board meeting materials - cmh...2019/06/26 · • cmh foundation golf tournament • joint meeting...

BOARD OF DIRECTORS MEETING

Wednesday June 26, 2019 1830h –1940h

C.1.229 OPEN SESSION

AGENDA

Board Members: Ian Miles (Chair), David Pyper, Denise Smith, Tom Dean, Elaine Habicher, Nicola Melchers, Tim Edworthy, Katie Hamilton, Bill Deley, Suren Rao, Joe Kane

Ex officio Members: Patrick Gaskin, Sandra Hett, Dr. Kunuk Rhee, Dr. Vlad Miropolsky, Dr. Heather MacLeod

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*Agenda Item (* Indicates attachment) (TBC- to be circulated) Page #

Time Responsibility Purpose

Vision To provide exceptional healthcare by

exceptional people

Mission A progressive acute care hospital and

teaching facility committed to quality and integrated patient centered care

Values

Caring, Respect, Innovation, Collaboration, Accountability

1. CALL TO ORDER 1830 I. Miles 1.1 Land Acknowledgement 1.2 Confirmation of Quorum (6)

Confirm

1.3 Declarations of Conflict Declaration

1.4 Consent Agenda (Any Board member may request that any item be removed from this consent agenda and moved to the regular agenda.) 1.3.1 Minutes of May 29, 2019* 1.3.2 CEO Report* 1.3.3 Trillium Gift of Life Network* 1.3.4 Board Work Plan*

2 8 13 16

Approval

1.5 Confirmation of Agenda I. Miles Approval 2. PRESENTATIONS

2.1 Strategic Plan*

23

1835

Stephan Beckhoff/

Corey Kimpson

Approval

3. DISCUSSION ITEMS 3.1 Chair’s Report

3.1.1 Events Calendar*

42

1855

I. Miles

Information 3.2 Resources Committee (June 24, 2019)

3.2.1 May Financial Statements*

44

1900

T. Edworthy

Approval

3.3 Capital Projects Sub Committee (June 24, 2019)

3.3.1 CRP Update

1905

T. Dean

Information 3.4 Quality Committee

3.4.1 June 19, 2019 Meeting Summary*

51

1915

S. Rao

Information 3.5 Medical Advisory Committee

3.5.1 June 12, 2019 Meeting Summary* 3.5.2 Privileges and Credentialing (May/June)*

90 92

1925

Dr. M. Shafir Dr. M. Shafir

Information Approval

3.6 CEO Update 3.6.1 5 Things – TBC

1935 P. Gaskin

Information

4. ADJOURNMENT 1940 I. Miles Motion

5. DATE OF NEXT MEETING: September 25, 2019

1

Cambridge Memorial Hospital BOARD OF DIRECTORS MEETING

Wednesday, May 29, 2019 OPEN SESSION

Minutes of the open session of the Board of Directors meeting, held in C.1.229 on May 29, 2019

Mr. J. Kane T Mr. T. Edworthy P Mr. I. Miles P Mr. S. Rao R Ms. E. Habicher P Mr. T. Dean P Mr. D. Pyper P Dr. V. Miropolsky R Ms. D. Smith P Mr. P. Gaskin P Mr. B. Deley R Dr. K. Rhee P Ms. K. Hamilton P Ms. S. Hett P Ms. N. Melchers P Dr. H. MacLeod P

Staff Present: Mr. M. Prociw, Mr. S. Beckhoff, Ms. S. Toth

Guests: Recorder: Ms. C. Vandervalk P- Present, R – Regrets, T – Present via Teleconference

1. CALL TO ORDERMr. Miles called the meeting to order at 1703 hours.

1.1. Confirmation of QuorumQuorum requirements having been met, the meeting proceeded, as per the agenda.

1.2. Conflict of Interest Board members were asked to declare any known conflicts of interest regarding this meeting.

1.3. Consent Agenda 1.3.1 Minutes of April 24, 2019*

1.3.2 CEO Report* 1.3.3 Governance Policy Summary

• 2-B-15 Recruitment and Selection of CEO• 2-B-16 Recruitment and Selection of COS• 2-B-25 CEO Performance Review Policy• 2-B-26 COS Performance Review Policy

1.3.4 Board Scorecard* 1.3.5 Board Work Plan*

There being no requests the consent agenda was approved as circulated.

1.4 Confirmation of Agenda Mr. Miles noted the following:

MOTION: (Smith/Habicher) that, the agenda be approved as circulated CARRIED

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Board of Directors Meeting (Open Session) May 27, 2019 Page 2 2. PRESENTATIONS

2.1 Staff Engagement The 3 year staff engagement plan was presented to the Board. The framework for the plan was built on the IHI document Improving Joy at Work. The plan is presented for information purposes only – the Board is not required to approve, however reflections and input was encouraged. The following critical areas were selected by the staff council: • Physical & psychological safety • Camaraderie & teamwork • Choice & autonomy • Meaning & purpose

Staff Council and Operations provided input into initiatives needed for each of the change ideas and were critical in the discussions. The capacity of leaders and staff to adopt and sustain new behaviours and actions was deemed important.

Each of the priorities was discussed and how over the next three years the changes will be introduced, enhanced and implemented.

3. Chair’s Report

3.1.1 Strategic Plan Update As the Board is aware a Steering committee was struck for the purpose of developing the Strategic Plan. A meeting of the committee took place last evening and the plan is to socialize the plan with key stakeholders over the next month and bring back to the Board for approval in June.

3.1.2 Events Calendar

The Board was reminded of the upcoming events: • CMH Foundation Golf Tournament • Joint meeting with City Council • Staff BBQ on June 18

3.2 Resources Committee

3.2.1 Declaration of Compliance Broader Public Sector Accountability Act Attestation Schedule A As part of the accountability requirements from the Broader Public Sector Accountability Act 2010 (BPSAA), the hospital is required to prepare reports concerning the use of consultants, using a prescribed template. The report is attached. The hospital board is required to approve this report

Also, the hospital is required to annually submit an attestation in accordance with section 15 of the BPSAA by June 30, 2015.

The following motions were brought forward:

MOTION: (Edworthy/Dean) that, the hospital Board approves the report on the use of consultants for the period April 1, 2018 to March 31, 2019 as outlined in the attached report. CARRIED

MOTION: (Edworthy/Smith) that, the hospital Board receives and approves the attestation prepared by the President and CEO in accordance with section 15 of the Broader Public Sector Accountability Act 2010 for the period April 1, 2018 to March 31, 2019. CARRIED 3

Board of Directors Meeting (Open Session) May 27, 2019 Page 3

3.3 Capital Projects Sub Committee 3.3.1 CRP Update

An update on the project was provided. The project remains in the “Deficiency Correction” phase in the new wing, as some subcontractors are on-site on a daily basis however no “major effort” to complete is being applied to the project.

Overall, approx. 80% of deficiencies have been corrected at this time. Updated construction schedule received this month moved the IC date

out again – the fifth date this year. There is no confidence the new deadline will be met. The Project Team

continues to push for and track the progress going forward. Critical Deficiencies to complete are:

• Cladding issues from Thermal Scan – condensation, heat loss • IT system completion including Nurse Call, Security System • Some exterior Door corrections • Roofing corrections

There is a continuing and growing sense of hospital staff frustration with the inability to move into the new Wing-A and with no firm date to do so.

3.4 Quality Committee 3.4.1 May 15, 2019 Meeting Summary* Ms. Habicher provided an update on the Quality Committee work to date and

highlighted the work being done in the ICU specifically the introduction of ICU Staff Stress Check. The Quality Committee was especially impressed with this.

The majority of stress checks show staff are typically in the green/low yellow stress zone. This is a discussion at huddle with all attendees and self-reported. For staff reporting yellow or red, a conversation occurs regarding what assistance from the team would be helpful. A subsequent check in by the Manager and staff or charge nurse mid shift to confirm improvement or further assist. If warranted a 1:1 follow up meeting with the Manager may occur. EAP is an organizational resource that can assist in select situations. The staff are comfortable reporting their status and will often determine the need to assist their colleagues in the absence of this more formal discussion.

3.5 Governance Committee

3.5.1 May 9, 2019 Meeting Summary* Ms. Melchers provided an overview for information of the Governance meeting that

took place last month. • Board/Committee Member Peer Assessment, the Committee determined that

the survey results are not providing clear data to properly assess effectiveness and therefore will be reviewed.

• Accreditation, Mr. Gaskin and Ms. Melchers will complete the Organizational Self-Assessment on behalf of the committee and will submit to Accreditation Canada.

3.6 MAC

3.6.1 May 8, 2019 Meeting Summary Dr. Rhee provided highlights of the briefing note. 4


3.6.3 Privileges and Credentialing Dr. Rhee attested that due diligence was exercised and the following names have been brought forward for approval.

New Privileges & Credentialing Name Program Specialty Appointment Supervisor

Dr. Robert Adams

Emergency Medicine

Emergency Medicine

Requesting Associate Privileges effective March 1, 2019

Dr. Arthur Eugenio

Dr. Inga Isupov Diagnostic Imaging

Diagnostic Imaging

Requesting privileges for training period effective April 29 – May 1, associate privileges commencing July 1, 2019

Dr. Winnie Lee

Dr. Caitlin Deidre Lapper

Oncology Oncology Requesting Locum Privileges from April 1 – September 30, 2019

Dr. Edmond Chouinard

Dr. Gordon Tsang

Surgery

Otolaryngology Requesting Locum privileges effective April 17 – June 27, 2019

Dr. Joyce Daly

Dr. Srinidhi Jayaram

Surgery Vascular Requesting Temporary One-day Privileges for March 28, 2019

Dr. Joyce Daly / Dr. Jasmine Mathew

Dr. Srinidhi Jayaram

Surgery Vascular Requesting Affiliate Privileges effective April 24, 2019

Dr. Joyce Daly

Ms. Julia Heyens

Midwifery Midwifery Requesting extension of Locum Privileges from July 1 – December 31, 2019

Ms. Diana Doe

Dr. Jeff Main Family Medicine

Family Medicine Resigning from Affiliate privileges effective March 26, 2019

Dr. Anil Maheshwari

Dr. Kathryn Giles

Internal Medicine

Neurology Resigning from Affiliate privileges effective April 9, 2019

Dr. Augustin Nguyen

Dr. David Cape Internal Medicine

Critical Care Unit Transition from associate to active staff effective April 25, 2019

Dr. Augustin Nguyen

Dr. Mohammed Naser

Internal Medicine

Internal Medicine

Requesting Temporary Privileges from April 15-16, 2019

Dr. Augustin Nguyen

Dr. Jonathan Marjong

Internal Medicine

Internal Medicine

Requesting Locum Privileges from May 20 – July 1, 2019

Dr. Augustin Nguyen

Dr. Vidya Sujana Kumar

Internal Medicine

Internal Medicine

Requesting Locum Privileges from April 23-April 30, 2019

Dr. Augustin Nguyen

2019 E-Reappointment Applications for Approval DEPARTMENT OF DIAGNOSTIC IMAGING

MARRIOTT, Christopher: Courtesy NO Admitting

5

Board of Directors Meeting (Open Session) May 27, 2019 Page 5 DEPARTMENT OF FAMILY MEDICINE

PENGELLY, Sarah: Active

HANKINSON, Keith: Active

BENJAMIN, Prabhu: Affiliate

ELM, Colleen (NP): Affiliate

WHAN, Deborah: Active

CHERNIAK, Victor: Active

DEPARTMENT OF HOSPITAL MEDICINE

QURESHY, Kamran: Active

SWEKLA, Michelle: Active

DEPARTMENT OF INTERNAL MEDICINE

JAIN, Hem: Affiliate

DEPARTMENT OF PEDIATRICS

MARTINEZ, Jose Carlos: Active

MOTION: (Habicher/Hamilton) that, the Privileges for ratification and granting recommended to the Board be approved. CARRIED

3.7 CEO Update

3.7.1 5 Things • Code Orange

CMH's emergency department took part in a LHIN wide mock code orange today that included our region's EMS. The scenario was a huge traffic accident on highway 24 and another on highway 6 with multiple people injured. CMH and Guelph General Hospital received the brunt of the victims as they worked through a three-hour scenario, talking through how patients were being triaged and treated in real time. As time passed, our region's ambulance service called a code red, exacerbating the situation. Most WWLHIN EDs took part, working through a booklet, turning pages at predetermined time intervals to reveal more patient and situational complications. Moderators also called in to add twists to the scenario. This mock code was based on the hospital's capacity, including personnel, from April 18, 2019.

