AGENDA - Bluewater Health...AGENDA OPEN SESSION BOARD MEETING Wednesday, June 27, 2018 Lambton College Event Centre 4:00 pm Directors: Marg Dragan, Treasurer Anthony Iafrate …

AGENDA OPEN SESSION BOARD MEETING

Wednesday, June 27, 2018 Lambton College Event Centre

4:00 pm Directors:

Marg Dragan, Treasurer Anthony Iafrate Bill Gillam Jenny Greensmith

Louis Guimond Brian Knott Dr. Guy Kohlmeier Katherine Mantha

Bob McKinley Wayne Pease, Chair Fred Vanderheide Paul Wiersma, Vice-Chair

Ex-Officio Directors: Mike Lapaine Dr. Michel Haddad

Shannon Landry Dr. Sharon Rutledge

Dr. Nathan Taylor

Professional Staff/Staff: Dr. Kapil Kohli Samer Abou-Sweid

Laurie Zimmer Julia Oosterman

Paula Reaume-Zimmer

Recorder: Melissa Rondinelli *attached

NO. TOPIC ACTION TIME PRESENTER 1.0 CALL TO ORDER: WELCOME AND OPENING REMARKS 1 min Wayne Pease

1.1 Report on May and June In-Camera Board Meetings 1 min Wayne Pease

2.0 AGENDA APPROVAL

2.1 Approval of Agenda Decision 1 min Wayne Pease

2.2 Declaration of Conflict of Interest Decision 1 min Wayne Pease

3.0 CONSENT AGENDA

3.1 ITEMS FOR APPROVAL Wayne Pease

3.1.1 Open Session Board Minutes – May 23, 2018* Decision 1 min Wayne Pease

3.1.2 Broader Public Sector Accountability Act (BPSAA) Attestation*

Decision Marg Dragan

3.1.3 Board Policy Revisions* • Principles of Governance and Board

Accountability (5.10)* • Roles and Responsibilities of the Board of

Directors (5.15)* • Board Chair Position Description (5.45)* • Board Vice-Chair Position Description (5.50)* • Board Treasurer Position (5.55)* • Board Committee Chair Position Description

(5.60)* • Non-Director Committee Members (5.65)* • Code of Conduct (5.75)* • Board Committee Member Declaration

Decision Brian Knott

NO. TOPIC ACTION TIME PRESENTER (5.25)* – to replace Director Declaration (5.25) Non-Director Committee Member Declaration (5.27)

• Freedom Of Information – Delegation Of Authority And Oversight*

4.0 BOARD DECISIONS/OVERSIGHT

4.1 Strategic Plan Progress Report – Year 2* Discussion 10 mins Mike Lapaine

4.2 Governance and Nominating Committee Highlights* Information 2 mins Brian Knott

4.3 Quality Committee Highlights* Information 2 mins Paul Wiersma

4.4 Quality Committee Performance Scorecard* Discussion 5 mins Paul Wiersma

4.5 Resource Utilization & Audit Committee Highlights* Information 2 mins Marg Dragan

4.6 Financial Statement* Discussion 5 mins Marg Dragan

4.7 Resource Utilization and Audit Committee Performance Scorecard*

Discussion 5 mins Marg Dragan

4.8 Medical Advisory Committee Highlights* Information 2 mins Dr. M. Haddad

4.9 Board Work Plan* Information 3 mins Brian Knott

6.0 POLICY FORMATION – None

7.0 OPEN FORUM Opportunity for Directors to reflect on how patients, families and community were considered in discussions

Discussion 5 mins Wayne Pease

8.0 ADJOURNMENT: Next Meeting: September 26, 2018 Wayne Pease

MINUTES

OPEN SESSION BOARD MEETING Wednesday, May 23, 2018

Directors:

Marg Dragan, Treasurer √ Anthony Iafrate √ Bill Gillam √ Jenny Greensmith √

Louis Guimond √ Brian Knott √ Dr. Guy Kohlmeier √ Katherine Mantha √

Bob McKinley - R Wayne Pease, Chair - R Fred Vanderheide √ Paul Wiersma, Vice-Chair √

Ex-Officio Directors:

Mike Lapaine √ Dr. Michel Haddad √

Shannon Landry √ Dr. Sharon Rutledge √

Dr. Nathan Taylor √

Professional Staff, Staff and Guests:

Dr. Kapil Kohli – R Samer Abou-Sweid √

Laurie Zimmer √ Julia Oosterman √

Paula Reaume-Zimmer √

Recorder: Melissa Rondinelli (*attached in the minute record book)

1.0 CALL TO ORDER - Paul Wiersma called the meeting to order at 5:03 pm and welcomed the

Board and guests. 1.1 Report on February In-Camera Board Meeting

Paul reported on the items discussed at the April In-Camera Board meeting, which included professional staff appointments, audit plans, insurance coverage, property matters, compensation and executive performance evaluation.

2.0 AGENDA APPROVAL 2.1 Approval of Agenda*

Motion (K. Mantha/G. Kohlmeier): to approve the agenda as presented.

2.2 Declaration of Conflict of Interest Paul invited Directors to share any conflicts of interest. No conflicts were declared.

3.0 CONSENT AGENDA

3.1 ITEMS TO BE RECEIVED – REPORTS 3.1.1 Board Chair* 3.1.2 Professional Staff Association Report* 3.1.3 Quarterly Facilities Report* 3.1.4 Analysis of Loans and Investments* 3.1.5 Accreditation Self-Assessment Report and Action Plan* 3.1.6 Board Meeting Effectiveness Survey Results* 3.1.7 Board Attendance Records* 3.1.8 Board Education Record*

Bluewater Health – Open Meeting May 23, 2018 Page 2 ____________________________________________________________________________ 3.2 ITEMS FOR APPROVAL

3.2.1 Open Session Board Minutes – April 25, 2018* 3.2.2 Chief Financial Officer Certificate* 3.2.3 Revised Board Policy – 5.20 Roles and Responsibilities of an Elected and Ex-Officio

Director* 3.2.4 Delegation of Authority – Freedom of Information and Protection of Privacy Act

(FIPPA)* Motion (B. Knott/F. Vanderheide) and carried: to receive the reports presented and to approve the following items in the Consent Agenda: • Open Session Board Minutes of April 28, 2018 • Chief Financial Officer Certificate for the period ending March 31, 2018 • Revised Board Policy 5.20 – Roles and Responsibilities of an Elected and Ex-

Officio Director • Authorization for the Board Chair to sign the Delegation of Authority document

4.0 PRESIDENT AND CEO REPORT* Mike Lapaine presented his report and highlighted the new Indigenous Patient Navigator position at BWH, noting BWH is one of a few hospitals with this position. He then shared that Margaret Dragan will be recognized at the Sarnia Foundation’s 2018 Women of Excellence Awards on June 6, 2018. Mike congratulated Marg on this recognition and thanked her for her contribution to the BWH Board.

5.0 BOARD DECISIONS/OVERSIGHT

5.1 Resource Utilization and Audit Committee (RUAC) Highlights* Marg Dragan presented the RUAC Committee Highlights. She reported the Committee was updated on capital projects and the status of Health Infrastructure Renewal Funding (HIRF) and Hospital Energy Efficiency Program (HEEP) applications. She also noted Colleen Cook provided an update on union negotiations and Bill 148 implementation costs. Lastly, Marg reported the Committee reviewed financial risks. No questions or comments were raised.

5.2 Financial Statement* Marg presented the Financial Statement for the period ended March 31, 2018. She

commended staff for the hospital being in a $2M surplus position, and explained this was achieved through additional LHIN revenue - surge capacity and QBP (hip and knee replacements) funding, and utilities being $977K under budget.

Motion (M. Dragan/F. Vanderheide) and carried: to approve the Financial Statement for

the period ended March 31, 2018 as presented.

Bluewater Health – Open Meeting May 23, 2018 Page 3 ____________________________________________________________________________ 5.3 2018-19 Capital Budget* Marg presented the capital budget of $7,484,283. She reported RUAC received an overview

of how the Capital Budget Committee determined the recommended items, which includes mammography equipment, ultrasound machines, urology suite, new investment, replacement of equipment, etc.

Motion (M. Dragan/G. Kohlmeier) and carried: to approve the 2018-19 Capital Budget as presented.

The Board inquired about the hospital’s plan for the capital items not approved, the status

of the Chiller project, and whether the contingency and capital budget amounts were typical. Samer Abou-Sweid explained the items not approved will remain on the Five-Year Capital Plan and will continue to be assessed annually to determine which items must be purchased vs. deferred. Samer then reported the Chiller project was a three-year project and the remaining costs will be incurred this year.

In regards to the $500K contingency amount, Samer indicated the amount is based on the

requests that are denied, and it consistent with past practice. He added the hospital does not normally spend the full contingency amount. Mike then explained the capital budget would be funded through a combination of Health Infrastructure Renewal Funding, Foundation Funds and working capital.

The total capital budget amount was discussed next. Samer noted the budget was slightly

higher last year, and was even higher the year before. Mike explained the rule of thumb for calculating the capital budget is to consider amortization costs and add for inflation, unless extraordinary expenses are being considered. He noted BWH’s amortization is currently low. There were no further questions or comments.

5.4 Revised 2018-19 Operating Plan* Marg presented the revised operating plan. She explained Ministry funding was unknown

when the plan was first approved in January. Since then, BWH has learned its funding and has more information about expected expenses. BWH is now responsible for managing bundled payments, which is the rehabilitation portion of hip and knees replacements. The new Ministry funding received is expected to cover these bundled payments, which includes operating expenses estimated at $600K. In addition, the hospital is now anticipating expenses in the range of $700K to $1M to absorb the financial impact of Bill 148. It was noted the Ontario Hospital Association (OHA) has been advocating for hospital relief from the implications of this Bill without success.

It was noted the preliminary expenditure plan for 2018-19 was estimated at a $2.8M deficit

and is now $920,746. Although, the Board is being asked to approve a deficit plan similar to last year, there is confidence the hospital can manage to a balanced position by year-end. Mike pointed out the most important indicator for the hospital is its positive working

Bluewater Health – Open Meeting May 23, 2018 Page 4 ____________________________________________________________________________

capital, and even with the projected deficit, BWH will be able to fund the capital budget with its working capital.

Katherine Mantha asked why there is a reduction in CCO funding. It was explained there

was a reduction in cancer surgeries and the drugs associated with it this year, therefore, the funding was reduced. It was questioned if there were cases left untreated or fewer cases. BWH confirmed the hospital encouraged surgeries and the reduction was not due to resources, rather fewer cases. Louis commented that in principle he would not approve a deficit budget, but in light of the surplus this year and the conservative nature of the Chief Financial Officer, he would support the recommendation.

Marg clarified the hospital’s net new funding was $2.7M. She also noted some capital

spending could be delayed to be in a balanced position as well.

Motion (M. Dragan/G. Kohlmeier) and carried: to approve the 2018-19 Operating Plan as presented.

5.5 Community Accountability Planning Submission (CAPS)* Marg deferred presentation of this agenda item to Mike. He explained the submission

covers funding for community mental health programs including residential withdrawal management (RWMS). Mike advised the item was not discussed at RUAC due to timing issues. The ESC LHIN has requested Board approval of the submission by May 31, 2018. He noted the submission is the same as last year with the exception of RWMS. He also noted BWH has not received confirmation of funding for RWMS and does not expect it until after the election, although the ESC LHIN has provided verbal approval of the funding. There were no questions or concerns.

Motion (B. Knott/F. Vanderheide) and carried: to approve the CAPS as presented.

5.6 Resource Utilization and Audit Committee (RUAC) Performance Scorecard*

Marg noted the scorecard was updated since the RUAC meeting to include March data for the Emergency Department (ED) indicators. She then presented the scorecard and summarized the status of the following:

• 90th Percentile ED Length of Stay (LOS) for Complex Patients – Sarnia performing close to target of 8 hours at 8.4 hours, and Petrolia performing at 3.7 hours.

• 90th Percentile ED Wait Time for Admitted Patients – improvement over last month for both sites at 26 hours in Sarnia and 7.7 hours in Petrolia.

• ALC Rate% - on target • Cost per Weighted Case (CPWC) – Q4 data not available. • Mental Health Inpatient Cost per Patient Day – positive position • Surplus - $2.1M • Adjusted working capital – positive position • Capital budget – positive position with 78% of budget spent


It was questioned if the current surplus will affect CPWC. Mike explained CPWC influences funding in a year or two from now, therefore, this year’s funding is not affected by the current CPWC. Jenny Greensmith then congratulated BWH on the improved ED length of stay indicator. She noted performance has been poor since last August and asked what other challenges have influenced the indicator besides the seasonal surge in the fall/winter. Mike explained the ED is pressured by patients attending for primary care concerns. He noted the hospital would be focusing heavily on improving wait time indicators this year. Dr. Kohlmeier noted the ALC rate has been positive and asked what the major cause of wait times is. He also questioned if the target was too aggressive. Mike indicated that even though the ALC rate has improved, the hospital has experience more admissions this year. The reduction in ALCs has opened up beds and improved patient flow. Laurie Zimmer added a lot of work has taken place within BWH and with its partners to reduce the number of acute ALC patients, such as education and the Intensive Hospital to Home program. Bill Gillam arrived for the meeting at 5:32 pm.

5.7 Medical Advisory Committee Highlights* Dr. Haddad presented the Committee Highlights and brought attention to quality improvement initiatives, recruitment and succession planning activities, and physician development and engagement strategies. He reported BWH has recruited two hospitalists and a new internist. Dr. Haddad also noted work is underway to arrange a session for the Professional Staff focused on leadership skills. He then provide a high-level overview of the Professional Staff Engagement Survey results which indicate positive changes. More details about the results will follow. Katherine Mantha asked about specific initiatives to support physician wellness and health. Dr. Haddad explained the work is being co-led by the Professional Staff Association and is in early development. Initiatives include Physician Wellness Committee, Professional Staff social events, and Professional Staff support group. He reported it is too early to measure whether the work is making a difference. It was questioned if other hospitals are involved in this work. Dr. Haddad suggested BWH is ahead of other hospitals on this issue. Jenny Greensmith asked for more information about the geriatrician business case. Dr. Haddad explained a business case for the position was presented to the Ministry of Health and Long-Term Care and has received support from the ESC LHIN. The intent is for the position to become part of the regional geriatric clinic and be supported by an interdisciplinary team at BWH. Anthony Iafrate arrived at 5:42 pm.

Bluewater Health – Open Meeting May 23, 2018 Page 6 ____________________________________________________________________________ 5.8 Quality Committee Highlights* Shannon Landry highlighted the report from the Rural Health and Inpatient Medicine

Programs, which focused on success at CEEH with the introduction of a Nurse Practitioner. She also brought attention to work underway to address falls. Next, Shannon noted the Committee received presentations about Workplace Violence and the no excuse for abuse campaign to begin in June, the ED Quality Revisit Program, annual privacy reporting, and the new approved Ethical Framework. Shannon indicated the Board would receive education for the Ethical Framework this fall. Brian commented the new Ethical Framework and education is timely given it is an Accreditation focus. Discussion about the Ethical Framework tool under development followed.

5.9 Quality Committee Performance Scorecard* Shannon presented the scorecard and discussed the indicators not reaching target

including: • Readmission within 30 days for COPD – currently at 21.6% and up from the previous

quarters. Shannon reported BWH investigated the patients and some are being readmitted for different diagnoses.

• Strengthen Patient and Family-Centre Care indicators - both indicators have been off target in the Inpatient area for the last four months. Shannon noted BWH is working hard on these indicators and will be considering new targets for the next scorecard given the hospital is performing better than its peers but not reaching targets.

• Was patient/family treated with kindness – It was noted kindness continues to be an organization wide focus and the Culture of Kindness Employee Council has been expanded to include more staff. Shannon also noted the Employee Engagement Survey results indicate the “kindness” score has improved. More details will follow in the fall.

There were no questions or comments. 5.10 Bluewater Health Foundation Report*

Brian Knott presented the report and highlighted the recent education event focused on Withdrawal Management. He then noted the Hoedown for Healthcare raised $7K for CEEH and brought attention to upcoming Foundation events: Golf fore Health (June 7, 2018) and the annual Gala (October).

5.11 Governance and Nominating Committee Highlights* Brian presented the Committee Highlights and brought attention to the education regarding Accreditation that will begin in the fall to prepare for the event in April 2019. He then noted members would receive an education tool/checklist to review prior to completing the OHA GCE Board Self-Assessment Tool. Next, Brian discussed timing for the June Board meetings and Annual General Meeting. Mike noted there were plans to share presentations with the Board about the Integrated


Risk Management (IRM) framework and Staff and Professional Staff Engagement scores in June. However, given the importance of the items and the limited time available at the June meetings, he proposed they be reviewed at a fall Board Retreat instead. There was no objection to this idea. Mike also indicated it is best practice for a Board liaison to be involved in the IRM framework. He asked that anyone interested in participating in this work over the summer please contact Shannon.

5.12 Annual General Meeting (AGM) Brian brought forward a motion to hold the AGM at the Lambton College Event Centre to comply with the By-laws. There were no comments, questions or concerns raised.

Motion (B. Knott/K. Mantha) and carried: to approve the Annual General Meeting be held at the Lambton College Event Centre.

5.13 Board Education

Brian advised the Board a link to the OHA Governance Centre of Excellence (GCE) educational offerings was provided on the agenda. He noted several members recently attended the Advanced Board Governance conference and advised a reporting template had been prepared to assist members with reporting to the Board after attending a conference.

6.0 POLICY FORMATION – None.

7.0 OPEN FORUM

Brian indicated he has found the more frequent use of briefing notes to be very helpful when making decisions. Paul reminded the Board it is best practice for any significant decision to be supported with briefing notes. Katherine then shared that she attended the OHA GCE Advance Board program. She noted the speaker was very engaging, she learned one of eighteen patients are harmed in healthcare, and she was interested in investigating how risk can be addressed by the Board Sub-Committees with the introduction of the Integrated Risk Management framework.

8.0 IN-CAMERA AGENDA ITEMS Paul reported the Board would be meeting In-Camera following this meeting to discuss Board succession planning, Professional Staff credentialing, property matters, Board and executive expenses, risks, and performance evaluations.

9.0 ADJOURNMENT Motion (J. Greensmtih/A. Iafrate) and carried: to adjourn the meeting at 6:06 pm.

Bluewater Health – Open Meeting May 23, 2018 Page 8 ____________________________________________________________________________ ________________________ ____________________________ Paul Wiersma Mike Lapaine Vice-Chair Secretary Board of Bluewater Health Board of Bluewater Health

___________________________ Melissa Rondinelli Senior Executive Assistant Recorder

TO: The Board of Bluewater Health, (the “Board”)

FROM: Mike Lapaine, President and Chief Executive Officer

DATE: June 8, 2018

RE: April 1, 2017 to March 31, 2018 (“the Applicable Period”)

On behalf of Bluewater Health (the Hospital), I attest to:

• the completion and accuracy of reports required of the Hospital pursuant to Bill 122, section 6 of the Broader Public Sector Accountability Act, 2010 (BPSAA) on the use of consultants;

• the Hospital’s compliance with the prohibition in section 4 of the BPSAA on engaging lobbyist services using public funds;

• the Hospital’s compliance with any applicable expense claims directives issued under section 10 of the BPSAA by the Management Board of Cabinet;

• the Hospital’s compliance with any applicable perquisite directives issued under section 11.1 of the BPSAA by the Management Board of Cabinet; and

• the Hospital’s compliance with any applicable procurement directives issued under section

12 of the BPSAA by the Management Board of Cabinet, during the applicable period. In making this attestation, I have exercised care and diligence that would reasonably be expected of a President and Chief Executive Officer in these circumstances, including making due inquiries of Hospital staff and those of our procurement agency, TransForm Shared Service Organization that have knowledge of these matters.

I further certify that any material exceptions to this attestation are documented in the attached Schedule A.

Dated at Sarnia, Ontario this 8th day of June 2018.

Mike Lapaine President and Chief Executive Officer, Bluewater Health

I certify that this attestation has been approved by the Board of Bluewater Health on this 27th day of June, 2018.

Wayne L. Pease Chair of the Board, Bluewater Health Prepared in accordance with section 15 of the Broader Public Sector Accountability Act, 2010 (BPSAA)

SCHEDULE A to Attestation

1. Exceptions to the completion and accuracy of reports required in section 6 of the BPSAA on the use of consultants;

No known exceptions 2. Exceptions to the Hospital’s compliance with the prohibition in section 4 of the

BPSAA on engaging lobbyist services using public funds; No known exceptions

3. Exceptions to the Hospital’s compliance with the expense claims directive issued under section 10 of the BPSAA by the Management Board of Cabinet;

No known exceptions

4. Exceptions to the Hospital’s compliance with the perquisites directive issued under section 11.1 of the BPSAA by the Management Board of Cabinet; and

No known exceptions

5. Exceptions to the Hospital’s compliance with the procurement directive issued under section 12 of the BPSAA by the Management Board of Cabinet.

No known exceptions

1

Bluewater Health Briefing Note

Name of Committee: Board of Directors Date of Meeting: June 27, 2018 Submitted by: Julia Oosterman Subject: Board Policy Revisions Purpose of Report: Information Input Approval

Situation The Board follows a three-year review cycle for Board policies and requires all policies to be reviewed with the Accreditation cycle, which is taking place in April 2019.

Background Through recent governance review processes, a number of best practice opportunities have come to the Board’s attention. These opportunities and the majority of the Board’s policies will be reviewed over the summer months for potential revisions/adoption for presentation and approval to the Board in the fall. In the meantime, the following policies related to Board membership and new Committee member onboarding have been compared against other leading Board policy examples and Accreditation Standards, to ensure readiness for onboarding in September.

1. Principles of Governance and Board Accountability (5.10) 2. Roles and Responsibilities of the Board of Directors (5.15) 3. Board Chair Position Description (5.45) 4. Board Vice-Chair Position Description (5.50) 5. Board Treasurer Position (5.55) 6. Board Committee Chair Position Description (5.60) 7. Non-Director Committee Members (5.65) 8. Code of Conduct (5.75) 9. Board Committee Member Declaration (5.25) – to replace Director Declaration

(5.25) Non-Director Committee Member Declaration (5.27)

Analysis The recommended revisions simply language, and ensure policy alignment and compliance with Accreditation Standards. See draft revised policies attached.

