed on the
safe use of bed alarms to mitigate risk • workplace violence signage has been completed and is ready for deployment • several skills days have taken place: wound care, PICC lines and safe practice • preparation for the April 2019 Accreditation is happening • quality of care reviews have been increased to explore themes for continuous improvement of
patient experience and allow for more open communication than formal QCIPA reviews • patient falls continue to be an area of focus due to the frequency on the critical incident list, PSWs
are rounding hourly to assist in preventing falls, improvements have been noted over the past 2 months
• at present there is nothing to report for the Quality Improvement Plan
Monitor Litigation Claims Report, Margaret Mai, Coordinator Risk Management, shared the 2017 Annual Liability/Crime Claims Report. Monitor Research being undertaken within BWH, Margaret Mai, reviewed the infographic that details BWH’s research activity in 2017. The Ethics and Research Committee reviews all research requests utilizing BWH’s Ethical Framework. NOW Update, Julie Acker and Kim Kraeft, Performance and Transformation Specialists reviewed the slides, driver diagram and whiteboard video outlining the purpose of this initiative. Activities are currently being prioritized and staff assigned into working groups. Submitted by: Paul Wiersma
Meets/Exceeds Target .
Within 5% of Target
Worse than Target by 5+%
Data Unavailable
FOI Masked due to n size <5
Italics n Size between 6 - 30
* no established target
ⱡ corporate target
Jan
17
Feb
17
Mar
17
Apr
17
May
17
Jun
17
Jul
17
Aug
17
Sep
17
Oct
17
Nov
17
Dec
17
Jan
18
Feb
18
Mar
18
Apr
18 Re
po
rt
Pe
rio
d
YTD
1 QIP n/a * 97 97 97 95 97 97 97 96 96 98 98 97 97 97 97 98Apr -
Mar98%
Med Rec at Discharge calculation now excludes disposition X (left without
being seen), locations Emergency Department Inpatient (EDIN), Day Surgery
(SURDS) and Residential Withdrawal Management (RWMS). Scorecard data
has been modified to reflect this change
◄
2 SP n/a 49.6% 0.00 0.00 0.00 0.00 0.00 0.00Apr -
Mar46.9%
Top Box Responses for all sectors, n size for Q3 reporting period 165. No data
available for Q2 as the survey was not administered. 0.00
3 0 n/a 0 0Apr-
Mar7
YTD number is 17/18 for high severity incidents
3 Level 3 incidents, 4 Level 4 incidents in FY 17/180.00
Sarnia 10.1 8.1 9.3 9.6 9.0 9.7 8.0 8.9 9.8 9.4 10.0 8.8 11.2 9.6 8.4 9.5 9.60
◄
Petrolia 4.1 3.9 4.3 4.4 3.9 4.0 4.1 4.7 4.0 5.0 3.7 3.8 4.6 4.2 3.7 4.1 4.20.0
◄
Exceptional Relationships - Expand innovative partnerships and collaborations to improve experiences, services, transitions and community
5QIP/
HSAA12.7% 21.0% 18.4 17.2 18.5 16.7 17.8 -- 21.5 17.2 17.7 18.6 14.8 15.7 16.9 15.9 16.4 15.0
Apr -
Mar15.0%
ALC Rate denominator has changed with the implementation of the Daily Bed
Census Summary in June 2017, values are subject to change; March & April
2018 data is preliminary and subject to change
◄
6 QIP n/a 16.5%Apr-
Mar13.0%
OMHRS assessments: 30 days or less since last discharge from this facility;
excluding short-stay assessments ◄
7 QIP 18.2% 16.9% 0.0 0.0 0.0Apr-
Mar19.0% This is preliminary data and subject to change 0.0
ED n/a 49.1% 41.7 43.5 53.3 55.8 50.8 46.0 48.6 50.9 46.6 51.2 36.8 53.1 57.6 55.6 41.5 49.8%Positive score = 9 & 10
◄
Inpatient 65.2% 75.9% 68.4 72.2 82.1 78.0 67.3 66.0 67.8 75.5 63.1 73.7 63.5 61.0 70.5 62.3 73.5 68.4%Positive score = 9 & 10
◄
ED 82.2% 81.0% 82.3 87.5 84.7 94.1 87.5 72.5 81.6 70.9 80.6 70.5 82.1 86.2 91.5 79.4 84.6 82.1%Positive score = Yes
◄
Inpatient 53.4% 61.6% 63.8 61.0 53.7 57.4 55.6 57.1 52.6 67.3 44.6 62.2 56.2 58.3 54.7 45.7 54.2 55.4%Positive score = Completely
◄
Inspired People - Advance our culture of kindness with an intention to learn, lead, collaborate and celebrate
10 SP n/a 67.3% 0.0 0.0 0.0Apr -
Mar69.4%
Strategic Engagement Survey, top Box Responses Q3 employee reporting
period n=137 0.0%
ED n/a 64.5% 68.9 66.7 69.5 66.7 62.9 57.7 73.0 70.4 71.2 55.8 68.4 69.8 76.3 65.1 57.5 66.6%Positive score = Yes, definitely
◄
Inpatient n/a 80.4% 75.9 73.4 88.3 81.4 81.8 71.4 81.7 85.7 82.1 84.0 73.9 81.4 66.7 68.5 78.0 77.9%Positive score = Yes, definitely
◄
12 SP n/a * 0.0Apr -
Mar74.3%
YTD is Top Box Responses for all sectors, Q3 reporting period n=1650.0%69.1
0 0
Q1 17/18
73.168.2
11.3
Apr -
Mar
Apr -
Mar
Jan-
Dec
Q4 16/17
19.2
12.0 8.4
21.6
Strengthen Patient and Family-Centred Care
10.1
hrs
19.2
ALC Rate % -All Inpatient Services
(Sarnia and Petrolia)
13.0
18.8
QIP
64.2 0.00
Up
da
ted
Comments
0
Q3 17/18 Q4 17/18
5
YTD Performance
41.9
Q2 17/18
43.0
2
49.4
Quality Care - Assure the right care, in the right place, at the right time, by the right provider
Q1
18/19
11
Readmission within 30 days for COPD
Was Patient/Family Treated with
Kindness
Is a Culture of Kindness Promoted at BWH
Supervisor helps access training and
development
8
Leaving hospital did patients
receive enough information
Total High Severity Patient Safety Incidents
Overall Rating of Experience
9
Performance Indicator Ref.
Ingrain patient safety
Improve access to care
#
Pe
er
Co
mp
ara
tor
BW
H
Ta
rge
t4
90th Percentile ED Length of Stay
for Complex Patients
Bluewater Health Quality Committee
Performance Scorecard
77.5
SPApr -
Mar
Build sustainable partnerships and collaborations
QIP/
HSAA/
P4R
30-Day Mental Health Readmission
Focus on the experience of care and caring
Difficult to speak up if perceive a problem with
patient care
Medication Reconciliation at Discharge
<=8
hrs
60.1
QIP
15.4
June 2018 with April data
n size: 41 n size: 44
n size: 49 n size: 51
Is a Culture of Kindness Promoted at Bluewater Health
Target:
N/A
YTD n size: 432
Quality Committee Key Performance Indicators
Inspired People - Advance our culture of kindness with an intention to learn, lead, collaborate and celebrate
Focus on the experience of care and caring
Target
49.6%
Quality Care - Assure the right care, in the right place, at the right time, by the right provider
Ingrain patient safety
Difficult to speak up if perceive a
problem with Patient Care
YTD n size: 432
Received Enough
Information Emergency
Improve access to care
21.0%
June data unavailable
province-wide due to daily
bed census summary
methodology changes
Exceptional Relationships - Expand innovative partnerships and collaborations to improve experiences, services, transitions and community
Build sustainable partnerships and collaborations
Strengthen Patient and Family-Centered Care
Overall Rating of Experience
Emergency Department
BWH Target
54.2%BWH Target
61.6%
BWH Target
49.1%
Overall Rating of Experience
Inpatient Units
BWH Target
75.9%
41.5%
73.5%
Received Enough
Information Inpatient
BWH Target
81.0%
77.3%
97 97 9795 97 97 97 96 96 98 98 97 97 97 97 98
60
70
80
90
100
JAN
17
FEB
17
MAR
17
APR
17
MAY
17
JUN
17
JUL
17
AUG
17
SEP
17
OCT
17
NOV
17
DEC
17
JAN
18
FEB
18
MAR
18
APR
18
Medication Reconciliation at Discharge
0
5
2
0
0
0 1 2 3 4 5 6
Q4 16/17
Q1 17/18
Q2 17/18
Q3 17/18
Q4 17/18
Total High Severity Incidents
18.4
17.2
18.5
16.7
17.8
0.0
21.5
17.2
17.7
18.6
14.8
15.7
16.9
15.9
16.4
15.0
0.0
5.0
10.0
15.0
20.0
25.0
Jan17
Feb 17
Mar 17
Apr17
May17
Jun17
Jul17
Aug17
Sep17
Oct17
Nov17
Dec17
Jan18
Feb18
Mar18
Apr18
ALC Rate % - All Inpatient Services (Sarnia & Petrolia)
ALC Rate Provincial Target BWH Target
0.0
20.0
40.0
60.0
80.0
100.0
Jan17
Feb 17
Mar 17
Apr17
May17
Jun17
Jul17
Aug17
Sep17
Oct17
Nov17
Dec17
Jan18
Feb18
Mar18
Overall Rating of Experience
ED Inpatient ED Target IP Target
0.0
20.0
40.0
60.0
80.0
100.0
Jan17
Feb 17
Mar 17
Apr17
May17
Jun17
Jul17
Aug17
Sep17
Oct17
Nov17
Dec17
Jan18
Feb18
Mar18
Leaving Hospital did Patients Receive Enough Information
ED Inpatient BWH ED Target BWH IP Target
68.9
66.7
69.5
66.7
62.9
57.7
73.0
70.4
71.2
55.8
68.4
69.8
76.3
65.1
57.5
75.9
73.4
88.3
81.4
81.8
71.4
81.7
85.7
82.1
84.0
73.9
81.4
66.7
68.5
78.0
0.0
20.0
40.0
60.0
80.0
100.0
Jan17
Feb 17
Mar 17
Apr17
May17
Jun17
Jul17
Aug17
Sep17
Oct17
Nov17
Dec17
Jan18
Feb18
Mar18
Was Patient/Family Treated with Kindness
ED Inpatient BWH ED Target BWH IP Target
74.3%
46.9%
10.1
8.1
9.3
9.6
9.0
9.7
8.0
8.9
9.8
9.4
10.0
8.8
11.2
9.6
8.4
9.5
4.1
3.9
4.3
4.4
3.9
4.0
4.1
4.7
4.0
5.0
3.7
3.8
4.6
4.2
3.7
4.1
0
2
4
6
8
10
12
Jan17
Feb 17
Mar 17
Apr17
May17
Jun17
Jul17
Aug17
Sep17
Oct17
Nov17
Dec17
Jan18
Feb18
Mar18
Apr18
90th Percentile ED Length of Stay for Complex Patients
Sarnia Petrolia Peer Comparator BWH Target
Resource Utilization and Audit Committee (RUAC)
June 14, 2018 Highlights