• OHT submission The 31 signatory partners represent 10 sectors across the continuum of care and includes the participation and support of ehealth and municipal community partners. This proposed initial complement of partners will enable CND to design, plan, implement and scale an effective OHT that delivers on the government’s

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vision. As the design and plan continues for the OHT model, additional partners will be engaged to ensure that CND is well-positioned to deliver all health, community and social services for CND within a single OHT.

• Person Centered care

44% staff and physicians have completed the person centred care best practice guideline as of May 24, 2019

The purpose of this Guideline is to promote the evidence-based practices associated with person- and family-centred care, and to help nurses and other healthcare providers acquire the knowledge and skills necessary to become more adept at practising person- and family-centred care. his evidence-based approach, combined with a perspective that recognizes the place of the person at the centre of heath care, will improve individuals’ experience of and satisfaction with the care and services provided within the health system.

• Dr. Jonny Elserafi who earned this year's Michael G.DeGroote School of Medicine's Waterloo Regional Campus Undergraduate Teacher of the Year in Emergency Medicine award.

• Dr. Michelle Acorn, Provincial Chief Nursing Officer visit CMH during Nursing week.

4. ADJOUNMENT

The meeting adjourned at 1830h. (Melchers/Habicher) CARRIED

5. DATE OF NEXT MEETING The next scheduled meeting is June 26, 2019 Ian Miles Board Director CMH Board of Directors

Patrick Gaskin Board Secretary CMH Board of Directors

7

Agenda Item 1.3.2

Page 1 of 5

CMH President & CEO Report June 2019

This report provides a brief update on some key activities within CMH as an FYI. Organized by stories supporting our five driver goals, it may include other projects that are thematically related. As always, I’m happy to answer questions and discuss issues within this report or other matters.

Mock critical care surge a success!

• On June 11, CMH carried out a table-top critical care surge exercise to test our surge policies and processes. This was done within the parameters of the Waterloo Wellington and Provincial frameworks for Critical Care Surge.

• CMH took the lead as the index hospital. Our colleagues from St. Mary's General Hospital, Grand River Hospital and Guelph General Hospital were participants. Criticall and Critical Care Services Ontario supported us on the phone to follow Provincial standards in this mock process.

• Special thanks to our own star participants: Dr. David Cape; Pauline Chapeski; April McCulloch; Anna Racine; Kim Siegel and Melissa Sockett.

8

Agenda Item 1.3.2

Page 2 of 5

MyChart soft launch a success

• MyChart - a portal where patients can access much of their personal health information - did a soft launch at CMH over the week.

• The reason for the soft launch was to ensure our hospital is able to validate identity with the health card.

• CMH clerical staff invited patients who were in the process of registration, whether this would be of interest to them.

• Information patients can see once enrolled include radiology reports, discharge summaries, microbiology reports, blood results and lab results among other things.

• Patients can also add their own personal records or provide access to a family member.

• The full launch is set for July. More to come on this exciting, patient experience initiative.

CCO After Hours Nursing Support to Medical Day Clinic

• Cancer Care Ontario (CCO) has provided after hours care support for our Medical Day Clinic since May. Offered at this time to new patients undergoing treatment, it has been used more than 10 times over a one-month period.

• Most of the questions to CCO nurses related to symptom management. This feedback has been invaluable as it provides us with a starting point to review discharge instructions and supporting patient education materials.

• Work is underway to expand it to all patients visiting the clinic.

9

Agenda Item 1.3.2

Page 3 of 5

Hospital wide staff council undergoing a refresh

• A call is out for staff and physicians to join the Hospital Wide Staff Council. We are looking for new members to join the group and want to make sure that we have members from the many diverse programs and services of the hospital.

• The current council is a cross-section of CMH personnel that have met for the past two years to help develop and implement strategies to improve work life at CMH. Most recently the Council helped author our 2019-22 Staff Engagement Plan.

• This is an opportunity for interested staff to provide feedback and shape the work ahead at our hospital and make a real difference.

Accreditation processes underway

• CMH is preparing for the on-site visit this November 4 through 7, where four Accreditors, including a patient, will assess our organizational practices against standards of excellence.

• These standards focus on patient safety and are inclusive of the entire organization. Each person within the organization (volunteers, staff, and physicians) plays an integral role in the success of the assessment.

• At this time, Require Organizational Practice (ROP) Leaders are assessing our current practices and processes, and implementing, where necessary, new ROP standards in their areas.

10

Agenda Item 1.3.2

Page 4 of 5

Work of the groups focused on this continues – nothing to report for this month.

CMH's Draft 2019-21 Strategic Plan review underway

• CMH embarked on a strategic planning process earlier this year to replace the one expiring in June. A planning committee was struck with staff, physicians, administration, board members and representation from PFAC, the Foundation and our Volunteer Association.

• Given the rapid changes in our health care environment and our commitments to very large, organizational priorities like Accreditation and the Capital Redevelopment Project, the committee recommended the hospital focus on a shorter, two-year bridging plan to help navigate these events.

• Feedback was sought from staff, CMH leadership, community partners, patients through our Patient and Family Advisory Council, Volunteers and Foundation.

CMH looking to become an OHT

• In May, CMH submitted a self-assessment as part of a process to become an Ontario Health Team (OHT). CMH's submission is in partnership with over 30 local and regional agencies that proposes to provide care to residents of Cambridge and North Dumfries.

11

Agenda Item 1.3.2

Page 5 of 5

• Ontario Health Teams are being introduced to provide a new way of organizing and delivering services in local communities. Under Ontario Health Teams, the health care providers (including hospitals, doctors and home and community care providers) will work as one coordinated team – no matter where they provide care, with the goal is to provide seamless transitions from one service to the next.

• The ministry will connect with all applicants over the summer to provide an update on the status of their application. Applicants identified to be in the best position to move forward in becoming an Ontario Health Team Candidate will be asked to complete a full application. More to come.

12

Agenda Item 1.3.3

Page 1 of 2

BRIEFING NOTE – QUALITY COMMITTEE Date: June 12, 2019 Issue: Update on Trillium Gift of Life Network (TGLN) Performance & Program Changes Purpose: Approval Discussion Information Prepared by: Kim Siegel, Director of Medicine Programs Approved by: Dr. A. Nguyen, Chief of Medicine Attachments: Appendix 1: TGLN Dashboard Items for Board Information Organ and Tissue donation continues to be a priority at CMH. The 18/19 Q3 performance is noted in the attached Dashboard (Appendix 1). CMH generally achieves above the provincial average in performance metrics. This performance data is reviewed at quarterly meetings with the CMH team and the TGL coordinator and action plans developed to improve performance. In Organ & Tissue awareness week in April, there was a guest speaker Dr. Gord Boyd at Grand Rounds who spoke about organ and tissue donation. CMH Physician Leadership Change Dr. I. Biswas has been the medical lead for the CMH organ donation program for many years and has been a strong advocate and champion to support this program. The leadership for this program will be assumed by Dr. David Cape in his role as medical lead for intensive care. New Provincial Practices: 1) Change & Signing of Death Certificate

Background: Trillium Gift of Life Network (TGLN) has communicated a provincial practice change. Deceased patients who are candidates for multi tissue recovery will now be transferred to the Coroner’s office for the intervention vs a medical team dispatched to hospitals. This change is in attempt to reduce cost for hospitals, reduce TGLN’s use of hospital surgical suite resources, and increase the number of recoveries that can be performed each day. In this new model, it remains imperative for the death certificate to be signed in advance, however given the time sensitive nature of this work and the transfer,

700 Coronation Blvd, Cambridge, ON N1R 3G2 Tel. 519.621 2333 Fax 519.740.4934. www.cmh.org

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http://www.cmh.org/

Agenda Item 1.3.3

Page 2 of 2

mandated window of time is now within one hour of notification to hospital that the patient is to be transferred for multi-tissue recovery. Once TGLN receives consent from the family and deems the patient medically suitable for multi-tissue donation, TGLN calls the nursing staff back to notify them that the patient is suitable for multi-tissue donation. At that time, TGLN confirms that the body is still being held in the morgue, requests for the death certificate to be completed, and dispatches a transfer service to transfer the patient to the coroner’s office. The expedited signing of a death certificate within one hour of notification would primarily be for expected deaths, such as palliative patients, as physicians would already be present with other deaths. CMH requires a revision to current processes to ensure a standardized process for timely physician sign off of the death certificate to ensure multi-tissue recovery as deemed appropriate. This is currently under review by the Chief of Medicine to implement this change.

2) Standardization in Withdrawal of Life Sustaining Measures Protocols

Trillium Gift of Life Network is reaching out to hospital partners to work with us to collaboratively review their current end-of-life policies and procedures. It has been noted that there is variation in practices and policies across the province. Based on the results of the review, hospitals will be asked to establish a plan to address any gaps in meeting the Canadian Critical Care Society (CCCS) Withdrawal of Life Sustaining Measures (WLSM) guidelines. This initiative will form the 19/20 work plan for the CMH committee.

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Trillium Gift of Life Network

Cambridge Memorial Hospital

Organ and Tissue Performance Dashboard 2018/19

No Target Set

Meets or Exceeds Target

≤ 5% below Target

≥ 5.1% below target

No Data Available

Routine Notification Rate: percentage of notified deaths to TGLN / all reportable deathsConversion Rate: percentage of donors / potential eligible deathsDeclaration Rate: percentage of confirmed NDD deaths / (number of confirmed NDD + suspected NDD deaths)Eligible Approach Rate: percentage of approaches¹ for organ donation / cases eligible for approachMissed Eligible Approaches: total number of missed approaches for cases eligible for approachTissue Timeliness: percentage of death notifications prior to or 1-hour post death / all death notifications

¹Approaches consistent with TGLN guidelines²Preliminary Data

Donors 2017/18 Q1Apr - Jun

Q2Jul - Sep

Q3Oct - Dec

Q4Jan - Mar

Trend(Quarterly)

2018/19YTD

ProvincialYTD

Organ 1 1 1 1 3 251

Tissue 20 2 11 10 23 1854

Metric 2017/18 Q1Apr - Jun

Q2Jul - Sep

Q3Oct - Dec

Q4Jan - Mar

Trend(Quarterly)

2018/19YTD

Status(YTD)

Target ProvincialYTD

Routine Notification Rate 97% 100% 98% 99% 99% 100% 96%

Conversion Rate 50% 50% 100% 100% 75% 63% 59%

Declaration Rate 0% 50% 100% - 67% 75%

Eligible Approach Rate 75%² 100% 100% 80% 89% 90% 82%

Tissue Timeliness² 70% 78% 80% 76% 78% 75%

2

Agenda Item 1.3.3 Appendix 1

15

Agenda Item 1.3.4 BOARD WORK PLAN – 2018-19

Page 1 of 7 = Due C = Complete I = In progress D = Delayed 21 June 2019

Charter Section #4

Action (Italics-comments) Committee Responsible

Oct Nov Jan Feb Apr May Jun

Tone at the Top

a-i, ii a-iii

Approve CEO goals and objectives Approve COS goals and objectives

Mid-year CEO assessment input from Board Mid-year COS assessment input from Board

Mid-year/Year-end CEO report and assessment Mid-year/Year-end COS report and assessment CEO evaluation/feedback – mid-year COS evaluation/feedback – mid-year

CEO evaluation/feedback –year end and performance based compensation COS evaluation/feedback –year end and performance based compensation

Executive

Board

Executive

Executive

Executive

C C

C C

C C

C C

√ √ √ √ √ √

Reviewing the performance assessments of the VPs – summary report provided to the Board (as per policy 2-B-10)

Executive D

b Strategic Plan: approve process, participate in development, approve plan (done

in 2017; will be done again in 2018-19) Board

b Progress report on Strategic Plan (2x year Jan for 17-19 plan) Board I

b-iii-c Approve annual Quality Improvement Plan (QIP) Quality C b-iii-c Review and approve the Hospital Services Accountability Agreement (H-SAA)

Review and approve Multi-Sector Accountability Agreement (MSAA) Review and Approve Community Annual Planning Submission (CAPS) Review and Approve Hospital Accountability Planning Submission (HAPS)

Resources, Quality

C

√

C C

Due 2020

16



Charter Section #4



b-iii-C Monitor performance indicators and progress toward achieving the quality improvement plan

Quality C

C

C

c-i-B c-i-B

Critical incidents report – (as per the Excellent Care for All Act). (Brought forward to Board as deemed necessary)

Monitor, mitigate, decrease and respond to principal risks

Quality

Audit

C

C

C

c-i-E c-i-F c-i-F c-i-F

Review the functioning of the Corporation, in relation to the objects of the Corporation the Bylaw, Legislation, and the HSAA

Governance

C

C

√

Receive and review: • Resources /HSAA Scorecard • Quality Scorecard • Board Scorecard

Note: Quality scorecard is available on the portal in the Quality Committee section. The HSAA scorecard appears under Resources in Board package. The Board Scorecard is in the consent agenda of the Board package.