Recommendation The Board approves the above noted Board policies as presented.

x

Page 1 of 4 Manual GOVERNANCE POLICY

POLICY Section 5.0 Board Effectiveness – Governance Policy Framework

Title PRINCIPLES OF GOVERNANCE & BOARD ACCOUNTABILITY

Issuing Body/ Prepared By

Governance and Nominating Committee

Approved by Board of Directors Number: GOV 5.10 Effective Date Revised Date

O: January 2009 R: June 2012 November 2015

June 2018

Version 34 File Name: S:\CHIEF EXECUTIVE OFFICER\BOARD AND BOARD COMMITTEES\BOARD BWH\BOARD POLICIES\5.10 - Principles Of Governance Board Accountability - November 2015.Docx

Controlled document. Any documents appearing in paper form must be used for reference purposes only. The on-line copy on the file server above must be considered the current documentation.

Purpose As part of its responsibility for ensuring Board effectiveness, the Board of Bluewater Health (BWH) will establish, approve and periodically review a statement of Principles of Governance and Board Accountability. This statement is an important requirement of effective governance and addresses the Board’s overarching philosophy and approach to its governance responsibilities, including its model of governance and accountabilities. This policy sets out the Principles of Governance and Board Accountability as developed and approved by the Board of BWH. Policy 1. The Board of Directors governs BWH through the direction and supervision of the

business and affairs of the corporation in accordance with its articles of incorporation, its by-laws, vision, mission and values, governance policies and other laws and regulations.

2. The Board adheres to the Modified Pointer and Orlikoff Governance Model, (as referenced in the Roles and Responsibilities of the Board of Directors policy (GOV-5.15) a model of governance through which it provides strategic leadership and direction.

3. The Board acts at all times in the best interests of BWH, having regard for its accountabilities to its patients and the communities served, the Ministry of Health

APPROVED DRAFT

Formatted: Indent: Left: 0.25"

PRINCIPLES OF GOVERNANCE & BOARD ACCOUNTABILITY

Number: GOV 5.10 Page 2 of 5

and Long-Term Care (MOHLTC) and the Erie St Clair Local Health Integration Network (ESC LHIN) and its relationship with other service providers.

3. 4. The Board maintains a culture of honesty and integrity, open debate, ethical

decision making, forthright examination of all issues and strives for a consensual approach to decision-making based on evidence-informed, best practice.

5. The Board, through the strategic planning process, defines values for BWH which will be reflected in the Board’s decision making processes, recognizing that decisions and actions taken must be consistent with the approved values.

6. The Board maintains at all times a clear distinction between Board and management roles, while recognizing the interdependencies between them.

7. The Board is accountable to: BWH’s patients and its communities served to:

• engage the communities served when developing plans and setting priorities for the delivery of health care;

• advocate for and seek resources to provide appropriate health care;

• utilize its resources effectively to fulfill BWH’s mission and mandate;

• ensure the quality and safety of patient care and service delivery • ensure the appropriate use of community contributions and

resources; • consider the diversity of needs and interests in its policy

formulation and decision-making; • work within its resources, monitoring their efficient and effective

use consistent with BWH’s mission and mandate; • measure and report on BWH performance against accepted

standards and best practices in comparable hospitals and in accordance with requirements of the Excellent Care for All Act (ECFAA), Broader Public Sector Accountability Act (BPSAA) and other all applicable legislation;

• inform the MOHLTC/ESC LHIN of any gaps between needs of the communities served and scope of services provided, based on resources allocated by the Ministry and the ESC LHIN to fulfill the BWH’s mission and mandate; and

• apprise the MOHLTC/ESC LHIN and the communities served of Board policies and decisions related to the BWH’s mandate that might be required to operate within its resources.

• identify and undertake integration opportunities (separately and in conjunction with the ESC LHIN) and other health service providers to provide appropriate, co-ordinated, effective and efficient services and that are consistent with the mission, vision, values and strategic plan of BWH and in the best interests of the community.

Formatted: List Paragraph

Commented [MR1]: This is not best practice



• disclose information about BWH’s governance processes, decision-

making and performance in an open and transparent manner.



the Ministry of Health and Long-Term Care (MOHLTC) and/or the Erie St.

Clair LHIN (ESC LHIN) to: • comply with applicable government legislation, regulations,

directives policies and directions; • ensure that BWH operates within:

• the MOHLTC’s provincial strategic plan; • the ESC LHIN’s integrated health service plan; • the service accountability agreements with the ESC LHIN

• work within its resources, monitoring their efficient and effective use consistent with BWH’s mission and mandate;

• measure and report on BWH performance against accepted standards and best practices in comparable hospitals;

• inform the MOHLTC/ESC LHIN of any gaps between needs of the communities served and scope of services provided, based on resources allocated by the MOHLTC/ESC LHIN to fulfill the BWH’s mission and mandate; and

• apprise the MOHLTC/ ESC LHIN and the communities served of Board policies and decisions related to the BWH’s mandate that might be required to operate within its resources.

• identify and undertake integration opportunities (separately and in conjunction with the ESC LHIN) and other health service providers to provide appropriate, co-ordinated, effective and efficient services and that are consistent with the mission, vision, values and strategic plan of BWH and in the best interests of the community.

• disclose information about BWH’s governance processes, decision-making and performance in an open and transparent manner.

8. Consistent with the Board’s commitment to good governance practices, timely access to information, appropriate protection of personal privacy, and appropriate protection of other information that is exempt or excluded from disclosure under the Freedom of Information and Protection of Privacy Act, the Board will make available to the public information about its governance processes, decision making and organizational performance including, but not limited to: the statement of Board and Director roles, responsibilities and

accountabilities; a list and biographies of elected and ex-officio Directors and their

participation on Board committees; the Board policies addressing governance structures and processes,

including those which address how the Board functions independently of management;

the terms of reference governing Board standing committees; the results of BWH’s participation in the voluntary national accreditation

process through Accreditation Canada; the Hospital and Multi-Sectoral Service Accountability Agreements with

the MOHLTC and ESC LHIN; the Open Board meeting information package with the CEO report and

Board meeting highlights;



an annual report, including audited financial statements, outlining BWH’s

accomplishments and performance; performance reporting information in compliance with the requirements of

ECFAA, BPSAA, and the FIPPA and other applicable government legislation or directives; and

a summary of the processes through which BWH demonstrates accountability, transparency and engagement.

Monitoring Method and Frequency: 1) Accreditation Canada Survey and report (timing

aligned with Accreditation cycleevery three years) 2) Board Evaluation (as per Policy 5.86)

3) Review of Global Communications and Community Engagement Plan/Status Report (every three years, aligned with Strategic Planning cycle)

4) CAP and RHAP reports and evaluations (annually) 5) Review of the Policy (every three years)


POLICY Section 5.0 Board Effectiveness – Governance Policy Framework

Title ROLES AND RESPONSIBILITIES OF THE BOARD OF DIRECTORS




O: January 2009 R: June 2012 January 2016

June 2018

Version 34 File Name:


Purpose As part of its responsibility for ensuring Board effectiveness, the Board of Bluewater Health (BWH) will establish, approve and periodically review a description of the Roles and Responsibilities of the Board of Directors. This description is an important requirement of effective governance. It addresses the Board’s expectations for itself and provides the foundation upon which the Board’s performance can be evaluated. This policy sets out the Roles and Responsibilities of the Board of Directors as developed and approved by the Board of BWH. Policy The Board governs by fulfilling the following roles: 1.0 Policy Formulation Establish policies to provide guidance to those empowered with the responsibility to lead and manage BWH operations. 2.0 Decision-Making On matters that specifically require Board approval, choose from alternatives that are consistent with Board policies and that advance the goals of BWHDirectors will ensure the ethical framework/principle based decision making approach is applied in Board decision making processes. 3.0 Oversight Monitor and assess organizational processes and outcomes. Responsibilities of the Board A) Establish Strategic Direction

APPROVEDRAFT


ROLES AND RESPONSIBILITIES OF THE BOARD OF DIRECTORS


• Consider key healthcare needs and stakeholders, and engage the

community of diverse persons and entities when developing plans and setting priorities for the delivery of healthcare

• Establish and periodically review BWH’s mission, vision and values • Contribute to the development of and approve the strategic plan of BWH,

ensuring . Ensure that it is alignedalignment with the provincial strategic plan and the LHIN integrated health services plan. Conduct a review of the strategic plan as part of a regular annual planning cycle

• Ensure that Board decisions are consistent with BWH’s mission, vision, values and strategic plan

• Monitor corporate performance regularly against the strategic plan and performance indicators

B) Provide for Excellent Management

• Select and appoint the President and Chief Executive Officer (“CEO”) • Establish measurable annual performance expectations in co-operation with

the President/CEO, assess the President/CEO performance annually and determine compensation

• Delegate responsibility and authority to the President/CEO for the management and operation of BWH and require accountability to the Board

• Select and appoint the Chief of Professional Staff (COPS) • Establish measurable annual performance expectations in co-operation with

the Chief of Professional StaffCOPS, assess Chief of Professional Staff COPS performance annually and determine compensation

• Delegate responsibility and authority to the Chief of Professional Staff COPS for the supervision of the practice of medicine, dentistry and midwifery, and extended class nurses with privileges, within BWH and require accountability to the Board

• Provide for President/CEO and Chief of Professional Staff COPS succession

• Ensure that the President/CEO and the Chief of Professional Staff COPS establish an appropriate succession plan for senior management and Professional Staff and a human resource plan, with review of such plans annually

• Appoint Medical Directors and other medical leadership positions, on the recommendation of the Chief of Professional StaffCOPS, as required under Bluewater Health’s by-laws and the Public Hospitals Act

• Establish and monitor implementation of policies to provide the framework for the management and operation of BWH, in compliance with applicable laws and regulations

C) Ensure Program Quality and Effectiveness • Ensure the effectiveness and fairness of the annual credentialing process

for the Professional Staff • Review and approve appointments, reappointments and privileges for

Professional Staff as recommended by the Medical Advisory Committee, in consideration of BWH’s resources and the community’s needs

• Provide oversight of the credentialed Professional Staff through the Chief of Professional Staff COPS and the Medical Advisory Committee and, if necessary or advisable, effect the restriction, suspension or revocation of privileges of any credentialed professional staff member as provided under



the Public Hospitals Act, following recommendation by the Medical Advisory Committee

• Review and approve the Quality Improvement Plan , quality goals and performance indicators (using best practices and benchmarks) and monitor indicators of clinical outcomes, quality of care and service delivery, patient safety, satisfaction and organizational risk

• Ensure the development of a process for identifying, managing and monitoring organizational risks

• Ensure that policies and processes to manage resource utilization and patient safety are in place and operating effectively

• Ensure that policies are in place to provide a framework for addressing ethical issues arising from clinical care, education and research

• Ensure that management has plans in place to address variances from performance standards, including management of critical incidents , systemic or recurring quality of care issues, and complaints and concerns, and oversee implementation of the remediation plans

D) Ensure Financial Viability

• Approve the annual operating and capital budget, and monitor financial performance periodically against the budget and agreed-upon indicators

• Ensure that management undertakes multi-year financial planning, optimizes the use of resources, operates within the resource envelope, adheres to the Hospital (H-SAA) and Multi-Sectoral (M-SAA) Service Accountability Agreements and manages to acceptable levels of risk

• Ensure policies are in place on asset protection, procurement, borrowing, signing authority, resource planning, financial condition, expense reimbursement and perquisites

• Approve an investment policy and monitor compliance • Ensure that management has measures in place to ensure the integrity of

internal accounting controls and reporting processes and the effectiveness of management information systems

• Ensure that the Members appoint qualified auditors, and examine, consider and approve the Corporation’s financial statements and the report of the auditors at least annually

E) Ensure Board Effectiveness

• Recruit Directors who are skilled, experienced and committed to BWH, and plan for the succession of Directors and Officers

• Establish comprehensive Board orientation and ongoing Board development and education programs

• Establish and monitor implementation of Board goals and annual work plans for the Board and its standing committees

• Ensure that the Board receives timely, appropriate information to support informed policy formulation, decision-making and oversight

• Establish and periodically review policies concerning governance structures and processes to maximize the effective functioning of the Board

• Establish a policy and process for evaluating the performance of the Board as a whole and individual Directors that fosters continuous improvement

• Ensure decision-making processes are transparent • Ensure that effective mechanisms are in place for reporting on BWH

performance



• Ensure that the Board adheres to the Principles of Governance and

Accountability statement and demonstrates accountability to its stakeholders

• Ensure that the Board fulfills all of its responsibilities as set forth by the Public Hospitals Act, the Excellent Care for All Act, the Broader Public Sector Accountability Act and all other applicable legislation.

F) Foster Relationships

• Ensure that BWH builds and maintains positive relationships with the ESC LHIN in fulfilling BWH’s service accountability agreements with the ESC LHIN and its obligations under provincial policies established by the Ministry of Health and Long-Term Care

• Ensure that BWH is fulfilling its role within the ESC LHIN region by fostering effective coordination and integration of patient care and health service delivery and positive working relationships with other community health service providers

• Ensure that mechanisms are in place to build and maintain positive relationships and effective two-way communication within BWH with Professional Staff, staff, volunteers, the Foundations and with the community served.

Monitoring Method and Frequency: 1. Accreditation Canada Survey and report (timing

aligned with Accreditation cycleevery three years) 2. Review of Global Communications and Community

Engagement Plan/Status Report (every three years, aligned with Strategic Planning cycle)

3. Board Evaluation (as per Policy 5.86) 4. Individual Director Evaluation (as per Policy 5.86) 5. Review of the Policy (every three years)


POLICY

Section 5.0 Board Effectiveness – Governance Policy Framework

Title BOARD CHAIR POSITION DESCRIPTION Issuing Body/ Prepared By



O: January 2005 R: March 2007 October 2007 January 2009 June 2012 October 2015 June 2018

Version 67 File Name: S:\CHIEF EXECUTIVE OFFICER\BOARD AND BOARD COMMITTEES\BOARD BWH\BOARD POLICIES\5.45 - Board Chair Position Description - October 2015.Docx


Purpose As part of its responsibility for ensuring Board effectiveness, the Board of Bluewater Health (BWH) will establish, approve and periodically review a position description for Board Chair. This description is an important requirement of effective governance as it provides the Chair and all Directors and Non-Director Committee Members (NDCMs) with a clear understanding of what is expected of this position and serves as a benchmark against which the performance of the Chair can be assessed. This policy sets out the position description of the Board Chair as developed and approved by the Board of BWH. Policy Role Statement The Board Chair, working collaboratively with the President/CEO and the Chief of Professional Staff, provides leadership to the Board, ensures the integrity and effectiveness of the Board’s governance role and processes and represents the Board within the hospital and to outside parties. The Board Chair co-ordinates the activities of the Board in fulfilling its governance responsibilities and facilitates co-operative relationships among Board and NDCMs, between the Board and President/CEO and the Board and Chief of Professional Staff and with internal and external stakeholders. The Board Chair ensures that all matters relating to the Board’s mandate are brought to the attention of, and discussed by, the Board.

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BOARD CHAIR POSITION DESCRIPTION Number: GOV 5.45 Page 2 of 5

Responsibilities Board Governance: Through the work of the Governance and Nominating Committee, overseeensures the quality of the Board’s governance processes including that: • the Board’s governance structures and processes are reviewed, evaluated and revised,

as required • Ensuring that the Board performs a governance role that respects and understands the

role of management; • Ensuring that the Board develops and implements annual goals and a work plan that are

aligned with the hospital’s mission, vision and values and strategic priorities and embrace continuous improvement;

• Ensuring that the work of the Board committees is aligned with the Board’s role and annual work plan and that the Board respects and understands the role of Board committees;

• Ensuring Board succession planning through processes to recruit, select and educate Directors and NDCMs with the skills, experience, background and personal qualities required for effective governance;

• Ensuring that the Board , individual Directors and NDCMsmembers have have access to appropriate orientation and education;

• Overseeing the Board orientation and education processes • and providing cConstructive feedback is provided to to Committee Chairs, Directors

and NDCMs, as required, to foster continuous improvement; and • Ensuring that the Board’s governance structures and processes are reviewed, evaluated

and revised, as required.

Board Meetings: • Ensure that a schedule of Board meetings is prepared annually and is reflective of

current Board issues, needs and/or interests. • Establish agendas for board meetings in collaboration with the President/CEO that are

aligned with the Board’s roles, annual goals, work plan and current issues. • Preside over meetings of the Board and Executive Committee. • Ensure that meetings are conducted according to applicable legislation, the by-laws,

and the Board’s governance policies and Rules of Order. • Facilitate and advance the business of the Board, ensuring that meetings are effective

and efficient for the performance of governance work. • Utilize a practice of referencing BWH’s Strategic Priorities, Board goals and Board

policies in guiding discussions in order to support the decision-making processes of the Board.

• Encourage input and ensure that the Board hears all sides of a debate or discussion. • Encourage all Directors to participate in the discussions. • Facilitate the Board in reaching consensus and decisions. • Ensure relevant information is made available to the Board in a timely manner, and that

external advisors are available to assist the Board as required.

Direction: • Serve as the Board’s central point of official communication with the President/CEO and

Chief of Professional Staff.


• Guide and counsel the President/CEO and Chief of Professional Staff regarding the

Board’s expectations and concerns. • Serve as a resource to the President/CEO and Chief of Professional Staff at his/her

request. • In collaboration with the President/CEO, develop standards for Board decision-support

packages. This documents that includes formats for reporting to the Board and the with level of detail provided to ensure that BWH management strategies and planning and performance information are appropriately presented to the Board.

Performance Evaluation: • Lead the Board in monitoring and evaluating the performance of the President/CEO and

Chief of Professional Staff through an annual process as outlined in Board policies (GOV 2.30 – CEO and COPS Performance Management and Evaluation).

• Representation: • Ensure that the Board is appropriately represented at BWH functions, other official

functions and to the community and public at large. • Serve as the Board’s exclusive official spokesperson and contact with the media, unless

otherwise delegated. Relationships and Mentorship: • Facilitate relationships with, and communication among Directors and NDCMs and

between Directors, NDCMs and the President/CEO and Chief of Professional Staff • Provide assistance and advice to committee Chairs to ensure they understand Board

expectations and have resources required to fulfill their Terms of reference • Serve as a mentor to other Directors and NDCMs to ensure that each is supported and

contributes his/her special skills and expertise effectively in the performance of their roles

• Provide feedback to individual Directors and NDCMs on performance, including addressing issues associated with underperformance, in order to facilitate continuous improvement

• Maintain a constructive working relationship with the President/CEO and Chief of Professional Staff providing advice, counsel and an understanding of Board expectations

Reporting: • Report regularly and promptly to the Board regarding issues that are relevant to its

governance responsibilities. • Report to the annual meeting of the members concerning the operations of BWH. Board Conduct: • Set a high standard for Board conduct and enforce by-laws and policies regarding

Director and NDCM conduct. Succession Planning: • Ensure succession planning occurs for the President/CEO, Chief of Professional Staff

and the Board and its Standing Committees.

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Committee Membership: • Serve as an ex-officio member of all Board standing committees, sub-committees and

special committees (but not generally be expected to participate in their work and deliberations). •

Skills, Attributes and Experience The Board Chair will possess the following personal qualities, skills and experience: • All of the personal attributes required of a Director; • Substantial governance experience in the hospital, not-for profit or broader public sector,

preferably as a Board Chair; • Demonstrated leadership skills; • Strategic and facilitation skills; • Tact and diplomacy skills; • Ability to effectively influence and build consensus within the Board; • Ability to establish trusted advisor relationship with the President/CEO, Chief of

Professional Staff and other Directors and NDCMs; • Ability to make the necessary time commitment and required flexibility in work schedule

to meet the requirements of this leadership role; • Ability to communicate effectively with the Board, Senior Management, the Ministry of

Health and Long-Term Care, the Erie St. Clair Local Health Integration Network and the community;

• Demonstrated commitment to continuous learning and self-development in areas of skills and expertise required by the Board and that will enhance Board effectiveness;

• Demonstrated commitment to the Principles of Governance and Board Accountability.

Term The Board Chair shall be elected by the Board to serve a two-year term. Following completion of the two-year term, the individual may be re-elected for a further one-year term. Monitoring: Method and Frequency 1. Board Evaluation (as per Policy 5.86)

2. Individual Director and NDCM Evaluation (as per Policy 5.86) 32. Review of the Policy (every three years) 3. Accreditation Canada Survey and Report (timing aliged with

Accreditation cycle)

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POLICY

Section 5.0 Board Effectiveness - Governance Policy Framework

Title BOARD VICE-CHAIR POSITION DESCRIPTION




O: January 2009 R: June 2012 October 2015

June 2018

Version 34 File Name: S:\CHIEF EXECUTIVE OFFICER\BOARD AND BOARD COMMITTEES\BOARD BWH\BOARD POLICIES\5.50 - Board Vice-Chair Position Description - October 2015.Docx


Purpose As part of its responsibility for ensuring Board effectiveness, the Board of Bluewater Health (BWH) will establish, approve and periodically review a position description for the Board Vice-Chair. This description is an important requirement of effective governance as it provides the Vice-Chair and all Directors and Non-Director Committee Members (NDCMs) with a clear understanding of what is expected of this position and serves as a benchmark against which the performance of the Vice-Chair can be assessed. This policy sets out the position description of the Board Vice-Chair as developed and approved by the Board of BWH. Policy Role Statement The Vice Chair works collaboratively with the Board Chair and . He or she supports the Board Chair in fulfilling his/ or her responsibilities. Responsibilities Board Chair Substitute: Assume the duties of the Board Chair in his or /her absence, as requested by the Chair, including representing the Board and the Hospital at official functions and to the public at large. Board Conduct: Maintain a high standard for Board conduct and enforce by-laws and policies regarding Director and NDCM conduct. Mentorship:

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BOARD VICE-CHAIR POSITION DESCRIPTION Number: GOV 5.50 Page 2 of 3

Serve as a mentor to other Directors and NDCMs.