N.O.W. (No One Waits Collaborative Organizational Planning Update The Committee received a presentation on the N.O.W. (No One Waits) initiative which highlighted the aim, work done to date and challenges facing BWH. The feedback was collated to form a Driver Diagram outlining the specific priorities for the initiative. 2018-19 - Hospital Accountability Planning Submission Refresh – Hospital Service Accountability Agreement (H-SAA) Schedules The Committee was informed the schedules in the Hospital Accountability Planning Submission (HAPS) will need to be updated to reflect the new funding information submitted in the Hospital Service Accountability Agreement (H-SAA) extension. The revised HAPS will then be submitted to the ESC LHIN in July. ESC LHIN Framework Community Investment The ESC LHIN Funding Framework Guideline for Community Investment briefing note and Ministry of Health and Long-Term Care mandate letter were shared with the Committee. The Funding Framework Guideline provides decision-making guidance for the distribution of elective community related funding. The framework aligns with the ESC LHIN Integrated Health Services Plan (IHSP) and the Patients First: Proposal to Strengthen Patient Centred Health Care in Ontario. It was noted the BWH’s Strategic Priorities align with the ESC LHIN IHSP 4 Strategy Priorities, and the funding framework aligns with the ESC LHIN Strategic Priorities. In addition, the following will be coming forward separately for Board approval: - Auditor’s Report and 2017-18 Financial Statement - Appointment of the Audit Firm - Broader Public Sector Accountability Act (BPSAA) Compliance – Consultant
Use/Allowable-Perquisites - Monthly Financial Statement - Multi-Sector Accountability Agreement (M-SAA) - 2018-19 Targets for the RUAC Strategic Indicators Submitted by: Marg Dragan Chair, Resource Utilization and Audit Committee
Statement of Revenue and ExpenseForecast surplus/(deficit) as at March 31, 2019Based upon the one (1) months ended April 30, 2018(000's)
18/19 18/19 18/19 18/19 18/19 18/19 Projected 18/19 NotesYTD YTD YTD YTD % Annual Forecast Variance to Forecast %
Budget Actual Variance Variance Budget Amount Budget Variance
Revenue $
LHIN Revenue 12,114 12,044 (70) -1% 147,384 147,384 - 0% 1Cancer Care Ontario Revenue 566 598 32 6% 6,882 6,914 32 0% 2Paymaster Funding 102 101 (1) -1% 1,243 1,243 - 0%OHIP Revenue 1,042 1,090 48 5% 12,682 12,730 48 0% 3Patient Revenue - Other 132 129 (3) -2% 1,604 1,604 - 0%Room differential 236 214 (23) -10% 2,876 2,853 (23) -1%Co-payment 34 36 3 8% 410 413 3 1%External Recoveries 223 139 (85) -38% 2,896 2,896 - 0%Parking Revenue 152 123 (28) -19% 1,020 1,020 - 0%Other Revenue 2 2 (0) -21% 189 188 (0) 0%Deferred Equipment Grants 199 183 (16) -8% 2,427 2,427 - 0%Interest and Donations 5 14 10 193% 60 70 10 16%
Total Revenue $ 14,808 14,674 (133) -1% 179,671 179,740 69 0%
Expenses $
Salaries and Wages 7,333 7,505 (172) -2% 89,903 89,903 - 0% 4Medical Staff Remuneration 1,669 1,723 (54) -3% 20,301 20,362 (61) 0% 3Employee Benefits 2,091 2,054 38 2% 24,202 24,202 - 0% 4Employee Future Benefits 26 41 (15) -57% 320 335 (15) -5%Utilities, Buildings & Grounds 368 300 67 18% 4,474 4,399 75 2% 5Equipment Expense 493 482 11 2% 6,529 6,532 (3) 0%Supplies and Expenses 997 856 141 14% 11,983 11,983 - 0%Contracted Out Services 301 291 10 3% 3,662 3,652 10 0%Medical/Surgical Supplies 706 763 (57) -8% 8,588 8,645 (57) -1% 6Drug Expense 451 436 15 3% 5,480 5,466 15 0%Interest Expense 14 12 2 13% 168 166 2 1%Amortization 425 368 57 13% 5,344 5,344 - 0%
Total Expenses $ 14,873 14,831 42 0% 180,954 180,988 (34) 0%
Hospital Operating Surplus/(Deficit) $ (65) (156) (91) n/a (1,283) (1,248) 36 n/a
Net Marketed Service Surplus/(Deficit) 28 77 49 175% 362 362 - 0%
Net Other Vote Surplus/(Deficit) (4) (0) 4 n/a 0 0 - n/a
LHIN Operating Surplus/(Deficit) $ (41) (80) (39) (921) (885) 36
Deferred Building Grants 727 739 11 2% 8,854 8,854 - 0%Building Amortization (843) (863) (19) 2% (10,405) (10,405) - 0%Interest on L/T Liabilities (7) (8) (1) 12% (168) (168) - 0%
Operating Surplus/(Deficit) $ (164) (212) (48) (2,639) (2,604) 36
Notes to Financial StatementsApril 30, 2018 Actual and Full Year Forecast
Note 1
Note 2
YTD Actual Annual Budget
Year-End Forecast
$ 220,000 $ 2,280,000 $ 2,312,250
$ 361,476 $ 4,397,963 $ 4,397,963 $ 16,378 $ 203,570 $ 203,570
$ 597,854 $ 6,881,533 $ 6,913,783
Note 3
Note 4
Note 5
Note 6
Total FundingOntario Breast Screening Program Funding
Bluewater Health is forecasting a deficit of $885K for the 18/19 fiscal year which is slightly better than the budgeted deficit of $921K. At the end of April, the hospital had a deficit of $80K which is $39K higher than the budgeted deficit for the month of April.
LHIN Revenue is forecasted to be on budget for year-end. For the month of April, LHIN Revenue is under budget by $70K. This is mainly due to a timing issue regarding post acute QBP funding for bundled payments.
Bluewater Health does OHIP billings for various physician groups. There is an offsetting Med Staff Remuneration expense for these billings. The April variance is primarily CT, and MRI. There has been an increase in exams for both of these areas in the month of April.
Bluewater Health receives CCO funding for Oncology Drugs, QBPs, and the Ontario Breast Screening Program. Bluewater Health is forecasting achieving all QBP funding for Cancer Surgeries and the Oncology program.
Description
Oncology Drug Funding
QBP Funding (Cancer Surgeries, Endoscopy, Systemic Therapy)
Utilities are under budget $67K in the month of April. The budget was reduced to align with the 17/18 actual utility expense. The hospital is forecasting a postive variance of $75K for the end of the fiscal year.
Salaries & benefits are over budget by a net $134K in April. The variance in the month is primarily due to over-time costs. This negative variance should lessen over the summer months.
Med/Surg supplies are over budget by $57K in April. This negative variance is primarily attributed to the Operating Room which performed higher volumes of hip & knee replacements in the month. This negative variance is forecasted to remain until year-end.
Balance SheetAs at April 30, 2018Comparison to April 30, 2017(000's)
% Change
Assets
Current AssetsOperating Cash $ 10,308 6,179 67%Short-Term Investments 494 357Investments - CEE Site 770 1,281 116%Accounts Receivable 5,134 6,544 301%Accounts Receivable - MOHLTC 6 394 -100% Inventories 884 512 124%Prepaid Expenses 1,883 1,421 268%
Total Current Assets 19,479 16,688 17%
Fixed AssetsLand and Land Improvements 7,446 7,446Building/Building services Equipment 333,272 331,471Furniture and Equipment 87,860 84,656Less: Accumulated Amortization (175,261) 253,316 (161,095) 262,478 -3%Construction in Progress 1,238 1,247 -1%Other Non Current Assets 399 353 13%
Total Fixed Assets 254,953 264,078 -3%
Total Assets $ 274,432 280,766 -2%
Current LiabilitiesAccounts Payable 4,262 2,256 89% Accounts Payable - MOHLTC 1,074 576 87%Accrued Salaries & Vacation Pay 9,379 8,181 15%Current Portion - Long Term Debt 1,016 992 2%Other Liabilities 6,917 8,486 -18%
Total Current Liabilities 22,648 20,491 11%
Long Term LiabilitiesLong Term Bank Loans Payable 2,970 4,076 -27%Deferred Revenue 219,947 227,506 -3%Post Employment Benefits 15,706 16,393 -4%Other L/T Liabilities 1,505 985 53%
Total Long Term Liabilities $ 240,128 248,961 -4%
EquityOpening Equity 11,869 11,289Accumulated Remeasurement Gain/(Loss) 11R&E Surplus/(Deficit) (213) 14
Total equity 11,656 11,314 3%
Total Liabilities and Equity $ 274,432 280,766 -2%
Hospital Accountability Agreement Indicators: Negotiated Target
Current Ratio 0.83 0.75 0.72
Adjusted Working Capital 2,887$ 1,422$ -$
Note: Current ratio excludes CEEH Site Investments
Adjusted Working Capital is calculated using the definition of the Working Capital Funding Initiative
Apr-18 Apr-17
2018/19 2017/18Actual Actual
Meets/Exceeds Target .
Within 5% of Target
Worse than Target by 5+%
Data Unavailable
FOI Masked due to n size <5
Italics n Size between 6 - 30
* no established target
ⱡ corporate target
Jan
17
Feb
17
Mar
17
Apr
17
May
17
Jun
17
Jul
17
Aug
17
Sep
17
Oct
17
Nov
17
Dec
17
Jan
18
Feb
18
Mar
18
Apr
18 Re
po
rt
Pe
rio
d
YTD
Sarnia 10.1 8.1 9.3 9.6 9.0 9.7 8.0 8.9 9.8 9.4 10.0 8.8 11.2 9.6 8.4 9.5 9.60
◄
Petrolia 4.1 3.9 4.3 4.4 3.9 4.0 4.1 4.7 4.0 5.0 3.7 3.8 4.6 4.2 3.7 4.1 4.20.0
◄
Sarnia 27.2 19.9 24.9 26.5 23.9 27.6 16.6 20.9 25.0 27.0 28.2 25.7 29.9 27.9 26.0 21.6 27.2 0 ◄
Petrolia 7.5 7.7 7.3 7.2 7.9 8.8 7.3 6.9 8.4 13.8 10.1 7.0 7.8 10.2 7.7 7.9 8.0 0.0 ◄
Exceptional Relationships - Expand innovative partnerships and collaborations to improve experiences, services, transitions and community
3QIP/
HSAA12.7% 21.0% 18.4 17.2 18.5 16.7 17.8 -- 21.5 17.2 17.7 18.6 14.8 15.7 16.9 15.9 16.4 15.0
Apr -
Mar15.0%
ALC Rate denominator has changed with the implementation of the Daily Bed
Census Summary in June 2017, values are subject to change; March & April
2018 data is preliminary and subject to change
◄
Inspired People - Advance our culture of kindness with an intention to learn, lead, collaborate and celebrate
4 0.00 3.10 3.10Apr -
Mar0.00 Q4 data has been validated and reflects extended absences due to illness 0
5 SP n/a $5,366 $5,799
Our overall expenses for this indicator have increased by $2.54M compared to
16/17 while our weighted cases are 37 lower for the same period. ◄
6 n/a $5,419 $5,849
Our overall expenses for this indicator have increased by $856K and our
weighted cases have increased by 57 cases compared to 16/17. ◄
7 n/a $12,703 $10,823
0
◄
8 n/a $517 $0Apr -
Mar$620
Our overall expenses for this indicator have decreased by $316K compared to
16/17. The weighted patient days have decreased as well. ◄
9 0 n/a $350 $333 $354 $332 $341 $290 $278 $285 $289 $303 $300 $302 $303 $302 $304 $338 $338Apr-
Mar$338 0 ◄
10 n/a $0 -$202 $0 $0 -$59 $0 $0 $0 -$160 -$238 -$350 -$370 -$418 -$426 $134 $143 -$44Apr -
Mar-$44
Underage a result of new Bundled Payment QBP funding.