Resource Quality Board

C C C

C C C

C C C

C C C

Declaration of Compliance with M-SAA Schedule G (due Oct 31 and Apr 30 to the WWLHIN)

Resources

C

C

Declaration of Compliance with BPSAA Schedule A (due May 31 to the WWLHIN) Resources C

Receive and review quarterly the CEO certificate of compliance regarding the obligations for payments of salaries, wages, benefits, statutory deductions and financial statements

Resources C

C

C

C

Procedures to monitor and ensure compliance with applicable legislation and regulations

Audit C

17



Charter Section #4



e-i-A

Receive a summary report on:

• CEO succession plan and process • COS succession plan and process • Succession plan for executive management and professional staff leadership

Executive Executive Executive

C C I

C

Professional Staff

f-i-A f-i-B/C

Ensure the effectiveness and fairness of the credentialing process Monitor indicators of clinical outcomes, quality of service, patient safety and

achievement of desired outcomes (MAC scorecard)

MAC/Quality

MAC

I

C

C

C

C

C

√

f-i-C Make the final appointment, reappointment and privilege decisions for Medical/Professional Staff

Oversee the Medical/Professional Staff through and with the MAC and COS

Board

COS

C

C

C

C

C

C

C

C

C

C

C

C

√ √

Financial Viability

h-i-A,C h-i-A,C h-i-A, B h-i-A i-i-C

Review and approve multi-year capital strategy Review and approve multi-year information technology strategy

Resources Resources

C

C

Review and approve annual operating plan – service changes, operating plan, capital plan, salary increases, material amendments to benefit plans, programs and policies

Resources/ Quality

I

C

Approve the year-end financial statements Board C Approve key financial objectives that support the corporation’s financial needs

(including capital allocations and expenditures) (assumptions for following year budget)

Review of management programs to oversee compliance with financial principles and policies

Resources

Resources

I

C

C

18



Charter Section #4



Board Effectiveness

i Establish Board Work Plan Board C

i-i-A Ensure Board Members adhere to corporate governance principles and guidelines Declaration of conflict agreement signed by Directors

Governance

√

i-i-B Ensure the Board’s own effectiveness and efficiency, including monitoring the effectiveness of individual Directors and Board officers and employing a process for Board renewal that embraces evaluation and continuous improvement

Governance/ Board

√

i-i-C Ensure compliance with audit and accounting principles Audit C i-i-D

Periodically review and revise governance policies, processes and structures as appropriate

Governance

C

C

C

C

C

C

Fundraising

k Support fundraising initiatives including donor cultivation activities. (through Foundation Report and Upcoming Events)

Foundation C

C

C

C

C

C

√

Public Hospitals Act required programs

l-i-A l-i-B l-i-C

Ensure that an occupational health and safety program and a health surveillance program are established and require accountability on a regular basis

Audit

Next due 2020

Ensure that policies are in place to encourage and facilitate organ procurement and donation

Quality

√

Ensure that the Chief Executive Officer, Nursing Management, Medical/Professional staff, and employees of the Hospital develop plans to deal with emergency situations and the failure to provide services in the Hospital

Quality

C

Recruitment

n

Approve Nominating Committee membership (noted in By-law) Governance C

19



Charter Section #4



Review recommendations for new Directors, non-director committee members (2-D-20)

Governance

C C C

Conduct the election of officers (2-D-18) Governance √

Review evaluation results and improvement plans for the Board, the Board Chair (by the Governance Chair), Board committees, committee chairs (2-D-40)

Review committee reports on work plan achievements (2-A-16)

Governance

Governance

I

D

20



ON GOING AS NEEDED Charter Section #4

Charter Item Action (Italics-comments) Committee Responsible

Current Year 2018-19

i-i-E Board Effectiveness Compliance with the By-Law Governance

c-i-A, B Corporate Performance Ensure there are systems in place to identify, monitor, mitigate, decrease and respond to the principal risks to the Corporation:

o financial o quality o patient/workplace safety

Audit, Resources Quality

c-i-C

Corporate Performance Oversee implementation of internal control and management information systems to oversee the achievement of the performance metrics

Resources

c-i-D Corporate Performance Processes in place to monitor and continuously improve upon the performance metrics

Resources/ Quality

c-i-G Corporate Performance Policies providing direction for the CEO and COS in the management of the day-to-day processes within the hospital

Governance/ Executive

d-ii-A,B CEO and COS Select the CEO, delegate responsibility and authority, and require accountability to the Board

Executive

d-ii-C CEO and COS Policy and process for the performance evaluation and compensation of the CEO


(January 30, 2019) 2-D-50

d-ii-D, E CEO and COS

Select the COS, delegate responsibility and authority, and require accountability to the Board

Executive

d-ii-F CEO and COS Policy and process for the performance evaluation and compensation of the COS


(January 30, 2019) 2-D-50

h Financial Viability Approve collective bargaining agreements Board April 24, 2019 h Financial Viability Approve capital projects Resources

21



ON GOING AS NEEDED – Led by CEO/COS – reported in CEO report/Quality Presentations Charter Section #4

Charter Item Action (Italics-comments) Committee Responsible

g Build Relationships Build and maintain good relationships with the Corporation’s key stakeholders

Board oversight Led by CEO/COS

j-i-A Communication and Community Relationships

Establish processes for community engagement to receive public input on material issues

Board oversight Led by CEO

j-i-B Communication and Community Relationships

Promote effective collaboration and engagement between the Corporation and its community, particularly as it relates to organizational planning, mission and vision

Board oversight Led by CEO/COS and Chair

j-i-C Communication and Community Relationships

Work collaboratively with other community agencies and institutions in meeting the healthcare needs of the community

Board oversight Led by CEO/COS Quality

j-i-D Communication and Community Relationships

Maintain information on the website Board oversight Led by CEO

j-i-E Communication and Community Relationships

Establish a communication policy for the Corporation; review periodically (1-B-15 last reviewed Sept 30, 2015 reviewed every 3 years)


m Communications Policy Oversee the maintenance of effective stakeholder relations through the Corporation’s communications policy and programs


22

Agenda Item 2.2

Page 1 of 1

BRIEFING NOTE – Board Date: May 23, 2019 Issue: Strategic Plan Purpose: Approval Discussion Information Prepared by: Stephan Beckhoff Attachment: Draft Strategic Plan 2019-2021 Items for Board Approval As you are aware, the final strategic plan draft will be presented to the Board at our meeting on June 26. The draft plan (attached) has been widely circulated internally and externally for input. The Strategic Planning Steering Committee is scheduled to review the input and finalize the plan prior to the Board meeting. Attached to this briefing note is the draft plan that is out for consultation – it is provided to you so that you have a good idea of the proposed plan. I do expect that there will be some final “tweaks” and improvements based on the feedback received from our staff, medical leaders, community partners and others. The final version will be sent to you late no later than the morning of June 26 in advance of the Board meeting. As you read this version over the weekend, if you have any reflections please provide them to me [email protected]


23

mailto:[email protected]

http://www.cmh.org/

Ensuring Continued Success Cambridge Memorial Hospital

Strategy for 2019-2021

(DRAFTv3)

24

In the fall 2018, CMH begun a comprehensive planning process with the goal of developing a strategy to take us into 2022 and possibly beyond.

Just as our planning got underway, two unexpected “twists” occurred. First, the provincial government announced major changes to how health care services will be delivered in Ontario. We also learned that further delays in the move to our new building were a reality.

Faced with these unexpected circumstances, the Strategic Planning committee carefully considered the task of creating our next strategy. It became clear that we are planning in a time of uncertainty and transition. While this made it challenging to plan for the long term, it provided some clear opportunities for the near term. We see this as the time to focus on fundamentals to ensure that, come what may, CMH will be successfully positioned to continue to meet the care needs of the community that we serve.

As a result, we have chosen to create a short term strategic plan. As the healthcare system transformation unfolds over the next two years we will focus on three key things: demonstrating to our patients and families that they matter most, improving joy at work for our staff, patients and volunteers who provide care, and leading boldly with our system partners as we grow services and define the future.

We are pleased to share with your our 24-month strategic plan for ensuring continued success.

Patrick Gaskin, CEO Ian Miles, Chair, Board of Directors

Why a 24-month strategic plan?

25

Who we are:

CMH is a progressive acute care hospital

and teaching facility committed to quality

and integrated patient-centred care

We work towards our vision to provide exceptional healthcare by exceptional people.

Our values of caring, collaboration, accountability, innovation and respect guide how we approach our work.

3 26

Who we serve:

150,000 people in Cambridge and North

Dumfries rely primarily on CMH for

secondary care.

Our population is unique in our region:

More smokers More elderly living in low income

households Higher density of Indigenous people

More frequent visitors to the Emergency Department

More frequently seek care for mental health and addictions needs

The demand for hospital based care is increasing because more of us are older. By 2035, a full quarter of our population will be over 65 years old.

Opioid use is an emerging health

crisis in our community. We have the highest use of opioids and the most overdose related ED calls in the region.

Heart disease, lung cancer and

intentional self harm are the leading causes of death for our population. All of these are preventable to some degree.

4 27

Our people:

Our team is 510 volunteers, 1178

employees and 287 medical staff and midwives strong

We are proud of our:

Active Patient and Family Advisory Council Mental Health Family Advisory Council

Strong ties to Primary Care Providers and to Home & Community Care

New relationships with the McMaster School of Medicine

We develop our people. We have made major commitments in clinical, quality improvement (QI) and leadership training.

Employee engagement to enable our

people to provide the best care possible. A comprehensive, evidence -based strategy designed to disrupt persistent barriers to engagement and to increase joy at work has just been developed.

Our team includes patients, families and

our community. We strive to ensure that patients help direct their own care and our service delivery decisions.

5 28

CMH Operations:

In 2018/19 CMH provided: • 57,042 total patient days

• 52,253 Emergency Department (ED) visits

• 1,477 births

• 4,984 Rehab patient days

• 15,316 Mental Health outpatient visits

• 14,643 surgeries in total (in- and out-patient)

Operating Budget (Balanced): $125M

Capital Plan: $10.3M

Our new building will provide us approximately 33% more capacity to

provide care when complete

Our clinical service strategy involves strengthening core services and planned growth in each of our four “Petals of Care”: specialized surgical, specialized medicine, mental health and women & children’s services

Growth & Repatriation. Part of our growth strategy is focused on bringing some services closer to home for our community.

We have funding but no place to grow.

We are working hard to maximize the $5M available annually for clinical program expansions even though the space we were counting on to accommodate growth is delayed.

6 29

Our Performance:

We measure, monitor and report indicators of clinical

outcomes, access, quality, safety, utilization, staff

engagement, patient satisfaction, fiscal

performance/efficiency and more.

Our balanced scorecard provides a

quick “heat map” of how we are doing.

We are accountable for our performance.

We constantly plan to do better.

Our residents have the shortest wait in the province for discharge to alternate level of care: ALC days are now approaching the provincial target of 15%.

We have decreased wait times for hip/knee surgeries substantially: now the shortest waits in region.

We are achieving our 2018/19 targets for patient experience

in communications, readiness for discharge and understanding of medications at discharge.

About 45% of patients would recommend CMH’s Emergency

Department for care. This is lower than our target of 52%, and unchanged for the last few years as we wait for new space.

Three quarters of our staff feel we are committed to

improving patient safety, but ¼ worry about personal repercussions of errors.

For the past several years, only 37% of our employees think CMH is an excellent place to work. We would like to do better.

We have a track record of fiscal responsibility and balanced budgets

7 30

CMH has multiple priorities and commitments underway:

8 31

Assessing the risks in our current environment

9

•Bill 74’s Ontario Health Teams will involve integration, structural and funding changes for the providers who deliver services for large portions of the population. With our local partners, CMH has expressed interest, and may become part of one of these teams.

•We want to participate in defining any changes to our role or operations, rather than have changes imposed on us.

•Despite our efforts, engagement and experience of our patients, volunteers and staff remain below where we would like them

•We need others to be certain that CMH provides top quality, effective services

•In times of uncertainty it will be critical that the hospital is seen as a trusted and valued provider/employer/partner

•Bill 74: The People’s Health Care Act has major implications for how health care (and hospital) services will be governed, planned, funded, administered and delivered in the province. Details are unclear: we don’t yet know what the impact on CMH will be.