BOARD VICE-CHAIR POSITION DESCRIPTION Number: GOV 5.50 Page 3 of 3

Committee Membership: Serve as a member of the Executive Committee and at least one additional standing committee of the Board. Skills, Attributes and Experience The Vice-Chair will possess the following personal qualities, skills and experience: • Hospital Board experience • All of the personal attributes required of a Director and Committee Chair; • Demonstrated management Leadership skills; • Strategic and facilitation skills; • Tact and diplomacy skills; • Ability to effectively influence and build consensus within the Board; • Ability to establish trusted advisor relationship with the President/CEO, Chief of

Professional Staff, other Directors and NDCMs; • Ability to make the necessary time commitment and required flexibility in work schedule

to meet the requirements of this leadership role; • Ability to communicate effectively with the Board, Senior Management, the Ministry of

Health and Long-Term Care, the Erie St Clair Local Health Integration Network and the community;

• Demonstrated commitment to continuous learning and self-development in areas of skills and expertise required by the Board and that will enhance Board effectiveness;


Term The Vice-Chair shall be elected annually by the Board. An individual may serve a maximum of three (3) consecutive annual terms as Vice-Chair provided that the Board may approve extensions in exceptional circumstances. Monitoring Method and Frequency 1. Board Evaluation (as per Policy 5.86)

2. Individual Director and NDCM Evaluation (as per Policy 5.86)

32. Review of the Policy (every three years) 3. Accreditation Canada Survey and report (timing aligned with



POLICY


Title BOARD TREASURER POSITION DESCRIPTION




O: January 2009 R: June 2012 October 2015

June 2018

Version 34 File Name: S:\CHIEF EXECUTIVE OFFICER\BOARD AND BOARD COMMITTEES\BOARD BWH\BOARD POLICIES\5.55 - Board Treasurer Position Description - October 2015.Docx


Purpose As part of its responsibility for ensuring Board effectiveness, the Board of Bluewater Health (BWH) will establish, approve and periodically review a position description for Board Treasurer. This description is an important requirement of effective governance as it provides the Chair and all Directors and Non-Director Committee Members (NDCMs) with a clear understanding of what is expected of this position and serves as a benchmark against which the performance of the Treasurer can be assessed. This policy sets out the position description of the Board Treasurer as developed and approved by the Board of BWH. Policy Role Statement The Treasurer works collaboratively with the Board Chair and President/CEO to support the Board in fulfilling its fiduciary responsibilities. Responsibilities Board Conduct: Maintain a high standard for Board conduct and uphold by-laws and policies regarding Director and NDCM conduct, with particular emphasis on fiduciary responsibilities. Mentorship: Serve as a mentor to other Directors and NDCMs.

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BOARD TREASURER POSITION DESCRIPTION Number: GOV 5.55 Page 2 of 2

Committee Membership: Serve as a member of the Executive Committee and chair the Resource Utilization and Audit Committee. Audited Financial Statement: Present to the annual general meeting as part of the annual report, an audited financial statement of BWH and the report thereon of the independent auditors. Skills, Attributes and Experience The Treasurer will possess the following personal qualities, skills and experience: • All of the personal attributes required of a Director and Committee Chair; • Strong financial management literacy, preferably with education and work experience in

the professional accounting and/or finance fields; • Ability to make the necessary time commitment and required flexibility in work schedule

to meet the requirements of this leadership role; • Ability to communicate effectively and efficiently; • Demonstrated commitment to continuous learning and self-development in areas of

skills and expertise required by the Board and that will enhance Board effectiveness; • Demonstrated commitment to the Principles of Governance and Board Accountability.

Term The Treasurer shall be elected annually by the Board. An individual may serve a maximum of three (3) consecutive annual terms as Treasurer provided that the Board may approve extensions in exceptional circumstances. Monitoring Method and Frequency 1. Board Evaluation (as per Policy 5.86)

2. Individual Director and NDCM Evaluation (as per Policy 5.86) 3. Review of the Policy (every three years) 4. Accreditation Canada Survey and report (timing aligned with



POLICY


Title BOARD COMMITTEE CHAIR POSITION DESCRIPTION




O. January 2009 R: June 2012 October 2015

June 2018

Version 34 File Name: S:\CHIEF EXECUTIVE OFFICER\BOARD AND BOARD COMMITTEES\BOARD BWH\BOARD POLICIES\5.60 - Board Committee Chair Position Description - October 2015.Docx


Purpose As part of its responsibility for ensuring Board effectiveness, the Board of Bluewater Health (BWH) will establish, approve and periodically review a position description for Board Committee Chair. This description is an important requirement of effective governance as it provides the Committee Chair, all Directors and Non-Director Committee Members (NDCMs) with a clear understanding of what is expected of this position and serves as a benchmark against which the performance of the Committee Chair can be assessed. This policy sets out the position description of the Committee Chair as developed and approved by the Board of BWH. Policy Role Statement A Committee Chair, working collaboratively with assigned staff support, provides leadership to the committee. He or she ensures that the terms of reference of the committee are followed. He or she effectively manages issues to promote effective dialogue. He or/ she respects that the committee has no direct management role with Hospital staff. Responsibilities Agendas: Establish agendas, consistent with the Board approved committee work plan, in collaboration with staff support and preside over meetings of the committee.

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BOARD COMMITTEE CHAIR POSITION DESCRIPTION


Leadership: Effectively leadfacilitate each committee meeting in a manner that encourages thoughtful participation and promotes understanding of complex issues. Ensure a fair discussion, especially when differences and conflicting opinions arise. Expertise: Serve as a leader within the Board on the matters addressed in the committee’s terms of reference. Advise Board Chair: AdviseLiaise with the Board Chair on the key issues and recommendations addressed by the committee. Report to the Board: After each committee meeting, with the assistance of executive staff support, prepare a report and where appropriate, decision-support recommendations summaries, as applicable, for consideration by submission to the Board. Work Plan: With the assistance of executive staff support, develop an annual work plan that fulfills the responsibilities of the committee and is consistent with the Board work plan. Mentorship: Serve as a mentor to committee members and with the Board Chair develop a succession plan for the chair. Skills, attributes and experience: A Committee Chair will possess the following personal qualities, skills and experience:

• All of the personal attributes required of a Director; • Interest and experience related to the work of the Committee; • Ability to chair a meeting such that decisions are made in a manner that is respectful and

efficient; • Willingness and ability to commit time to the responsibilities of the Committee Chair; • Demonstrated commitment to continuous learning and self-development in areas of

skills and expertise required by the Board and that will enhance Board effectiveness;


Term A Committee Chair shall be elected by the Board for a one (1) year term. An individual may be re-elected to chair the same committee or may be elected to chair a different committee following completion of his/her term.

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BOARD COMMITTEE CHAIR POSITION DESCRIPTION


Monitoring Method and Frequency: 1. Board Evaluation (as per Policy 5.86)

2. Committee Evaluation (as per policy 5.86) 3. Individual Director and NDCM Evaluation (as per policy 5.86) 4. Review of the policy (every three years) 5. Accreditation Canada Survey and Report (timing aligned with



POLICY Section 5.0 Board Effectiveness - Governance Policy Framework

Title NON-DIRECTOR COMMITTEE MEMBERS Issuing Body/ Prepared By



O: January 2006 R: January 2009 June 2012 June 2015

June 2018

Version 45 File Name: J:\Departmental\Admin\CHIEF EXECUTIVE OFFICER\BOARD AND BOARD COMMITTEES\BOARD BWH\BOARD POLICIES\5.65 - Non Director Committee Members - April 2015 (XREF 570).Docx


Purpose As part of its responsibility for ensuring Board effectiveness, the Board of Bluewater Health (BWH) has determined that the participation of Non-Directors from the community as members of certain Board Committees is beneficial to obtain a broad range of perspectives, to provide additional expertise and to identify and assess individuals’ interest and aptitude to be Directors in the future. This policy sets out selection process and responsibilities of Non-Director Committee Members (NDCMs). Policy Selection The Governance & Nominating Committee is responsible for recommending individuals to the Board to serve as Non-Director Committee Members NDCMsfor in accordance with the Nominations Process pPolicy (GOV-5.70). Non-Director Committee Members NDCMs shall meet the qualifications for Directors as set out in this Policy and in the in s.5.03 of the Corporate By-laws of BWH. Non-Director Committee Members NDCMs shall have one (1) year renewable terms. No individual shall serve more than five (5) consecutive one-year terms as a Non-Director Committee MemberNDCM, except as otherwise permitted from time to time by resolution of the Board. Professional Staff Association (PSA) The PSA annually elects Professional Staff members to its Executive Committee. These PSA members are then appointed to Board Standing Committees through processes established by the Chief Executive Officer (CEO) and Chief of Professional Staff (CoPS). For the purposes of role clarity at Board Standing Committee meetings, the Vice-President Sarnia and Secretary/Treasurer should be considered NDCMs once appointed.

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NON-DIRECTOR COMMITTEE MEMBERS Number: GOV 5.65 Page 2 of 4

Other NDCM Positions The Quality Committee of the Board membership includes two Patient Experience Partners (PEPs), one Professional Staff Association member (non-executive) and one hospital employee member other than a physician or nurse. The PEPs are selected by the BWH Patient Experience Partner Council. The Professional Staff and hospital employee positions are selected through processes established by the CEO and CoPS respectively. For the purposes of role clarity at Quality Committee of the Board meetings, these positions should be considered NDCMs once appointed. Responsibilities 1.0 Accountability and Fiduciary Duties A Non-Director Committee Member NDCM acts ethically, honestly, in good faith and in the best interests of Bluewater Health and in so doing, supports Bluewater Health in fulfilling its mission and mandate, and discharging its accountabilities. A Non-Director Committee Member NDCM exercises the care, diligence and skill that a reasonably prudent person would exercise in comparable circumstances. Non-Director Committee Members NDCMs with special skill and knowledge are expected to apply that skill and knowledge to matters that come before the Committee. A Non-Director Committee Member NDCM does not represent the specific interests of any constituency. A Non-Director Committee Member NDCM acts and makes decisions that are in the best interest of Bluewater Health as a whole. A Non-Director Committee Member NDCM adheres to the vision, mission and values of Bluewater Health and complies with the Public Hospitals Act, the Corporations Act, by-laws, applicable laws and regulations and Board policies. A Non-Director Committee Member NDCM adheres to the Principles of Governance and Board Accountabilities policy (GOV-5.10). 2.0 Exercise of Authority A Non-Director Committee Member NDCM carries out the powers of office only when acting as a voting member during a duly constituted meeting of the Committee. A Non-Director Committee Member NDCM respects the responsibilities delegated by the Board to the President/Chief Executive Officer and Chief of Professional Staff, avoiding interference with their duties but insisting upon accountability to the Committee and reporting mechanisms for assessing organizational performance. 3.0 Conflict of Interest A Non-Director Committee Member NDCM does not place him/herself in a position where his/her personal interests conflict with those of Bluewater Health. A Non-Director Committee Member NDCM complies with the Conflict of Interest provisions in the by-laws and Board policy. 4.0 Team Work A Non-Director Committee Member NDCM works positively, cooperatively and respectfully with others in the performance of his or her duties while exercising independence in decision making. 5.0 Participation A Non-Director Committee Member NDCM reviews pre-circulated material and comes prepared to Committee meetings and educational activities, asks informed questions, and makes a constructive contribution to discussions. A Non-Director Committee Member NDCM considers the need for independent advice to the Committee on major corporate actions.



6.0 Formal Dissent A Non-Director Committee Member NDCM reviews the minutes of the previous meeting on receipt and insists that they record any Non-Director Committee MemberNDCM’s disclosure of an actual or potential conflict of interest, abstention or dissent. A Non-Director Committee Member NDCM who is absent from a Committee meeting is deemed to have supported the decisions taken and policies approved by the Committee in his or her absence unless he or she formally records a dissenting view with the Committee secretary. 7.0 Board Solidarity The official spokesperson for the Board and its committees is the Chair or the Chair’s designate. A Non-Director Committee MemberNDCM supports the decisions and policies of the Committee in discussions with outsiders, even if the Non-Director Committee Member NDCM holds another view or voiced another view during a Committee discussion or was absent from the Committee meeting. A Non-Director Committee Member NDCM refers requests for comments on behalf of the Committee to the Committee Chair. 8.0 Confidentiality A Non-Director Committee MemberNDCM respects the confidentiality of Committee discussions and information. 9.0 Time and Commitment A Non-Director Committee Member NDCM is expected to commit the time required to fulfill Committee responsibilities. A Non-Director Committee Member NDCM is expected to attend a minimum of 85% of the meetings of the Committees of which he/she is a member. Non-Director Committee Members NDCMs who fail to meet the attendance requirements are subject to review by the Committee Chair and may be asked to step down from the Committee. 10.0 Competencies A Non-Director Committee Member NDCM actively contributes specific expertise, skills and other attributes that are needed on the Committee. 11.0 Education A Non-Director Committee Member NDCM seeks opportunities to be educated and informed about the Committee, the Board and the key issues at Bluewater Health and in the broader health care system through participation in Board and Committee orientation and education programs, maximizing use of information and resources on the Board website, participation in strategic planning processes, Board retreats and other mechanisms, as appropriate. 12.0 Self-Evaluation and Continuous Improvement A Non-Director Committee Member NDCM is committed to a process of continuous self-improvement as a Committee member. All Non-Director Committee Member NDCMs participate in the evaluation of the Committee and in individual Non-Director Committee Member NDCM evaluations and act upon results in a positive and constructive manner. 13.0 Fundraising Activity A Non-Director Committee Member NDCM supports the efforts of the Bluewater Health Foundation and Charlotte Eleanor Englehart Hospital Foundation. Monitoring Method and Frequency: 1. Non-Director Committee Member evaluation (as per Policy

5.86)


2. Committee Evaluation (as per Policy 5.86) 3. Board Evaluation (as per Policy 5.86) 4.. Review of the Policy (every three years) 3. Accreditation Survey and Report (timing aligned with


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POLICY Section 5.0 Board Effectiveness – Governance Process Title CODE OF CONDUCT Issuing Body/ Prepared By



O: January 2005 R: May 2006 January 2013 February 2016

June 2018

Version 45 File Name: S:\CHIEF EXECUTIVE OFFICER\BOARD AND BOARD COMMITTEES\BOARD BWH\BOARD POLICIES\5.75 - Code of Conduct.rtf


Purpose As part of its responsibility for ensuring Board effectiveness, the Board of Bluewater Health (BWH) will establish, approve and periodically review a Code of Conduct for Elected and Ex-Officio Directors and Non-Director Committee Members (NDCMs). This Code is an important requirement of effective governance as it provides Directors and NDCMs with a clear understanding of the conduct which is expected of them and supports the Board’s commitment to the highest standards for public trust, honesty and integrity in all aspects of its affairs. This policy sets out the Code of Conduct as developed and approved by the Board of BWH. Directors and NDCMs are also required to comply with the Hospital’s Code of Conduct Policy (COR-HR-A-3.80) which applies to all employees and volunteers.. Policy The Board, its Directors and NDCMs will demonstrate ethical, respectful, businesslike, and lawful conduct, including proper use of authority and appropriate decorum in carrying out their responsibilities. Fiduciary Duties Directors and NDCMs stand in a fiduciary relationship to BWH. As fiduciaries, Directors and NDCMs must act ethically, honestly, in good faith, and solely in the best interests of BWH. Directors and NDCMs will be held to strict standards of honesty, integrity and loyalty. Conflict of Interest Directors and NDCMs will not place themselves in positions in which their personal interests will conflict with the interests of BWH. Directors and NDCMs must also avoid situations in which their duties to BWH may conflict with duties owed elsewhere. Where conflicts of interest arise, Directors and NDCMs will comply with the Conflict of Interest provisions of the by-laws.

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CODE OF CONDUCT Number: GOV 5.75 Page 2 of 4

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Confidentiality Directors and NDCMs will respect the confidentiality of matters brought before the Board and its Committees or coming to their attention through the course of their duties. Specifically, they will respect the confidentiality of in camera Board discussions and information and such other Board discussions and information as deemed to be confidential by the Board, and comply with the Confidentiality provisions of the by-laws. Directors and NDCMs owe a duty to the corporation to respect the confidentiality of information about the corporation whether that information is received in a meeting of the Board or a committee or is otherwise provided to or obtained by the Director or committee member. Directors and NDCMs shall not disclose or use for their own purpose confidential information concerning the business and affairs of the corporation unless otherwise authorized by the board. Media Relations As outlined in the Hospital’s Media Relations Policy (COR-COMPA-A-5.120), media requests are facilitated by Communications and Public Affairs. Any Director or NDCM who is questioned by media representatives will refer such individuals to Communications and Public Affairs to ensure that the most applicable spokesperson is speaking on behalf of the organization. A representative from Communications & Public Affairs will be at all Board meetings to facilitate media requests. The Board Chair will be the designated spokesperson for issues pertaining to the Board /governance, the President/CEO or Chief, Communications and Public Affairs for corporate/organizational issues and the Chief of Professional Staff (COPS) for Professional Staff issues, unless otherwise directed by Communications & Public Affairs. Board Solidarity and Spokesperson Directors and NDCMs will support the decisions and policies of the Board in discussions with outsiders, even if the Director holds another view or voiced another view during a Board or Committee discussion or was absent from the meeting. With the official spokesperson for the Board being the Chair, Directors and NDCMs will refer requests for statements on behalf of the Board to the Chair. The Board Chair may delegate his/her responsibility for representing and acting as spokesperson for the Board to other Directors, as required. When so authorized, the Director’s or NDCM’s representations will be consistent with decisions and policies of the Board. Directors will be held to strict standards of honesty, integrity and loyalty. A director shall not put personal interests ahead of the best interests of the corporation. Respectful Conduct It is recognized that Directors and NDCMs bring to the Board and its Committees diverse backgrounds, skills, experience and opinions. Directors and NDCMs will not always agree with one another on issues. All discussions and interactions will take place in an atmosphere of mutual respect and courtesy, with all striving for a consensual approach to decision-making. The authority of the Board and Committee Chairs will be respected by all Directors and NDCMs. All Directors and NDCMs must be in compliance with all municipal, provincial and federal laws and conduct themselves in a respectful, lawful manner.

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3

Director - Management Interactions In all interactions with the President/CEO and COPS, Directors and NDCMs will do so within the scope of the Board’s authority, recognizing the lack of authority vested in the individuals except when explicitly Board authorized. Directors and NDCMs will respect the responsibilities delegated by the Board to the President/CEO and COPS, avoiding interference with their duties. Attendance Directors and NDCMs are expected to commit the time required to fulfill Board and Committee responsibilities. Those who fail to meet the attendance and participation requirements as outlined in the Roles and Responsibilities as an Elected and Ex-Officio Director Policy (GOV 5.20) or the Non-Director Committee Member Policy (GOV 5.65) will be subject to review by the Board Chair and may be asked to step down from the Board or Committee.


4

Obtaining Advice of Counsel Requests to obtain outside opinions or advice regarding matters before the Board will be made through the Board Chair. Breach of the Code of Conduct In the event of a breach of this Code of Conduct by a Director or NDCM, the issue will be referred to the Executive Committee for review, to take appropriate action, up to and including recommending to the Board removal of the Director or NDCM from the Board or Committee(s). All Directors have an obligation to report a breach of the code of conduct or any illegal behavior. Monitoring Method and Frequency: 1. Board ,Evaluation Individual Director, NDCM,

Committee and Meeting Evaluations (as per Policy 5.86) 2. Review of the Policy (every three years)

3. Accreditation Report and Survey (timing aligned with Accreditation Cycle)

Manual GOVERNANCE POLICY POLICY


Title BOARD COMMITTEE MEMBER DECLARATION




O: January 2005 R: June 2018

Version 8 File Name:


I _______________________________________, consent to act as a: ☐ Director/Ex-officio Director of Bluewater Health (BWH) ☐ Non-Director Committee Member of BWH ☐ Patient Experience Partner of BWH ☐ Professional Staff Association Member of BWH ☐ I acknowledge and accept the accountabilities as outlined in the appended Principles of

Governance and Board Accountability Policy. ☐ I agree to comply with the performance expectations as stated in the appended Roles

and Responsibilities as an Elected and Ex-officio Director Policy/Non-Director Committee Members Policy, as applicable.

☐ I confirm that I have read, understand and will comply with the Code of Conduct Policy

as appended. ☐ I confirm that as a Committee Member, I am bound to adhere to and respect these and

all other Board policies and I undertake to do so. ☐ I confirm that I have read, understand and will comply with the specific provisions as

outlined in “Conflict of Interest” and “Confidentiality” sections of the Corporate By-law of BWH, as appended.

☐ I confirm I do not have a conflict of interest which would prevent me from serving as a

Committee Member of BWH, pursuant to the Corporate By-law of BWH. ☐ I consent to holding meetings of the Board of Directors or of any Committee of the Board

of Directors by means of such telephone, electronic or other communication facilities as permit all persons participating in the meeting to communicate with each other

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BOARD COMMITTEE MEMBER DECLARATION Number: GOV 5.25 Page 2 of 2

simultaneously and instantaneously. These consents will continue in effect from year to year so long as I am a Committee Member of the BWH Board pursuant to the Corporate By-law of BWH.

☐ I confirm I have a criminal record check, including vulnerable sector screen, on record

with BWH Administration and confirm that there have been no changes since I filed this information with BWH.

☐ I confirm that I have provided BWH Administration with a secure e-mail address/account

to receive board information and communications which may be considered confidential and I undertake to advise the Hospital in writing of any change of address/account as soon as possible after such change.

☐ I declare the above information to be true and accurate as of the date hereof.

_______________________________ _______________________________ Signature Date ______________________________ _______________________________ Chair Date Attachments: 1) Principles of Governance and Board Accountability Policy (5.10) 2) Roles and Responsibilities as an Elected and Ex-officio Director Policy (5.20) 3) Non-Director Committee Members Policy (5.65) 4) BWH Corporate By-law 5) Code of Conduct Policy (5.75)

Monitoring Method and Frequency: 1) Review by Board Chair 2) Review of the Policy (annually)

3) Accreditation Canada Survey and report (timing aligned with Accreditation cycle)

Page 1 of 1

Manual GOVERNANCE POLICY POLICY


Title DIRECTOR BOARD COMMITTEE MEMBER DECLARATION




O: January 2005 R: March 2007 October 2007 January 2009 June 2012 May 2014 June 2017June 2018

Version 78 File Name: S:\Chief Executive Officer\Board\Policies\5.25 - Director Declaration - June 2017.docx


As a Director, I _______________________________________, consent to act as a: ☐ Director/Ex-officio Director of Bluewater Health (BWH). ☐ Non-Director Committee Member of BWH ☐ Patient Experience Partner of BWH ☐ Professional Staff Association Member of BWH

•

☐ I acknowledge and accept the accountabilities as outlined in the appended “Principles of Governance and Board Accountability” pPolicy. (GOV 5.10)

☐ I and agree to comply with the performance expectations as stated in the

appended “Roles and Responsibilities as an Elected and Ex-officio Director” pPolicy/Non-Director Committee Members Policy, as applicable. (GOV 5.20).

☐ I confirm that I have read, understand and will comply with the Code of Conduct

Policy as appended. ☐ I confirm that as a DirectorCommittee Member, I am bound to adhere to and

respect these and all other Board policies and I undertake to do so..