◄
11 0 n/a $172 $1,220 $794 $883 $142 $206 $349 $762 $1,096 $873 $1,411 $1,141 $1,370 $1,218 $1,711 $2,094 -$80Apr -
Mar-$80 0 ◄
12 HSAA n/a $89 $31 $47 $818 $1,422 $2,705 $2,934 $3,003 $4,228 $3,638 $3,881 $3,425 $3,921 $3,780 $5,357 $2,373 $2,887Apr -
Mar$2,887 0 ◄
13 0 n/a % 66 81 83 0 0 15 21 22 23 26 36 36 40 71 79 0Apr -
Mar0% 0 ◄
$10,964
$5,849
3.42
$5,925
<=8
hrs
<= 20
hrs
$5,799
Absenteeism Rate- (avg # 7.5hr sick days)-All
Staff
$5,991
$620
Bluewater Health Resource Utilization &
Audit Committee Performance Scorecard
Apr -
Mar
P4R
2.80
Build sustainable partnerships and collaborations
Cost per
Weighted Case
(Actual YTD):
2.92
QIP/
HSAA/
P4R
$5,853
$622$559
33.2
hrs
90th Percentile ED Length of Stay
for Complex Patients
90th Percentile ED Wait Times
(Admitted Patients)
2.80 3.25
# Performance Indicator Ref.
Improve access to care
Pe
er
Co
mp
ara
tor
BW
H
Ta
rge
t
1
2
Adjusted Working Capital Actual YTD in 000s
Mental Health Inpatient Cost per Patient Day
QBP Financial Exposure (Potential lost revenue
related to QBP achievement) Actual YTD in 000s
Outstanding Performance - Optimize roles, resources, revenues, technology and innovation
Promote individual, team and professional development
$10,248
Up
da
ted
Comments
Q3 17/18 Q4 17/18 YTD PerformanceQ2 17/18
Quality Care - Assure the right care, in the right place, at the right time, by the right provider
Q1
18/19
$5,599
$5,642
$618
$5,937
ALC Rate % -All Inpatient Services
(Sarnia and Petrolia)
$10,446 $10,823
Demonstrate accountability and efficiency
Continuing Care Cost per Weighted Patient Day
% Capital Budget Spent Actual YTD
ED Outpatient
(12% of overall activity)
Acute Inpatient & Day Surgery
(53% of overall activity)
Rehab Inpatient
(4% of overall activity)
Ensure continuous investment in strategic infrastructure
Surplus/(Deficit) Actual YTD in 000s
10.1
hrs
Q1 17/18
Jan-
Dec
Jan-
Dec
Q4 16/17
Quarter Rate
Q4 16/17 2.92
Q1 17/18 2.80
Q2 17/18 2.80
Q3 17/18 3.25Q4 17/18 3.42
BWH Target
3.1
Resource Utilization & Audit Committee Key Performance Indicators
Ensure continuous investment in strategic infrastructure
Outstanding Performance - Optimize roles, resources, revenues, technology and innovation
Demonstrate accountability and efficiency
Inspired People - Advance our culture of kindness with an intention to learn, lead, collaborate and celebrate
Promote individual, team and professional development
Absenteeism Rate- (avg # 7.5hr sick days)
All Staff
Quality Care - Assure the right care, in the right place, at the right time, by the right provider
Improve access to care
21.0%
June data unavailable
province-wide due to daily
bed census summary
methodology changes
Exceptional Relationships - Expand innovative partnerships and collaborations to improve experiences, services, transitions and community
Build sustainable partnerships and collaborations
BWH Target
18.4
17.2
18.5
16.7
17.8
0.0
21.5
17.2
17.7
18.6
14.8
15.7
16.9
15.9
16.4
15.0
0.0
5.0
10.0
15.0
20.0
25.0
Jan17
Feb 17
Mar 17
Apr17
May17
Jun17
Jul17
Aug17
Sep17
Oct17
Nov17
Dec17
Jan18
Feb18
Mar18
Apr18
ALC Rate % - All Inpatient Services (Sarnia & Petrolia)
ALC Rate Provincial Target BWH Target
$31 $47
$818$1,422
$2,705 $2,934 $3,003
$4,228$3,638
$3,881$3,425
$3,921 $3,780
$5,357
$2,373$2,887
$0
$1,000
$2,000
$3,000
$4,000
$5,000
$6,000
Jan 1
7
Feb 1
7
Mar
17
Apr
17
May 1
7
Jun 1
7
Jul 17
Aug 1
7
Sep 1
7
Oct
17
Nov 1
7
Dec
17
Jan 1
8
Feb 1
8
Mar
18
Apr
18
Adjusted Working Capital YTD in 000s
0102030405060708090
100
Jan17
Feb 17
Mar 17
Apr17
May17
Jun17
Jul17
Aug17
Sep17
Oct17
Nov17
Dec17
Jan18
Feb18
Mar18
Apr18
% Capital Budget Spent Actual YTD
$5,599
$5,991
$5,937
$5,799
$5,400 $5,500 $5,600 $5,700 $5,800 $5,900 $6,000 $6,100
Q4 16/17
Q1 17/18
Q3 17/18
Q4 17/18
Cost per Weighted Case (Actual YTD)Acute Inpatient & Day Surgery (53% of overall activity)
Q1/Q2 17/18
$5,642
$5,925
$5,853
$5,849
$5,500$5,550$5,600$5,650$5,700$5,750$5,800$5,850$5,900$5,950
Q4 16/17
Q1 17/18
Q3 17/18
Q4 17/18
Cost per Weighted Case (Actual YTD)ER Outpatient (12% of overall activity)
Q1/Q2 17/18
10.1
8.1
9.3
9.6
9.0
9.7
8.0
8.9
9.8
9.4
10.0
8.8
11.2
9.6
8.4
9.5
4.1
3.9
4.3
4.4
3.9
4.0
4.1
4.7
4.0
5.0
3.7
3.8
4.6
4.2
3.7
4.1
0
2
4
6
8
10
12
Jan17
Feb 17
Mar 17
Apr17
May17
Jun17
Jul17
Aug17
Sep17
Oct17
Nov17
Dec17
Jan18
Feb18
Mar18
Apr18
90th Percentile ED Length of Stay for Complex Patients
Sarnia Petrolia Peer Comparator BWH Target
27.2
19.9
24.9
26.5
23.9
27.6
16.6
20.9
25.0
27.0
28.2
25.7
29.9
27.9
26.0
21.6
7.5
7.7
7.3
7.2 7.9 8.8
7.3
6.9 8.4
13.8
10.1
7.0 7.8 10.2
7.7
7.9
BWH Target
Peer Comparator
05
101520253035
Jan17
Feb 17
Mar 17
Apr17
May17
Jun17
Jul17
Aug17
Sep17
Oct17
Nov17
Dec17
Jan18
Feb18
Mar18
Apr18
90th Percentile ED Wait Times (Admitted Patients)
Sarnia Petrolia
Bluewater Health Target
0.00
0.50
1.00
1.50
2.00
2.50
3.00
3.50
4.00
Q4 16/17 Q1 17/18 Q2 17/18 Q3 17/18 Q4 17/18
Absenteeism Rate - (avg # 7.5hr sick days) All Staff
1
Medical Advisory Committee (MAC) Highlights
June 20, 2018
Quality Improvement Initiatives • Approved recommendations from the Pharmacy and Therapeutics Committee,
the Infection and Prevention Control Committee and the Order Sets Committee • Approved a PICC line policy and procedure, a PICC line removal procedure and
a patient benefits and risk form • Discussed ideas for a community-wide Choosing Wisely quality improvement
initiative, including a regional initiative to address acute prescribing of opioids • Approved a policy outlining CEEH transfer criteria for consult and/or admission to
the Sarnia site • Discussed the Chief of Professional Staff’s goals for 2018/19 • Received updates on:
o Nurse Practitioner Diagnostic and Prescriptive Authority Policy o Erythromycin ointment shortage o The N.O.W. patient flow initiative o Emergency Department redesign
• Discussed improved electronic communication between physicians and the hospital
Physician Education, Development and Engagement
• Members discussed next steps regarding the NRC Health Physician Survey • Discussed ways to support physician wellness and health initiatives • To support Professional Staff (Active/Associate) experiencing difficulties,
Bluewater Health will be offering access to qualified counselling professionals, through the Employee and Family Assistance Program
• Recognized Dr. Al-Dhaher for receiving Schulich Award of Excellence for Faculty in Community/Distributed Sites
• Discussed upcoming events: o Bluewater Health Annual General Meeting – June 27, 2018 o Physician Family BBQ – July 29, 2018 o Session for clinical instructors - September 22,2018 in conjunction with
Schulich School of Medicine o Physician Leadership Institute (PLI) “Leading Change” course – will be
offered in the fall Recruitment/Succession Planning
• A new hospitalist has recently signed, a rheumatologist will be providing clinics in Petrolia, and there is a potential neurologist to provide locum coverage
• increased recruitment for an anaesthesiologist, a replacement urologist is required, and surgery is preparing an impact analysis for a second ENT surgeon
Submitted by: Mike Haddad, MD, MSc, FRCSC, Chief of Professional Staff
1
No. Work Plan Item Committee Responsible
Alignment Policy/Strategic Plan/Legislation
Board Agenda Category (P=Public) Au
gust
Sept
embe
r
Oct
ober
Nov
embe
r
Dece
mbe
r
Janu
ary
Febr
uary
Mar
ch
April
May
June
Status (CompleteIn ProgressDeferred)
Comments
1.1 Monitor Strategic Plan annually G&N P. 1.30/5.15 Discussion (P) x x x Complete
1.2 Monitor strategic goals and quality/resource objectives via Balanced Scorecards and provide oversight for remediation/improvement plans
Quality/RUACECFAA
SPP. 1.40/5.15
Discussion (P) x x x x x x x x x xComplete
1.3 Review/approve/monitor Quality Improvement Plan (QIP)Quality
P. 3.30/5.15 ECFAA
Decision (P) x x x x x xComplete
2.1 Complete CEO/CoPS performance evaluation and approve goals/objectives
Exec P. 2.30 In-Camerax x
Complete
2.2 Establish annual CEO/CoPS performance expectations Exec P. 2.30 In-Camera x x Complete
2.3 Determine annual CEO/CoPS compensation Exec P. 230 In-Camera x Complete
2.4 Ensure CEO/CoPS establish an appropriate succession plan for BWH leaders and Professional Staff
RUAC P. 2.10/5.15 Minutesx x
Complete
2.5 Review/approve annual HR and Physician HR plans RUAC P. 5.15 Decision (P) x x Complete
2.6 Review/approve executive performance-based compensation Board P. 2.30ECFAA In-Camerax x
Complete
2.7 Review/approve salary recommendation for non-union compensation
RUAC P. 2.30ECFAA
In-Camerax x
Complete
2.8 Review/approve Medical Director and other medical leadership appointments as required
MAC P. 5.15 In-Camerax x x x x x x x x x
Complete
3.1 Monitor Quality and Patient Safety program including: development of the Q&PS Plan, staff safety survey, legislation changes, risk management (incidents and adverse events)
Quality P. 3.10/3.30 SP
In-Camera
x x x x x
Complete
3.2 Monitor accreditation activities and respond as required (timing aligned with accreditation cycle)
Quality/G&N P. 3.30/5.15/5.40 Discussionx x x x x
Complete
3.3 Review Critical Incident Aggregated Data reports quarterly (legislation: at least two times per year)
Quality P. 3.30ECFAA
In-Camerax x x x x
Complete
BLUEWATER HEALTH WORK PLAN 2017-18
1.0 Establishing Strategic Direction
2.0 Providing for Excellence Management
3.0 Ensuring Program Quality and Effectiveness
2
No. Work Plan Item Committee Responsible
Alignment Policy/Strategic Plan/Legislation
Board Agenda Category (P=Public) Au
gust
Sept
embe
r
Oct
ober
Nov
embe
r
Dece
mbe
r
Janu
ary
Febr
uary
Mar
ch
April
May
June
Status (CompleteIn ProgressDeferred)
Comments