• Provincial review of regional government and possible amalgamation brings concerns re: representation and governance

•While CMH is the only hospital in our region that is positioned for growth, the delayed move/renovation is creating space limitations that may impact some of the program growth (and funding) that we have been planning for .

•We have an extensive Clinical Services Plan that needs to be operationalized. There is a need to proceed thoughtfully

•Strategy is needed to deal with new clinical needs in our population (e.g. opioid addictions) Growth

System Instability & Uncertainty

Role & Structural

Change

Engagement & Trust

32

Acknowledging strengths and opportunities

10

•As a hospital, we are behind on adoption and implementation of technology. We have identified what we could do if we had the opportunity.

•We look forward to leveraging, increased government interest in technological enablers as new system structures are created.

•We care about our relationships with the community, patients, our workers, volunteers and other health care partners. Together we are stronger. Trust is key.

•We must demonstrate our commitment to our relationships by doing the right things and deepening mutual trust, understanding and collaboration.

•No matter what our role, CMH is committed to providing high quality, safe, cost effective, accessible care to the community it serves

•We are committed to person centred care and excellent patient experience, and must actively demonstrate this

•We are committed to creating a safe, enabling and fulfillingwork environment for the people that provide care on our behalf

•We are committed to aligning with government strategy and objectives

•CMH has the capacity to serve and lead in many ways. Not only do we have clinical growth plans, CMH has clinical expertise, leadership, planning and analysis and operational resources that can be leveraged as the system moves forward with transition

•The hospital is well positioned to lead in clinical areas of specific need, such as addition and mental health and chronic diseases

Capacity Commitment

Technology Relationships

33

We believe that to ensure continued success, these principles should guide our efforts for next two

years at CMH:

We have many operational issues and goals already. We need to clearly articulate what is “strategic” and ensure we invest sufficient efforts in the right places.

We are stronger when we work together. We will change as needed to improve the care that is provided to our community.

We are an important healthcare provider with big ideas and the capacity to lead. We will be pro-active and thoughtful in making decisions and defining the future.

To position ourselves successfully for whatever comes, we must be internally strong in service quality, financials and reputation.

11

FOCUS

PARTNER

LEAD

EXCELL

34

Given this, our priorities for the next 24 months are to:

“Ensuring Continued Success”

Prove patients matter most

Increase joy in work

Lead boldly

12 35

Our 2019-21 Strategy Summarized

13

•Build our patient experience culture

•Design care together

•Grow our services to better meet the needs of our community

•Equip leaders to create more joyful and enabling work environments

•Plan together

•Provide leadership in defining how care is provided to our community

•Prepare for our changing role


“Ensuring Continued Success”


Lead boldly

36



•Grow services to meet the needs of our community

Why it’s a priority:

What we will do:

Measures of success :

Our patients are why we exist. We are committed to ensuring that patients and families understand that they are our priority, and we will continue to build a culture that supports this notion. Now is the time to action our desire to engage our patients and their families in ways we haven’t in the past, to ensure we are getting things right as we plan for the services our community needs.

1. Build our patient experience culture Implement best practice strategies that ensure that every interaction in every

department enhances the patient and family experience

2. Design care together Action strategies and methods that ensure service planning and delivery

decisions being made for the next several years are co-lead by the voices of our patients, families and community.

Develop new mechanisms for engaging the voices of groups we may not have heard from in the past (e.g. youth, new residents, LGBTQ, Indigenous peoples, etc.).

3. Grow services to better meet the needs of our community

Clarify the clinical service strategy priorities that we will pursue in the next 24 months and act on these growth plans

Continue to focus on quality and efficiency improvements, particularly in medicine, ICU and the Emergency Department.

By expanding services, increasing market share and improving patient experience we will become the “hospital of choice” for secondary care services for our community. Our patients will see themselves as active participants in their care and in design of healthcare services in this community. Our patient experience scores will exceed our peers.

14


37

•Equip our leaders to create more joyful and enabling work environments

•Plan together


What we will do:

Measures of success:

Our workforce…the staff, physicians, midwifes and volunteers at CMH.. are our greatest asset at CMH. We want...and need…our people to want to give their best. We have the foundations for an engaged workforce at CMH, and have identified an evidence based framework focused on improving “joy in work” to enable our workers to bring the best that they can to their jobs. We are committed to beginning to implement the strategies we have identified to build a more enabling work environment and to increase the joy in our everyday work.

1. Equip leaders to create more joyful and enabling work environments Ensure we have the right leaders in place (including clinical/medical

leadership) Clarify the roles and accountabilities of our leaders Support our leaders in adopting practices and behaviours that have positive

impacts on workforce performance, joy and engagement Optimize how we monitor organizational performance

2. Plan together

Redesign mechanisms for departmental/program decision making to enhance staff, physician/midwife and volunteer input

Develop and implement new methods for ensuring staff, physicians/midwives and volunteers are actively involved in making decisions about our role and how care is provided.

We will have a more engaged workforce as demonstrated through improved outcomes on our existing staff, physician/midwife and volunteer engagement indicators. We will be able to demonstrate that multiple voices have been included in in creating our next strategic plan. 15


38




What we need to do:

Measure of success:

The largest provincial healthcare transformation is underway. Care is expected to be delivered in new ways – integrated care delivery and funding which will enable patients, families, community, providers and system leaders to better work together. CMH is a trusted partner with the experience, expertise, capacity , vision and commitment to lead change for the better. We will see change as an opportunity to contribute to real improvements in health outcomes for our community.

1. Provide leadership in defining how care is provided to our community Dedicate the leadership and resources required to actively collaborate with our

partners to define how services are delivered within the new Ontario Health Team framework

Focus on opportunities in mental health and addictions and other areas of CMH expertise

Be willing to adopt changes to hospital departments, services accountabilities (including home/community care), governance and technology in order to improve efficiency and effectiveness of services

2. Prepare for our changing role

Invest resources to understand the implications of system change on our role Recast our mission and vision as appropriate Develop and launch the strategy that will see us through to year 2024 (or

beyond) Articulate any key changes to our role, operations, administration and/or

governance that are anticipated in the next strategic cycle.

We will be prepared and positioned for a successful future. With our partners, we will implement an Ontario Health Team model in CND. We will complete CMH’s next strategic plan that articulates priorities for the next 5 to 10 years. 16

Lead boldly

39

Increase Joy in Work

•Equip leaders to create more joyful and enabling work environments

•Plan together

Prove Patients Matter Most



•Grow our services to better meet the needs of our community

Lead Boldly



Our Mission: “A progressive acute-care hospital and teaching facility committed to integrated patient-centred care “

Our Vision: “To provide exceptional care by exceptional people”

Ensuring Continued Success

Our Values: Caring Collaboration Accountability Innovation Respect

2019-2021 Strategic Plan

40

To follow

18

High Level Implementation Plan

41

Agenda Item 3.1.2 21 June 2019 Events Calendar 2018-2019

Page 1 of 2 21 June 2019

Board/Committee Meeting and Event Dates Sep Oct Nov Dec Jan Feb Mar Apr May Jun Sep (2019)

Board of Directors 5:00pm – 8:00pm – C.1.229

17 28 30 27 24 29 26

25

Meeting with City Council and CMH Board of Directors 6:30pm – 8:00pm - City Hall (Ian, David, Tim, Denise, Tom, Katie, Nicola)

19

Joint CMH/CMHF Board Meeting – TBD

Waterloo Hospitals Collaborative Committee 20 18 Waterloo Wellington Collaborative Council (Hospital Chairs and Vice Chairs) 23

Quality Committee 7:00am – 9:00am – C.1.229

19 17 21 16 20

17 15 19

Quality Committee QIP Meeting 7:00am – 8:30am – C.1.229

7

Quality/Resources Joint Meeting 5:30pm – 6:30pm – C.1.229

25

Resources Committee 5:30pm – 7:30pm – C.1.229

24 26 28 25 22 27 24

Capital Projects Sub - Committee 4:00pm – 5:30pm– C.1.229

24 22 26 28 25 22 27 24

Governance Committee 4:30pm – 7:00pm – C.1.229

4 8 10 21 9

Audit Committee 5:00pm-6:30pm – C.1.229

21 22 27

Executive Committee 5:00pm – 6:30pm – C.1.229

20 14 16 16

Strategic Planning Sub-Committee 5:00pm – 6:30pm

29 26 26 23 28 25

WWLHIN Board Meetings November – Katie Hamilton 14 January - Suren Rao 25 March - 20

2018-19 Events

42

Agenda Item 3.1.2 21 June 2019 Events Calendar 2018-2019

Page 2 of 2 21 June 2019

Board/Committee Meeting and Event Dates Sep Oct Nov Dec Jan Feb Mar Apr May Jun Sep (2019)

Best Bites – 1:00pm – Shades Mill Conservation Park 9 Ken Seiling Celebration (Steve Pawelko, Tom Dean, Ian Miles, David Pyper) 21 WeCareCMH North Dumfries House Tour 8 Staff Holiday Lunch 11:00am – 1:30pm 4:00 pm – 6:00 pm – D.0.305

Ian Miles, Suren Rao, David Pyper 5

Mayor Doug Craig Celebration 5:30pm – Cambridge Conference Centre Tom Dean

24

Career Achievement 2:00pm – 4:00pm – D.0.305 Elaine Habicher

30

CMHF Donor Recognition Celebration – Galt Country Club David Pyper

21

CMH Foundation Golf Tournament 11:30am – Galt Country Club 3

Staff Summer BBQ 11:00am – 1:30 pm and 9:00pm – D.0.307 18

Best Bites – 1:00pm – Shades Mill Conservation Park 8 Board Education Opportunities Questions Healthcare Boards should ask Sr. Leaders about Risk – Webinar

• Monika Hempel, Nicola Melchers, Alison McCarthy 26

Governors Education Sessions • Governors Session on State of Healthcare 5:30-8:30pm – Galt Country Club

Ian Miles, David Pyper, Elaine Habicher, Joe Kane, Denise Smith, Suren Rao, Tim Edworthy, Katie Hamilton, Nicola Melchers

19

CMHVA Hospital Tours • Tour of the existing hospital provided third Wednesday of every month

4:00pm-5:00pm – meeting in the Volunteer Lounge on Level 2 19 17 21 19 16 20 20 17 15 20

43

Agenda Item 2.1

Page 1 of 4

BRIEFING NOTE – RESOURCES Date: June 18, 2019 Issue: May Financial Statements Purpose: Approval Discussion Information Prepared by: Mike Prociw Approved by: Patrick Gaskin Attachments: Financial Statements Items for Board Approval Assuming that the Resource Committee that meets on June 24, 2019 approves the May 31, 2019 financial statements, the following motion is proposed for the Board. Proposed Board motion: The hospital Board approves the May 31, 2019 financial statements as presented. Summary CMH has a May year to date operating surplus of $333K after building amortization and related capital grants which represents a $279K positive variance from budget. The YTD positive variance is driven by

• A large positive variance in benefits primarily a result of a favourable position in maternity. The positive variance is a timing difference and expected to be equal to budget by year end.

• A favourable variance of $105k in med surge supplies in the OR. The variance is expected to be timing

• A favourable timing difference in supplies of $100k Activity Volumes


44

http://www.cmh.org/

Agenda Item 2.1

Page 2 of 4

• The medicine floors have averaged YTD 58 patients per day. This represents a 2% decrease from last year. The budget was built on 55 beds with 10 beds of surge occurring for all twelve months.

• The surgical floor has an average of 22 patients per day YTD. The volume for the month of May is equal to the average for the year and the YTD volume is 5 % higher than the previous year’s volume.

• The mental health unit has an average of 18 patients per day YTD. During the month of May volume was the same as the YTD average.

• The average numbers of YTD visits in the Emergency Room are 141 per day. This is 1% higher than the same period last year.

Revenue The total budget surplus of $500K is higher than the breakeven budget approved to allow for a contingency for unforeseen costs that may arise as result of moving into the new building and expanding programs. The budget was built under the assumption that we will have moved into the new building April. As a result of the delay, significant negative variances have occurred in MOH One Time revenue with positive variances occurring in salaries and supplies. There is a net negative impact to the bottom line of $90k per month for each month of the delay. A brief summary of some of the major year to date revenue variances include: MOH Funding:

• The targets for elective QBPs (hip, knee, shoulders, cataract, arthroscopy and tonsillectomy) have all been exceeded and funding for the excess will come from PCOP one time funding. Volumes for emergent QBPs are equal to budget until coded data becomes available.