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BOARD COMMITTEE MEMBER DIRECTOR DECLARATION


• ☐ I • confirm that I have read, understand and will comply with the specific provisions as outlined in Article 5.09 “Conflict of Interest” and Article 5.10 “Confidentiality”, sections of the BWH Corporate By-law of BWHs, as appended. ☐ I • confirm that I do not have a conflict of interest which would prevent me from serving as a

Committee Member Director of BWH, pursuant to Article 5.09 “Conflict of Interest”, of the BWH Corporate By-law of BWHs. .

☐ I c consent , pursuant to the provisions of the Article 1.02 (a) of the BWH By-laws, as

appended, to holding meetings of the Board of Directors or of any Committee of the Board of Directors by means of such telephone, electronic or other communication facilities as permit all persons participating in the meeting to communicate with each other simultaneously and instantaneously. These consents will continue in effect from year to year so long as I am a Committee Member Director onf the BWH Board pursuant to the Corporate By-law of BWH.

• ☐ I confirm I

have a criminal record check, including vulnerable sector screen, on record with BWH Administration and confirm that there have been no changes since I filed this information with BWH.*

• ☐ I confirm that I have provided BWH Administration with a secure e-mail address/account

to receive board information and communications which may be considered confidential and I undertake to advise the Hospital in writing of any change of address/account as soon as possible after such change.

• ☐ I • declare the above information to be true and accurate as of the date hereof.

_______________________________ _______________________________ Signature Date



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BOARD COMMITTEE MEMBER DIRECTOR DECLARATION


______________________________ _______________________________ Chair Date Attachments: 1) “Principles of Governance and Board Accountability” pPolicy (GOV 5.10) 2) “Roles and Responsibilities as an Elected and Ex-officio Director” pPolicy (GOV 5.20) 3) Non-Director Committee Members Policy (5.65) 2) 3) Articles 1.02 (a), 5.09 and 5.10 of the BWH Corporate By-law By-laws 4) 5) Code of Conduct Policy (5.75)

Monitoring Method and Frequency: 1) Review by Board Chair 2) Review of the Policy (every three yearsannually)

3) Accreditation Canada Survey and report (timing aligned with Accreditation cycle)

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Policy Section 6.0 Fostering Relationships

Title FREEDOM OF INFORMATION – DELEGATION OF AUTHORITY AND OVERSIGHT


Governance and Nominating Committee Quality Committee of the Board


O: November 2011 R: September 2015

May 2018

Version 23 File Name: S:\Admin\Chief Executive Officer\Board\Policies\6.50 Freedom of Information FOI Delegation of Authority and Oversight.doc


Purpose As part of its responsibility for fostering relationships and pursuant to the requirements of the Freedom of Information and Protection of Privacy Act (“FIPPA”), the Board of Bluewater Health is responsible for ensuring that the Hospital’s policies and processes comply with FIPPA. This policy sets out processes to support the Board in fulfilling this responsibility. Policy The Board hereby authorizes and directs the CEO to implement appropriate and effective processes to ensure that the Hospital is in compliance with FIPPA. In particular, the Board directs adequate personnel and resources to permit the Hospital to fulfill its obligations in respect of access to information and protection of privacy. FIPPA designates the Chair of the Board as the “Head” of the Hospital. The Board hereby directs the Chair to consult with the CEO to identify appropriate Hospital personnel to whom the Head’s powers and duties should be delegated, and to take all necessary steps to effect such delegation. The CEO shall: • annually report to the Board on FIPPA compliance • advise the Board of FIPPA-related activities which are particularly significant • ensure that the Hospital meets its reporting obligations to the Information and Privacy

Commission (IPC)

APPROVED

FREEDOM OF INFORMATION – DELEGATION OF AUTHORITY AND OVERSIGHT


:

Monitoring Method and Frequency: 1. Review of policy (every 3 years)

2. Review of Delegation of Authority of ‘Head’ (annually) 3. CEO Performance Evaluation (annually) 4. Accreditation Canada Survey and report (timing aligned with accreditation cycle)

References: Freedom of Information and Protection of Privacy Act: https://www.ontario.ca/laws/statute/90f31

Successes Completed Quality and Patient Safety Plan Embedded “just culture” education into orientation program Identified patient safety champions for each program Initiated Good Catch Program Launched Red Rule – requirement for two patient identifiers Developed Integrated Risk Management System Increased supervision and security on Mental Health Inpatient Unit specifically in Child and Youth and

Residential Withdrawal Management Services areas Revised Surgical Safety Checklist – requirement for two signatures Implemented bedside reporting in Surgery Program Completed monthly hospital-wide Morbidity and Mortality patient case reviews, with department

reviews held at least semi annually Challenges Fear of “speaking up” Trust in organization Influenza vaccination rate Limitations of documentation system

Key Priorities for 2018/19 Readiness for Accreditation Canada Survey – April 2019 Fall Reduction Strategy Illicit drug strategy to improve patient experience, ensure consistent practice and minimize risk (ED,

ICU, and medicine) Additional strategies to increase influenza vaccination rate

Goal Initiative Indicator

Ingrain patient safety

Implement a Quality and Patient Safety Plan

It is difficult to speak up if I perceive a problem with patient care

Strategic Plan Progress Report

April 1, 2017 to March 31, 2018

Bluewater Health Strategic Plan Progress Report 2018

2

Successes Reconfigured beds and standardized model of care in Medicine unit, to allow for greater flexibility

during surge periods and to accommodate patients with contact precautions Holiday and Influenza “Surge Planning” Dedicated pharmacy technicians in ED to improve quality of medication histories, support outpatients

with COPD, and to collaborate closely with community partners Developed and implemented Geriatric Care Pathway in the ED Introduced Nurse Practitioner Role at CEEH site Increased patient access to Cardiac Clinic to ensure timely access to diagnostics and consultation for

patients with chest pain and to reduce inpatient admission rates Patient Flow/ALC Avoidance Improvements Mental Health and Addiction Integration in ED to support community resources and access

o Addition of Psychiatric Assessment Nurse and greater CMHA after-hours coverage o Improved response for psychiatry consultations in ED o Ongoing engagement and expansion of Child and Youth Collaborative between BWH and St.

Clair Child and Youth Services o Implementation of BSharp for all Mental Health and Addictions patients, which includes use of

interRAI, a standard assessment systems that better flags risk, and triggers Clinical Assessment Protocols

o Child and Youth Mental Health Inpatient Improvement Initiative Exceptional wait time results for many other priority indicators (CT, MRI, Hip/Knee/Cancer Surgeries,

lab tests, etc.) Other Access to Care Improvements Launched Critical Care Outreach Team (ICU and Respiratory Therapy with Intensivist support) Developed and implemented In-House Code Stroke Process Implemented 24/7 access to CT/CTA improving more timely access for endovascular therapy Introduced Iron Infusion Clinic in Dialysis Unit Expanded Palliative Care Services for Dialysis patients to improve quality of life Implemented anterior and SuperPATH hip replacements reducing the length of stay for these

procedures Expanded Cancer Care Program with the addition of a second oncologist funded through Cancer Care

Ontario

Improve access to care

Improve Emergency Department (ED) wait

times 90th percentile length of stay for admitted patients


3

Established Electroconvulsive Therapy Program Introduced Transesophageal echocardiogram services

Challenges Limited primary care access Appropriate resources and capacity to support specialized marginalized populations i.e. homelessness Mental Health & Addictions demand on the ED and patient flow Long-Term Care repatriation/admission processes when facilities are in outbreak Limited access to Interprofessional Community Based services/Outpatient Rehabilitation Limited physician coverage i.e. Rehab or psychiatric support on CCOG unit Consistent practices/processes with “Estimated Date of Discharge” (EDD)

Key Priorities for 2018/19 No One Waits (NOW) initiative to improve time to inpatient bed and align with best practices in bed

management/patient flow o Improve collaboration between Department of Psychiatry and ED to identify and implement

opportunities to discharge patients to the community for follow-up as an alternative to admission to the Mental Health unit

o Discharge Strategy – including real time reporting from Oculys Stay-Track boards, EDD practices, Patient Oriented Discharge Strategy (PODS)

o Improve workflow in the ED to decrease left without being seen (LWBS) patients, improve wait times and patient experience, improve triage practices and minimize risk in the waiting room

o Development of Pharmacist Discharge Facilitator Program to reduce afterhours backlog and ensure medication history is available in a more timely manner

o Psychiatry Primary Care Collaboration/Outreach to decrease Form 1 and 2 patients presenting from Primary Care to the ED

Implementation of Mobilization of Vulnerable Elders (MOVE) Program


4

Successes Five-year strategic capital plan finalized Submission of Stage 1 Parts A and B of the CEEH Capital Redevelopment Plan Opening of temporary Residential Withdrawal Management Services beds Real-time Location Service (RTLS) commissioned and fully installed

Challenges Dealing with end of life on equipment and substandard inpatient facilities at CEEH Managing public expectations on capital development projects

Key Priorities for 2018/19 Continued development at CEEH Ongoing planning for permanent Residential Withdrawal Management Services and CEEH Capital

Redevelopment Projects Ongoing participation in Regional Hospital Information System (HIS) project Further expansion of Pharmacy Retail Store Redesign and separate Child and Youth Mental Health Physical Space


Ensure continuous investment in strategic infrastructure

Implement a sustainable plan for services, facilities, capital equipment and technology

Status of plan


5

Successes

3M Audit to identify weighted case opportunities Increased volume of hip and knee replacement surgeries Ongoing implementation and adoption of Choosing Wisely initiatives Improved collaboration with partners to repatriate ICU patients earlier Implementation of Oculys Stay-Track interactive boards on inpatient units Deployed Key Performance Indicator Boards across the organization to increase knowledge and align

quality/performance indicators with strategic plan Successful expansion of Pharmacy Retail Store Fully implemented work order system

Challenges Decrease in non-elective weighted cases Recruitment challenges

Key Priorities for 2018/19 Introduction of Clinical Documentation Specialist to ensure comprehensive documentation Introduction of Hip and Knee Bundled Quality Based Procedures (QBP)- an extension of the existing

surgical QBP into a bundled model. Expansion of the Clinical Reserve Unit to broader the number of individuals able to work in multiple

areas to address sick calls and vacation time Development of supply and parts inventory system Refinement of scorecard reporting using case costing data Optimization of Material Handler Cart to include pricing Implementation of MModal – front end voice recognition technology Continued focus with Professional Staff to ensure all diagnoses, comorbidities and procedures are

documented to capture to accurate weighted case information


Demonstrate accountability and efficiency

Increase awareness and understanding of resource decisions Cost per weighted case


6

Successes Culture of Kindness Employee Council established, with principles and action plan developed Established Well Being Advisory Team with representation from the Healthy Living Team, Culture of

Kindness Employee Council and Employee Engagement team, with formalized aims and priorities for each team

Dedicated focus on Professional Staff Wellness Creation of the Workplace Violence Prevention Committee with “No Excuse for Abuse” campaign to

begin in June Resilience training embedded in leadership training and other workplace education sessions

Challenges

Complexity of transformational culture change in a 24/7 - 365 environment Inspiring staff during surge periods or when staffing resources are stretched

Key Priorities for 2018/19: Solidify a Wellbeing Strategy by aligning current practices and expanding support for resilience

education and prevention and or management of compassion fatigue Planning for ED redesign to improve workflow Development of workplace violence prevention metrics and increased staff training in workplace

violence prevention Development of Staff Duress System with full deployment of staff duress buttons and

policies/procedures to support usage Creation of action plan from Employee Engagement Results 2018 Rollout of Kindness Plan


Focus on the experience of care and caring

Strengthen our culture of kindness

Patient: Treated with kindness

BWH: Is a culture of kindness promoted at BWH?


7

Successes Introduction of Personal Support Workers Talent development activities embedded in Human Resource and Organizational Development

planning Fully implemented Knowledge Management Council, a multi-disciplinary team that shares education

plans and collaborates on the organization calendar of development opportunities Training opportunities with Schulich School of Medicine & Dentistry for physicians to become Adjunct

Professors Successful recruitments of new Professional Staff specialists Invited community partners to thought leadership and educational events 2017 leadership development opportunities

2nd cohort - Leading in the Middle Wave 4 - Innovative Management 3rd program - Board of Governors Certificate Lambton College Leadership Retreats – September 2017 and March 2017

Challenge Recruitment demands – high volume areas, specialty positions

Key Priorities for 2018/19: Continued development of Succession Planning Model Increase number of composite positions and expand Clinical Reserve Unit Create fourth development program for individuals expressing interest in future management careers Education on the LEADS leadership capabilities framework Train midwives to full scope Physician Management Institute (PMI) physician leadership educational session Partnering with Schulich School of Medicine & Dentistry at Western University to expand training

opportunities, for example CCFP- EM (3rd year in Family Medicine – Emergency Medicine training position at Sarnia Emergency Department)


Promote individual, team and professional development

Enhance an environment of continuous learning

Supervisor helps access training and development


8

Successes Lambton Health Quality Partners collaborative work focused on care transitions Created shared Health Links/Patient Flow Coordinator position between BWH and the Lambton County

Lake Huron Health Link Implemented Community Paramedic Program Enhanced relationships with community partners

weekly ALC reviews enhanced discharge plans with Intensive Hospital to Home Program (IHH) review of ALC leading strategies to identify gaps in practice

Strengthened relations between Pharmacy team and community pharmacies Implemented Admission Family Conferences for patients admitted to CCOG unit Increased Social Work services dedicated to Mental Health Inpatient and Child and Youth programs Strengthened relationships between BWH Medical Affairs and health care providers not affiliated with

BWH Challenges

Inconsistent messaging to patients/families around transition planning (Home First) when dealing with

the myriad community agencies Community capacity for patients with behavioural issues Housing for marginalized populations

Key Priorities for 2018/19 Ongoing advocacy with the ESC LHIN for continued support in the Intensive Hospital to Home program Lambton Health Quality Partners collaborative projects Improved flow of information between BWH and Primary Care Providers Improved coordination between Mental Health and Addiction Services to Community


Build sustainable partnerships and collaborations

Provide a seamless patient journey across the continuum of care

Alternate level of care (ALC) rate


9

Successes Created Indigenous Patient Navigator position Improved Transitions of Care and Discharge Planning Implemented Collaborative Model of Care across all units Launched paediatric, surgical pre-admit and MIC video tour on BWH website Opened Indigenous Birthing Room on Maternal and Infant Care Unit Initiated Anxiety and Fears Rounding with Patient Experience Partners (PEPs) Participation of PEPs in Skills Day to educate staff on role of PEPs Expanded Hospital Elder Life Program (HELP) to CEEH site Developed patient watch policy to ensure right level of service for supporting high-risk patients

Challenges Timeliness and subjectivity of data obtained through patient experience surveys to drive changes at

the point of care

Key Priorities for 2018-19 Staff education on anxiety and fears for patients Introduction of Patient Orientated Discharge Strategy (PODS) to improve communication and the

overall experience Provision of Palliative Care services at CEEH site


Strengthen Patient & Family-Centred Care (PFCC)

Ingrain the four principles of Patient & Family-Centred Care

Overall rating of experience

Goal Initiative Indicator PerformanceJune 2016

TargetYear 1 - 2017

PerformanceYear 1 - May 2017

Target Year 2 - 2018

PerformanceYear 2 - March 2018

Target Year 3 - 2019

Ingrain patient safety Implement a Quality and Patient Safety Plan

It is difficult to speak up if I perceive a problem with patient care

Collecting Baseline Data

To be determined Jan - Mar 2017 41.9%

49.6% April 2017 - Mar 201846.9%

50%

Improve access to care Improve Emergency Department wait times

90th percentile length of stay for admitted patients

22 hours 20 hours Sarnia - 24.6 hours CEEH - 6.8 hours

Sarnia - <=20 hoursCEEH - <= 8 hours

Jan - Dec 2017 Sarnia - 24.9 hours

CEEH - 8 hours

Sarnia - <=20 hoursCEEH - <= 8 hours

Build sustainable partnerships & collaborations

Provide a seamless patient journey across the continuum of care

Alternate level of care (ALC) rate 27.40% 25.00% 21.40% 21.00% April 2017 - Mar 201815.00%

17.20%

ED - 49.1% Apr 2017 - Mar 2018 ED - 49.7%

ED - 50.6%

Inpt - 75.9% Apr 2017 - Mar 2018 Inpt. 68.6% Inpt. 72.0%

Supervisor helps access training and development

63.30% 65.30% December 201666.3%

67.30% Apr 2017 to Mar 201869.4%

NA

NEW INDICATOR- The organization promotes staff health and wellness.

49.40% 51.60% 55.7%

ED - 64.5% Apr 2017 to Mar 2018ED - 66.8%

68.6%

Inpt - 80.4%Apr 2017 to Mar 2018

Inpt - 78.2%81.4%

BWH: Is a culture of kindness promoted at BWH?

Employees -61.9% Prof Staff -56.1%

Volunteers -80.1%

Employees -63.9% Prof Staff -58.1

Volunteers -82.1%

December 2016Employees -58.9% Prof Staff -56.1%

Volunteers -88.6%

Employees -65.9%Prof Staff -60.1%

Volunteers - 84.1%

Apr 2017 - Mar 2018 Employees - 69.9%Prof Staff - 69.1%

Employees - 71.9%Prof Staff - 71.1%


Increase awareness and understanding of resource decisions

Cost per weighted case 2015/16 Q3 $5,537 $5,361 2016/17 Q3$5,669

$5,366 Apr 2017 - Mar 2018$5,788

$5,800


Implement a sustainable plan for services, facilities, capital equipment and technology

Status of plan - Yr 1 No plan Plan Developed Under development Plan Updated Plan Updated Plan Updated

Strategic Plan: Kaleidoscope of Care Monitoring Tool

Outstanding PerformanceOptimize roles, resources, revenues, technology and innovation


Patient: Treated with kindness Q2 2016/1766.7%

To be determined April - Sept. 201676.8%

Strengthen our culture of kindness

To be determined Collecting baseline data

Quality CareAssure the right care, in the right place, at the right time, by the right provider

Exceptional RelationshipsExpand innovative partnerships and collaborations to improve experiences, services, transitions and community health

Inspired PeopleAdvance our culture of kindness with an intention to learn, lead, collaborate and celebrate

Strengthen Patient & Family-Centred Care

Ingrain the four principles of Patient & Family-Centred Care

Overall rating of experience Q2 2016/1771.10 %

Enhance an environment of continuous learning


Revised: May 2018 Next Update: September 2018 Page 5 of 44

Indicator Name: It is difficult to speak up if perceive a problem with patient care

Alignment: Quality and Patient Experience Committee (QPEC)/Quality Committee of the Board (QCB)

Strategic Goal: Ingrain Patient Safety

Definition: This is a custom employee survey question that asks employees to respond to the statement “in this unit it is difficult to speak up if I perceive a problem with patient care”. The top box responses request respondents to “strongly disagree” and “disagree” with the proposed statement. A higher percentage of employees disagreeing or strongly disagreeing with this statement is preferred.

Rationale: “It is difficult to speak up if I perceive a problem with patient care” is a measure that comes from a reliable and valid survey through patient safety research. To ensure we can track and measure this indicator we will assess a baseline and target by sending staff surveys thorough a Survey Monkey process. This indicator is a measure indicative of patient safety culture throughout the organization and will identify how safe the inter-professional team feels to report patient safety incidents. The development, dissemination, education and implementation of a Quality and Patient Safety Plan will enable a culture of safety by enhancing knowledge transfer of the importance of reporting patient safety incidents to improve quality and safety of the patients we serve.

Additional Specifications:

This indicator was released in December 2016. Responses to this question are collected routinely in a Strategic Engagement survey.

Target for 17/18: 49.6%

Bluewater Health Target 49.6%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Q3 16/17 Q4 16/17 Q1 17/18 Q2 17/18 Q3 17/18

Dif

ficu

lt

to s

pe

ak u

p

Difficult to Speak up if Perceive a Problem with Patient Care

Pre

ferre

d Tre

nd

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Our Status


Indicator Name: 90th Percentile Emergency Department Length of Stay (LOS) for Admitted Patients

Alignment: Performance & Utilization Committee (PUC)/Resource Utilization & Audit Committee (RUAC)

Strategic Goal: Improve access to care

Definition: ED length of stay for admitted visits is defined as the time from triage or registration, whichever comes first, to the time the patient leaves the ED to an inpatient bed. It is measured in hours. The 90th percentile is the maximum length of time in which 9 of 10 of admitted patients have completed their ED visit and have been moved to an inpatient unit. A small number is desirable.

Rationale: Time is crucial to the effectiveness and outcome of patient care, especially for emergency patients. In conjunction with other indicators, this can be used to monitor the total length of time admitted patients spend in the ED in an effort to improve the efficiency and, ultimately, the outcome of patient care. This measure remains one of Bluewater Health’s top priorities in our Quality Improvement Plan (QIP) and Strategic Plan.


Inclusions:

1. Admitted unscheduled emergency visits2. ED visits with a valid and known registration date/time or triage date/time

and a valid and known date/time the patient left the ED

Exclusions:

1. Scheduled emergency visits2. Non-admitted unscheduled emergency visits3. Visits with both unknown/invalid registration and triage date/time OR with

unknown/invalid patient left ED date/time

Peer Comparator: Ontario high-volume community hospitals, Sarnia Site only

Sarnia Site

Petrolia Site

Target

Ontario high-volume community hospitals 16/17

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Q1 16/17 Q2 16/17 Q3 16/17 Q4 16/17 Q1 17/18 Q2 17/18 Q3 17/18 Q4 17/18

ED

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90th Percentile ED LOS(Admitted Patients)

Pre

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Sarnia

Status

CEEH

Status


Indicator Name: Alternate Level of Care (ALC) Rate %-All Inpatient Services

Alignment: Quality and Patient Experience Committee (QPEC), Quality Committee of the Board (QCB), Performance & Utilization Committee (PUC), Resource Utilization & Audit Committee (RUAC)

Strategic Goal: Build sustainable partnerships and collaborations

Definition: The rate at which patients who have been designated ALC occupy inpatient beds.

Rationale: Ensuring that each patient receives the appropriate level of care at all times during their healthcare journey is a priority at Bluewater Health. Our goal is for Emily to receive the right care, given at the right time, in the right place, always. The ALC rate represents an opportunity for inpatients to be transitioned to the next level of care, where their care needs and the services provided are better matched. Multiple factors can influence ALC rate, including overall hospital occupancy, and availability of resources both internal and external to the hospital.