BLUEWATER HEALTH WORK PLAN 2017-18
3.4 Monitor litigation claims (minimum annually based on policy) Quality P. 3.40 In-Camerax x x
Complete
3.5 Monitor ethical framework outcomes and related policies Quality P. 3.70 In-Camerax x
Complete
3.6 Monitor research being undertaken within the organization Quality P. 3.45/3.70 Minutesx x x x
Complete
3.7 Monitor pandemic plan and emergency preparedness (i.e. Disaster plan and other related activities)
Quality P. 3.10/3.30/5.15 Minutesx
Complete
3.8 Monitor Quality Improvement Initiatives (through monthly program tours or didactic presentations) - education articles will be linked to program
Quality P. 5.40 ECFAA
Minutesx x x x x x x x
Complete
3.9 Review recommendations from MAC on any systemic/recurring issues related to quality of care provided by professional staff as required (standing agenda item)
Quality/MAC P. 3.30PHA
In-Camera
x x x x x x x x x
Complete
3.10 Receive reports from the Quality and Patient Experience Committee
Quality Policy 5.40 Minutesx x x x x x x
Complete
3.11 Monitor patient experience results via Balanced Scorecard, Concerns/Compliments reports and PFCC Action Plan quarterly
Quality P. 3.40ECFAA
SP
Minutesx x x x
Complete
3.12 Provide update on Workplace Violence (will also be incorporated into 2018_19 QIP and scorecard)
Quality ECFAA Minutesx x
Complete
3.13 Monitor staff, professional staff and volunteer engagement survey results
Quality ECFAASP
Minutesx x
Deferred Deferred to Fall Board Retreat
3.14 Monitor Emergency Department Return Visit Quality Program Quality Minutesx x
Complete
3.15 Review/approve Professional Staff appointments, reappointments, privileges as required
MAC PHA In-Camerax x x x x x x x x x
Complete
3.16 Review fairness/effectiveness of credentialing process annually MAC In-Camerax x
Complete
3.17 Receive reports from the CEO in relation to the 3rd party whistleblower service
RUAC P. 3.60 Minutesx
Complete
4.1 Monitor financial performance via monthly financial statements
RUAC P. 4.10/4.40 Discussion (P)x x x x x x x x x x
Complete 4.0 Ensuring Financial Viability
3
No. Work Plan Item Committee Responsible
Alignment Policy/Strategic Plan/Legislation
Board Agenda Category (P=Public) Au
gust
Sept
embe
r
Oct
ober
Nov
embe
r
Dece
mbe
r
Janu
ary
Febr
uary
Mar
ch
April
May
June
Status (CompleteIn ProgressDeferred)
Comments
BLUEWATER HEALTH WORK PLAN 2017-18
4.2 Review/approve annual operating plan Quality/RUAC P. 3.30/4.30 Decision (P) x x x x Complete
4.3 Review/approve Hospital Accountability Planning Submission (HAPS)
RUAC P. 4.10/4.15 Decision (P)
x x
In Progressrevised HAPS to be submitted to ESC LHIN July 13, 2018.
4.4 Review/approve/monitor capital expenditure plan RUAC P. 4.30 Decision (P) x x x x x x x x x Complete
4.5 Review/approve Hospital Service Accountability Agreement (H-SAA)
RUAC P. 4.10/5.15 Decision (P)x x
Complete Agreement extended to March 31, 2018
4.6 Review/approve Multi-Sectoral Accountability Agreement (M-SAA)
RUAC P. 4.10/4.15 Decision (P)
x x x x x
Complete Agreement to be extended to September 30, 2018
4.7 Review/approve Chief Financial Officer Report - legislative requirements/risk management
RUAC P. 3.40/4.40/4.505.15/5.40
Consent A (P)x x x x
Complete
4.8 Review/receive quarterly report on investments and loans RUAC P. 4.50/4.60/5.15 Consent R (P)x x x x
Complete
4.9 Review/receive Human Resources Report quarterly RUAC P. 5.15 Consent R (P) x x x x Complete
4.10 Review/receive Facilities/HIRF Report quarterly RUAC P. 4.10/5.15 Consent R (P) x x x x Complete
4.11 Review/receive insurance annually RUAC P. 4.50 Minutes x Complete
4.12 Review/approve banking arrangements/resolutions RUAC P. 4.80 Consent R (P) x x Complete
4.13 Review/approve audit activities as required(post-audit/management letter, management's response and action plan, audit plan, finanial statements, firm/compensation)
RUAC P. 5.15/5.40 Consent R
x x x
Complete
4.14 Review/approve Executive and Director expenses RUAC BPSAAP. 4.75/5.10/5.105
Consent R x x
Complete
4.15 Review/approve Public Sector Salary Disclosure Attestation RUAC PSSDAP. 5.10
Consent R (P)x
Complete
4.16 Review/approve BPSAA Attestation - consultant use, perquisites, lobbyist rules, etc.
RUAC BPSAAP. 4.75/5.105/5.10
Consent A (P)x Complete
4.17 Provide update on HIS or any other significant technology investments as needed
RUAC P. 51.5SP
Minutesx x x x x x x x
Complete
4
No. Work Plan Item Committee Responsible
Alignment Policy/Strategic Plan/Legislation
Board Agenda Category (P=Public) Au
gust
Sept
embe
r
Oct
ober
Nov
embe
r
Dece
mbe
r
Janu
ary
Febr
uary
Mar
ch
April
May
June
Status (CompleteIn ProgressDeferred)
Comments
BLUEWATER HEALTH WORK PLAN 2017-18
4.18 Monitor/approve decisions related to property matters as required
RUAC P. 410/4.15 In-Camerax x x x
Complete
4.19 Monitor status of the development of the 5-Year Plan - services, facilities, capital equipment, and technology
RUAC P. 4.30/5.15SP
Minutesx x
Complete
5.1 Develop/approve annual work plan All P. 5.85 Decision (P)x x
Complete
5.2 Review/revise/approve Terms of Reference All P. 5.40 Decision (P) x x Complete
5.3 Develop/approve/monitor Board Goals G&N/All P. 585/5.86 Decision (P) x x Complete
5.4 Complete Board/Director/NDCM/Committee/Meeting evaluations as required and address opportunities identified by results
G&N?All P. 5.45/5.50/5.55/5.60/5.65/5.86
Consent R (P)x x x x x
Complete
5.5 Strengthen Board Orientation/Education/Team Building G&N/All P. 5.80/5.85/5.90SP
Discussion (P)x x x x x x x x x x x
Complete
5.5a Quality Committee Education Article Review - article to be linked to program who is scheduled for tour or didactic presentation item 3.8
Quality P. 5.80/5.85/5.90SP
Discussion (P)x x NA x x x x x
Complete
5.6 Complete Board succession planning, recruitment and nomination process
G&N P 5.90 Minutesx x x x x x
Complete
5.7 Review Board/NDCM member meeting attendance and education record
G&N P 5.90 Discussion (P)x Complete
5.8 Review/revise/approve Board policies as required All P. 5.85 Consent R (P)x x x x x x x x x x x
Complete
5.9 Plan for Annual General Meeting G&N P. 5.15 Minutes x x x x x x x Complete
5.10 Review/receive annual FIPPA/PHIPPA compliance report and complete FIPPA Delegation of Authority
Quality P. 5.15FIPPA
PHIPPA
Consent A (P)x Complete
5.11 Review/approve Corporate By-Law amendments/3-year cycle review
G&N By-laws Decision (P)x x x
Complete
6.1 Review/receive Global Communication and Community Engagement Plan
G&N P. 5.10/5.15/6.10SP Information (P)
x Complete
6.0 Fostering Relationships
5.0 Ensuring Board Effectiveness
5
No. Work Plan Item Committee Responsible
Alignment Policy/Strategic Plan/Legislation
Board Agenda Category (P=Public) Au
gust
Sept
embe
r
Oct
ober
Nov
embe
r
Dece
mbe
r
Janu
ary
Febr
uary
Mar
ch
April
May
June
Status (CompleteIn ProgressDeferred)
Comments
BLUEWATER HEALTH WORK PLAN 2017-18
6.2 Review/receive reports from CEO/Board liaison representatives re: stakeholder relationships as necessary ie. Governance Advisory/Foundation Boards/CAP/RHAP
G&N P. 5.00/5.15/6.10/6.20
SP
Information (P)
x x x
x Complete
6.3 Complete annual review of BWH collaborations - Monitor partnerships and collaborations and support integration initiatives with other community health service providers
G&N Corporate Collaboration
Policy/SPP. 3.30/5.10/ Discussion
x Completemerged with Annual Report
Quality Committee Performance Indicator Definitions and Graphs
Performance Indicator
Quality Care – Assure the right care, in the right place, at the right time, by the right provider
Ingrain patient safety
1 Medication Reconciliation at Discharge
2 Difficult to speak up if I perceive a problem with patient care
3 Total High Severity Patient Safety Incidents
Improve access to care
4 90th Percentile ED Length of Stay for Complex Patients
Exceptional Relationships – Expand innovative partnerships and collaborations to improve experiences, services, transitions and community health
Build sustainable partnerships and collaborations
5 ALC Rate % - All Inpatient Services (Sarnia & Petrolia)
6 30 day Mental Health Readmission
7 Readmission within 30 days for COPD
Strengthen Patient and Family – Centered Care
8 Overall Rating of Experience
9 Leaving hospital did Patient receive enough information
Inspired People – Advance our culture of kindness with an intention to learn, lead, collaborate and celebrate
Focus on the experience of care and caring
10 Supervisor helps access training and development
11 Was Patient/Family Treated with Kindness
12 Is a Culture of Kindness Promoted at Bluewater Health
Employees
Professional Staff
Volunteer
Revised: May 2018 Next Update: September 2018 Page 2 of 13
Indicator Name: Medication Reconciliation at Discharge
Alignment: Quality and Patient Experience Committee (QPEC)/Quality Committee of the Board (QCB)
Strategic Goal: Ingrain patient safety
Definition: Total percentage of patients for whom Discharge Medication Reconciliation was finalized as a proportion of the total number of patients discharged from the hospital.
Rationale: Hospital discharge is a critical interface of care where patients are at a high risk of medication discrepancies as they transition out of the hospital. The goal of discharge medication reconciliation is to reconcile the medications the patient is taking prior to admission and those initiated in hospital, with the medications they should be taking post-discharge to ensure all changes are intentional and that discrepancies are resolved prior to discharge. This should result in avoidance of therapeutic duplications, omissions, unnecessary medications and confusion.