• For the Cancer Care Ontario (CCO) QBP revenue, breast, colorectal and prostate are higher than budgeted expectations.

• The negative variance in one time MOH revenue is a result of the delay in moving into the new building which resulted in no revenue being recognized in facility PCOP. The decline in revenue has resulted in $ 632K decline in salaries and supplies.

Billable Patient Services

• The positive YTD variance of $222K is primarily due to positive variances in Technical Fees, Professional Fees and uninsured procedures. Preferred accommodation has a small surplus year to date.

Recoveries and Other Revenues • The year to date positive variance of $384K is primarily due to the increased utilization of

Oncology drugs ($184K), billings to Project Co of steam, water and electricity ($ 54K), and one time sessional fee recovery of $45K. The increase in drug revenue is offset by an increase in drug expense.

Expenses Salaries and Wages

• There is a positive variance of $46K for the month and a negative variance of $5K year to date. The negative pressures resulting from additional staff due to the expected move into the new building plus high levels of training, one to ones, sick and overtime are

45

Agenda Item 2.1

Page 3 of 4

offset by a large positive variance due to the delay in planned salaries from PCOP. (The PCOP salaries are offset by reduced funding)

• Sick and overtime was over budget in the month by $51K (2018 – over budget $81K). The YTD sick and overtime is over budget by $117K (2018 – over budget $191K). The table below provides a summary in hours for sick and overtime.

A brief overview of the year to date over time variance is as follows:

• 23% of the overtime variance is attributed to the Emergency Department of which most of the variance is as a result of vacant positions.

• The Women and Children program contribute 27% of the variance which is a result of a large variance in sick time.

• The medicine program contributes 16% of the variance which is driven by large amounts of sick and one to one care.

• The Mental Health contributes 12% of the variance resulting from one to one level of care.

A brief overview of the year to date sick variance is as follows

• The negative sick variance is primarily driven by Medicine and Women and Children.

Other variances in salaries and wages are

• The ED program has a negative variance of $95K which is a result of overtime, training and one to one level of care.

• Plant and property has a negative variance of $46k driven by increased staffing levels in anticipation of the new building.

• In-patient mental health has a negative variance of $72K due to increased staffing levels in anticipation of the new building and high levels of one to one care

Benefits • The variance in benefits is primarily attributed to a surplus in the maternity benefits.

When a person goes off on maternity, the entire amount of the maternity supplement is expensed in the month that they go off. Based on historical utilization and the addition of new staff with little experience, it is expected that the positive variance will be eliminated by year end.

Medical Remuneration

• The negative YTD variance is mainly attributed to higher volumes in CT and funding payments to the ED physicians. ED physician payments are flow through and have no

May YTD HOURS Actual Budget 2018 Actual Budget 2018 Overtime 2,215 1,671 2,446 4,704 3,829 5,091 Sick 5,188 3,341 5,223 10,517 6,577 10,031

46

Agenda Item 2.1

Page 4 of 4

impact to the hospital bottom line.

Medical and Surgical Supplies • The majority of the positive YTD variance is attributed to the Operating Room. It is

expected that the variance will be timing and actual expenses will be close to budget by year end.

Drug Expense • The negative variance is primarily attributed to an increase in utilization of oncology

drugs in medical day care. There are new drugs and protocols which have increased the utilization of high end drugs in the first two months. Approximately 95% of the variance is recovered from funding from Cancer Care Ontario.

Other Supplies and Expenses • Administration and HR contribute $63K of the positive variance. As in past years the

variance will vary based on the need to engage professional services and contingencies. • Due to the delay in the building there are 4 months of savings of facility costs resulting in

a savings of $311K. There is an offsetting reduction of PCOP facility revenue. • Plant Operations have a negative variance of $56K from higher utility consumption. • As in previous years the clinical areas have a cumulative positive variance of $61k. The

positive variance is expected to be diminished over the year.

Balance Sheet and Statement of Cash CMH’s current cash position is $110.3M and includes $66.9M for a sinking fund payment due at the end of phase 2, restricted cash of $16.3M and unrestricted cash of $ 19.2M. The working capital ratio meets the requirements of our HSAA target. The Capital Redevelopment Project has increased to $138.9M. The project value includes payment 1 of $12M the bank made to Project Co for overhead costs and $8.3M of financing costs. The balance only includes Project Co costs. In accordance with the agreement with the Ministry of Health, CMH will make a lump sum payment of $66.2M to the general contractor once CMH takes ownership of the building. The amount paid may be reduced to reflect the value of deficiencies in the building at handover date. $59.6M of the payment has been funded by the Ministry with the remaining amount, $6.6M, has been funded by the CMH Foundation.

47

Agenda Item 3.2.1

20-Jun-19

CAMBRIDGE MEMORIAL HOSPITALSTATEMENT OF INCOME AND EXPENSE

19/20Actual Plan Variance % var YTD Actual YTD Plan YTD Variance % var Plan MAY 18 YTD MAY 18 18/19 YE

Operating IncomeMoH Funding

4,106,928$ 4,065,944$ 40,984$ 1.0% MoH Base $ 8,000,731 8,000,731$ -$ 0.0% 48,004,373$ 4,868,698$ 8,524,372$ $ 50,983,766 2,405,329 2,405,329 - 0.0% MoH HBAM 4,733,068 4,733,068 - 0.0% 28,398,403 2,282,232 4,746,034 28,398,403 1,523,082 1,581,891 (58,809) (3.7%) MoH QBP 3,195,546 3,161,616 33,930 1.1% 18,420,203 1,523,762 2,952,028 18,060,466

965,249 1,375,498 (410,249) (29.8%) MoH Onetime / Other 1,894,405 2,706,624 (812,219) (30.0%) 16,239,733 640,977 1,005,649 6,370,364 9,000,588 9,428,662 (428,074) -4.5% Total MoH Funding 17,823,750 18,602,039 (778,289) -4.2% 111,062,712 9,315,669 17,228,083 103,812,999

1,358,536 1,228,160 130,376 10.6% Billable Patient Services 2,638,800 2,416,697 222,103 9.2% 14,500,230 1,243,508 2,368,131 14,424,122 1,164,866 921,967 242,899 26.3% Recoveries and Other Revenue 2,198,636 1,814,197 384,439 21.2% 11,471,014 1,125,947 1,963,518 15,326,298

80,316 74,701 5,615 7.5% Amort'n of Deferred Equip Capital Grants 159,492 146,990 12,502 8.5% 881,937 146,373 293,338 1,278,061 311,805 301,124 10,681 3.5% MoH Special Votes Revenue 585,287 592,536 (7,249) (1.2%) 3,555,212 315,789 569,093 3,555,212

11,916,111 11,954,614 (38,503) (0.3%) Total 23,405,965 23,572,459 (166,494) (0.7%) 141,471,105 12,147,286 22,422,163 138,396,692 Operating Expense

5,396,631 5,442,419 45,788 0.8% Salaries & Wages 10,721,940 10,717,101 (4,839) (0.0%) 64,002,159 5,230,454 10,242,435 62,336,669 1,469,429 1,522,636 53,207 3.5% Employee Benefits 2,868,431 3,003,180 134,749 4.5% 16,993,373 1,418,641 2,809,435 16,412,949 1,621,963 1,631,257 9,294 0.6% Medical Remuneration 3,238,500 3,214,149 (24,351) (0.8%) 19,298,810 1,605,058 2,959,787 18,423,110

873,985 911,172 37,187 4.1% Medical & Surgical Supplies 1,659,111 1,785,741 126,630 7.1% 10,191,855 835,313 1,652,779 9,782,014 702,406 576,715 (125,691) (21.8%) Drug Expense 1,326,004 1,134,089 (191,915) (16.9%) 6,751,282 657,419 1,165,560 6,989,357

1,155,298 1,295,060 139,762 10.8% Other Supplies & Expenses 2,128,392 2,530,000 401,608 15.9% 16,185,366 906,784 1,933,049 13,887,279 224,258 213,193 (11,065) (5.2%) Equipment Depreciation 447,142 419,508 (27,634) (6.6%) 2,517,034 310,853 622,318 3,278,378 311,805 306,290 (5,515) (1.8%) MoH Special Votes Expense 585,287 602,751 17,464 2.9% 3,555,212 292,427 569,093 3,555,212

11,755,775 11,898,742 142,967 1.2% Total 22,974,807 23,406,519 431,712 1.8% 139,495,091 11,256,949 21,954,456 134,664,968 160,336 55,872 104,464 187.0% MOH Surplus (Deficit) 431,158 165,940 265,218 159.8% 1,976,014 890,337 467,707 3,731,724

Other income (expense):(144,498) (153,910) 9,412 (6.1%) Building Depreciation (289,000) (302,856) 13,856 (4.6%) (2,624,445) (145,838) (291,888) (1,712,876)

95,527 97,271 (1,744) (1.8%) Amortization of Deferred Build Capital Grants 191,054 191,405 (351) (0.2%) 1,148,431 92,062 183,851 1,103,652 111,365$ (767)$ 112,132$ (14,619.6%) Net Surplus (Deficit) for the period 333,212$ 54,489$ 278,723$ 511.5% 500,000$ 836,561$ 359,670$ 3,122,500$

CONFIDENTIAL

Month of MAY 2019 Year to date ending MAY 31, 2019 17/18 prior year actuals

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CAMBRIDGE MEMORIAL HOSPITAL 20-Jun-19

COMPARATIVE BALANCE SHEETMAY MARCH

2019 2019ASSETS

Current Assets Cash and short-term investments 25,997,605$ 19,216,655$ Sinking Fund 68,050,449 66,228,500 Due from Ministry of Health/LHIN - 4,101,370 Due from Ministry of Health - Capital Redevelopment 455,087 - Other receivables 3,510,553 4,866,447 Inventories 2,130,120 1,977,289 Prepaid expenses 1,403,266 1,445,213

101,547,080 97,835,474 Non-Current Assets Cash and investments restricted - Capital 16,297,428 15,195,992 Endowment and special purpose fund cash & investments 187,427 187,427

Capital Assets 92,246,229 92,531,033 Capital Redevelopment Construction in Progress 138,887,166 138,874,656

TOTAL ASSETS 349,165,330$ 344,624,582$

LIABILITIES & EQUITY

Current Liabilities Due to Ministry of Health/LHIN 1,287,464$ 1,078,835$ Accounts payable and accrued liabilities 89,528,664 88,181,031 Accounts payable - Capital redevelopment - -

90,816,128 89,259,866 Long Term Liabilities Employee future benefits 3,995,492 4,001,200 Capital Redevelopment Construction Payable 69,944,914 69,944,914 Deferred Capital Grants and Donations 150,956,600 148,377,512 Deferred Capital Grants Capital Redevelopment 5,642,651 5,642,651

230,539,657 227,966,277 Net Assets: Unrestricted 6,735,461 4,574,409 Externally restricted special purpose funds 187,427 187,427 Invested in Capital Assets 20,886,657 22,636,605

27,809,545 27,398,441

TOTAL LIABILITIES & EQUITY 349,165,330$ 344,624,584$

Working Capital Balance 10,730,952 8,575,608Working Capital Ratio (Current Ratio) 1.12 1.10

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CAMBRIDGE MEMORIAL HOSPITAL 20-Jun-19

STATEMENT OF CHANGES IN FINANCIAL POSITIONFor the Month Ending May 31, 2019 Cash Provided By (used in) Operations: YTD MAR19 FY 2017/18

Excess (deficiency) of revenue over expenses 333,212$ 3,122,500$ Items not involving cash: -Amortization 736,142 4,991,254 -Loss on Disposal of Assets - - -Amortization of deferred grants and donations (350,546) (2,381,713) Change in non-cash operating working capital 6,525,449 82,672 Change in employee future benefits (5,708) (60,300)

7,238,549 5,754,413

Investing:

Acquisition of capital assets & CRP (463,848) (37,436,219) (463,848) (37,436,219)

Financing:

Capital donations and grants & CRP 2,929,634 16,198,456 Construction payable - 20,574,171

2,929,634 36,772,627

Increase (Decrease) In Cash for the period 9,704,335 5,090,821 Cash & Investments - Beginning of Year 100,641,147 95,550,326 Cash & Investments - End Of Period 110,345,482$ 100,641,147$

Cash & Investments Consist of:

Unrestricted Endowment and Special Purpose Investments 29,668$ 29,668$ Cash & Investments Operating 25,967,937 19,186,987 Sinking Fund 68,050,449 67,795,280 Cash & Investments Restricted 16,297,428 13,629,212

Total 110,345,482$ 100,641,147$

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COMMITTEE MEETING SUMMARY - OPEN

Date: June 20, 2019

Issue: Quality Committee of the Board Meeting, June 19, 2019

Purpose: Approval Discussion Information

Prepared by: Iris Anderson, Administrative Assistant, Clinical Programs

Approved by: Sandra Hett, Vice President Clinical Programs & CNE

Attachments: Women’s & Children’s (WC) Services Program PresentationPatient Experience Accreditation – update Patient Family Advisory Council (PFAC) – update

Items for Board Information

Women’s & Children’s Services (WC) (found in package 2) Ms. Hett introduced Ms. Craven, Director of Surgical Programs.