ALC Rate = Total number of ALC Days in a given period

Total number of inpatient days in the same time period ×100%

Peer Comparator: Ontario hospital value

ALC Rate

Bluewater HealthTarget

Provincial Target FY 17/18

ALC Days

0

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Q1 16/17 Q2 16/17 Q3 16/17 Q4 16/17 Q1 17/18 Q2 17/18 Q3 17/18 Q4 17/18

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ALC Rate % -All Inpatient Services (Sarnia and Petrolia)

Pre

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Our Status


Indicator Name: Overall Rating of Experience


Strategic Goal: Strengthen Patient and Family-Centered Care

Definition: Overall Rating of Experience: Inpatient (IP) and Emergency Department (ED), patients are asked to rate their hospital experience on a scale from 0 to 10, with 0 being I had very poor experience and 10 being I had a very good experience.

Rationale: Patient experience measurement is an industry best practice and hospitals are required to survey patients at least once every fiscal year, according to Ontario’s Excellent Care for All Act (ECFAA), 2010. “We create exemplary healthcare experiences with patients and families every time”, is the mission of Bluewater Health. These questions reflect how well the hospital is achieving its overall mission. The patient experience is what we strive to excel at. Measurement of patient experience is important because it provides an opportunity to improve care, enhance strategic decision making, meet patients’ expectations, effectively manage and monitor healthcare performance, and document benchmarks for the organization.


Scores are calculated using the following measure recommended by the National Research Corporation Canada (NRCC): Positive - Positive measure type is calculated by counting “Positive” response (i.e., 9-10 or Yes, Definitely or Always) and dividing by the total number of responses.

Inclusion Criteria: - Patients who have received active treatment at Bluewater Health

- 18 years or older at the time of admission- Alive at the time of discharge

Exclusion Criteria: - Patients who have notified Bluewater Health they wish to be excluded from

the mailing list- Patients who are stillborn or deceased while in the hospital- Patients with no fixed address

- Psychiatric patients (unless being specifically surveyed using the MentalHealth inpatient or outpatient survey tool)

- Patients who present with evidence of sexual assault or with sensitiveissues (e.g., miscarriage)

Peer Comparator: The Ontario Hospital Association Patient Reported Performance Management (OHA PRPM) benchmark includes OHA member hospitals. The Ontario Inpatient (IP) Community Hospital (Hosp) Average compares hospitals of the same size within the province. Peer comparators are updated quarterly.

Inpatient OHA-PRPM – 68.2% Ontario IP Community Hosp Average – 65.0%

Emergency Department (ED) There is no peer comparator as this is a Bluewater Health custom question for the Emergency Department Patient Experience of Care Survey (EDPEC)

Target for 2017/2018:

ED - 49.1% Inpatient – 75.9%

ED Target 49.1%

Inpatient Target 75.9%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Apr16

May16

Jun16

Jul16

Aug16

Sep16

Oct16

Nov16

Dec16

Jan17

Feb17

Mar17

Apr17

May17

Jun17

Jul17

Aug16

Sep16

Oct17

Nov17

Dec17

Jan18

Feb18

Mar18

Q1 16/17 Q2 16/17 Q3 16/17 Q4 16/17 Q1 17/18 Q2 17/18 Q3 17/18 Q4 17/18

Ov

era

ll R

ati

ng

of

Exp

eri

en

ce

Overall Rating of Experience

ED Inpatient

Pre

ferre

d T

ren

din

g

ED

StatusInpatient

Status

http://www.health.gov.on.ca/en/pro/programs/ecfa/legislation/patientsurvey/update.aspx


Indicator Name: Supervisor helps access training and development


Strategic Goal: Focus on the experience of care and caring

Definition: This is a custom employee survey question that will ask “My Supervisor helps me to access training and development?” The top box responses request respondents to “Agree” and “Strongly Agree” with the proposed statement. A higher percentage of employees agreeing or strongly agreeing with this statement is preferred.

Rationale: Ensuring that each patient receives the best care possible begins with exceptional care providers. Bluewater Health is committed to strengthening the skills and education of our employees. This commitment to education promotes inspired people who will advance our culture of kindness with an intention to learn, lead, collaborate and celebrate. Evidence suggests that investment in employee training and development leads to employees feeling more valued and willing and able to invest in their work. Employee training and development supports efficiencies and standardized procedures, risk reduction, patient safety and quality of patient care. Research links high levels of employee engagement with increased patient satisfaction when an organization focuses on processes and people. This reflects on the organization’s ability to provide opportunities for personal development to stay up to date with latest techniques and technologies and recognize employees for acquiring additional skills and knowledge sets.




67.3%


0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Q3 16/17 Q4 16/17 Q1 17/18 Q2 17/18 Q3 17/18

Su

pe

rvis

or

he

lps a

cce

ss t

rain

ing

&

de

ve

lop

me

nt

Supervisor Helps Access Training and Development

Pre

ferre

d T

ren

din

g

Our Status


Indicator Name: Was Patient/Family Treated with Kindness



Definition: This is a new, custom question for Bluewater Health’s patient experience surveys which are mailed to a random selection of patients after they are discharged. Our aim is that the culture of kindness at Bluewater Health will be increasingly felt by our patients and families over time. This question asks Emily to reflect and respond to the statement “Were you and your family treated with kindness by employees, volunteers and physicians at Bluewater Health?” Responses available for this question are as follows: No/ Yes, somewhat/ Yes, mostly/ Yes definitely

Rationale: Exemplary healthcare experiences begin with kindness. We understand that patients expect courtesy, respect and dignity, beginning with an expression and attitude of kindness and caring. We understand that having highly skilled and competent staff isn’t enough. Ensuring that you and your family are treated with kindness is a key focus of Bluewater Health’s commitment to Patient & Family-Centered Care. Patient experience measurement is an industry best practice and hospitals are required to survey patients at least once every fiscal year, according to Ontario’s Excellent Care for All Act (ECFAA), 2010.


Scores are calculated using the following measure recommended by the National Research Corporation Canada (NRCC): Positive - Positive measure type is calculated by counting “Positive” response (i.e., 9-10 or Yes, Definitely or Always) and dividing by the total number of responses. Inclusion Criteria: - Patients who have received active treatment at Bluewater Health





Peer Comparator: This is a Bluewater Health custom question and no peer comparator data is available. NRC Health establishes benchmarks/peer comparators based on the following requirements:

- Made up of one year of data- Questions must be used by at least five facilities

Must have at least 1000 responses for the question

Target for 2017/18: ED - 64.5% Inpatient - 80.4%

ED Target 64.5%

IP Target 80.4%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Apr16

May16

Jun16

Jul16

Aug16

Sep16

Oct16

Nov16

Dec16

Jan17

Feb17

Mar17

Apr17

May17

Jun17

Jul17

Aug16

Sep16

Oct17

Nov17

Dec17

Jan18

Feb18

Mar18

Q1 16/17 Q2 16/17 Q3 16/17 Q4 16/17 Q1 17/18 Q2 17/18 Q3 17/18 Q4 17/18

Wa

s P

atie

nt/

Fa

mily

Tre

ate

d w

ith

K

ind

ne

ss

Was Patient/Family Treated with KindnessED Inpatient

Pre

ferre

d T

ren

din

g

Inpatient

Status

ED

Status



Indicator Name: Is a Culture of Kindness Promoted at Bluewater Health Alignment: Quality and Patient Experience Committee (QPEC)/Quality Committee of the Board

(QCB)


Definition: This is a custom survey question that will ask “Is a culture of kindness promoted at BWH?” Top Box responses from Employees, Professional Staff and Volunteers are displayed. The top box responses request respondents to “Agree” and “Strongly Agree” with the proposed statement. A higher percentage of employees agreeing or strongly agreeing with this statement is preferred.

Rationale: Bluewater health is committed to strengthening our culture of kindness while we deliver Quality Care to Emily. Creating a kindness culture in the workplace reduces stress, fosters relationships, increases psychological wellness and health and leads to increased engagement, energy and resiliency at work. Evidence suggests that high engagement influences human resource goals of increased retention and recruitment, high job performance and lower absenteeism. Research links high levels of employee engagement with increased patient satisfaction when an organization focuses on processes and people. Caring for people creates a workforce with physical energy, mental focus and the emotional drive necessary to provide exemplary care to Emily every day. The culture of kindness has been measured in the “joy” people bring to work; it is palpable throughout the organization and referred to as measuring “humanity”.




Employees – 65.9% Professional Staff - 60.1% Volunteers - 84.1%

Employee Target 65.9%

Professional Staff Target 60.1%

Volunteer Target 84.1%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Q3 16/17 Q4 16/17 Q1 17/18 Q2 17/18 Q3 17/18Is a

Culture

of Kin

dness

Pro

mote

d a

t BW

H

Is a Culture of Kindness Promoted at Bluewater Health

Employees Prof. Staff Volunteers

Pre

ferre

d Tre

nd

ing

Our Status


Indicator Name: Acute Cost per Weighted Case

Alignment: Resource Utilization and Audit Committee (RUAC)/Performance Utilization Committee (PUC)

Strategic Goal: Demonstrate accountability and efficiency

Definition: Acute Cost per Weighted Case is an indicator that measures the cost associated with caring for a standard acute patient. It is calculated as total acute inpatient and newborn expenses (both direct and indirect) divided by acute inpatient weighted cases. The direct costs are the expenses incurred in the departments providing service to our acute patients (e.g., Medicine, Surgery, and Obstetrics). The indirect costs are an allocation of Administration and Support expenses (e.g., Housekeeping, Lab, Pharmacy, etc.). A weighted case is a case with an assigned Resource Intensity Weight (RIW).

Rationale: This is an important indicator as it tracks how an organization is utilizing its resources. It combines the financial spending with the activity that drives the spending. By focusing on weighted cases, comparability is enhanced as differences in acuity, severity and complexity of cases are taken into consideration.


Peer Comparator: No established peer comparator data

Target

5000

5100

5200

5300

5400

5500

5600

5700

5800

5900

6000

Q1 16/17 Q2 16/17 Q3 16/17 Q4 16/17 Q1 17/18 Q2 17/18 Q3 17/18 Q4 17/18

Co

st

pe

r W

eig

hte

d C

ase

Cost per Weighted Case: Acute Inpatient & Day Surgery (53% of overall activity)

Pre

ferr

ed

Tre

nd

ing

Our StatusOur Status

1

Governance and Nominating Committee Highlights

June 13, 2018

Board Evaluation Members were requested to complete a Committee evaluation survey and reviewed the Exit Survey to be distributed to members leaving the Board. Special note was made of the Committee’s accomplishments and appreciation was shared for the work of all involved. Board Education/Orientation/Team Building The Committee received an overview of orientation/education plans for new and existing Board members to begin this summer and continue into next spring. The plan includes general governance orientation, committee specific orientation, a fall Board Retreat focused on Accreditation, the new Ethical and Integrated Risk Management Frameworks, and more. The Committee also discussed governance best practice information learned through recent Ontario Hospital Association (OHA) conferences, with plans to address the recommendations in the fall. Review of Board Policies The Committee learned a full review of the Board’s policies would take place over the summer months to ensure readiness for Accreditation in April 2019. Members also reviewed a number of policies recommended for Board approval in the Consent Agenda. Submitted by: Brian Knott

Quality Committee of the Board Highlights

June 18, 2018

Program Report: Best Practice, Director Quality & Patient Experience and Interprofessional Practice, Dave Remy • Successes: implementation of Red Rule where BWH is required to use two approved patient

identifiers before provision of patient care; Choosing Wisely Committee employing several communication strategies to reduce the amount of rib and spine x-rays – this initiative is aimed at reducing unnecessary tests

• Challenges: fear of reporting breaches to the Red Rule due to performance management; ensuring Choosing Wisely communication strategies are clear and sustainable as well as education of new physicians is occurring

• Next Steps: continue Red Rule Fridays, promotion of the Good Catch Program and Rounding; continue reporting and auditing for Choosing Wisely initiative

Patient Experience Concerns and Compliments Report and Patient Family-Centred Care Action Plan, Dave Remy • January 1 to March 31, 2018 concerns and compliments data was reviewed • Lisa Hawthornthwaite has been hired as the new Patient Experience Specialist • BWH has hired an Indigenous Patient Navigator, Nikki George, a media announcement and contact

information are available on the BWH website • Patient Experience Partners (PEPs) have been rounding to the units with Shannon Landry to meet

with staff and patients regarding anxiety and fears Quality and Patient Safety Program Report, Dave Remy • a review and current state of patient falls has been conducted and training is being completed on the

safe use of bed alarms to mitigate risk • workplace violence signage has been completed and is ready for deployment • several skills days have taken place: wound care, PICC lines and safe practice • preparation for the April 2019 Accreditation is happening • quality of care reviews have been increased to explore themes for continuous improvement of

patient experience and allow for more open communication than formal QCIPA reviews • patient falls continue to be an area of focus due to the frequency on the critical incident list, PSWs

are rounding hourly to assist in preventing falls, improvements have been noted over the past 2 months

• at present there is nothing to report for the Quality Improvement Plan

Monitor Litigation Claims Report, Margaret Mai, Coordinator Risk Management, shared the 2017 Annual Liability/Crime Claims Report. Monitor Research being undertaken within BWH, Margaret Mai, reviewed the infographic that details BWH’s research activity in 2017. The Ethics and Research Committee reviews all research requests utilizing BWH’s Ethical Framework. NOW Update, Julie Acker and Kim Kraeft, Performance and Transformation Specialists reviewed the slides, driver diagram and whiteboard video outlining the purpose of this initiative. Activities are currently being prioritized and staff assigned into working groups. Submitted by: Paul Wiersma

Meets/Exceeds Target .

Within 5% of Target

Worse than Target by 5+%

Data Unavailable

FOI Masked due to n size <5

Italics n Size between 6 - 30

* no established target

ⱡ corporate target

Jan

17

Feb

17

Mar

17

Apr

17

May

17

Jun

17

Jul

17

Aug

17

Sep

17

Oct

17

Nov

17

Dec

17

Jan

18

Feb

18

Mar

18

Apr

18 Re

po

rt

Pe

rio

d

YTD

1 QIP n/a * 97 97 97 95 97 97 97 96 96 98 98 97 97 97 97 98Apr -

Mar98%

Med Rec at Discharge calculation now excludes disposition X (left without

being seen), locations Emergency Department Inpatient (EDIN), Day Surgery

(SURDS) and Residential Withdrawal Management (RWMS). Scorecard data

has been modified to reflect this change

◄

2 SP n/a 49.6% 0.00 0.00 0.00 0.00 0.00 0.00Apr -

Mar46.9%

Top Box Responses for all sectors, n size for Q3 reporting period 165. No data

available for Q2 as the survey was not administered. 0.00

3 0 n/a 0 0Apr-

Mar7

YTD number is 17/18 for high severity incidents

3 Level 3 incidents, 4 Level 4 incidents in FY 17/180.00

Sarnia 10.1 8.1 9.3 9.6 9.0 9.7 8.0 8.9 9.8 9.4 10.0 8.8 11.2 9.6 8.4 9.5 9.60

◄

Petrolia 4.1 3.9 4.3 4.4 3.9 4.0 4.1 4.7 4.0 5.0 3.7 3.8 4.6 4.2 3.7 4.1 4.20.0

◄

Exceptional Relationships - Expand innovative partnerships and collaborations to improve experiences, services, transitions and community

5QIP/

HSAA12.7% 21.0% 18.4 17.2 18.5 16.7 17.8 -- 21.5 17.2 17.7 18.6 14.8 15.7 16.9 15.9 16.4 15.0

Apr -

Mar15.0%

ALC Rate denominator has changed with the implementation of the Daily Bed

Census Summary in June 2017, values are subject to change; March & April

2018 data is preliminary and subject to change

◄

6 QIP n/a 16.5%Apr-

Mar13.0%

OMHRS assessments: 30 days or less since last discharge from this facility;

excluding short-stay assessments ◄

7 QIP 18.2% 16.9% 0.0 0.0 0.0Apr-

Mar19.0% This is preliminary data and subject to change 0.0

ED n/a 49.1% 41.7 43.5 53.3 55.8 50.8 46.0 48.6 50.9 46.6 51.2 36.8 53.1 57.6 55.6 41.5 49.8%Positive score = 9 & 10

◄

Inpatient 65.2% 75.9% 68.4 72.2 82.1 78.0 67.3 66.0 67.8 75.5 63.1 73.7 63.5 61.0 70.5 62.3 73.5 68.4%Positive score = 9 & 10

◄

ED 82.2% 81.0% 82.3 87.5 84.7 94.1 87.5 72.5 81.6 70.9 80.6 70.5 82.1 86.2 91.5 79.4 84.6 82.1%Positive score = Yes

◄

Inpatient 53.4% 61.6% 63.8 61.0 53.7 57.4 55.6 57.1 52.6 67.3 44.6 62.2 56.2 58.3 54.7 45.7 54.2 55.4%Positive score = Completely

◄

Inspired People - Advance our culture of kindness with an intention to learn, lead, collaborate and celebrate

10 SP n/a 67.3% 0.0 0.0 0.0Apr -

Mar69.4%

Strategic Engagement Survey, top Box Responses Q3 employee reporting

period n=137 0.0%

ED n/a 64.5% 68.9 66.7 69.5 66.7 62.9 57.7 73.0 70.4 71.2 55.8 68.4 69.8 76.3 65.1 57.5 66.6%Positive score = Yes, definitely

◄

Inpatient n/a 80.4% 75.9 73.4 88.3 81.4 81.8 71.4 81.7 85.7 82.1 84.0 73.9 81.4 66.7 68.5 78.0 77.9%Positive score = Yes, definitely

◄

12 SP n/a * 0.0Apr -

Mar74.3%

YTD is Top Box Responses for all sectors, Q3 reporting period n=1650.0%69.1

0 0

Q1 17/18

73.168.2

11.3

Apr -

Mar

Apr -

Mar

Jan-

Dec

Q4 16/17

19.2

12.0 8.4

21.6

Strengthen Patient and Family-Centred Care

10.1

hrs

19.2

ALC Rate % -All Inpatient Services

(Sarnia and Petrolia)

13.0

18.8

QIP

64.2 0.00

Up

da

ted

Comments

0

Q3 17/18 Q4 17/18

5

YTD Performance

41.9

Q2 17/18

43.0

2

49.4

Quality Care - Assure the right care, in the right place, at the right time, by the right provider

Q1

18/19

11

Readmission within 30 days for COPD

Was Patient/Family Treated with

Kindness

Is a Culture of Kindness Promoted at BWH

Supervisor helps access training and

development

8

Leaving hospital did patients

receive enough information

Total High Severity Patient Safety Incidents


9

Performance Indicator Ref.



#

Pe

er

Co

mp

ara

tor

BW

H

Ta

rge

t4

90th Percentile ED Length of Stay

for Complex Patients

Bluewater Health Quality Committee

Performance Scorecard

77.5

SPApr -

Mar


QIP/

HSAA/

P4R

30-Day Mental Health Readmission


Difficult to speak up if perceive a problem with

patient care

Medication Reconciliation at Discharge

<=8

hrs

60.1

QIP

15.4

June 2018 with April data

n size: 41 n size: 44

n size: 49 n size: 51


Target:

N/A

YTD n size: 432

Quality Committee Key Performance Indicators



Target

49.6%



Difficult to speak up if perceive a

problem with Patient Care

YTD n size: 432

Received Enough

Information Emergency


21.0%

June data unavailable

province-wide due to daily

bed census summary

methodology changes



Strengthen Patient and Family-Centered Care


Emergency Department

BWH Target

54.2%BWH Target

61.6%

BWH Target

49.1%


Inpatient Units

BWH Target

75.9%

41.5%

73.5%

Received Enough

Information Inpatient

BWH Target

81.0%

77.3%

97 97 9795 97 97 97 96 96 98 98 97 97 97 97 98

60

70

80

90

100

JAN

17

FEB

17

MAR

17

APR

17

MAY

17

JUN

17

JUL

17

AUG

17

SEP

17

OCT

17

NOV

17

DEC

17

JAN

18

FEB

18

MAR

18

APR

18

Medication Reconciliation at Discharge

0

5

2

0

0

0 1 2 3 4 5 6

Q4 16/17

Q1 17/18

Q2 17/18

Q3 17/18

Q4 17/18

Total High Severity Incidents

18.4

17.2

18.5

16.7

17.8

0.0

21.5

17.2

17.7

18.6

14.8

15.7

16.9

15.9

16.4

15.0

0.0

5.0

10.0

15.0

20.0

25.0

Jan17

Feb 17

Mar 17

Apr17

May17

Jun17

Jul17

Aug17

Sep17

Oct17

Nov17

Dec17

Jan18

Feb18

Mar18

Apr18

ALC Rate % - All Inpatient Services (Sarnia & Petrolia)

ALC Rate Provincial Target BWH Target

0.0

20.0

40.0

60.0

80.0

100.0

Jan17

Feb 17

Mar 17

Apr17

May17

Jun17

Jul17

Aug17

Sep17

Oct17

Nov17

Dec17

Jan18

Feb18

Mar18


ED Inpatient ED Target IP Target

0.0

20.0

40.0

60.0

80.0

100.0

Jan17

Feb 17

Mar 17

Apr17

May17

Jun17

Jul17

Aug17

Sep17

Oct17

Nov17

Dec17

Jan18

Feb18

Mar18

Leaving Hospital did Patients Receive Enough Information

ED Inpatient BWH ED Target BWH IP Target

68.9

66.7

69.5

66.7

62.9

57.7

73.0

70.4

71.2

55.8

68.4

69.8

76.3

65.1

57.5

75.9

73.4

88.3

81.4

81.8

71.4

81.7

85.7

82.1

84.0

73.9

81.4

66.7

68.5

78.0

0.0

20.0

40.0

60.0

80.0

100.0

Jan17

Feb 17

Mar 17

Apr17

May17

Jun17

Jul17

Aug17

Sep17

Oct17

Nov17

Dec17

Jan18

Feb18

Mar18

Was Patient/Family Treated with Kindness

ED Inpatient BWH ED Target BWH IP Target

74.3%

46.9%

10.1

8.1

9.3

9.6

9.0

9.7

8.0

8.9

9.8

9.4

10.0

8.8

11.2

9.6

8.4

9.5

4.1

3.9

4.3

4.4

3.9

4.0

4.1

4.7

4.0

5.0

3.7

3.8

4.6

4.2

3.7

4.1

0

2

4

6

8

10

12

Jan17

Feb 17

Mar 17

Apr17

May17

Jun17

Jul17

Aug17

Sep17

Oct17

Nov17

Dec17

Jan18

Feb18

Mar18

Apr18

90th Percentile ED Length of Stay for Complex Patients

Sarnia Petrolia Peer Comparator BWH Target

Resource Utilization and Audit Committee (RUAC)