Additional Specifications:
Exclusions: 1. Mothers delivered and Newborns, including Newborn Repatriations2. Patients with Meditech Discharge Dispositions:
I. ExpiredII. Triaged/Reg'd/Left Against Medical Advice (AMA)
III. Site to Site (CEEH to Sarnia or vice versa)IV. Signed Medical ReleaseV. Transfer
VI. Transfer to another Acute Care FacilityVII. Transfer to an Ambulatory Care Clinic
Peer Comparator: No peer comparator data available
80
82
84
86
88
90
92
94
96
98
100
Apr
16
May
16
Jun
16
Jul
16
Aug
16
Sep
16
Oct
16
Nov
16
Dec
16
Jan
17
Feb
17
Mar
17
Apr
17
May
17
Jun
17
July
17
Aug
17
Sep
17
Oct
17
Nov
17
Dec
17
Jan
18
Feb
18
Mar
18
Q1 16/17 Q2 16/17 Q3 16/17 Q4 16/17 Q1 17/18 Q2 17/18 Q3 17/18 Q4 17/18
% P
erc
en
tag
e F
ina
lize
d
up
on
Dis
ch
arg
e
Medication Reconciliation Upon Discharge
Pre
ferre
d T
ren
din
g
Revised: May 2018 Next Update: September 2018 Page 3 of 13
Indicator Name: It is difficult to speak up if perceive a problem with patient care
Alignment: Quality and Patient Experience Committee (QPEC)/Quality Committee of the Board (QCB)
Strategic Goal: Ingrain Patient Safety
Definition: This is a custom employee survey question that asks employees to respond to the statement “in this unit it is difficult to speak up if I perceive a problem with patient care”. The top box responses request respondents to “strongly disagree” and “disagree” with the proposed statement. A higher percentage of employees disagreeing or strongly disagreeing with this statement is preferred.
Rationale: “It is difficult to speak up if I perceive a problem with patient care” is a measure that comes from a reliable and valid survey through patient safety research. To ensure we can track and measure this indicator we will assess a baseline and target by sending staff surveys thorough a Survey Monkey process. This indicator is a measure indicative of patient safety culture throughout the organization and will identify how safe the inter-professional team feels to report patient safety incidents. The development, dissemination, education and implementation of a Quality and Patient Safety Plan will enable a culture of safety by enhancing knowledge transfer of the importance of reporting patient safety incidents to improve quality and safety of the patients we serve.
Additional Specifications:
This indicator was released in December 2016. Responses to this question are collected routinely in a Strategic Engagement survey.
Target for 17/18: 49.6%
Bluewater Health Target 49.6%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Q3 16/17 Q4 16/17 Q1 17/18 Q2 17/18 Q3 17/18
Dif
ficu
lt
to s
pe
ak u
p
Difficult to Speak up if Perceive a Problem with Patient Care
Pre
ferre
d Tre
nd
ing
Our Status
Revised: May 2018 Next Update: September 2018 Page 3 of 13
Indicator Name: Total High Severity Patient Safety Incidents
Alignment: Quality and Patient Experience Committee (QPEC)/Quality Committee of the Board (QCB)
Strategic Goal: Ingrain patient safety
Definition: This measure tracks the total number of patient safety incidents categorized as Level 4 or Level 5. An example of a Level 4 patient safety incident is a fall in which the patient falls and sustains a fractured hip requiring surgical repair.
Rationale: A patient safety incident is an event or circumstance that could have resulted, or did result, in unnecessary harm to a patient. Bluewater Health FY17/18 Target for Total High Severity Patient Safety Incidents is set 0, “as zero patient harm is an indisputable goal that must be a priority for all stakeholders. It is the right thing to do for patients and families.” (Cochrane et. al. 2017, p.66) In compliance with the Public Hospital’s Act, there is an obligation of hospitals to report critical incidents to the Quality Committee of the Board.
Additional Specifications:
On September 6, 2017, Bluewater Health implemented a new incident reporting system RL6. With the implementation of the new incident reporting software the severity levels have been amended to reflect the updated guidelines set by the Ontario Hospital Association (OHA).
Level 4 - Patient outcome is symptomatic, requiring life-saving intervention or major surgical/medical intervention, shortening life expectancy or causing major permanent or long-term harm or loss of function.
Level 5 - On balance of probabilities, death was caused or brought forward in the short-term by the incident.
Peer Comparator: No peer comparator data available
Bluewater Health Target
-1
0
1
2
3
4
5
6
Q1 16/17 Q2 16/17 Q3 16/17 Q4 16/17 Q1 17/18 Q2 17/18 Q3 17/18 Q4 17/18Nu
mb
er
of
Hig
h S
ev
eri
ty P
ati
en
t S
afe
ty I
ncid
en
ts
Total High Severity Patient Safety Incidents
Pre
ferr
ed
Tre
nd
ing
Our StatusOur Status
Revised: May 2018 Next Update: September 2018 Page 5 of 13
Indicator Name: 90th Percentile Emergency Department (ED) Length of Stay (LOS) for Complex Patients
Alignment: Quality and Patient Experience Committee (QPEC)/Quality Committee of the Board (QCB)/Performance & Utilization Committee (PUC)/Resource Utilization & Audit Committee (RUAC)
Strategic Goal: Improve access to care
Definition: The total ED length of stay where 9 out of 10 complex patients completed their visits. ED Length of Stay defined as the time from triage or registration, whichever comes first, to the time the patient leaves the ED.
Rationale:
Additional Specifications:
Peer Comparator: Ontario high-volume community hospitals, Sarnia Site only
Sarnia Site
Petrolia Site
Target
Ontario high-volume community hospitals 16/17
0.0
2.0
4.0
6.0
8.0
10.0
12.0
Apr16
May16
Jun16
Jul16
Aug16
Sep16
Oct16
Nov16
Dec16
Jan17
Feb17
Mar17
Apr17
May17
Jun17
July17
Aug17
Sep17
Oct17
Nov17
Dec17
Jan18
Feb18
Mar18
Q1 16/17 Q2 16/17 Q3 16/17 Q4 16/17 Q1 17/18 Q2 17/18 Q3 17/18 Q4 17/18
ED
LO
S (
ho
urs
)
90th Percentile ED LOS Complex Patients
Pre
ferr
ed
Tre
nd
ing
CEEH
Status
Sarnia
Status
Revised: May 2018 Next Update: September 2018 Page 6 of 13
Indicator Name: Alternate Level of Care (ALC) Rate %-All Inpatient Services
Alignment: Quality and Patient Experience Committee (QPEC), Quality Committee of the Board (QCB), Performance & Utilization Committee (PUC), Resource Utilization & Audit Committee (RUAC)
Strategic Goal: Build sustainable partnerships and collaborations
Definition: The rate at which patients who have been designated ALC occupy inpatient beds.
Rationale: Ensuring that each patient receives the appropriate level of care at all times during their healthcare journey is a priority at Bluewater Health. Our goal is for Emily to receive the right care, given at the right time, in the right place, always. The ALC rate represents an opportunity for inpatients to be transitioned to the next level of care, where their care needs and the services provided are better matched. Multiple factors can influence ALC rate, including overall hospital occupancy, and availability of resources both internal and external to the hospital.
Additional Specifications:
ALC Rate = Total number of ALC Days in a given period
Total number of inpatient days in the same time period ×100%
Peer Comparator: Ontario hospital value
ALC Rate
Bluewater HealthTarget
Provincial Target FY 17/18
ALC Days
0
200
400
600
800
1000
1200
1400
1600
1800
2000
0
5
10
15
20
25
30
35
40
45
50
Apr
16
May
16
Jun
16
Jul
16
Aug
16
Sep
16
Oct
16
Nov
16
Dec
16
Jan
17
Feb
17
Mar
17
Apr
17
May
17
Jun
17
July
17
Aug
17
Sep
17
Oct
17
Nov
17
Dec
17
Jan
18
Feb
18
Mar
18
Q1 16/17 Q2 16/17 Q3 16/17 Q4 16/17 Q1 17/18 Q2 17/18 Q3 17/18 Q4 17/18
AL
C D
ay
s In
pa
tie
nt
Se
rvic
es
AL
C R
ate
%
ALC Rate % -All Inpatient Services (Sarnia and Petrolia)
Pre
ferr
ed
Tre
nd
ing
Our Status
Revised: May 2018 Next Update: September 2018 Page 7 of 13
Indicator Name: 30 Day Mental Health Readmission
Alignment: Quality and Patient Experience Committee (QPEC)/Quality Committee of the Board (QCB)
Strategic Goal: Build sustainable partnerships and collaborations
Definition: The percentage of Ontario Mental Health Reporting System (OMHRS) full admissions that were discharged 30 days ago or less from this facility.
Rationale:
Additional Specifications:
Peer Comparator: No peer comparator data available
Target
0.0
5.0
10.0
15.0
20.0
25.0
Q1 16/17 Q2 16/17 Q3 16/17 Q4 16/17 Q1 17/18 Q2 17/18 Q3 17/18
% o
f 3
0 D
ay
Me
nta
l H
ea
lth
Re
ad
mis
sio
ns
30 Day Mental Health Readmissions
Pre
ferr
ed
Tre
nd
ing
Our Status
Revised: May 2018 Next Update: September 2018 Page 8 of 13
Indicator Name: Readmission within 30 days for Chronic Obstructive Pulmonary Disease (COPD)
Alignment: Quality and Patient Experience Committee (QPEC)/ Quality Committee of the Board (QCB)
Strategic Goal: Build sustainable partnerships and collaborations
Definition: The measuring unit of this indicator is an admission for COPD, as defined for the quality based procedure (QBP). Results are expressed as crude 30-day non-elective readmission rate among patients admitted to Ontario acute care facilities.
Rationale: Readmission rates are considered a marker of poor hospital performance. High rates may indicate inadequate care, inadequate follow up, and inadequate preparation for discharge or poor doctor to doctor communication at the time of discharge. Reducing readmission rates benefit the patient through a higher quality of care and the hospital through cost containment.
Additional Specifications:
Peer Comparator: Crude calculation of 30 day readmission for COPD in the Erie St Clair LHIN Hospitals for Fiscal Year 16/17 – 18.2%
Target
ESC-LHIN Crude Rate 18.2%
10%
12%
14%
16%
18%
20%
22%
24%
Q1 16/17 Q2 16/17 Q3 16/17 Q4 16/17 Q1 17/18 Q2 17/18 Q3 17/18
% o
f B
WH
P
ati
en
ts R
ea
dm
itte
d to
BW
H w
ith
in 3
0 D
ay
s
(Se
lect
HIG
s)
30 Day Readmission for COPD
Pre
ferr
ed
Tre
nd
ing
Our Status
Revised: May 2018 Next Update: September 2018 Page 9 of 13
Indicator Name: Overall Rating of Experience
Alignment: Quality and Patient Experience Committee (QPEC)/Quality Committee of the Board (QCB)
Strategic Goal: Strengthen Patient and Family-Centered Care
Definition: Overall Rating of Experience: Inpatient (IP) and Emergency Department (ED), patients are asked to rate their hospital experience on a scale from 0 to 10, with 0 being I had very poor experience and 10 being I had a very good experience.
Rationale: Patient experience measurement is an industry best practice and hospitals are required to survey patients at least once every fiscal year, according to Ontario’s Excellent Care for All Act (ECFAA), 2010. “We create exemplary healthcare experiences with patients and families every time”, is the mission of Bluewater Health. These questions reflect how well the hospital is achieving its overall mission. The patient experience is what we strive to excel at. Measurement of patient experience is important because it provides an opportunity to improve care, enhance strategic decision making, meet patients’ expectations, effectively manage and monitor healthcare performance, and document benchmarks for the organization.
Additional Specifications:
Scores are calculated using the following measure recommended by the National Research Corporation Canada (NRCC): Positive - Positive measure type is calculated by counting “Positive” response (i.e., 9-10 or Yes, Definitely or Always) and dividing by the total number of responses.