Ms. Craven introduced Ms. Lywood, Manager of Women’s & Children’s Services, Dr. Rajguru, Chief of Paediatrics, Dr. Green, Chief of Obstetrics, and Ms. Witteveen, Chief of Midwifery, to the Committee members.

Ms. Craven highlighted that births are up over the previous year – there is a 5% increase in the number of births which aligns with the CRP growth plan

Ms. Lywood referred the previously circulated presentation, and provided a summary of several slides. The following highlights were noted:

− To improve the patient experience, WC worked closely with PFAC to explore and implement quality improvements in OBs based on patient feedback – immediate lactation support and communication/interactions with providers

− Breast Buddy Program was introduced and continues to provide support to new parents − All staff participated in a Breast Feeding education course and Crucial Conversations

course was introduced as a new expectation


Agenda Item 3.4.1

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Extensive work continues to improve the Patient Experience and address any feedback or complaints. Ms. Lywood elaborated on the following:

− Transfer of Accountability with the patient at shift change for Obstetricians − The majority of negative comments focused on physical environment, food options, lack

of private rooms/shared washrooms and parking challenges − All comments are shared and discussed at Huddles

Dr. Rajguru spoke of the advancement of the Special Care Nursery (SCN) and how it affects patients in the region. Continuous feeds was introduced in late 2018; nCPAP was introduced in February 2019. These services have decreased the number of infant transfers to other facilities, and provide the ability to transfer infants back to CMH sooner.

The new Paediatric Model of Care was discussed. Paediatric Rounding will include patient, family, pediatrician and nurse.

Dr. Rajguru noted the challenges with recruiting Paediatric physicians due to lifestyle expectations. New graduates prefer a less onerous call schedule with shorter shifts. As a result, modernizing the Paediatrician role is underway with a small test of change commencing in July 2019. One change is the 24-hour on-call shift which has been replaced with 12-hour shifts.

Dr. Green spoke of the recruitment to the OBs medical team. Two Obstetricians have been recruited and will start later this summer. There are two physicians eligible for retirement within the next couple of years.

Ms. Witteveen provided a brief overview of Midwifery Management of Epidurals. Midwifery access to full scope of practice affects patient satisfaction and access to pain management modalities. Anesthesia reviewing their position on current Midwifery model of care. The Canadian Medical Protection Society will be presenting to physician group August 8, 2019.

Mr. Rao opened the floor for further questions and comments.

Discussion ensued regarding the collaboration between Midwives and Obstetricians. Ms. Lywood responded by stating there is overall a positive relationship between the two professions at CMH. Midwives are included in all staff training, patient rounding and handovers at shift change.

Ms. Witteveen answered questions related to home births and neonatal blood sampling. Ms. Craven noted that WC will continue to grow and evolve over the next couple of years. WC will continue to focus on the voice of the patient and the needs of the community.

Mr. Rao thanked the guests for their presentation.

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Accreditation – update Ms. Iromoto referred to the previous circulated briefing note, and provided a short summary of the work being done in preparation of the 2019 on-site visit by Accreditation Canada. Significant focus is on medication administration practices in various care settings; illustrating the paramount importance of this practice on patient safety.

Ms. Iromoto added that the on-site visit surveyor team will include a Patient Surveyor. The Patient Surveyor will be tasked with meeting patients and care teams to determine if the patient and family centred care standards were met, from the perspective of a patient.

Quality Committee members can expect more updates on Accreditation in the Fall.

Patient Experience – update Mr. Gaskin directed the Committee members to the previously circulated presentation, and summarized the slides related to complaints.

Approximately 50% of the complaints are generated from the ED and Medical units. The reasons for complaints include Care/treatment, Attitude and/or Communication. Results from NRC 2018/19 “Would you recommend” ranking, CMH score has decreased. A lengthy discussion took place regarding engaging and connecting with patients, better communication between staff, and providing assistance to those who need to feel supported.

Patient Family Advisory Council (PFAC) – update Ms. Kimpson provided some highlights of activities from September 2018 to June 2019:

− The opportunity to share patient experience stories with the Board − Two PFAC members assisted in the creation of the e-learning module on person

centered care that introduced the concept of Person Centred Care and what that means through the eyes of a patient by sharing personal experiences

− Strategic Plan Steering Committee - PFAC members were to co-lead and invited to provide input alongside operational and medical leaders

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Caring Respect Innovation Collaboration Accountability

Patient Experience Semi-Annual

Report

Quality Committee of the Board Presentation

June 19, 2019

Gillian Dyck Patient Experience Lead

Liane Barefoot Director, Patient Experience, Quality & Risk

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Who We Serve • Current and former patients • Family members • Visitors • Staff and Volunteers • Professional and medical staff • Liaison to community groups

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Patient Experience Lead

3

Gillian Dyck, BScN RN

• Registered Nurse • Clinical experience in Pediatrics

and Neonatal Intensive Care • Formerly Clinician Educator for

tertiary Neonatal Nurseries in Hamilton

• Passionate about the human experience and finding ‘joy’ in the work you do

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What our patients are saying

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Total Feedback Files by Fiscal Year

5

• Although volumes this past fiscal year have decreased, the 4 year trend line remains relatively unchanged

520

540

560

580

600

620

640

660

680

700

720

2015-16 2016-17 2017-2018 2018/19

Total Number of Files Per Fiscal Year

Linear (Total Number of Files Per Fiscal Year)

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Distribution of Feedback Types

6

• Requests have an upward trend, and this may be a function of patients being more easily connected to the patient experience office. Patient Experience lead contact info is available on the CoHealth App, NRC Survey, comment cards and easily found with an online search

• A large number of requests are related to Release of Information, and usually are associated with a chart review, or review of care provided by CMH leadership – may be lessened with MyChart

65% 67% 56% 55%

13% 8% 18%

12%

22% 25% 27% 33%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2015-16 2016-17 2017-18 2018-19Fiscal Year

Complaints Compliments Requests/ Suggestions

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Severity Levels of Complaints

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• Files of a minor severity continue a downward trend, and major complaints continue to increase • Explanation: Clinical Units are directly managing lower severity complaints, leaving the Patient

Relations process for higher-complexity Complaints. This is shift allows more direct and timely resolution of simpler complaints, and a more specialized response to higher level complaints.

38%

30%

9%

23%

56% 57%

53%

44%

6%

13%

38%

33%

0%

10%

20%

30%

40%

50%

60%

2015-16 2016-17 2017-18 2018-19

Minor

Moderate

Major

Linear (Minor)

Linear (Major)

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Complaints by Department

8

• Selection of the areas displayed in the chart above was based on # of complaints being >10 per fiscal year

• Approximately 50% of complaints have come from the areas of ED and Medicine (A&B combined)

Other areas includes: Cardiorespiratory Unit, Clinics/Pain/Diabetic/COPD/Senior/Bili, ICU, MDC, Parking, Surgical Clinics/Endoscopy/Fracture Clinic, and Miscellaneous.

132

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31 20 17 16 13 10

65

0

20

40

60

80

100

120

140

ED Medicine IP Surgery Mental Health(IP + OP)

OR, SDC/PACU DI OB + Peds Rehab All other areas

# of

Com

plai

nts

Department

51%

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Reasons for Complaints

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Nearly identical to the data from the January report, 58% (57% in January) of complaints include concerns about Care/treatment, Attitude, and/or Communication. These results suggest opportunities for improvement with a focus on patient-provider relationships, and patient and family member perception of medical quality, which we know is directly influenced by the presence/absence of a good working patient-provider relationship).

0 50 100 150 200 250 300 350

Confidentiality

Patient/Resident Property

Does not align with any

Privacy/Patient or resident rights

Facility Issues/Environment

safety

Administration

Timing

Access

Communication

Attitude

Care/Treatment

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10

• ECFAA 2010 Response Time Regulation is 5 calendar days • Staffing challenges spring to summer 2018 were rectified with additional temporary staffing and

permanent staff changes • September 1 to December 31: 5 day initial first response = 99%, and we anticipate that our

improved response time will land above 90% at end of fiscal year

Time from Initiation to First Response

Days to Response All

Types

Fiscal 2016/17

Fiscal 2017/18

Fiscal 2018/19

Current Calendar

year

Same day 74% 69% 69% 75%

Less than 2 days 92% 87% 82% 88%

Less than 5 days 97% 94% 89% 99%

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External Satisfaction Survey % Top Box Answers to ‘Would You Recommend?’ compared to local benchmark*

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• PR = Percentile ranking compared to local benchmark • New benchmarks (Local Benchmark)

• Adult inpatient areas – Ontario Inpatient Community Hospital 50th Percentile • Pediatrics – Ontario Paed Average • Emergency – Ontario ED Community Hospital 50th Percentile

2016/17 2017/18 2018/19

CMH (PR)* CMH (PR) CMH (PR) Local Benchmark

All In Patients 51.6% (11) 53.8% (15) 47.5%(6) 64.8%

Medicine 46.8% (6) 47.5% (6) 42.9% (3) 64.8%

Surgery 58.2% (29) 54.4% (16) 55.5% (19) 64.8%

Paeds 46.3%(NA) 55.6%(NA) 43.1%(NA) 76.1%

Obstetrics 46.7% (6) 58.6% (32) 37.6% (1) 64.8%

ED 47.1% (24) 42.9% (15) 42.1% (13) 57.0%

NEW

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Most Highly Correlated…

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Question Correlation Coefficient

CMH Score (PR)

Helped by hospital stay 0.55 72% (61)

Got support needed with anxiety/fears 0.54 58.4% (48)

Good communication between staff 0.52 54.3% (44)

Nurses listened carefully to you 0.46 68.9% (63)

Treated with courtesy/respect by nurses 0.47 80.4% (59)

Got info needed about condition/treatment

0.46 64.9% (69)

Help going to bathroom as soon as wanted

0.46 59.5% (57)

Nurses explained things understandably 0.47 68.3% (61)

Priority Matrix for 2018/19 FY relating NRC questions to a top box response to “Would You Recommend CMH to family or friends?” for all adult inpatient areas.

It is important for us to think about how we are

engaging and connecting with the patients, AND with each other in the

presence of patients.

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Preparing for Accreditation

• As of 2018, Accreditation Canada has woven wording into all standards that evokes patients as partners

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Examples of Exact Wording from Accreditation Standards

• Services are co-designed with clients and families, partners, and the community

• (Individual) Care plans are developed in partnership with the clients and family…

• Services are reviewed and monitored for appropriateness, with input from clients and families

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Patients as Partners at CMH • This shift continues, and will continue for some

time • We have made some exciting strides in how we

engage, learn from patients, and in turn enhance care plans, and services

• The following are three examples of how we are doing this…

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Services are co-designed with … A Patient and her sister were stuck in an elevator after an appointment. This would be an unpleasant experience at anytime, but how it was handled (no line of communication established, responding staff minimized fears/anxieties, felt like they had been forgotten about in the elevator) further exacerbated this unpleasant situation.

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Services are co-designed with … • Staff reflection of intent/impact of what was/was

not said was deep and sincere • Comprehensive checklist developed and will be

reviewed with the patient and family member to see if this would have changed their experience

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(Individual) Care plans are developed in partnership with…

Based on solid research to support the practice, the ICU team encouraged family presence at a Code Blue resuscitation. Family was ill-prepared for the sight of their loved one being resuscitated, and shared with us the impact of this experience. • Staff, leader & medical staff reflection of

intent/impact of their actions was deep & sincere

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(Individual) Care plans are developed in partnership with…

• New process developed – families will be asked ahead of time, should this occur, if they wish to observe (care plan developed)

• A staff member will be assigned to solely explain/support family who choose to be present at a resuscitation

• Subsequent similar scenario has occurred with family being grateful to have been present

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Services are reviewed with input from…

Staff member with personal experience as a patient shared her experience with Post Partum Depression (PPD) and CMH. She had visited ED a few times and was eventually admitted to the Mental Health Unit. • This was the first time we have had this many

leaders, physicians and educators in the room to do a review in this way

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Services are reviewed with input from…

• Emotional discussion, brainstorming and acknowledgement occurred

• Tangible outcomes include: improved staff education of PPD in all of these areas, adoption of standardized assessment tool for PPD, collaboration between MH and OB for post partum depression education, and Grand Rounds presentation planned for January of 2020 to update on progress

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What worries us most... • Increasing complexity of patient complaints and

decreasing Would You Recommend results in all areas

• Staff and Physician Burnout and its impact on experiences at CMH

• Leader capacity for timely & thorough management of files, engaging and coaching staff, and implementing meaningful improvement initiatives

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What we are excited about… • Becoming a MyChart enrollment site – easing

patient access to their own information • The organization’s acknowledgment and

commitment to the link between Staff Engagement & Person Centred Care

• CRP – beautiful, bigger, bright space

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Questions??