June 14, 2018 Highlights

N.O.W. (No One Waits Collaborative Organizational Planning Update The Committee received a presentation on the N.O.W. (No One Waits) initiative which highlighted the aim, work done to date and challenges facing BWH. The feedback was collated to form a Driver Diagram outlining the specific priorities for the initiative. 2018-19 - Hospital Accountability Planning Submission Refresh – Hospital Service Accountability Agreement (H-SAA) Schedules The Committee was informed the schedules in the Hospital Accountability Planning Submission (HAPS) will need to be updated to reflect the new funding information submitted in the Hospital Service Accountability Agreement (H-SAA) extension. The revised HAPS will then be submitted to the ESC LHIN in July. ESC LHIN Framework Community Investment The ESC LHIN Funding Framework Guideline for Community Investment briefing note and Ministry of Health and Long-Term Care mandate letter were shared with the Committee. The Funding Framework Guideline provides decision-making guidance for the distribution of elective community related funding. The framework aligns with the ESC LHIN Integrated Health Services Plan (IHSP) and the Patients First: Proposal to Strengthen Patient Centred Health Care in Ontario. It was noted the BWH’s Strategic Priorities align with the ESC LHIN IHSP 4 Strategy Priorities, and the funding framework aligns with the ESC LHIN Strategic Priorities. In addition, the following will be coming forward separately for Board approval: - Auditor’s Report and 2017-18 Financial Statement - Appointment of the Audit Firm - Broader Public Sector Accountability Act (BPSAA) Compliance – Consultant

Use/Allowable-Perquisites - Monthly Financial Statement - Multi-Sector Accountability Agreement (M-SAA) - 2018-19 Targets for the RUAC Strategic Indicators Submitted by: Marg Dragan Chair, Resource Utilization and Audit Committee

Statement of Revenue and ExpenseForecast surplus/(deficit) as at March 31, 2019Based upon the one (1) months ended April 30, 2018(000's)

18/19 18/19 18/19 18/19 18/19 18/19 Projected 18/19 NotesYTD YTD YTD YTD % Annual Forecast Variance to Forecast %

Budget Actual Variance Variance Budget Amount Budget Variance

Revenue $

LHIN Revenue 12,114 12,044 (70) -1% 147,384 147,384 - 0% 1Cancer Care Ontario Revenue 566 598 32 6% 6,882 6,914 32 0% 2Paymaster Funding 102 101 (1) -1% 1,243 1,243 - 0%OHIP Revenue 1,042 1,090 48 5% 12,682 12,730 48 0% 3Patient Revenue - Other 132 129 (3) -2% 1,604 1,604 - 0%Room differential 236 214 (23) -10% 2,876 2,853 (23) -1%Co-payment 34 36 3 8% 410 413 3 1%External Recoveries 223 139 (85) -38% 2,896 2,896 - 0%Parking Revenue 152 123 (28) -19% 1,020 1,020 - 0%Other Revenue 2 2 (0) -21% 189 188 (0) 0%Deferred Equipment Grants 199 183 (16) -8% 2,427 2,427 - 0%Interest and Donations 5 14 10 193% 60 70 10 16%

Total Revenue $ 14,808 14,674 (133) -1% 179,671 179,740 69 0%

Expenses $

Salaries and Wages 7,333 7,505 (172) -2% 89,903 89,903 - 0% 4Medical Staff Remuneration 1,669 1,723 (54) -3% 20,301 20,362 (61) 0% 3Employee Benefits 2,091 2,054 38 2% 24,202 24,202 - 0% 4Employee Future Benefits 26 41 (15) -57% 320 335 (15) -5%Utilities, Buildings & Grounds 368 300 67 18% 4,474 4,399 75 2% 5Equipment Expense 493 482 11 2% 6,529 6,532 (3) 0%Supplies and Expenses 997 856 141 14% 11,983 11,983 - 0%Contracted Out Services 301 291 10 3% 3,662 3,652 10 0%Medical/Surgical Supplies 706 763 (57) -8% 8,588 8,645 (57) -1% 6Drug Expense 451 436 15 3% 5,480 5,466 15 0%Interest Expense 14 12 2 13% 168 166 2 1%Amortization 425 368 57 13% 5,344 5,344 - 0%

Total Expenses $ 14,873 14,831 42 0% 180,954 180,988 (34) 0%

Hospital Operating Surplus/(Deficit) $ (65) (156) (91) n/a (1,283) (1,248) 36 n/a

Net Marketed Service Surplus/(Deficit) 28 77 49 175% 362 362 - 0%

Net Other Vote Surplus/(Deficit) (4) (0) 4 n/a 0 0 - n/a

LHIN Operating Surplus/(Deficit) $ (41) (80) (39) (921) (885) 36

Deferred Building Grants 727 739 11 2% 8,854 8,854 - 0%Building Amortization (843) (863) (19) 2% (10,405) (10,405) - 0%Interest on L/T Liabilities (7) (8) (1) 12% (168) (168) - 0%

Operating Surplus/(Deficit) $ (164) (212) (48) (2,639) (2,604) 36

Notes to Financial StatementsApril 30, 2018 Actual and Full Year Forecast

Note 1

Note 2

YTD Actual Annual Budget

Year-End Forecast

$ 220,000 $ 2,280,000 $ 2,312,250

$ 361,476 $ 4,397,963 $ 4,397,963 $ 16,378 $ 203,570 $ 203,570

$ 597,854 $ 6,881,533 $ 6,913,783

Note 3

Note 4

Note 5

Note 6

Total FundingOntario Breast Screening Program Funding

Bluewater Health is forecasting a deficit of $885K for the 18/19 fiscal year which is slightly better than the budgeted deficit of $921K. At the end of April, the hospital had a deficit of $80K which is $39K higher than the budgeted deficit for the month of April.

LHIN Revenue is forecasted to be on budget for year-end. For the month of April, LHIN Revenue is under budget by $70K. This is mainly due to a timing issue regarding post acute QBP funding for bundled payments.

Bluewater Health does OHIP billings for various physician groups. There is an offsetting Med Staff Remuneration expense for these billings. The April variance is primarily CT, and MRI. There has been an increase in exams for both of these areas in the month of April.

Bluewater Health receives CCO funding for Oncology Drugs, QBPs, and the Ontario Breast Screening Program. Bluewater Health is forecasting achieving all QBP funding for Cancer Surgeries and the Oncology program.

Description

Oncology Drug Funding

QBP Funding (Cancer Surgeries, Endoscopy, Systemic Therapy)

Utilities are under budget $67K in the month of April. The budget was reduced to align with the 17/18 actual utility expense. The hospital is forecasting a postive variance of $75K for the end of the fiscal year.

Salaries & benefits are over budget by a net $134K in April. The variance in the month is primarily due to over-time costs. This negative variance should lessen over the summer months.

Med/Surg supplies are over budget by $57K in April. This negative variance is primarily attributed to the Operating Room which performed higher volumes of hip & knee replacements in the month. This negative variance is forecasted to remain until year-end.

Balance SheetAs at April 30, 2018Comparison to April 30, 2017(000's)

% Change

Assets

Current AssetsOperating Cash $ 10,308 6,179 67%Short-Term Investments 494 357Investments - CEE Site 770 1,281 116%Accounts Receivable 5,134 6,544 301%Accounts Receivable - MOHLTC 6 394 -100% Inventories 884 512 124%Prepaid Expenses 1,883 1,421 268%

Total Current Assets 19,479 16,688 17%

Fixed AssetsLand and Land Improvements 7,446 7,446Building/Building services Equipment 333,272 331,471Furniture and Equipment 87,860 84,656Less: Accumulated Amortization (175,261) 253,316 (161,095) 262,478 -3%Construction in Progress 1,238 1,247 -1%Other Non Current Assets 399 353 13%

Total Fixed Assets 254,953 264,078 -3%

Total Assets $ 274,432 280,766 -2%

Current LiabilitiesAccounts Payable 4,262 2,256 89% Accounts Payable - MOHLTC 1,074 576 87%Accrued Salaries & Vacation Pay 9,379 8,181 15%Current Portion - Long Term Debt 1,016 992 2%Other Liabilities 6,917 8,486 -18%

Total Current Liabilities 22,648 20,491 11%

Long Term LiabilitiesLong Term Bank Loans Payable 2,970 4,076 -27%Deferred Revenue 219,947 227,506 -3%Post Employment Benefits 15,706 16,393 -4%Other L/T Liabilities 1,505 985 53%

Total Long Term Liabilities $ 240,128 248,961 -4%

EquityOpening Equity 11,869 11,289Accumulated Remeasurement Gain/(Loss) 11R&E Surplus/(Deficit) (213) 14

Total equity 11,656 11,314 3%

Total Liabilities and Equity $ 274,432 280,766 -2%

Hospital Accountability Agreement Indicators: Negotiated Target

Current Ratio 0.83 0.75 0.72

Adjusted Working Capital 2,887$ 1,422$ -$

Note: Current ratio excludes CEEH Site Investments

Adjusted Working Capital is calculated using the definition of the Working Capital Funding Initiative

Apr-18 Apr-17

2018/19 2017/18Actual Actual

Meets/Exceeds Target .

Within 5% of Target

Worse than Target by 5+%

Data Unavailable

FOI Masked due to n size <5

Italics n Size between 6 - 30

* no established target

ⱡ corporate target

Jan

17

Feb

17

Mar

17

Apr

17

May

17

Jun

17

Jul

17

Aug

17

Sep

17

Oct

17

Nov

17

Dec

17

Jan

18

Feb

18

Mar

18

Apr

18 Re

po

rt

Pe

rio

d

YTD

Sarnia 10.1 8.1 9.3 9.6 9.0 9.7 8.0 8.9 9.8 9.4 10.0 8.8 11.2 9.6 8.4 9.5 9.60

◄

Petrolia 4.1 3.9 4.3 4.4 3.9 4.0 4.1 4.7 4.0 5.0 3.7 3.8 4.6 4.2 3.7 4.1 4.20.0

◄

Sarnia 27.2 19.9 24.9 26.5 23.9 27.6 16.6 20.9 25.0 27.0 28.2 25.7 29.9 27.9 26.0 21.6 27.2 0 ◄

Petrolia 7.5 7.7 7.3 7.2 7.9 8.8 7.3 6.9 8.4 13.8 10.1 7.0 7.8 10.2 7.7 7.9 8.0 0.0 ◄


3QIP/

HSAA12.7% 21.0% 18.4 17.2 18.5 16.7 17.8 -- 21.5 17.2 17.7 18.6 14.8 15.7 16.9 15.9 16.4 15.0

Apr -

Mar15.0%

ALC Rate denominator has changed with the implementation of the Daily Bed

Census Summary in June 2017, values are subject to change; March & April

2018 data is preliminary and subject to change

◄


4 0.00 3.10 3.10Apr -

Mar0.00 Q4 data has been validated and reflects extended absences due to illness 0

5 SP n/a $5,366 $5,799

Our overall expenses for this indicator have increased by $2.54M compared to

16/17 while our weighted cases are 37 lower for the same period. ◄

6 n/a $5,419 $5,849

Our overall expenses for this indicator have increased by $856K and our

weighted cases have increased by 57 cases compared to 16/17. ◄

7 n/a $12,703 $10,823

0

◄

8 n/a $517 $0Apr -

Mar$620

Our overall expenses for this indicator have decreased by $316K compared to

16/17. The weighted patient days have decreased as well. ◄

9 0 n/a $350 $333 $354 $332 $341 $290 $278 $285 $289 $303 $300 $302 $303 $302 $304 $338 $338Apr-

Mar$338 0 ◄

10 n/a $0 -$202 $0 $0 -$59 $0 $0 $0 -$160 -$238 -$350 -$370 -$418 -$426 $134 $143 -$44Apr -

Mar-$44

Underage a result of new Bundled Payment QBP funding.

◄

11 0 n/a $172 $1,220 $794 $883 $142 $206 $349 $762 $1,096 $873 $1,411 $1,141 $1,370 $1,218 $1,711 $2,094 -$80Apr -

Mar-$80 0 ◄

12 HSAA n/a $89 $31 $47 $818 $1,422 $2,705 $2,934 $3,003 $4,228 $3,638 $3,881 $3,425 $3,921 $3,780 $5,357 $2,373 $2,887Apr -

Mar$2,887 0 ◄

13 0 n/a % 66 81 83 0 0 15 21 22 23 26 36 36 40 71 79 0Apr -

Mar0% 0 ◄

$10,964

$5,849

3.42

$5,925

<=8

hrs

<= 20

hrs

$5,799

Absenteeism Rate- (avg # 7.5hr sick days)-All

Staff

$5,991

$620

Bluewater Health Resource Utilization &

Audit Committee Performance Scorecard

Apr -

Mar

P4R

2.80


Cost per

Weighted Case

(Actual YTD):

2.92

QIP/

HSAA/

P4R

$5,853

$622$559

33.2

hrs

90th Percentile ED Length of Stay

for Complex Patients

90th Percentile ED Wait Times

(Admitted Patients)

2.80 3.25

# Performance Indicator Ref.


Pe

er

Co

mp

ara

tor

BW

H

Ta

rge

t

1

2

Adjusted Working Capital Actual YTD in 000s

Mental Health Inpatient Cost per Patient Day

QBP Financial Exposure (Potential lost revenue

related to QBP achievement) Actual YTD in 000s

Outstanding Performance - Optimize roles, resources, revenues, technology and innovation


$10,248

Up

da

ted

Comments

Q3 17/18 Q4 17/18 YTD PerformanceQ2 17/18


Q1

18/19

$5,599

$5,642

$618

$5,937

ALC Rate % -All Inpatient Services

(Sarnia and Petrolia)

$10,446 $10,823


Continuing Care Cost per Weighted Patient Day

% Capital Budget Spent Actual YTD

ED Outpatient

(12% of overall activity)

Acute Inpatient & Day Surgery


Rehab Inpatient



Surplus/(Deficit) Actual YTD in 000s

10.1

hrs

Q1 17/18

Jan-

Dec

Jan-

Dec

Q4 16/17

Quarter Rate

Q4 16/17 2.92

Q1 17/18 2.80

Q2 17/18 2.80

Q3 17/18 3.25Q4 17/18 3.42

BWH Target

3.1

Resource Utilization & Audit Committee Key Performance Indicators


Outstanding Performance - Optimize roles, resources, revenues, technology and innovation




Absenteeism Rate- (avg # 7.5hr sick days)

All Staff



21.0%

June data unavailable

province-wide due to daily

bed census summary

methodology changes



BWH Target

18.4

17.2

18.5

16.7

17.8

0.0

21.5

17.2

17.7

18.6

14.8

15.7

16.9

15.9

16.4

15.0

0.0

5.0

10.0

15.0

20.0

25.0

Jan17

Feb 17

Mar 17

Apr17

May17

Jun17

Jul17

Aug17

Sep17

Oct17

Nov17

Dec17

Jan18

Feb18

Mar18

Apr18

ALC Rate % - All Inpatient Services (Sarnia & Petrolia)

ALC Rate Provincial Target BWH Target

$31 $47

$818$1,422

$2,705 $2,934 $3,003

$4,228$3,638

$3,881$3,425

$3,921 $3,780

$5,357

$2,373$2,887

$0

$1,000

$2,000

$3,000

$4,000

$5,000

$6,000

Jan 1

7

Feb 1

7

Mar

17

Apr

17

May 1

7

Jun 1

7

Jul 17

Aug 1

7

Sep 1

7

Oct

17

Nov 1

7

Dec

17

Jan 1

8

Feb 1

8

Mar

18

Apr

18

Adjusted Working Capital YTD in 000s

0102030405060708090

100

Jan17

Feb 17

Mar 17

Apr17

May17

Jun17

Jul17

Aug17

Sep17

Oct17

Nov17

Dec17

Jan18

Feb18

Mar18

Apr18

% Capital Budget Spent Actual YTD

$5,599

$5,991

$5,937

$5,799

$5,400 $5,500 $5,600 $5,700 $5,800 $5,900 $6,000 $6,100

Q4 16/17

Q1 17/18

Q3 17/18

Q4 17/18

Cost per Weighted Case (Actual YTD)Acute Inpatient & Day Surgery (53% of overall activity)

Q1/Q2 17/18

$5,642

$5,925

$5,853

$5,849

$5,500$5,550$5,600$5,650$5,700$5,750$5,800$5,850$5,900$5,950

Q4 16/17

Q1 17/18

Q3 17/18

Q4 17/18

Cost per Weighted Case (Actual YTD)ER Outpatient (12% of overall activity)

Q1/Q2 17/18

10.1

8.1

9.3

9.6

9.0

9.7

8.0

8.9

9.8

9.4

10.0

8.8

11.2

9.6

8.4

9.5

4.1

3.9

4.3

4.4

3.9

4.0

4.1

4.7

4.0

5.0

3.7

3.8

4.6

4.2

3.7

4.1

0

2

4

6

8

10

12

Jan17

Feb 17

Mar 17

Apr17

May17

Jun17

Jul17

Aug17

Sep17

Oct17

Nov17

Dec17

Jan18

Feb18

Mar18

Apr18

90th Percentile ED Length of Stay for Complex Patients

Sarnia Petrolia Peer Comparator BWH Target

27.2

19.9

24.9

26.5

23.9

27.6

16.6

20.9

25.0

27.0

28.2

25.7

29.9

27.9

26.0

21.6

7.5

7.7

7.3

7.2 7.9 8.8

7.3

6.9 8.4

13.8

10.1

7.0 7.8 10.2

7.7

7.9

BWH Target

Peer Comparator

05

101520253035

Jan17

Feb 17

Mar 17

Apr17

May17

Jun17

Jul17

Aug17

Sep17

Oct17

Nov17

Dec17

Jan18

Feb18

Mar18

Apr18

90th Percentile ED Wait Times (Admitted Patients)

Sarnia Petrolia

Bluewater Health Target

0.00

0.50

1.00

1.50

2.00

2.50

3.00

3.50

4.00

Q4 16/17 Q1 17/18 Q2 17/18 Q3 17/18 Q4 17/18

Absenteeism Rate - (avg # 7.5hr sick days) All Staff

1

Medical Advisory Committee (MAC) Highlights

June 20, 2018

Quality Improvement Initiatives • Approved recommendations from the Pharmacy and Therapeutics Committee,

the Infection and Prevention Control Committee and the Order Sets Committee • Approved a PICC line policy and procedure, a PICC line removal procedure and

a patient benefits and risk form • Discussed ideas for a community-wide Choosing Wisely quality improvement

initiative, including a regional initiative to address acute prescribing of opioids • Approved a policy outlining CEEH transfer criteria for consult and/or admission to

the Sarnia site • Discussed the Chief of Professional Staff’s goals for 2018/19 • Received updates on:

o Nurse Practitioner Diagnostic and Prescriptive Authority Policy o Erythromycin ointment shortage o The N.O.W. patient flow initiative o Emergency Department redesign

• Discussed improved electronic communication between physicians and the hospital

Physician Education, Development and Engagement

• Members discussed next steps regarding the NRC Health Physician Survey • Discussed ways to support physician wellness and health initiatives • To support Professional Staff (Active/Associate) experiencing difficulties,

Bluewater Health will be offering access to qualified counselling professionals, through the Employee and Family Assistance Program

• Recognized Dr. Al-Dhaher for receiving Schulich Award of Excellence for Faculty in Community/Distributed Sites

• Discussed upcoming events: o Bluewater Health Annual General Meeting – June 27, 2018 o Physician Family BBQ – July 29, 2018 o Session for clinical instructors - September 22,2018 in conjunction with

Schulich School of Medicine o Physician Leadership Institute (PLI) “Leading Change” course – will be

offered in the fall Recruitment/Succession Planning

• A new hospitalist has recently signed, a rheumatologist will be providing clinics in Petrolia, and there is a potential neurologist to provide locum coverage

• increased recruitment for an anaesthesiologist, a replacement urologist is required, and surgery is preparing an impact analysis for a second ENT surgeon

Submitted by: Mike Haddad, MD, MSc, FRCSC, Chief of Professional Staff

1

No. Work Plan Item Committee Responsible

Alignment Policy/Strategic Plan/Legislation

Board Agenda Category (P=Public) Au

gust

Sept

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April

May

June

Status (CompleteIn ProgressDeferred)

Comments

1.1 Monitor Strategic Plan annually G&N P. 1.30/5.15 Discussion (P) x x x Complete

1.2 Monitor strategic goals and quality/resource objectives via Balanced Scorecards and provide oversight for remediation/improvement plans

Quality/RUACECFAA

SPP. 1.40/5.15

Discussion (P) x x x x x x x x x xComplete

1.3 Review/approve/monitor Quality Improvement Plan (QIP)Quality

P. 3.30/5.15 ECFAA

Decision (P) x x x x x xComplete

2.1 Complete CEO/CoPS performance evaluation and approve goals/objectives

Exec P. 2.30 In-Camerax x

Complete

2.2 Establish annual CEO/CoPS performance expectations Exec P. 2.30 In-Camera x x Complete

2.3 Determine annual CEO/CoPS compensation Exec P. 230 In-Camera x Complete

2.4 Ensure CEO/CoPS establish an appropriate succession plan for BWH leaders and Professional Staff

RUAC P. 2.10/5.15 Minutesx x

Complete

2.5 Review/approve annual HR and Physician HR plans RUAC P. 5.15 Decision (P) x x Complete

2.6 Review/approve executive performance-based compensation Board P. 2.30ECFAA In-Camerax x

Complete

2.7 Review/approve salary recommendation for non-union compensation

RUAC P. 2.30ECFAA

In-Camerax x

Complete

2.8 Review/approve Medical Director and other medical leadership appointments as required

MAC P. 5.15 In-Camerax x x x x x x x x x

Complete

3.1 Monitor Quality and Patient Safety program including: development of the Q&PS Plan, staff safety survey, legislation changes, risk management (incidents and adverse events)

Quality P. 3.10/3.30 SP

In-Camera

x x x x x

Complete

3.2 Monitor accreditation activities and respond as required (timing aligned with accreditation cycle)

Quality/G&N P. 3.30/5.15/5.40 Discussionx x x x x

Complete

3.3 Review Critical Incident Aggregated Data reports quarterly (legislation: at least two times per year)

Quality P. 3.30ECFAA

In-Camerax x x x x

Complete

BLUEWATER HEALTH WORK PLAN 2017-18

1.0 Establishing Strategic Direction

2.0 Providing for Excellence Management

3.0 Ensuring Program Quality and Effectiveness

2




gust

Sept

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May

June


Comments


3.4 Monitor litigation claims (minimum annually based on policy) Quality P. 3.40 In-Camerax x x

Complete

3.5 Monitor ethical framework outcomes and related policies Quality P. 3.70 In-Camerax x

Complete

3.6 Monitor research being undertaken within the organization Quality P. 3.45/3.70 Minutesx x x x

Complete

3.7 Monitor pandemic plan and emergency preparedness (i.e. Disaster plan and other related activities)

Quality P. 3.10/3.30/5.15 Minutesx

Complete

3.8 Monitor Quality Improvement Initiatives (through monthly program tours or didactic presentations) - education articles will be linked to program

Quality P. 5.40 ECFAA

Minutesx x x x x x x x

Complete

3.9 Review recommendations from MAC on any systemic/recurring issues related to quality of care provided by professional staff as required (standing agenda item)

Quality/MAC P. 3.30PHA

In-Camera

x x x x x x x x x

Complete

3.10 Receive reports from the Quality and Patient Experience Committee

Quality Policy 5.40 Minutesx x x x x x x

Complete

3.11 Monitor patient experience results via Balanced Scorecard, Concerns/Compliments reports and PFCC Action Plan quarterly

Quality P. 3.40ECFAA

SP

Minutesx x x x

Complete

3.12 Provide update on Workplace Violence (will also be incorporated into 2018_19 QIP and scorecard)

Quality ECFAA Minutesx x

Complete

3.13 Monitor staff, professional staff and volunteer engagement survey results

Quality ECFAASP

Minutesx x

Deferred Deferred to Fall Board Retreat

3.14 Monitor Emergency Department Return Visit Quality Program Quality Minutesx x

Complete

3.15 Review/approve Professional Staff appointments, reappointments, privileges as required

MAC PHA In-Camerax x x x x x x x x x

Complete

3.16 Review fairness/effectiveness of credentialing process annually MAC In-Camerax x

Complete

3.17 Receive reports from the CEO in relation to the 3rd party whistleblower service

RUAC P. 3.60 Minutesx

Complete

4.1 Monitor financial performance via monthly financial statements

RUAC P. 4.10/4.40 Discussion (P)x x x x x x x x x x

Complete 4.0 Ensuring Financial Viability

3




gust

Sept

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Oct

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Nov

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Janu

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Febr

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Mar

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April

May

June


Comments


4.2 Review/approve annual operating plan Quality/RUAC P. 3.30/4.30 Decision (P) x x x x Complete

4.3 Review/approve Hospital Accountability Planning Submission (HAPS)

RUAC P. 4.10/4.15 Decision (P)

x x

In Progressrevised HAPS to be submitted to ESC LHIN July 13, 2018.