Inclusion Criteria: - Patients who have received active treatment at Bluewater Health
- 18 years or older at the time of admission- Alive at the time of discharge
Exclusion Criteria: - Patients who have notified Bluewater Health they wish to be excluded from
the mailing list- Patients who are stillborn or deceased while in the hospital- Patients with no fixed address
- Psychiatric patients (unless being specifically surveyed using the MentalHealth inpatient or outpatient survey tool)
- Patients who present with evidence of sexual assault or with sensitiveissues (e.g., miscarriage)
Peer Comparator: The Ontario Hospital Association Patient Reported Performance Management (OHA PRPM) benchmark includes OHA member hospitals. The Ontario Inpatient (IP) Community Hospital (Hosp) Average compares hospitals of the same size within the province. Peer comparators are updated quarterly.
Inpatient OHA-PRPM – 68.2% Ontario IP Community Hosp Average – 65.0%
Emergency Department (ED) There is no peer comparator as this is a Bluewater Health custom question for the Emergency Department Patient Experience of Care Survey (EDPEC)
Target for 2017/2018:
ED - 49.1% Inpatient – 75.9%
ED Target 49.1%
Inpatient Target 75.9%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Apr16
May16
Jun16
Jul16
Aug16
Sep16
Oct16
Nov16
Dec16
Jan17
Feb17
Mar17
Apr17
May17
Jun17
Jul17
Aug16
Sep16
Oct17
Nov17
Dec17
Jan18
Feb18
Mar18
Q1 16/17 Q2 16/17 Q3 16/17 Q4 16/17 Q1 17/18 Q2 17/18 Q3 17/18 Q4 17/18
Ov
era
ll R
ati
ng
of
Exp
eri
en
ce
Overall Rating of Experience
ED Inpatient
Pre
ferre
d T
ren
din
g
ED
StatusInpatient
Status
Revised: May 2018 Next Update: September 2018 Page 10 of 13
Indicator Name: Leaving hospital did patients receive enough information
Alignment: Quality and Patient Experience Committee (QPEC)/Quality Committee of the Board (QCB)
Strategic Goal: Strengthen Patient and Family-Centered Care
Definition: As Emily leaves the hospital, this indicator asks the question of whether Emily perceives that she received the information she needed from Bluewater Health Staff and Physicians before leaving our care. This question is asked of both inpatients and emergency department patients. Inpatient Question: Did you receive enough information from hospital staff about what to do if you were worried about your condition or treatment after you left the hospital? Not at all/ Partly/ Quite a bit/ Completely Emergency Department Patient Question: Before you left the emergency department, did you understand what symptoms or health problems to look out for when you left the emergency department? Yes/No
Rationale: Patient experience measurement is an industry best practice and hospitals are required to survey patients at least once every fiscal year, according to Ontario’s Excellent Care for All Act (ECFAA), 2010.
Additional Specifications:
Scores are calculated using the following measure recommended by the National Research Corporation Canada (NRCC): Positive - Positive measure type is calculated by counting “Positive” response (i.e., 9-10 or Yes, Definitely or Always) and dividing by the total number of responses.
Inclusion Criteria: - Patients who have received active treatment at Bluewater Health
- 18 years or older at the time of admission- Alive at the time of discharge
- Exclusion Criteria:- Patients who have notified Bluewater Health they wish to be excluded from
the mailing list- Patients who are stillborn or deceased while in the hospital
- Patients with no fixed address- Psychiatric patients (unless being specifically surveyed using the Mental
Health inpatient or outpatient survey tool)- Patients who present with evidence of sexual assault or with sensitive
issues (e.g., miscarriage)
Peer Comparator: The Ontario Hospital Association Patient Reported Performance Management (OHA PRPM) benchmark includes OHA member hospitals. The Ontario Inpatient (IP) Community Hospital (Hosp) Average and the Ontario ED Community Hosp Average is a comparator of hospitals of the same size. Peer comparators are updated quarterly. Inpatient OHA PRMP – 57.5% Ontario IP Community Hosp Average – 54.3% ED OHA PRMP – 84.2% Ontario ED Community Hosp Average – 82.5%
Target 2017/2018: ED - 81.0% Inpatient - 61.6%
Emergency Department Target 81.0%
Inpatient Target 61.6%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Apr16
May16
Jun16
Jul16
Aug16
Sep16
Oct16
Nov16
Dec16
Jan17
Feb17
Mar17
Apr17
May17
Jun17
Jul17
Aug16
Sep16
Oct17
Nov17
Dec17
Jan18
Feb18
Mar18
Q1 16/17 Q2 16/17 Q3 16/17 Q4 16/17 Q1 17/18 Q2 17/18 Q3 17/18 Q4 17/18
Re
ce
ive
d e
no
ug
h I
nfo
rma
tio
n
Leaving Hospital did Patients receive Enough Information
ED Inpatient
Inpatient
Status
Pre
ferre
d T
ren
din
g
EDStatus
Revised: May 2018 Next Update: September 2018 Page 11 of 13
Indicator Name: Supervisor helps access training and development
Alignment: Quality and Patient Experience Committee (QPEC)/Quality Committee of the Board (QCB)
Strategic Goal: Focus on the experience of care and caring
Definition: This is a custom employee survey question that will ask “My Supervisor helps me to access training and development?” The top box responses request respondents to “Agree” and “Strongly Agree” with the proposed statement. A higher percentage of employees agreeing or strongly agreeing with this statement is preferred.
Rationale: Ensuring that each patient receives the best care possible begins with exceptional care providers. Bluewater Health is committed to strengthening the skills and education of our employees. This commitment to education promotes inspired people who will advance our culture of kindness with an intention to learn, lead, collaborate and celebrate. Evidence suggests that investment in employee training and development leads to employees feeling more valued and willing and able to invest in their work. Employee training and development supports efficiencies and standardized procedures, risk reduction, patient safety and quality of patient care. Research links high levels of employee engagement with increased patient satisfaction when an organization focuses on processes and people. This reflects on the organization’s ability to provide opportunities for personal development to stay up to date with latest techniques and technologies and recognize employees for acquiring additional skills and knowledge sets.
Additional Specifications:
This indicator was released in December 2016. Responses to this question are collected routinely in a Strategic Engagement survey.
Target for 2017/2018:
67.3%
Bluewater Health Target 67.3%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Q3 16/17 Q4 16/17 Q1 17/18 Q2 17/18 Q3 17/18
Su
pe
rvis
or
he
lps a
cce
ss t
rain
ing
&
de
ve
lop
me
nt
Supervisor Helps Access Training and Development
Pre
ferre
d T
ren
din
g
Our Status
Revised: May 2018 Next Update: September 2018 Page 12 of 13
Indicator Name: Was Patient/Family Treated with Kindness
Alignment: Quality and Patient Experience Committee (QPEC)/Quality Committee of the Board (QCB)
Strategic Goal: Focus on the experience of care and caring
Definition: This is a new, custom question for Bluewater Health’s patient experience surveys which are mailed to a random selection of patients after they are discharged. Our aim is that the culture of kindness at Bluewater Health will be increasingly felt by our patients and families over time. This question asks Emily to reflect and respond to the statement “Were you and your family treated with kindness by employees, volunteers and physicians at Bluewater Health?” Responses available for this question are as follows: No/ Yes, somewhat/ Yes, mostly/ Yes definitely
Rationale: Exemplary healthcare experiences begin with kindness. We understand that patients expect courtesy, respect and dignity, beginning with an expression and attitude of kindness and caring. We understand that having highly skilled and competent staff isn’t enough. Ensuring that you and your family are treated with kindness is a key focus of Bluewater Health’s commitment to Patient & Family-Centered Care. Patient experience measurement is an industry best practice and hospitals are required to survey patients at least once every fiscal year, according to Ontario’s Excellent Care for All Act (ECFAA), 2010.
Additional Specifications:
Scores are calculated using the following measure recommended by the National Research Corporation Canada (NRCC): Positive - Positive measure type is calculated by counting “Positive” response (i.e., 9-10 or Yes, Definitely or Always) and dividing by the total number of responses. Inclusion Criteria: - Patients who have received active treatment at Bluewater Health
Exclusion Criteria: - Patients who have notified Bluewater Health they wish to be excluded from
the mailing list- Patients who are stillborn or deceased while in the hospital- Patients with no fixed address
- Psychiatric patients (unless being specifically surveyed using the MentalHealth inpatient or outpatient survey tool)
- Patients who present with evidence of sexual assault or with sensitiveissues (e.g., miscarriage)
Peer Comparator: This is a Bluewater Health custom question and no peer comparator data is available. NRC Health establishes benchmarks/peer comparators based on the following requirements:
- Made up of one year of data- Questions must be used by at least five facilities
Must have at least 1000 responses for the question
Target for 2017/18: ED - 64.5% Inpatient - 80.4%
ED Target 64.5%
IP Target 80.4%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Apr16
May16
Jun16
Jul16
Aug16
Sep16
Oct16
Nov16
Dec16
Jan17
Feb17
Mar17
Apr17
May17
Jun17
Jul17
Aug16
Sep16
Oct17
Nov17
Dec17
Jan18
Feb18
Mar18
Q1 16/17 Q2 16/17 Q3 16/17 Q4 16/17 Q1 17/18 Q2 17/18 Q3 17/18 Q4 17/18
Wa
s P
atie
nt/
Fa
mily
Tre
ate
d w
ith
K
ind
ne
ss
Was Patient/Family Treated with KindnessED Inpatient
Pre
ferre
d T
ren
din
g
Inpatient
Status
ED
Status
Revised: May 2018 Next Update: September 2018 Page 1 3 of 13
Indicator Name: Is a Culture of Kindness Promoted at Bluewater Health Alignment: Quality and Patient Experience Committee (QPEC)/Quality Committee of the Board
(QCB)
Strategic Goal: Focus on the experience of care and caring
Definition: This is a custom survey question that will ask “Is a culture of kindness promoted at BWH?” Top Box responses from Employees, Professional Staff and Volunteers are displayed. The top box responses request respondents to “Agree” and “Strongly Agree” with the proposed statement. A higher percentage of employees agreeing or strongly agreeing with this statement is preferred.
Rationale: Bluewater health is committed to strengthening our culture of kindness while we deliver Quality Care to Emily. Creating a kindness culture in the workplace reduces stress, fosters relationships, increases psychological wellness and health and leads to increased engagement, energy and resiliency at work. Evidence suggests that high engagement influences human resource goals of increased retention and recruitment, high job performance and lower absenteeism. Research links high levels of employee engagement with increased patient satisfaction when an organization focuses on processes and people. Caring for people creates a workforce with physical energy, mental focus and the emotional drive necessary to provide exemplary care to Emily every day. The culture of kindness has been measured in the “joy” people bring to work; it is palpable throughout the organization and referred to as measuring “humanity”.
Additional Specifications:
This indicator was released in December 2016. Responses to this question are collected routinely in a Strategic Engagement survey.