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BRIEFING NOTE – QUALITY COMMITTEE Date: May 29, 2019 Issue: Accreditation Update Purpose: Approval Discussion Information Prepared by: Liane Barefoot, Director Patient Experience, Quality & Risk Emily Quantz, Clinical Educator Facilitator, Accreditation Lead Approved by: Sandra Hett, Vice President Clinical Programs &CNE Items for Board Information Accreditation Canada Background Established in 1958, Accreditation Canada is an independent, not-for-profit organization dedicated to improving the quality of health care systems in Canada and across the globe through a rigorous process of accreditation. Initially focused on Canadian health, the organization broadened its scope internationally in 2000. (From www.accreditation.ca). Every four (4) years healthcare organizations receive an onsite visit from the accreditors to assess our performance against standards. The Accreditation Survey is a process of assessing our organization against standards of excellence to identify what is being done well and what needs to be improved. The primary focus of Accreditation is quality and safety. During the Accreditation Survey, the organization will be evaluated on a variety of criteria. There are two types: Team Standards and Required Organizational Practices (ROPs).

Team Standards involve a unit or program and assesses multiple aspects of care or service. Required Organizational Practices (ROPs) cross over many units and focus on a particular topic or area that have the potential to significantly impact quality and/or safety. These are essential in the Accreditation Decision Level as outlined below.


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Decision Level Instrument Thresholds

Criteria – High Priority

Criteria – All other

ROP

Accredited Not Met Met 84% or less

Met 84% or less

Two or more tests of compliance unmet

Accredited with Commendation

Met Met 85 – 94% Met 85 – 94% One test of compliance unmet

Accredited with Exemplary Standing

Met at on-site survey

Met 95% or more at on-site survey

Met 95% or more at on-site survey

All tests of compliance met at the on-site survey

There are a total of 31 ROPs and 135 Tests of Compliance within the ROPs. These Tests of Compliance are assessed throughout various team(s) or unit(s) and translate to a total of 326 Tests of Compliance. Not demonstrating sufficient evidence for just one Test of Compliance, in one area, could impact our Organizational Decision Level. ROP Tests of

Compliance Total CMH Assessments

Accountability for Quality 1 6 Patient safety incident management 1 7 Patient safety incident disclosure 1 6 Patient Safety Quarterly Reports 1 3 Client Identification 14 14 ‘Do Not Use’ list of abbreviations 1 7 Medication reconciliation as a strategic priority 1 5 Medication reconciliation at care transitions 9 36 Medication reconciliation at care transitions - Ambulatory care services 2 10 Medication reconciliation at care transitions – ED 1 1 Safe surgery checklist 2 2 Information transfer at care transitions 11 55 Antimicrobial stewardship 1 5 Concentrated electrolytes 1 3 Heparin safety 1 4 High-alert medications 1 7 Infusion pump safety 3 18 Narcotics safety 1 3 Preventive maintenance program 1 4 Patient safety: education and training 1 1 Workplace violence prevention 1 8 Client flow 1 8 Patient safety plan 1 4 Hand- hygiene compliance 1 3 Hand- hygiene education and training 1 1 Infection rates 1 3 Reprocessing 1 2 Fall prevention and injury reduction 10 30 Pressure ulcer prevention 7 35 Suicide prevention 2 10 Venous thromboembolism (VTE) prophylaxis 5 25

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Preparing for the 2019 Onsite Survey Tools There are three (3) survey tools that each organization is required to implement once per accreditation cycle, with defined threshold (participation) levels for each. They include:

• Worklife Pulse o Staff Survey (required) – met threshold o Physician Survey (optional participation) – met threshold o While only required to be implemented once per accreditation cycle, the

Excellent Care for All Act (2010) requires healthcare organizations in Ontario to survey staff every two (2) years and as such, we have re-surveyed in 2019 – both the staff and physician surveys closed June 10, 2019.

o The results from the 2019 survey will allow us to validate (or course correct) the work we have been doing with the Corporate Count Us in Council and more recently the corporate Staff Engagement Plan.

• Safety and Culture Survey

o Survey was open from January 21 March 4, 2109 – met threshold o These results will be disseminated to leaders alongside the Worklife Pulse

survey results

• Governance Functioning Survey o Required once per Accreditation cycle o New this cycle, we can use the OHA governance survey in place of this to

demonstrate compliance Patients as Partners The inclusion of, and definition of, client and family centred care has been substantially elevated in the most recent iteration of the standards. The following chart from www.accreditation.ca illustrates the continuum of engaging patients in both Direct Care provision and Organizational Design and Governance.

Starting with onsite visits in 2018, Accreditation Canada has woven wording that evokes patients as partners. Some standard wording examples include:

• Services are co-designed with clients and families, partners, and the community • Service-specific goals and objectives are developed, with input from clients and family • Services are reviewed and monitored for appropriateness, with input from clients and

families

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Finally, our 2019 on-site visit surveyor team will include a Patient Surveyor who will be tasked with meeting patients and care teams to determine if the patient and family centred care standards were met, from the perspective of a patient. Medication Reconciliation Beginning in 2018 organizations have been required to demonstrate evidence of medication reconciliation at all transition points in all areas of service including Ambulatory Care settings. In comparison, for our 2015 survey we were only required to demonstrate mediation reconciliation at one (1) transition point. All transition points includes: admissions, discharges and transfers between programs. 16% of all Tests of Compliance (52/326 from the chart above) relate to Medication Reconciliation practices in various care settings; illustrating the paramount importance of this practice on patient safety. Next Steps

• Worklife Pulse & Safety Culture Survey results will be disseminated to teams • Weekly communication with staff • Huddle discussions/quiz questions • Mock Tracer to be organized for Fall 2019 • New Knowledge Best Practice Nursing fair will focus exclusively on Accreditation ROPs

– October 2019 • Quality Committee members can expect an update in early Fall 2019 prior to the onsite

visit

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BRIEFING NOTE – QUALITY COMMITTEE Date: May 24, 2019 Issue: Annual Report – Patient and Family Advisory Council (PFAC)

Update Purpose: Approval Discussion Information Prepared by: Liane Barefoot, Director Patient Experience, Quality & Risk Approved by: Patrick Gaskin, CEO Attachment: Appendix 1: PFAC Committee Survey Results Items for Board Information Background The last update on the PFAC was presented to Quality Committee in June 2018 and included a summary of activities from the 2017-18 fiscal year. This briefing note will provide an update of PFAC activities/discussions from September 2018 May 2019. Council PFAC was initially established in December 2014 and is currently at eight (8) active members in addition to one (1) staff representative who joined the council in September 2016. In April 2016 we transitioned from the CEO chairing PFAC meetings to a co-chair model and this evolved to a single chair in September 2018. Since Spring 2016 we have begun to structure the agendas to include an ‘in-camera/without management’ portion each month with feedback from the chairs to the CEO, COS and Director Patient Experience, Quality & Risk afterwards. Committee functionality is assessed using the same survey employed by the Board and Board committees and results are disseminated and discussed among council members. Results are attached to this Briefing Note as Appendix 1. 2018-19 Year in Review Below are some highlights of activities from the September 2018 June 2019 year. Patient Story Presentations to the Board Based on discussions at Governance Committee, the Board, and PFAC that ensued following the dissemination of the 2016 OHA Hospital Governance Benchmarking Survey, PFAC


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members agreed to pilot sharing their patient experience stories with the Board from January to May 2019. PFAC members worked with the Director Patient Experience, Quality & Risk to develop a standardized slide deck template to present their stories to the Board during the closed session. To date three (3) PFAC members (Jayne Herring, Corey Kimpson, Suzanne Sarrazin) have presented their stories to the Board of Directors. The Board agenda in June 2019 will include time for the fourth presentation (Becca Kadar) and for the Board members to evaluate the effectiveness of this pilot and determine next steps. Person Centred Care Learning Management System (LMS) Module Development Throughout Fall 2018 Emily Quantz, clinical educator worked to develop an online learning module intended to roll out the Registered Nurses Association of Ontario (RNAO) Best Practice Guideline (BPG) titled Person Centred Care. In doing so, Emily attended three (3) consecutive PFAC meetings to solicit input from PFAC members on the content and delivery of the learning module as it evolved. PFAC Video Development to Open New Knowledge, Best Practice Nursing Fair New Knowledge, Best Practice Nursing Fair is an annual learning environment for all nursing to attend educational sessions and be re-certified on various skills. While the scheduled sessions and skills re-certifications are specific to each unit, all attendees start each morning in the auditorium collectively. The Person Centred Care BPG was launched during these collective morning sessions. Two (2) PFAC members (Suzanne Sarrazin & Corey Kimpson) assisted by creating a video that was played daily to kick off these sessions that introduced the concept of Person Centred Care and what that means through the eyes of a patient. Co-Chairing Strategic Plan Steering Committee PFAC Chair Corey Kimpson has been co-chairing the corporate Strategic Plan Steering Committee alongside Stephan Beckhoff, Manager of Public Affairs & Communications. During the previous strategic plan development PFAC members were invited to provide input alongside operational and medical leaders which was a step forward from previous strategic plan iterations. Having a PFAC member co-chair the steering committee for the Strategic Plan is a testament to the organizational commitment of ensuring the patient voice is adequately captured in our next strategic plan and a substantial leap forward from 3 years ago.

Senior Director Interviews A PFAC member (Andrea Stebbings) participated in the interviews for the newly created role of Senior Director of Strategy, Performance and Chief Information Officer. During the interviews they asked questions related to the candidates’ views on patient centred care and commitment to keeping the patient voice front and centre. They were provided the opportunity to offer their input alongside other Senior Executive members.

Work on Various Hospital Committees Below is a list of PFAC members and the current hospital committees/teams they are working with:

• Corey Kimpson – participated in a 3 hour Accountable Care Unit (ACU) evaluation, co-chairing corporate Strategic Plan Steering Committee

• Sharon Wolgumut – member of the Oncology Quality & Operations Council • Jayne Herring – member of the Surgical Quality & Operations Council • Suzanne Sarizian – member of the corporate Ethics Committee

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CEO/COS 360 Reviews In 2019, an updated process for CMH leader 360 feedback was implemented. The same questions and survey tool were used for the CEO, COS and all leaders at CMH using a Values based assessment. For 2019, the survey tool was updated with input from CMH leadership and staff council group. The Executive Committee of the Board identifies the survey participants for CEO and COS reviews and for the first time PFAC members were invited to provide input. Collectively seven (7) responses split between the CEO and COS were received from PFAC members. The survey asks such questions as:

• This leader demonstrates caring through words and actions towards others. • I can trust this leader. • This leader champions patient and staff engagement. • This leader works effectively with others to further the goals of CMH and the health care

system. • How satisfied are you with this leaders overall performance? • How effective is this leader?

Patient Declaration of Values – Endorsed for CMH The Excellent Care for All Act (2010) legislates that hospitals develop, with public consultation, a Patient Declaration of Values. Though they should be aligned, the Patient Declaration of Values is to be distinctly different from the organizational mission, vision and values. The Patient Declaration of Values should reflect what patients can expect when receiving service and a commitment to delivering patient-centred care. Once developed, the Patient Declaration of Values should be made available publically and hospitals are to ensure that patient relations processes reflect the content.

Beginning in the Winter 2018 the Waterloo Wellington LHIN (WWLHIN) Patient and Family Advisory Committee (PFAC) led a regional redevelopment of the 2011 Patient Declaration of Values Waterloo Wellington (PDVWW). A few of CMH’s PFAC members attended a 3.5 hour session in March 2018 to provide input into the content of the new Declaration of Values. Further to this, input was provided collectively by the CMH Corporate PFAC members and the MH-FAC members in June 2018. Subsequently the PDVWW was endorsed at the CMH Board of Directors in October 2018. CMH has requested to be at the planning table as a scorecard evaluating the PDVWW is developed – this work is scheduled to commence in June 2019.