4.4 Review/approve/monitor capital expenditure plan RUAC P. 4.30 Decision (P) x x x x x x x x x Complete

4.5 Review/approve Hospital Service Accountability Agreement (H-SAA)

RUAC P. 4.10/5.15 Decision (P)x x

Complete Agreement extended to March 31, 2018

4.6 Review/approve Multi-Sectoral Accountability Agreement (M-SAA)

RUAC P. 4.10/4.15 Decision (P)

x x x x x

Complete Agreement to be extended to September 30, 2018

4.7 Review/approve Chief Financial Officer Report - legislative requirements/risk management

RUAC P. 3.40/4.40/4.505.15/5.40

Consent A (P)x x x x

Complete

4.8 Review/receive quarterly report on investments and loans RUAC P. 4.50/4.60/5.15 Consent R (P)x x x x

Complete

4.9 Review/receive Human Resources Report quarterly RUAC P. 5.15 Consent R (P) x x x x Complete

4.10 Review/receive Facilities/HIRF Report quarterly RUAC P. 4.10/5.15 Consent R (P) x x x x Complete

4.11 Review/receive insurance annually RUAC P. 4.50 Minutes x Complete

4.12 Review/approve banking arrangements/resolutions RUAC P. 4.80 Consent R (P) x x Complete

4.13 Review/approve audit activities as required(post-audit/management letter, management's response and action plan, audit plan, finanial statements, firm/compensation)

RUAC P. 5.15/5.40 Consent R

x x x

Complete

4.14 Review/approve Executive and Director expenses RUAC BPSAAP. 4.75/5.10/5.105

Consent R x x

Complete

4.15 Review/approve Public Sector Salary Disclosure Attestation RUAC PSSDAP. 5.10

Consent R (P)x

Complete

4.16 Review/approve BPSAA Attestation - consultant use, perquisites, lobbyist rules, etc.

RUAC BPSAAP. 4.75/5.105/5.10

Consent A (P)x Complete

4.17 Provide update on HIS or any other significant technology investments as needed

RUAC P. 51.5SP

Minutesx x x x x x x x

Complete

4




gust

Sept

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Oct

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Nov

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April

May

June


Comments


4.18 Monitor/approve decisions related to property matters as required

RUAC P. 410/4.15 In-Camerax x x x

Complete

4.19 Monitor status of the development of the 5-Year Plan - services, facilities, capital equipment, and technology

RUAC P. 4.30/5.15SP

Minutesx x

Complete

5.1 Develop/approve annual work plan All P. 5.85 Decision (P)x x

Complete

5.2 Review/revise/approve Terms of Reference All P. 5.40 Decision (P) x x Complete

5.3 Develop/approve/monitor Board Goals G&N/All P. 585/5.86 Decision (P) x x Complete

5.4 Complete Board/Director/NDCM/Committee/Meeting evaluations as required and address opportunities identified by results

G&N?All P. 5.45/5.50/5.55/5.60/5.65/5.86

Consent R (P)x x x x x

Complete

5.5 Strengthen Board Orientation/Education/Team Building G&N/All P. 5.80/5.85/5.90SP

Discussion (P)x x x x x x x x x x x

Complete

5.5a Quality Committee Education Article Review - article to be linked to program who is scheduled for tour or didactic presentation item 3.8

Quality P. 5.80/5.85/5.90SP

Discussion (P)x x NA x x x x x

Complete

5.6 Complete Board succession planning, recruitment and nomination process

G&N P 5.90 Minutesx x x x x x

Complete

5.7 Review Board/NDCM member meeting attendance and education record

G&N P 5.90 Discussion (P)x Complete

5.8 Review/revise/approve Board policies as required All P. 5.85 Consent R (P)x x x x x x x x x x x

Complete

5.9 Plan for Annual General Meeting G&N P. 5.15 Minutes x x x x x x x Complete

5.10 Review/receive annual FIPPA/PHIPPA compliance report and complete FIPPA Delegation of Authority

Quality P. 5.15FIPPA

PHIPPA

Consent A (P)x Complete

5.11 Review/approve Corporate By-Law amendments/3-year cycle review

G&N By-laws Decision (P)x x x

Complete

6.1 Review/receive Global Communication and Community Engagement Plan

G&N P. 5.10/5.15/6.10SP Information (P)

x Complete

6.0 Fostering Relationships

5.0 Ensuring Board Effectiveness

5




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April

May

June


Comments


6.2 Review/receive reports from CEO/Board liaison representatives re: stakeholder relationships as necessary ie. Governance Advisory/Foundation Boards/CAP/RHAP

G&N P. 5.00/5.15/6.10/6.20

SP

Information (P)

x x x

x Complete

6.3 Complete annual review of BWH collaborations - Monitor partnerships and collaborations and support integration initiatives with other community health service providers

G&N Corporate Collaboration

Policy/SPP. 3.30/5.10/ Discussion

x Completemerged with Annual Report

Quality Committee Performance Indicator Definitions and Graphs

Performance Indicator

Quality Care – Assure the right care, in the right place, at the right time, by the right provider


1 Medication Reconciliation at Discharge

2 Difficult to speak up if I perceive a problem with patient care

3 Total High Severity Patient Safety Incidents


4 90th Percentile ED Length of Stay for Complex Patients

Exceptional Relationships – Expand innovative partnerships and collaborations to improve experiences, services, transitions and community health


5 ALC Rate % - All Inpatient Services (Sarnia & Petrolia)

6 30 day Mental Health Readmission

7 Readmission within 30 days for COPD

Strengthen Patient and Family – Centered Care

8 Overall Rating of Experience

9 Leaving hospital did Patient receive enough information

Inspired People – Advance our culture of kindness with an intention to learn, lead, collaborate and celebrate


10 Supervisor helps access training and development

11 Was Patient/Family Treated with Kindness

12 Is a Culture of Kindness Promoted at Bluewater Health

Employees

Professional Staff

Volunteer


Indicator Name: Medication Reconciliation at Discharge


Strategic Goal: Ingrain patient safety

Definition: Total percentage of patients for whom Discharge Medication Reconciliation was finalized as a proportion of the total number of patients discharged from the hospital.

Rationale: Hospital discharge is a critical interface of care where patients are at a high risk of medication discrepancies as they transition out of the hospital. The goal of discharge medication reconciliation is to reconcile the medications the patient is taking prior to admission and those initiated in hospital, with the medications they should be taking post-discharge to ensure all changes are intentional and that discrepancies are resolved prior to discharge. This should result in avoidance of therapeutic duplications, omissions, unnecessary medications and confusion.


Exclusions: 1. Mothers delivered and Newborns, including Newborn Repatriations2. Patients with Meditech Discharge Dispositions:

I. ExpiredII. Triaged/Reg'd/Left Against Medical Advice (AMA)

III. Site to Site (CEEH to Sarnia or vice versa)IV. Signed Medical ReleaseV. Transfer

VI. Transfer to another Acute Care FacilityVII. Transfer to an Ambulatory Care Clinic

Peer Comparator: No peer comparator data available

80

82

84

86

88

90

92

94

96

98

100

Apr

16

May

16

Jun

16

Jul

16

Aug

16

Sep

16

Oct

16

Nov

16

Dec

16

Jan

17

Feb

17

Mar

17

Apr

17

May

17

Jun

17

July

17

Aug

17

Sep

17

Oct

17

Nov

17

Dec

17

Jan

18

Feb

18

Mar

18

Q1 16/17 Q2 16/17 Q3 16/17 Q4 16/17 Q1 17/18 Q2 17/18 Q3 17/18 Q4 17/18

% P

erc

en

tag

e F

ina

lize

d

up

on

Dis

ch

arg

e

Medication Reconciliation Upon Discharge

Pre

ferre

d T

ren

din

g


Indicator Name: It is difficult to speak up if perceive a problem with patient care


Strategic Goal: Ingrain Patient Safety

Definition: This is a custom employee survey question that asks employees to respond to the statement “in this unit it is difficult to speak up if I perceive a problem with patient care”. The top box responses request respondents to “strongly disagree” and “disagree” with the proposed statement. A higher percentage of employees disagreeing or strongly disagreeing with this statement is preferred.

Rationale: “It is difficult to speak up if I perceive a problem with patient care” is a measure that comes from a reliable and valid survey through patient safety research. To ensure we can track and measure this indicator we will assess a baseline and target by sending staff surveys thorough a Survey Monkey process. This indicator is a measure indicative of patient safety culture throughout the organization and will identify how safe the inter-professional team feels to report patient safety incidents. The development, dissemination, education and implementation of a Quality and Patient Safety Plan will enable a culture of safety by enhancing knowledge transfer of the importance of reporting patient safety incidents to improve quality and safety of the patients we serve.



Target for 17/18: 49.6%


0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Q3 16/17 Q4 16/17 Q1 17/18 Q2 17/18 Q3 17/18

Dif

ficu

lt

to s

pe

ak u

p

Difficult to Speak up if Perceive a Problem with Patient Care

Pre

ferre

d Tre

nd

ing

Our Status


Indicator Name: Total High Severity Patient Safety Incidents


Strategic Goal: Ingrain patient safety

Definition: This measure tracks the total number of patient safety incidents categorized as Level 4 or Level 5. An example of a Level 4 patient safety incident is a fall in which the patient falls and sustains a fractured hip requiring surgical repair.

Rationale: A patient safety incident is an event or circumstance that could have resulted, or did result, in unnecessary harm to a patient. Bluewater Health FY17/18 Target for Total High Severity Patient Safety Incidents is set 0, “as zero patient harm is an indisputable goal that must be a priority for all stakeholders. It is the right thing to do for patients and families.” (Cochrane et. al. 2017, p.66) In compliance with the Public Hospital’s Act, there is an obligation of hospitals to report critical incidents to the Quality Committee of the Board.


On September 6, 2017, Bluewater Health implemented a new incident reporting system RL6. With the implementation of the new incident reporting software the severity levels have been amended to reflect the updated guidelines set by the Ontario Hospital Association (OHA).

Level 4 - Patient outcome is symptomatic, requiring life-saving intervention or major surgical/medical intervention, shortening life expectancy or causing major permanent or long-term harm or loss of function.

Level 5 - On balance of probabilities, death was caused or brought forward in the short-term by the incident.


Bluewater Health Target

-1

0

1

2

3

4

5

6

Q1 16/17 Q2 16/17 Q3 16/17 Q4 16/17 Q1 17/18 Q2 17/18 Q3 17/18 Q4 17/18Nu

mb

er

of

Hig

h S

ev

eri

ty P

ati

en

t S

afe

ty I

ncid

en

ts

Total High Severity Patient Safety Incidents

Pre

ferr

ed

Tre

nd

ing



Indicator Name: 90th Percentile Emergency Department (ED) Length of Stay (LOS) for Complex Patients

Alignment: Quality and Patient Experience Committee (QPEC)/Quality Committee of the Board (QCB)/Performance & Utilization Committee (PUC)/Resource Utilization & Audit Committee (RUAC)


Definition: The total ED length of stay where 9 out of 10 complex patients completed their visits. ED Length of Stay defined as the time from triage or registration, whichever comes first, to the time the patient leaves the ED.

Rationale:



Sarnia Site

Petrolia Site

Target


0.0

2.0

4.0

6.0

8.0

10.0

12.0

Apr16

May16

Jun16

Jul16

Aug16

Sep16

Oct16

Nov16

Dec16

Jan17

Feb17

Mar17

Apr17

May17

Jun17

July17

Aug17

Sep17

Oct17

Nov17

Dec17

Jan18

Feb18

Mar18

Q1 16/17 Q2 16/17 Q3 16/17 Q4 16/17 Q1 17/18 Q2 17/18 Q3 17/18 Q4 17/18

ED

LO

S (

ho

urs

)

90th Percentile ED LOS Complex Patients

Pre

ferr

ed

Tre

nd

ing

CEEH

Status

Sarnia

Status











ALC Rate



ALC Days

0

200

400

600

800

1000

1200

1400

1600

1800

2000

0

5

10

15

20

25

30

35

40

45

50

Apr

16

May

16

Jun

16

Jul

16

Aug

16

Sep

16

Oct

16

Nov

16

Dec

16

Jan

17

Feb

17

Mar

17

Apr

17

May

17

Jun

17

July

17

Aug

17

Sep

17

Oct

17

Nov

17

Dec

17

Jan

18

Feb

18

Mar

18

Q1 16/17 Q2 16/17 Q3 16/17 Q4 16/17 Q1 17/18 Q2 17/18 Q3 17/18 Q4 17/18

AL

C D

ay

s In

pa

tie

nt

Se

rvic

es

AL

C R

ate

%


Pre

ferr

ed

Tre

nd

ing

Our Status


Indicator Name: 30 Day Mental Health Readmission



Definition: The percentage of Ontario Mental Health Reporting System (OMHRS) full admissions that were discharged 30 days ago or less from this facility.

Rationale:



Target

0.0

5.0

10.0

15.0

20.0

25.0

Q1 16/17 Q2 16/17 Q3 16/17 Q4 16/17 Q1 17/18 Q2 17/18 Q3 17/18

% o

f 3

0 D

ay

Me

nta

l H

ea

lth

Re

ad

mis

sio

ns

30 Day Mental Health Readmissions

Pre

ferr

ed

Tre

nd

ing

Our Status


Indicator Name: Readmission within 30 days for Chronic Obstructive Pulmonary Disease (COPD)

Alignment: Quality and Patient Experience Committee (QPEC)/ Quality Committee of the Board (QCB)


Definition: The measuring unit of this indicator is an admission for COPD, as defined for the quality based procedure (QBP). Results are expressed as crude 30-day non-elective readmission rate among patients admitted to Ontario acute care facilities.

Rationale: Readmission rates are considered a marker of poor hospital performance. High rates may indicate inadequate care, inadequate follow up, and inadequate preparation for discharge or poor doctor to doctor communication at the time of discharge. Reducing readmission rates benefit the patient through a higher quality of care and the hospital through cost containment.


Peer Comparator: Crude calculation of 30 day readmission for COPD in the Erie St Clair LHIN Hospitals for Fiscal Year 16/17 – 18.2%

Target

ESC-LHIN Crude Rate 18.2%

10%

12%

14%

16%

18%

20%

22%

24%

Q1 16/17 Q2 16/17 Q3 16/17 Q4 16/17 Q1 17/18 Q2 17/18 Q3 17/18

% o

f B

WH

P

ati

en

ts R

ea

dm

itte

d to

BW

H w

ith

in 3

0 D

ay

s

(Se

lect

HIG

s)

30 Day Readmission for COPD

Pre

ferr

ed

Tre

nd

ing

Our Status


Indicator Name: Overall Rating of Experience



Definition: Overall Rating of Experience: Inpatient (IP) and Emergency Department (ED), patients are asked to rate their hospital experience on a scale from 0 to 10, with 0 being I had very poor experience and 10 being I had a very good experience.

Rationale: Patient experience measurement is an industry best practice and hospitals are required to survey patients at least once every fiscal year, according to Ontario’s Excellent Care for All Act (ECFAA), 2010. “We create exemplary healthcare experiences with patients and families every time”, is the mission of Bluewater Health. These questions reflect how well the hospital is achieving its overall mission. The patient experience is what we strive to excel at. Measurement of patient experience is important because it provides an opportunity to improve care, enhance strategic decision making, meet patients’ expectations, effectively manage and monitor healthcare performance, and document benchmarks for the organization.









Peer Comparator: The Ontario Hospital Association Patient Reported Performance Management (OHA PRPM) benchmark includes OHA member hospitals. The Ontario Inpatient (IP) Community Hospital (Hosp) Average compares hospitals of the same size within the province. Peer comparators are updated quarterly.

Inpatient OHA-PRPM – 68.2% Ontario IP Community Hosp Average – 65.0%

Emergency Department (ED) There is no peer comparator as this is a Bluewater Health custom question for the Emergency Department Patient Experience of Care Survey (EDPEC)


ED - 49.1% Inpatient – 75.9%

ED Target 49.1%


0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Apr16

May16

Jun16

Jul16

Aug16

Sep16

Oct16

Nov16

Dec16

Jan17

Feb17

Mar17

Apr17

May17

Jun17

Jul17

Aug16

Sep16

Oct17

Nov17

Dec17

Jan18

Feb18

Mar18

Q1 16/17 Q2 16/17 Q3 16/17 Q4 16/17 Q1 17/18 Q2 17/18 Q3 17/18 Q4 17/18

Ov

era

ll R

ati

ng

of

Exp

eri

en

ce


ED Inpatient

Pre

ferre

d T

ren

din

g

ED

StatusInpatient

Status



Indicator Name: Leaving hospital did patients receive enough information



Definition: As Emily leaves the hospital, this indicator asks the question of whether Emily perceives that she received the information she needed from Bluewater Health Staff and Physicians before leaving our care. This question is asked of both inpatients and emergency department patients. Inpatient Question: Did you receive enough information from hospital staff about what to do if you were worried about your condition or treatment after you left the hospital? Not at all/ Partly/ Quite a bit/ Completely Emergency Department Patient Question: Before you left the emergency department, did you understand what symptoms or health problems to look out for when you left the emergency department? Yes/No

Rationale: Patient experience measurement is an industry best practice and hospitals are required to survey patients at least once every fiscal year, according to Ontario’s Excellent Care for All Act (ECFAA), 2010.





- Exclusion Criteria:- Patients who have notified Bluewater Health they wish to be excluded from

the mailing list- Patients who are stillborn or deceased while in the hospital

- Patients with no fixed address- Psychiatric patients (unless being specifically surveyed using the Mental

Health inpatient or outpatient survey tool)- Patients who present with evidence of sexual assault or with sensitive

issues (e.g., miscarriage)

Peer Comparator: The Ontario Hospital Association Patient Reported Performance Management (OHA PRPM) benchmark includes OHA member hospitals. The Ontario Inpatient (IP) Community Hospital (Hosp) Average and the Ontario ED Community Hosp Average is a comparator of hospitals of the same size. Peer comparators are updated quarterly. Inpatient OHA PRMP – 57.5% Ontario IP Community Hosp Average – 54.3% ED OHA PRMP – 84.2% Ontario ED Community Hosp Average – 82.5%

Target 2017/2018: ED - 81.0% Inpatient - 61.6%

Emergency Department Target 81.0%


0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Apr16

May16

Jun16

Jul16

Aug16

Sep16

Oct16

Nov16

Dec16

Jan17

Feb17

Mar17

Apr17

May17

Jun17

Jul17

Aug16

Sep16

Oct17

Nov17

Dec17

Jan18

Feb18

Mar18

Q1 16/17 Q2 16/17 Q3 16/17 Q4 16/17 Q1 17/18 Q2 17/18 Q3 17/18 Q4 17/18

Re

ce

ive

d e

no

ug

h I

nfo

rma

tio

n

Leaving Hospital did Patients receive Enough Information

ED Inpatient

Inpatient

Status

Pre

ferre

d T

ren

din

g

EDStatus



Indicator Name: Supervisor helps access training and development



Definition: This is a custom employee survey question that will ask “My Supervisor helps me to access training and development?” The top box responses request respondents to “Agree” and “Strongly Agree” with the proposed statement. A higher percentage of employees agreeing or strongly agreeing with this statement is preferred.

Rationale: Ensuring that each patient receives the best care possible begins with exceptional care providers. Bluewater Health is committed to strengthening the skills and education of our employees. This commitment to education promotes inspired people who will advance our culture of kindness with an intention to learn, lead, collaborate and celebrate. Evidence suggests that investment in employee training and development leads to employees feeling more valued and willing and able to invest in their work. Employee training and development supports efficiencies and standardized procedures, risk reduction, patient safety and quality of patient care. Research links high levels of employee engagement with increased patient satisfaction when an organization focuses on processes and people. This reflects on the organization’s ability to provide opportunities for personal development to stay up to date with latest techniques and technologies and recognize employees for acquiring additional skills and knowledge sets.