Target for 2017/2018:
Employees – 65.9% Professional Staff - 60.1% Volunteers - 84.1%
Employee Target 65.9%
Professional Staff Target 60.1%
Volunteer Target 84.1%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Q3 16/17 Q4 16/17 Q1 17/18 Q2 17/18 Q3 17/18Is a
Culture
of Kin
dness
Pro
mote
d a
t BW
H
Is a Culture of Kindness Promoted at Bluewater Health
Employees Prof. Staff Volunteers
Pre
ferre
d Tre
nd
ing
Our Status
Resource Utilization & Audit Committee Indicator Definitions and Graphs
Performance Indicator
Quality Care – Assure the right care, in the right place, at the right time, by the right provider
Improve access to care
1 90th Percentile ED Length of Stay for Complex Patients Sarnia
Petrolia
2 90th Percentile ED Length of Stay (Admitted Patients) Sarnia
Petrolia
Exceptional Relationships – Expand innovative partnerships and collaborations to improve experiences, services, transitions and community health
Build sustainable partnerships and collaborations
3 ALC Rate % - All Inpatient Services (Sarnia & Petrolia)
Inspired People – Advance our culture of kindness with an intention to learn, lead, collaborate and celebrate
Promote individual, team and professional development
4 Absenteeism Rate – (avg. # 7.5hr sick days) – All Staff
Outstanding Performance – Optimize roles, resources, revenues, technology and innovation
Demonstrate accountability and efficiency
5 Cost per Weighted Case: Acute Inpatient & Day Surgery (53% of overall activity) Actual YTD
6 Cost per Weighted Case: ED Outpatient (12% of overall activity) Actual YTD
7 Cost per Weighted Case: Rehab Inpatient (4% of overall activity) Actual YTD
8 Continuing Care Cost per Patient Day Actual YTD
9 Mental Health Cost per Patient Day Actual YTD
10 QBP Financial Exposure (Potential lost revenue related to QBP achievement) Actual YTD
11 Surplus/(Deficit) in 000s Actual YTD
Ensure continuous investment in strategic infrastructure
12 Adjusted Working Capital (in 000s) Actual YTD
13 % of Capital Budget Spent Actual YTD
Revised: May 2018 Next Update: September 2018 Page 2 of 14
Indicator Name: 90th Percentile Emergency Department (ED) Length of Stay (LOS) for Complex Patients
Alignment: Quality and Patient Experience Committee (QPEC)/Quality Committee of the Board (QCB)/Performance & Utilization Committee (PUC)/Resource Utilization & Audit Committee (RUAC)
Strategic Goal: Improve access to care
Definition: The total ED length of stay where 9 out of 10 complex patients completed their visits. ED Length of Stay defined as the time from triage or registration, whichever comes first, to the time the patient leaves the ED.
Rationale:
Additional Specifications:
Peer Comparator: Ontario high-volume community hospitals, Sarnia Site only
Sarnia Site
Petrolia Site
Target
Ontario high-volume community hospitals 16/17
0.0
2.0
4.0
6.0
8.0
10.0
12.0
Apr16
May16
Jun16
Jul16
Aug16
Sep16
Oct16
Nov16
Dec16
Jan17
Feb17
Mar17
Apr17
May17
Jun17
July17
Aug17
Sep17
Oct17
Nov17
Dec17
Jan18
Feb18
Mar18
Q1 16/17 Q2 16/17 Q3 16/17 Q4 16/17 Q1 17/18 Q2 17/18 Q3 17/18 Q4 17/18
ED
LO
S (
ho
urs
)
90th Percentile ED LOS Complex Patients
Pre
ferr
ed
Tre
nd
ing
CEEH
Status
Sarnia
Status
Revised: May 2018 Next Update: September 2018 Page 3 of 14
Indicator Name: 90th Percentile Emergency Department Length of Stay (LOS) for Admitted Patients
Alignment: Performance & Utilization Committee (PUC)/Resource Utilization & Audit Committee (RUAC)
Strategic Goal: Improve access to care
Definition: ED length of stay for admitted visits is defined as the time from triage or registration, whichever comes first, to the time the patient leaves the ED to an inpatient bed. It is measured in hours. The 90th percentile is the maximum length of time in which 9 of 10 of admitted patients have completed their ED visit and have been moved to an inpatient unit. A small number is desirable.
Rationale: Time is crucial to the effectiveness and outcome of patient care, especially for emergency patients. In conjunction with other indicators, this can be used to monitor the total length of time admitted patients spend in the ED in an effort to improve the efficiency and, ultimately, the outcome of patient care. This measure remains one of Bluewater Health’s top priorities in our Quality Improvement Plan (QIP) and Strategic Plan.
Additional Specifications:
Inclusions:
1. Admitted unscheduled emergency visits2. ED visits with a valid and known registration date/time or triage date/time
and a valid and known date/time the patient left the ED
Exclusions:
1. Scheduled emergency visits2. Non-admitted unscheduled emergency visits3. Visits with both unknown/invalid registration and triage date/time OR with
unknown/invalid patient left ED date/time
Peer Comparator: Ontario high-volume community hospitals, Sarnia Site only
Sarnia Site
Petrolia Site
Target
Ontario high-volume community hospitals 16/17
0
5
10
15
20
25
30
35
Apr
16
May
16
Jun
16
Jul
16
Aug
16
Sep
16
Oct
16
Nov
16
Dec
16
Jan
17
Feb
17
Mar
17
Apr
17
May
17
Jun
17
July
17
Aug
17
Sep
17
Oct
17
Nov
17
Dec
17
Jan
18
Feb
18
Mar
18
Q1 16/17 Q2 16/17 Q3 16/17 Q4 16/17 Q1 17/18 Q2 17/18 Q3 17/18 Q4 17/18
ED
LO
S (
ho
urs
)
90th Percentile ED LOS(Admitted Patients)
Pre
ferr
ed
Tre
nd
ing
Sarnia
Status
CEEH
Status
Revised: May 2018 Next Update: September 2018 Page 4 of 14
Indicator Name: Alternate Level of Care (ALC) Rate %-All Inpatient Services
Alignment: Quality and Patient Experience Committee (QPEC), Quality Committee of the Board (QCB), Performance & Utilization Committee (PUC), Resource Utilization & Audit Committee (RUAC)
Strategic Goal: Build sustainable partnerships and collaborations
Definition: The rate at which patients who have been designated ALC occupy inpatient beds.
Rationale: Ensuring that each patient receives the appropriate level of care at all times during their healthcare journey is a priority at Bluewater Health. Our goal is for Emily to receive the right care, given at the right time, in the right place, always. The ALC rate represents an opportunity for inpatients to be transitioned to the next level of care, where their care needs and the services provided are better matched. Multiple factors can influence ALC rate, including overall hospital occupancy, and availability of resources both internal and external to the hospital.
Additional Specifications:
ALC Rate = Total number of ALC Days in a given period
Total number of inpatient days in the same time period ×100%
Peer Comparator: Ontario hospital value
ALC Rate
Bluewater HealthTarget
Provincial Target FY 17/18
ALC Days
0
200
400
600
800
1000
1200
1400
1600
1800
2000
0
5
10
15
20
25
30
35
40
45
50
Apr
16
May
16
Jun
16
Jul
16
Aug
16
Sep
16
Oct
16
Nov
16
Dec
16
Jan
17
Feb
17
Mar
17
Apr
17
May
17
Jun
17
July
17
Aug
17
Sep
17
Oct
17
Nov
17
Dec
17
Jan
18
Feb
18
Mar
18
Q1 16/17 Q2 16/17 Q3 16/17 Q4 16/17 Q1 17/18 Q2 17/18 Q3 17/18 Q4 17/18
AL
C D
ay
s In
pa
tie
nt
Se
rvic
es
AL
C R
ate
%
ALC Rate % -All Inpatient Services (Sarnia and Petrolia)
Pre
ferr
ed
Tre
nd
ing
Our Status
Revised: May 2018 Next Update: September 2018 Page 5 of 14
Indicator Name: Absenteeism Rate
Alignment: Resource Utilization and Audit Committee (RUAC)/ Performance Utilization and Audit Committee (PUC)
Strategic Goal: Develop a sustainable plan for services, facilities, capital equipment and technology
Definition: Paid sick hours divided by 7.5 hrs. (for normal shift), divided by number of Full time and Permanent Part Time eligible employees.
Rationale: A lower absenteeism rate is preferred. Lower absenteeism is aligned with employee overall wellness.
Additional Specifications:
Peer Comparator: Ontario Hospital Association Average
Target
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
5
Apr
16
May
16
Jun
16
Jul
16
Aug
16
Sep
16
Oct
16
Nov
16
Dec
16
Jan
17
Feb
17
Mar
17
Apr
17
May
17
Jun
17
July
17
Aug
17
Sep
17
Oct
17
Nov
17
Dec
17
Jan
18
Feb
18
Mar
18
Q1 16/17 Q2 16/17 Q3 16/17 Q4 16/17 Q1 17/18 Q2 17/18 Q3 17/18 Q4 17/18
Ab
se
nte
eis
m R
ate
Absenteeism Rate - (avg # 7.5hr sick days)All Staff
Pre
ferr
ed
Tre
nd
ing
Our Status
Our Status
Our Status
Revised: May 2018 Next Update: September 2018 Page 6 of 14
Indicator Name: Acute Cost per Weighted Case
Alignment: Resource Utilization and Audit Committee (RUAC)/Performance Utilization Committee (PUC)
Strategic Goal: Demonstrate accountability and efficiency
Definition: Acute Cost per Weighted Case is an indicator that measures the cost associated with caring for a standard acute patient. It is calculated as total acute inpatient and newborn expenses (both direct and indirect) divided by acute inpatient weighted cases. The direct costs are the expenses incurred in the departments providing service to our acute patients (e.g., Medicine, Surgery, and Obstetrics). The indirect costs are an allocation of Administration and Support expenses (e.g., Housekeeping, Lab, Pharmacy, etc.). A weighted case is a case with an assigned Resource Intensity Weight (RIW).
Rationale: This is an important indicator as it tracks how an organization is utilizing its resources. It combines the financial spending with the activity that drives the spending. By focusing on weighted cases, comparability is enhanced as differences in acuity, severity and complexity of cases are taken into consideration.
Additional Specifications:
Peer Comparator: No established peer comparator data
Target
5000
5100
5200
5300
5400
5500
5600
5700
5800
5900
6000
Apr
16
May
16
Jun
16
Jul
16
Aug
16
Sep
16
Oct
16
Nov
16
Dec
16
Jan
17
Feb
17
Mar
17
Apr
17
May
17
Jun
17
July
17
Aug
17
Sep
17
Oct
17
Nov
17
Dec
17
Jan
18
Feb
18
Mar
18
Q1 16/17 Q2 16/17 Q3 16/17 Q4 16/17 Q1 17/18 Q2 17/18 Q3 17/18 Q4 17/18
Co
st
pe
r W
eig
hte
d C
ase
Cost per Weighted Case: Acute Inpatient & Day Surgery (53% of overall activity)
Pre
ferr
ed
Tre
nd
ing
Our StatusOur Status
Revised: May 2018 Next Update: September 2018 Page 7 of 14
Indicator Name: Emergency Department (ED) Outpatient Cost per Weighted Case
Alignment: Resource Utilization and Audit Committee (RUAC)/Performance Utilization Committee (PUC)
Strategic Goal: Demonstrate accountability and efficiency
Definition: ED Outpatient Cost per Weighted Case is an indicator that measures the cost associated with caring for a standard Emergency department patient. It is calculated as total emergency department expenses (both direct and indirect) divided by ED outpatient weighted cases. The direct costs are the expenses incurred in the departments providing service to our ED patients (both Sarnia & Petrolia sites). The indirect costs are an allocation of Administration and Support expenses (e.g., Housekeeping, Lab, Pharmacy, etc). A weighted case is a case with an assigned Resource Intensity Weight (RIW).
Rationale: This is an important indicator as it tracks how an organization is utilizing its resources. It combines the financial spending with the activity that drives the spending. By focusing on weighted cases, comparability is enhanced as differences in acuity, severity and complexity of cases are taken into consideration.