Regional Work Corey Kimpson, PFAC Chair alongside a few of the Mental Health Family Advisory Council members attended another session hosted by the LHIN PFAC on April 30, 2019. Moving forward there will be additional opportunities for CMH patients (PFAC + MH FAC) to collaborate with other PFAC committees regionally. Beryl Institute Conference – April 2019 – Dallas, TX Corey Kimpson, PFAC Chair joined the Chief of Staff, Deputy Chief of Staff and Director Patient Experience, Quality & Risk at the Beryl Institute conference in Dallas, Texas in April 2019. As a lead organization in patient experience, the Beryl Institute conference sessions once again did not disappoint. Many of the sessions focused on provider empathy, reigniting the provider WHY, and exploring the benefits of co-design.

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Patient Handbook A patient handbook intended to be placed in each cleaned hospital room for newly admitted patients was co-developed between Communications and PFAC last year and a final draft was presented to PFAC and MH-FAC members at the June 2018 meeting. No additional changes/updates were made to this handbook through the 2018-19 year as we have yet to move into A Wing and start utilizing the handbook; as such it remains a work in progress until the move.

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Q1 Please rank to what degree have you been satisfied.....Answered: 6 Skipped: 0

withopportunity ...

with themanner in wh...

that theagendas and...

that theagendas and...

that themeeting...

that theCouncil has...

that the chairhas been...

with what PFAChas...

with PFAC'soverall...

with yourlevel of...

0 1 2 3 4 5 6 7 8 9 10

4.83

4.83

4.83

4.83

4.83

4.83

4.83

4.83

4.83

4.83

4.83

4.83

4.83

4.83

4.67

4.67

4.67

4.67

4.67

4.67

4.67

4.67

4.67

4.67

4.67

4.67

4.67

4.67

4.80

4.80

4.80

4.80

4.80

4.80

4.80

4.67

4.67

4.67

4.67

4.67

4.67

4.67

4.83

4.83

4.83

4.83

4.83

4.83

4.83

4.33

4.33

4.33

4.33

4.33

4.33

4.33

4.50

4.50

4.50

4.50

4.50

4.50

4.50

4.83

4.83

4.83

4.83

4.83

4.83

4.83

VERYDISSATISFIED

SOMEWHATDISSATISFIED

NEITHERSATISFIED ORDISSATISFIED

SOMEWHATSATISFIED

VERYSATISFIED

UNABLE TORESPOND/NOTAPPLICABLE

TOTAL WEIGHTEDAVERAGE

1 / 5

PFAC Evaluation - 2019 SurveyMonkey

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0.00%0

0.00%0

0.00%0

16.67%1

83.33%5

0.00%0

6

4.83

0.00%0

0.00%0

0.00%0

16.67%1

83.33%5

0.00%0

6

4.83

0.00%0

0.00%0

0.00%0

33.33%2

66.67%4

0.00%0

6

4.67

0.00%0

0.00%0

0.00%0

33.33%2

66.67%4

0.00%0

6

4.67

0.00%0

0.00%0

0.00%0

16.67%1

66.67%4

16.67%1

6

4.80

0.00%0

0.00%0

0.00%0

33.33%2

66.67%4

0.00%0

6

4.67

0.00%0

0.00%0

0.00%0

16.67%1

83.33%5

0.00%0

6

4.83

0.00%0

0.00%0

16.67%1

33.33%2

50.00%3

0.00%0

6

4.33

0.00%0

0.00%0

16.67%1

16.67%1

66.67%4

0.00%0

6

4.50

0.00%0

0.00%0

0.00%0

16.67%1

83.33%5

0.00%0

6

4.83

with opportunity to participate in thediscussions?

with the manner in which other participantscontributed to the discussions?

that the agendas and discussion focused onissues where real value can be added?

that the agendas and discussions focused onissues relevant to the Council's work?

that the meeting schedule set for optimalattendance by members?

that the Council has members with the skillsand expertise that are needed by theCouncil?

that the chair has been effective in allowingdiffering views to be heard while bringingmatters to conclusion?

with what PFAC has accomplished?

with PFAC's overall performance?

with your level of contribution to PFAC'sdeliberations?

2 / 5


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Q2 Please provide any additional commentsAnswered: 3 Skipped: 3

# RESPONSES DATE

1 I enjoy attending this meeting as all members participates in a very friendly manner and every one respects each other for theirindividual opinion, either he or she agrees with it or not. Also the attending members from CMH members are very open to thefeed back provided by the PFAC members whether it is positive or negative. I believe we are making progress to make CMH apatient friendly health care provider.

5/18/2019 8:27 PM

2 While the current members have expertise and contribute, I believe it would be wise for the committee to bring in new memberswho are diverse both in culture and ideas.

5/17/2019 3:03 PM

3 I would like to encourage recruitment of new members as soon as possible, as there are 3-4 of us getting close to the end of ourterms. I

5/17/2019 2:59 PM

3 / 5


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Q3 What is important to you? Are there burning ideas that you have or areas where you feel afocus should be for 2019/20?

Answered: 2 Skipped: 4

# RESPONSES DATE

1 CMH to provide health care that will satisfy the patient and it's family members or the loved ones. Definitely CMH need toimprove patient care service at emergency area, in my opinion this should be number one goal for 2019/20.

5/18/2019 8:27 PM

2 I am very glad that we were able to participate in the focus group regarding the provincial Government's proposed changes toour local health network. The time was very short and went by very quickly - there was so much more to be said. I hope that wecan get the chance to do this again before any crucial decisions are made.

5/17/2019 2:59 PM

4 / 5


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Agenda Item 3.5.1

Page 1 of 2

BRIEFING NOTE – Medical Advisory Committee (OPEN) Date: June 12, 2019 Issue: Medical Advisory Committee-OPEN Purpose: Approval Discussion Information Prepared by: Dr. Kunuk Rhee, Chief of Staff Approved by: Mr. Patrick Gaskin, CEO Attachments: None Items for Board Information CRP Transition Project A revised Interim Completion date was shared with MAC members. Mr. Hildebrand will continue to update MAC through the summer if substantial changes to the dates occur in July or August. M&T Update The MAC was briefed on current backorders, new policies, new pre-printed orders and changes to the Code Blue travel bag. New Business Accreditation Summary Ms. Quantz presented a briefing note and an Accreditation Summary Manual to medical leadership. This year’s accreditation preparedness plan was shared with MAC members. Areas of focus include Dangerous Abbreviations, Information Transfer, Medication Reconciliation and Falls Prevention. There may be a challenge with the competing organizational challenge of the resources currently deployed toward the CRP Transition Plan. Patient partnerships (and demonstrable evidence of input) may also be a challenge.


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Agenda Item 3.5.1

Page 2 of 2

Clinical and Support service staff resources required Additional resources required for the day of the move were shared with MAC members. Additional physician staffing in the ED, on the Code Blue Team and in the ICU (may be an Admissionist) will be resourced on the day of the move. OB, pediatrics, hospitalist and midwifery resources will also be considered. An emphasis on reducing patient census prior to the move was also made by Mr. Hall. Clinical Services Plan The full plan with timelines and deliverables was shared with MAC members. Medical Directive 564: Heparin Flush This was approved by MAC. Medical Directive 303: DEP insulin in pregnancy This was approved with more precise wording from the clinical practice lead. N-acetylcysteine protocol for Acetaminophen This was approved by MAC in accordance with Poison Control guidelines. Consent to Treatment, Investigative Procedure, Operation or Administration of Blood or Blood Products Form This was approved by MAC.

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Agenda Item 3.5.2 (May)

Page 1 of 2

BRIEFING NOTE – Medical Advisory Committee, Privileges & Credentialing Date: June 12, 2019 Issue: Medical Advisory Committee Privileges & Credentialing – May 8,

2019 Purpose: Approval Discussion Information Prepared by: Dr. Kunuk Rhee, Chief of Staff Approved by: Mr. Patrick Gaskin, CEO Attachments: None Items for Board Approval Medical Advisory Committee Privileges & Credentialing Committee motion: Applications for privileges as displayed be approved. None Opposed. CARRIED. Proposed Board motion: Applications for privileges as displayed be approved

Name Program Specialty Appointment Supervisor Dr. Benjamin Hutten-Czapski

Emergency Medicine

Emergency Medicine

Requesting locum privileges effective May 1, 2019 – July 31, 2019

Dr. Arthur Eugenio

Dr. Adnan Qureshi

Surgery General Surgery

Requesting Locum Privileges effective May 17, 2019 – May 20, 2019

Dr. Joyce Daly

Dr. Adnan Qureshi


Requesting Locum Privileges effective August 23, 2019

Dr. Joyce Daly


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Agenda Item 3.5.2 (May)

Page 2 of 2

Dr. Timothy Rice


Requesting one day Temporary Privileges effective July 5, 2019

Dr. Joyce Daly

Dr. Vitali Petrounevitch

Anesthesia Anesthesia Requesting Locum Privileges effective May 13 – May 14, 2019

Dr. Laura Puopolo

Dr. Vitali Petrounevitch

Anesthesia Anesthesia Requesting Locum Privileges effective May 21 – May 24, 2019

Dr. Laura Puopolo

Dr. Catherine Menes

Internal Medicine

Sleep Clinic Requesting Affiliate Privileges effective June 4, 2019

Dr. Augustin Nguyen

Dr. Jordan Doherty

Oncology Oncology Requesting Locum Privileges effective July 8, 2019 – January 12, 2020

Dr. Edmond Chouinard

Dr. Mohammed Naser

Internal Medicine

Internal Medicine

Requesting Locum Privileges from June 1- June 2, 2019

Dr. Augustin Nguyen

Ms. Stacey Skelton

Midwifery Midwifery Requesting Temporary Privileges from June 1- June 20, 2019

Ms. D. Doe

2019 E-Reappointment Applications for Approval

DEPARTMENT OF FAMILY MEDICINE

Dr. Victor CHERNIAK: Active

DEPARTMENT OF INTERNAL MEDICINE

Dr. George MATHAI: Active

DEPARTMENT OF SURGERY

Dr. Russell EGERDIE: Courtesy WITH Admitting

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Agenda Item 3.5.2 (June)

Page 1 of 2

BRIEFING NOTE – Medical Advisory Committee, Privileges & Credentialing Date: June 12, 2019 Issue: Medical Advisory Committee Privileges & Credentialing – June 12,

2019 Purpose: Approval Discussion Information Prepared by: Dr. Kunuk Rhee, Chief of Staff Approved by: Mr. Patrick Gaskin, CEO Attachments: None Items for Board Approval Medical Advisory Committee Privileges & Credentialing Committee motion: Applications for privileges as displayed be approved. None Opposed. CARRIED. Proposed Board motion: Applications for privileges as displayed be approved

Name Program Specialty Appointment Supervisor Dr. Harvey Bhella

Hospitalist Oncology Requesting Associate Privileges effective July 1, 2019

Dr. Jasmine Mathew

Dr. Dante Pocrnich

Surgery Ophthalmology Requesting one-day Privileges for April 20, 2019

Dr. Joyce Daly

Dr. Leanne Martin

Mental Health

Mental Health Resigning associate privileges effective July 5, 2019

Dr. Anjali Sharma


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Agenda Item 3.5.2 (June)

Page 2 of 2

Dr. Adnan Qureshi

Surgery Surgery Requesting locum privileges from June 14-16, 2019

Dr. J. Daly

Dr. Haifeng Ren

Surgery Orthopedics Requesting Locum Privileges for July 31, August 1, & August 17

Dr. Joyce Daly

Dr. Matthew Purser

Pediatrics Pediatrics Requesting Affiliate Privileges effective August 14, 2019

Dr. Manju Rajguru

Dr. Christo Baben

Emergency Department

Emergency Department

Requesting change of department from Emergency Department to Surgical Assist

Dr. Anil Maheshwari

Dr. Alaa Alhendi

Internal Medicine

Internal Medicine

Requesting Courtesy with Admitting privileges effective July 1, 2019

Dr. Augustin Nguyen

Dr. Mohammed Naser

Internal Medicine

Internal Medicine

Requesting Locum Privileges from June 15- June 16, 2019

Dr. Augustin Nguyen

Dr. Omair Sarfaraz

Internal Medicine

Hepatology Requesting Associate Privileges effective July 1, 2019

Dr. Augustin Nguyen

Dr. Ailar Ansarian

Mental Health

Mental Health Resigning Associate Privileges effective July 12, 2019

Dr. Anjali Sharma

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