67.3%


0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Q3 16/17 Q4 16/17 Q1 17/18 Q2 17/18 Q3 17/18

Su

pe

rvis

or

he

lps a

cce

ss t

rain

ing

&

de

ve

lop

me

nt

Supervisor Helps Access Training and Development

Pre

ferre

d T

ren

din

g

Our Status


Indicator Name: Was Patient/Family Treated with Kindness



Definition: This is a new, custom question for Bluewater Health’s patient experience surveys which are mailed to a random selection of patients after they are discharged. Our aim is that the culture of kindness at Bluewater Health will be increasingly felt by our patients and families over time. This question asks Emily to reflect and respond to the statement “Were you and your family treated with kindness by employees, volunteers and physicians at Bluewater Health?” Responses available for this question are as follows: No/ Yes, somewhat/ Yes, mostly/ Yes definitely

Rationale: Exemplary healthcare experiences begin with kindness. We understand that patients expect courtesy, respect and dignity, beginning with an expression and attitude of kindness and caring. We understand that having highly skilled and competent staff isn’t enough. Ensuring that you and your family are treated with kindness is a key focus of Bluewater Health’s commitment to Patient & Family-Centered Care. Patient experience measurement is an industry best practice and hospitals are required to survey patients at least once every fiscal year, according to Ontario’s Excellent Care for All Act (ECFAA), 2010.


Scores are calculated using the following measure recommended by the National Research Corporation Canada (NRCC): Positive - Positive measure type is calculated by counting “Positive” response (i.e., 9-10 or Yes, Definitely or Always) and dividing by the total number of responses. Inclusion Criteria: - Patients who have received active treatment at Bluewater Health





Peer Comparator: This is a Bluewater Health custom question and no peer comparator data is available. NRC Health establishes benchmarks/peer comparators based on the following requirements:

- Made up of one year of data- Questions must be used by at least five facilities

Must have at least 1000 responses for the question

Target for 2017/18: ED - 64.5% Inpatient - 80.4%

ED Target 64.5%

IP Target 80.4%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Apr16

May16

Jun16

Jul16

Aug16

Sep16

Oct16

Nov16

Dec16

Jan17

Feb17

Mar17

Apr17

May17

Jun17

Jul17

Aug16

Sep16

Oct17

Nov17

Dec17

Jan18

Feb18

Mar18

Q1 16/17 Q2 16/17 Q3 16/17 Q4 16/17 Q1 17/18 Q2 17/18 Q3 17/18 Q4 17/18

Wa

s P

atie

nt/

Fa

mily

Tre

ate

d w

ith

K

ind

ne

ss

Was Patient/Family Treated with KindnessED Inpatient

Pre

ferre

d T

ren

din

g

Inpatient

Status

ED

Status


Revised: May 2018 Next Update: September 2018 Page 1 3 of 13

Indicator Name: Is a Culture of Kindness Promoted at Bluewater Health Alignment: Quality and Patient Experience Committee (QPEC)/Quality Committee of the Board

(QCB)


Definition: This is a custom survey question that will ask “Is a culture of kindness promoted at BWH?” Top Box responses from Employees, Professional Staff and Volunteers are displayed. The top box responses request respondents to “Agree” and “Strongly Agree” with the proposed statement. A higher percentage of employees agreeing or strongly agreeing with this statement is preferred.

Rationale: Bluewater health is committed to strengthening our culture of kindness while we deliver Quality Care to Emily. Creating a kindness culture in the workplace reduces stress, fosters relationships, increases psychological wellness and health and leads to increased engagement, energy and resiliency at work. Evidence suggests that high engagement influences human resource goals of increased retention and recruitment, high job performance and lower absenteeism. Research links high levels of employee engagement with increased patient satisfaction when an organization focuses on processes and people. Caring for people creates a workforce with physical energy, mental focus and the emotional drive necessary to provide exemplary care to Emily every day. The culture of kindness has been measured in the “joy” people bring to work; it is palpable throughout the organization and referred to as measuring “humanity”.




Employees – 65.9% Professional Staff - 60.1% Volunteers - 84.1%

Employee Target 65.9%

Professional Staff Target 60.1%

Volunteer Target 84.1%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Q3 16/17 Q4 16/17 Q1 17/18 Q2 17/18 Q3 17/18Is a

Culture

of Kin

dness

Pro

mote

d a

t BW

H


Employees Prof. Staff Volunteers

Pre

ferre

d Tre

nd

ing

Our Status

Resource Utilization & Audit Committee Indicator Definitions and Graphs

Performance Indicator

Quality Care – Assure the right care, in the right place, at the right time, by the right provider


1 90th Percentile ED Length of Stay for Complex Patients Sarnia

Petrolia

2 90th Percentile ED Length of Stay (Admitted Patients) Sarnia

Petrolia

Exceptional Relationships – Expand innovative partnerships and collaborations to improve experiences, services, transitions and community health


3 ALC Rate % - All Inpatient Services (Sarnia & Petrolia)

Inspired People – Advance our culture of kindness with an intention to learn, lead, collaborate and celebrate


4 Absenteeism Rate – (avg. # 7.5hr sick days) – All Staff

Outstanding Performance – Optimize roles, resources, revenues, technology and innovation


5 Cost per Weighted Case: Acute Inpatient & Day Surgery (53% of overall activity) Actual YTD

6 Cost per Weighted Case: ED Outpatient (12% of overall activity) Actual YTD

7 Cost per Weighted Case: Rehab Inpatient (4% of overall activity) Actual YTD

8 Continuing Care Cost per Patient Day Actual YTD

9 Mental Health Cost per Patient Day Actual YTD

10 QBP Financial Exposure (Potential lost revenue related to QBP achievement) Actual YTD

11 Surplus/(Deficit) in 000s Actual YTD


12 Adjusted Working Capital (in 000s) Actual YTD

13 % of Capital Budget Spent Actual YTD


Indicator Name: 90th Percentile Emergency Department (ED) Length of Stay (LOS) for Complex Patients

Alignment: Quality and Patient Experience Committee (QPEC)/Quality Committee of the Board (QCB)/Performance & Utilization Committee (PUC)/Resource Utilization & Audit Committee (RUAC)


Definition: The total ED length of stay where 9 out of 10 complex patients completed their visits. ED Length of Stay defined as the time from triage or registration, whichever comes first, to the time the patient leaves the ED.

Rationale:



Sarnia Site

Petrolia Site

Target


0.0

2.0

4.0

6.0

8.0

10.0

12.0

Apr16

May16

Jun16

Jul16

Aug16

Sep16

Oct16

Nov16

Dec16

Jan17

Feb17

Mar17

Apr17

May17

Jun17

July17

Aug17

Sep17

Oct17

Nov17

Dec17

Jan18

Feb18

Mar18

Q1 16/17 Q2 16/17 Q3 16/17 Q4 16/17 Q1 17/18 Q2 17/18 Q3 17/18 Q4 17/18

ED

LO

S (

ho

urs

)

90th Percentile ED LOS Complex Patients

Pre

ferr

ed

Tre

nd

ing

CEEH

Status

Sarnia

Status


Indicator Name: 90th Percentile Emergency Department Length of Stay (LOS) for Admitted Patients

Alignment: Performance & Utilization Committee (PUC)/Resource Utilization & Audit Committee (RUAC)


Definition: ED length of stay for admitted visits is defined as the time from triage or registration, whichever comes first, to the time the patient leaves the ED to an inpatient bed. It is measured in hours. The 90th percentile is the maximum length of time in which 9 of 10 of admitted patients have completed their ED visit and have been moved to an inpatient unit. A small number is desirable.

Rationale: Time is crucial to the effectiveness and outcome of patient care, especially for emergency patients. In conjunction with other indicators, this can be used to monitor the total length of time admitted patients spend in the ED in an effort to improve the efficiency and, ultimately, the outcome of patient care. This measure remains one of Bluewater Health’s top priorities in our Quality Improvement Plan (QIP) and Strategic Plan.


Inclusions:

1. Admitted unscheduled emergency visits2. ED visits with a valid and known registration date/time or triage date/time

and a valid and known date/time the patient left the ED

Exclusions:

1. Scheduled emergency visits2. Non-admitted unscheduled emergency visits3. Visits with both unknown/invalid registration and triage date/time OR with

unknown/invalid patient left ED date/time


Sarnia Site

Petrolia Site

Target


0

5

10

15

20

25

30

35

Apr

16

May

16

Jun

16

Jul

16

Aug

16

Sep

16

Oct

16

Nov

16

Dec

16

Jan

17

Feb

17

Mar

17

Apr

17

May

17

Jun

17

July

17

Aug

17

Sep

17

Oct

17

Nov

17

Dec

17

Jan

18

Feb

18

Mar

18

Q1 16/17 Q2 16/17 Q3 16/17 Q4 16/17 Q1 17/18 Q2 17/18 Q3 17/18 Q4 17/18

ED

LO

S (

ho

urs

)

90th Percentile ED LOS(Admitted Patients)

Pre

ferr

ed

Tre

nd

ing

Sarnia

Status

CEEH

Status











ALC Rate



ALC Days

0

200

400

600

800

1000

1200

1400

1600

1800

2000

0

5

10

15

20

25

30

35

40

45

50

Apr

16

May

16

Jun

16

Jul

16

Aug

16

Sep

16

Oct

16

Nov

16

Dec

16

Jan

17

Feb

17

Mar

17

Apr

17

May

17

Jun

17

July

17

Aug

17

Sep

17

Oct

17

Nov

17

Dec

17

Jan

18

Feb

18

Mar

18

Q1 16/17 Q2 16/17 Q3 16/17 Q4 16/17 Q1 17/18 Q2 17/18 Q3 17/18 Q4 17/18

AL

C D

ay

s In

pa

tie

nt

Se

rvic

es

AL

C R

ate

%


Pre

ferr

ed

Tre

nd

ing

Our Status


Indicator Name: Absenteeism Rate

Alignment: Resource Utilization and Audit Committee (RUAC)/ Performance Utilization and Audit Committee (PUC)

Strategic Goal: Develop a sustainable plan for services, facilities, capital equipment and technology

Definition: Paid sick hours divided by 7.5 hrs. (for normal shift), divided by number of Full time and Permanent Part Time eligible employees.

Rationale: A lower absenteeism rate is preferred. Lower absenteeism is aligned with employee overall wellness.


Peer Comparator: Ontario Hospital Association Average

Target

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

5

Apr

16

May

16

Jun

16

Jul

16

Aug

16

Sep

16

Oct

16

Nov

16

Dec

16

Jan

17

Feb

17

Mar

17

Apr

17

May

17

Jun

17

July

17

Aug

17

Sep

17

Oct

17

Nov

17

Dec

17

Jan

18

Feb

18

Mar

18

Q1 16/17 Q2 16/17 Q3 16/17 Q4 16/17 Q1 17/18 Q2 17/18 Q3 17/18 Q4 17/18

Ab

se

nte

eis

m R

ate

Absenteeism Rate - (avg # 7.5hr sick days)All Staff

Pre

ferr

ed

Tre

nd

ing

Our Status

Our Status

Our Status


Indicator Name: Acute Cost per Weighted Case



Definition: Acute Cost per Weighted Case is an indicator that measures the cost associated with caring for a standard acute patient. It is calculated as total acute inpatient and newborn expenses (both direct and indirect) divided by acute inpatient weighted cases. The direct costs are the expenses incurred in the departments providing service to our acute patients (e.g., Medicine, Surgery, and Obstetrics). The indirect costs are an allocation of Administration and Support expenses (e.g., Housekeeping, Lab, Pharmacy, etc.). A weighted case is a case with an assigned Resource Intensity Weight (RIW).




Target

5000

5100

5200

5300

5400

5500

5600

5700

5800

5900

6000

Apr

16

May

16

Jun

16

Jul

16

Aug

16

Sep

16

Oct

16

Nov

16

Dec

16

Jan

17

Feb

17

Mar

17

Apr

17

May

17

Jun

17

July

17

Aug

17

Sep

17

Oct

17

Nov

17

Dec

17

Jan

18

Feb

18

Mar

18

Q1 16/17 Q2 16/17 Q3 16/17 Q4 16/17 Q1 17/18 Q2 17/18 Q3 17/18 Q4 17/18

Co

st

pe

r W

eig

hte

d C

ase

Cost per Weighted Case: Acute Inpatient & Day Surgery (53% of overall activity)

Pre

ferr

ed

Tre

nd

ing



Indicator Name: Emergency Department (ED) Outpatient Cost per Weighted Case



Definition: ED Outpatient Cost per Weighted Case is an indicator that measures the cost associated with caring for a standard Emergency department patient. It is calculated as total emergency department expenses (both direct and indirect) divided by ED outpatient weighted cases. The direct costs are the expenses incurred in the departments providing service to our ED patients (both Sarnia & Petrolia sites). The indirect costs are an allocation of Administration and Support expenses (e.g., Housekeeping, Lab, Pharmacy, etc). A weighted case is a case with an assigned Resource Intensity Weight (RIW).




Target

5000

5100

5200

5300

5400

5500

5600

5700

5800

5900

6000

Apr

16

May

16

Jun

16

Jul

16

Aug

16

Sep

16

Oct

16

Nov

16

Dec

16

Jan

17

Feb

17

Mar

17

Apr

17

May

17

Jun

17

July

17

Aug

17

Sep

17

Oct

17

Nov

17

Dec

17

Jan

18

Feb

18

Mar

18

Q1 16/17 Q2 16/17 Q3 16/17 Q4 16/17 Q1 17/18 Q2 17/18 Q3 17/18 Q4 17/18

Co

st

pe

r W

eig

hte

d C

ase

Cost per Weighted Case: ER Outpatient (12% of overall activity)

Pre

ferr

ed

Tre

nd

ing

Our Status

Our Status


Indicator Name: Rehab Cost per Weighted Case



Definition: Rehab Inpatient Cost per Weighted Case is an indicator that measures the costs associated with caring for a standard rehab patient. It is calculated as total inpatient rehab expenses (both direct and indirect) divided by rehab weighted cases. The direct costs are the expenses incurred in the departments providing service to our rehab inpatients. The indirect costs are an allocation of Administration and Support expenses (e.g., Housekeeping, Lab, Pharmacy, etc.). A rehab weighted case is a case assigned a relative weight using the rehabilitation patient grouper (RPG).

Rationale: This is an important indicator as it tracks how an organization is utilizing its resources. It combines the financial spending with the activity that drives the spending. By focusing on weighted patient days, comparability is enhanced as differences in acuity, severity and complexity of cases are taken into consideration.



Target

8900

9900

10900

11900

12900

13900

Apr

16

May

16

Jun

16

Jul

16

Aug

16

Sep

16

Oct

16

Nov

16

Dec

16

Jan

17

Feb

17

Mar

17

Apr

17

May

17

Jun

17

July

17

Aug

17

Sep

17

Oct

17

Nov

17

Dec

17

Jan

18

Feb

18

Mar

18

Q1 16/17 Q2 16/17 Q3 16/17 Q4 16/17 Q1 17/18 Q2 17/18 Q3 17/18 Q4 17/18

Co

st

per

Weig

hte

d C

ase

Cost per Weighted Case: Rehab Inpatient(4% of overall activity)

Pre

ferr

ed

Tre

nd

ing

Our Status



Indicator Name: Continuing Care Cost per Weighted Patient Day



Definition: Continuing Care Inpatient Cost per Weighted Patient Day is an indicator that measures the costs of providing inpatient care to complex continuing care patients, and is stated on a weighted patient day basis. It is calculated as total inpatient continuing care expenses (both direct and indirect) divided by total RUG weighted patient days (RWPDs). The direct costs are the expenses incurred in the departments providing service to our continuing care inpatients. The indirect costs are an allocation of Administration and Support expenses (e.g., Housekeeping, Lab, Pharmacy, etc.). RWPDs are patient days weighted using an appropriate cost weight (CMI). The CMI is a cost weight reflecting the relative resource use of an individual within a specific RUG group compared with the overall average resource use for all Ontario complex continuing care residents.

Rationale: This is an important indicator as it tracks how an organization is utilizing its resources. It combines the financial spending with the activity that drives the spending. By focusing on weighted patient days, comparability is enhanced as differences in acuity, severity and complexity of cases are taken into consideration.


This indicator is also referred to as Cost per RUG weighted patient day (RWPD) where RUG stands for Resource Utilization Group.


Target

300

350

400

450

500

550

600

650

700

Apr

16

May

16

Jun

16

Jul

16

Aug

16

Sep

16

Oct

16

Nov

16

Dec

16

Jan

17

Feb

17

Mar

17

Apr

17

May

17

Jun

17

July

17

Aug

17

Sep

17

Oct

17

Nov

17

Dec

17

Jan

18

Feb

18

Mar

18

Q1 16/17 Q2 16/17 Q3 16/17 Q4 16/17 Q1 17/18 Q2 17/18 Q3 17/18 Q4 17/18

Co

st

pe

r W

eig

hte

d C

ase

Cost per Weighted Patient Day:

Continuing Care Inpatient

Pre

ferr

ed

Tre

nd

ing

Our Status

Our Status


Indicator Name: Mental Health Inpatient Cost per Patient Day



Definition: Mental Health Inpatient Cost per Patient Day is an indicator that measures the cost associated with caring for a Mental Health inpatient. It is calculated as total inpatient mental health departmental expenses divided by total inpatient mental health patient days.

Rationale:


Peer Comparator: To be determined

Target

250

270

290

310

330

350

370

390

Apr16

May16

Jun16

Jul16

Aug16

Sep16

Oct16

Nov16

Dec16

Jan17

Feb17

Mar17

Apr17

May17

Jun17

July17

Aug17

Sep17

Oct17

Nov17

Dec17

Jan18

Feb18

Mar18

Q1 16/17 Q2 16/17 Q3 16/17 Q4 16/17 Q1 17/18 Q2 17/18 Q3 17/18 Q4 17/18

Mental Health Cost per Patient Day

Pre

ferr

ed

Tre

nd

ing

Our Status


Indicator Name: Quality Based Procedure (QBP) Financial Exposure (Potential lost revenue related to QBP achievement)



Definition: Represents the potential lost revenue associated with under achievement of QBP funded volumes for both Ministry funded and CCO funded quality based procedures.

Rationale: The intent is that the hospital will achieve all anticipated volumes and not have to return any QBP funding to the Ministry and/or CCO.



-$700,000

-$600,000

-$500,000

-$400,000

-$300,000

-$200,000

-$100,000

$0

$100,000

$200,000

Apr

16

May

16

Jun

16

Jul

16

Aug

16

Sep

16

Oct

16

Nov

16

Dec

16

Jan

17

Feb

17

Mar

17

Apr

17

May

17

Jun

17

July

17

Aug

17

Oct

17

Nov

17

Dec

17

Jan

18

Feb

18

Mar

18

Q1 16/17 Q2 16/17 Q3 16/17 Q4 16/17 Q1 17/18 Q2 17/18 Q3 17/18 Q4 17/18

Re

ve

nu

e

QBP Financial Exposure(Potential lost revenue related to QBP achievement)

Pre

ferre

d T

ren

din

g

Our Status

Our StatusOur StatusOur Status

Our Status

Our Status


Indicator Name: Surplus/(Deficit) in 000s



Definition: The amount of operating revenue in excess of operating expense from regular hospital operations. This amount excludes building amortization, building deferred grants/donations and interest on long-term liabilities.

Rationale: The hospital compares its actual results to the Board approved budget. The hospital plans for a surplus each year.


Peer Comparator: Not applicable

Target

0.00

500.00

1000.00

1500.00

2000.00

2500.00

Apr

16

May

16

Jun

16

Jul

16

Aug

16

Sep

16

Oct

16

Nov

16

Dec

16

Jan

17

Feb

17

Mar

17

Apr

17

May

17

Jun

17

July

17

Aug

17

Sep

17

Oct

17

Nov

17

Dec

17

Jan

18

Feb

18

Mar

18

Q1 16/17 Q2 16/17 Q3 16/17 Q4 16/17 Q1 17/18 Q2 17/18 Q3 17/18 Q4 17/18

Su

rplu

s/(D

eficit

) in

00

0s

Surplus/(Deficit) in 000s

Pre

ferre

d T

ren

din

g

Our Status

Our StatusOr StatusOur Status


Indicator Name: Adjusted Working Capital (in 000s)


Strategic Goal: Ensure continuous investment in strategic infrastructure

Definition: Adjusted Working Capital is calculated as the hospital’s total current assets less current liabilities from its balance sheet. This definition is then adjusted per Ministry direction to exclude current liabilities such as vacation accrual, etc. and to exclude any externally restricted current assets/liabilities.

Rationale: Adjusted working capital is a critical indicator to evaluate the hospital’s financial outlook. A strong working capital position indicates a readiness for potential capital investment.


Peer Comparator: Not applicable

Target

-1000.00

0.00

1000.00

2000.00

3000.00

4000.00

5000.00

6000.00

Apr

16

May

16

Jun

16

Jul

16

Aug

16

Sep

16

Oct

16

Nov

16

Dec

16

Jan

17

Feb

17

Mar

17

Apr

17

May

17

Jun

17

July

17

Aug

17

Sep

17

Oct

17

Nov

17

Dec

17

Jan

18

Feb

18

Mar

18

Q1 16/17 Q2 16/17 Q3 16/17 Q4 16/17 Q1 17/18 Q2 17/18 Q3 17/18 Q4 17/18

Wo

rkin

g C

ap

ital

in 0

00

s

Adjusted Working Capital (in 000s)

Pre

ferre

d T

ren

din

g



Indicator Name: Percentage of Capital Budget Spent


Strategic Goal: Ensure continuous investment in strategic infrastructure

Definition: Capital purchases made during the time period as a percentage of the overall capital budget for that period. The overall budget includes a budget for contingency items. If capital items are carried over from a previous year, the capital budget associated with those carry over items will also be included in the denominator for this indicator.

Rationale:



0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Apr16

May16

Jun16

Jul16

Aug16

Sep16

Oct16

Nov16

Dec16

Jan17

Feb17

Mar17

Apr17

May17

Jun17

July17

Aug17

Sep17

Oct17

Nov17

Dec17

Jan18

Feb18

Mar18

Q1 16/17 Q2 16/17 Q3 16/17 Q4 16/17 Q1 17/18 Q2 17/18 Q3 17/18 Q4 17/18

Perc

enta

ge o

f Capita

l Budget Spent

Percentage of Capital Budget Spent

Pre

ferre

d T

ren

din

g

Documents

AGENDA - Bluewater Health...AGENDA OPEN SESSION BOARD MEETING Wednesday, June 27, 2018 Lambton College Event Centre 4:00 pm Directors: Marg Dragan, Treasurer Anthony Iafrate …