Additional Specifications:
Peer Comparator: No established peer comparator data
Target
5000
5100
5200
5300
5400
5500
5600
5700
5800
5900
6000
Apr
16
May
16
Jun
16
Jul
16
Aug
16
Sep
16
Oct
16
Nov
16
Dec
16
Jan
17
Feb
17
Mar
17
Apr
17
May
17
Jun
17
July
17
Aug
17
Sep
17
Oct
17
Nov
17
Dec
17
Jan
18
Feb
18
Mar
18
Q1 16/17 Q2 16/17 Q3 16/17 Q4 16/17 Q1 17/18 Q2 17/18 Q3 17/18 Q4 17/18
Co
st
pe
r W
eig
hte
d C
ase
Cost per Weighted Case: ER Outpatient (12% of overall activity)
Pre
ferr
ed
Tre
nd
ing
Our Status
Our Status
Revised: May 2018 Next Update: September 2018 Page 8 of 14
Indicator Name: Rehab Cost per Weighted Case
Alignment: Resource Utilization and Audit Committee (RUAC)/Performance Utilization Committee (PUC)
Strategic Goal: Demonstrate accountability and efficiency
Definition: Rehab Inpatient Cost per Weighted Case is an indicator that measures the costs associated with caring for a standard rehab patient. It is calculated as total inpatient rehab expenses (both direct and indirect) divided by rehab weighted cases. The direct costs are the expenses incurred in the departments providing service to our rehab inpatients. The indirect costs are an allocation of Administration and Support expenses (e.g., Housekeeping, Lab, Pharmacy, etc.). A rehab weighted case is a case assigned a relative weight using the rehabilitation patient grouper (RPG).
Rationale: This is an important indicator as it tracks how an organization is utilizing its resources. It combines the financial spending with the activity that drives the spending. By focusing on weighted patient days, comparability is enhanced as differences in acuity, severity and complexity of cases are taken into consideration.
Additional Specifications:
Peer Comparator: No established peer comparator data
Target
8900
9900
10900
11900
12900
13900
Apr
16
May
16
Jun
16
Jul
16
Aug
16
Sep
16
Oct
16
Nov
16
Dec
16
Jan
17
Feb
17
Mar
17
Apr
17
May
17
Jun
17
July
17
Aug
17
Sep
17
Oct
17
Nov
17
Dec
17
Jan
18
Feb
18
Mar
18
Q1 16/17 Q2 16/17 Q3 16/17 Q4 16/17 Q1 17/18 Q2 17/18 Q3 17/18 Q4 17/18
Co
st
per
Weig
hte
d C
ase
Cost per Weighted Case: Rehab Inpatient(4% of overall activity)
Pre
ferr
ed
Tre
nd
ing
Our Status
Our StatusOur Status
Revised: May 2018 Next Update: September 2018 Page 9 of 14
Indicator Name: Continuing Care Cost per Weighted Patient Day
Alignment: Resource Utilization and Audit Committee (RUAC)/Performance Utilization Committee (PUC)
Strategic Goal: Demonstrate accountability and efficiency
Definition: Continuing Care Inpatient Cost per Weighted Patient Day is an indicator that measures the costs of providing inpatient care to complex continuing care patients, and is stated on a weighted patient day basis. It is calculated as total inpatient continuing care expenses (both direct and indirect) divided by total RUG weighted patient days (RWPDs). The direct costs are the expenses incurred in the departments providing service to our continuing care inpatients. The indirect costs are an allocation of Administration and Support expenses (e.g., Housekeeping, Lab, Pharmacy, etc.). RWPDs are patient days weighted using an appropriate cost weight (CMI). The CMI is a cost weight reflecting the relative resource use of an individual within a specific RUG group compared with the overall average resource use for all Ontario complex continuing care residents.
Rationale: This is an important indicator as it tracks how an organization is utilizing its resources. It combines the financial spending with the activity that drives the spending. By focusing on weighted patient days, comparability is enhanced as differences in acuity, severity and complexity of cases are taken into consideration.
Additional Specifications:
This indicator is also referred to as Cost per RUG weighted patient day (RWPD) where RUG stands for Resource Utilization Group.
Peer Comparator: No established peer comparator data
Target
300
350
400
450
500
550
600
650
700
Apr
16
May
16
Jun
16
Jul
16
Aug
16
Sep
16
Oct
16
Nov
16
Dec
16
Jan
17
Feb
17
Mar
17
Apr
17
May
17
Jun
17
July
17
Aug
17
Sep
17
Oct
17
Nov
17
Dec
17
Jan
18
Feb
18
Mar
18
Q1 16/17 Q2 16/17 Q3 16/17 Q4 16/17 Q1 17/18 Q2 17/18 Q3 17/18 Q4 17/18
Co
st
pe
r W
eig
hte
d C
ase
Cost per Weighted Patient Day:
Continuing Care Inpatient
Pre
ferr
ed
Tre
nd
ing
Our Status
Our Status
Revised: May 2018 Next Update: September 2018 Page 10 of 14
Indicator Name: Mental Health Inpatient Cost per Patient Day
Alignment: Resource Utilization and Audit Committee (RUAC)/Performance Utilization Committee (PUC)
Strategic Goal: Demonstrate accountability and efficiency
Definition: Mental Health Inpatient Cost per Patient Day is an indicator that measures the cost associated with caring for a Mental Health inpatient. It is calculated as total inpatient mental health departmental expenses divided by total inpatient mental health patient days.
Rationale:
Additional Specifications:
Peer Comparator: To be determined
Target
250
270
290
310
330
350
370
390
Apr16
May16
Jun16
Jul16
Aug16
Sep16
Oct16
Nov16
Dec16
Jan17
Feb17
Mar17
Apr17
May17
Jun17
July17
Aug17
Sep17
Oct17
Nov17
Dec17
Jan18
Feb18
Mar18
Q1 16/17 Q2 16/17 Q3 16/17 Q4 16/17 Q1 17/18 Q2 17/18 Q3 17/18 Q4 17/18
Mental Health Cost per Patient Day
Pre
ferr
ed
Tre
nd
ing
Our Status
Revised: May 2018 Next Update: September 2018 Page 11 of 14
Indicator Name: Quality Based Procedure (QBP) Financial Exposure (Potential lost revenue related to QBP achievement)
Alignment: Resource Utilization and Audit Committee (RUAC)/Performance Utilization Committee (PUC)
Strategic Goal: Demonstrate accountability and efficiency
Definition: Represents the potential lost revenue associated with under achievement of QBP funded volumes for both Ministry funded and CCO funded quality based procedures.
Rationale: The intent is that the hospital will achieve all anticipated volumes and not have to return any QBP funding to the Ministry and/or CCO.
Additional Specifications:
Peer Comparator: No established peer comparator data
-$700,000
-$600,000
-$500,000
-$400,000
-$300,000
-$200,000
-$100,000
$0
$100,000
$200,000
Apr
16
May
16
Jun
16
Jul
16
Aug
16
Sep
16
Oct
16
Nov
16
Dec
16
Jan
17
Feb
17
Mar
17
Apr
17
May
17
Jun
17
July
17
Aug
17
Oct
17
Nov
17
Dec
17
Jan
18
Feb
18
Mar
18
Q1 16/17 Q2 16/17 Q3 16/17 Q4 16/17 Q1 17/18 Q2 17/18 Q3 17/18 Q4 17/18
Re
ve
nu
e
QBP Financial Exposure(Potential lost revenue related to QBP achievement)
Pre
ferre
d T
ren
din
g
Our Status
Our StatusOur StatusOur Status
Our Status
Our Status
Revised: May 2018 Next Update: September 2018 Page 12 of 14
Indicator Name: Surplus/(Deficit) in 000s
Alignment: Resource Utilization and Audit Committee (RUAC)/Performance Utilization Committee (PUC)
Strategic Goal: Demonstrate accountability and efficiency
Definition: The amount of operating revenue in excess of operating expense from regular hospital operations. This amount excludes building amortization, building deferred grants/donations and interest on long-term liabilities.
Rationale: The hospital compares its actual results to the Board approved budget. The hospital plans for a surplus each year.
Additional Specifications:
Peer Comparator: Not applicable
Target
0.00
500.00
1000.00
1500.00
2000.00
2500.00
Apr
16
May
16
Jun
16
Jul
16
Aug
16
Sep
16
Oct
16
Nov
16
Dec
16
Jan
17
Feb
17
Mar
17
Apr
17
May
17
Jun
17
July
17
Aug
17
Sep
17
Oct
17
Nov
17
Dec
17
Jan
18
Feb
18
Mar
18
Q1 16/17 Q2 16/17 Q3 16/17 Q4 16/17 Q1 17/18 Q2 17/18 Q3 17/18 Q4 17/18
Su
rplu
s/(D
eficit
) in
00
0s
Surplus/(Deficit) in 000s
Pre
ferre
d T
ren
din
g
Our Status
Our StatusOr StatusOur Status
Revised: May 2018 Next Update: September 2018 Page 13 of 14
Indicator Name: Adjusted Working Capital (in 000s)
Alignment: Resource Utilization and Audit Committee (RUAC)/Performance Utilization Committee (PUC)
Strategic Goal: Ensure continuous investment in strategic infrastructure
Definition: Adjusted Working Capital is calculated as the hospital’s total current assets less current liabilities from its balance sheet. This definition is then adjusted per Ministry direction to exclude current liabilities such as vacation accrual, etc. and to exclude any externally restricted current assets/liabilities.
Rationale: Adjusted working capital is a critical indicator to evaluate the hospital’s financial outlook. A strong working capital position indicates a readiness for potential capital investment.
Additional Specifications:
Peer Comparator: Not applicable
Target
-1000.00
0.00
1000.00
2000.00
3000.00
4000.00
5000.00
6000.00
Apr
16
May
16
Jun
16
Jul
16
Aug
16
Sep
16
Oct
16
Nov
16
Dec
16
Jan
17
Feb
17
Mar
17
Apr
17
May
17
Jun
17
July
17
Aug
17
Sep
17
Oct
17
Nov
17
Dec
17
Jan
18
Feb
18
Mar
18
Q1 16/17 Q2 16/17 Q3 16/17 Q4 16/17 Q1 17/18 Q2 17/18 Q3 17/18 Q4 17/18
Wo
rkin
g C
ap
ital
in 0
00
s
Adjusted Working Capital (in 000s)
Pre
ferre
d T
ren
din
g
Our StatusOur Status
Revised: May 2018 Next Update: September 2018 Page 14 of 14
Indicator Name: Percentage of Capital Budget Spent
Alignment: Resource Utilization and Audit Committee (RUAC)/Performance Utilization Committee (PUC)
Strategic Goal: Ensure continuous investment in strategic infrastructure
Definition: Capital purchases made during the time period as a percentage of the overall capital budget for that period. The overall budget includes a budget for contingency items. If capital items are carried over from a previous year, the capital budget associated with those carry over items will also be included in the denominator for this indicator.
Rationale:
Additional Specifications:
Peer Comparator: No established peer comparator data
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Apr16
May16
Jun16
Jul16
Aug16
Sep16
Oct16
Nov16
Dec16
Jan17
Feb17
Mar17
Apr17
May17
Jun17
July17
Aug17
Sep17
Oct17
Nov17
Dec17
Jan18
Feb18
Mar18
Q1 16/17 Q2 16/17 Q3 16/17 Q4 16/17 Q1 17/18 Q2 17/18 Q3 17/18 Q4 17/18
Perc
enta
ge o
f Capita
l Budget Spent
Percentage of Capital Budget Spent
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ferre
d T
ren
din
g