PROCÈS-VERBAL de la réunion du conseil d administration tenue le 7 mars 2012 à la Fondation du cancer de la région d Ottawa (Centre Maplesoft)

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1 Head Office 4200 Labelle Street Suite 100 Ottawa ON K1J 1J8 Siège social 4200, rue Labelle Bureau 100 Ottawa ON K1J 1J8 Tel/Tél : Fax/Téléc : MEMBRES DU CONSEIL ABSENCES MOTIVÉES MEMBRES DU PERSONNEL PRÉSENTS: SECRÉTAIRE DE SÉANCE INVITÉS PROCÈS-VERBAL de la réunion du conseil d administration tenue le 7 mars 2012 à la Fondation du cancer de la région d Ottawa (Centre Maplesoft) Lynn Graham Michael Ennis Ralph Moxness Denise Alcock Abdourahamane Diallo Melody Isinger Barbara Lajeunesse Anne Noonan Colette Rivet Sherryl Smith Diane Hupé Bob Kulas Gilles Lanteigne Patrice Connolly Kim Peterson Deryl Rasquinha Ashley Haugh Glenda Owens Ashley Haugh Capitaine de vaisseau Cyd Courchesne Adjum John Gallant Maj Cher Goulet, M me Charlene Langlais Maj Sheila McLean pm 2 Mario Richard Maj Brandy McKenna lcol Arshad Saeed M me Brenda Tilander-Masse M me Gillian Wheeler Linda Eagen Melanie MacDonald Présidente Vice-président Trésorier Directeur général Vice-présidente, RHDO et Communications Vice-présidente, Services à la clientèle Vice-président, Services généraux et Qualité Adjointe à la direction Directrice, Services à la clientèle Adjointe à la direction Directeur des soins primaires, Groupe des services de santé des Forces canadiennes (FC), ministère de la Défense nationale et Forces canadiennes (MDN/CF) Sergent-major de compagnie, Clinique de Petawawa, MDN/FC Commandante adjointe, Clinique d Ottawa, MDN/FC Gestionnaire national des soins à domicile, MDN/FC Commandante adjointe, MDN/FC Sergent major de l unité, Clinique d Ottawa, MDN/FC Gestionnaire de la clinique, Petawawa, MND/FC Chirurgien de la RCN, MDN/FC Gestionnaire des services de soins primaires, Petawawa, MDN/FC Coopération civilo-militaire des Services de santé, MDN/FC Présidente-directrice générale, Fondation du cancer de la région d Ottawa Membre du conseil, Centre de santé Perley et Rideau pour anciens combattants Procès-verbal conseil d administration du CASC de Champlain, le 7 mars 2012 Champlain Community Care Access Centre Centre d accès aux soins communautaires de Champlain

2 2 1.0 OUVERTURE DE LA SÉANCE POINT À L ORDRE DU JOUR MESURE À PRENDRE La présidente, Lynn Graham, ouvre la séance à 12 h. 1.1 Mot de bienvenue La présidente, Lynn Graham, souhaite la bienvenue à toutes les personnes présentes. 1.2 Déclaration de tout conflit d intérêts Aucun conflit d intérêts n est déclaré. 1.3 Remise d une plaque par le ministère de la Défense nationale et les Forces canadiennes Au nom du Groupe des services de santé des Forces canadiennes (FC), le capitaine de vaisseau Cyd Courchesne, directeur des soins primaires du Groupe des services de santé des FC, remet au CASC de Champlain une plaque de reconnaissance en tant que partenaire. Le CASC de Champlain a été le premier CASC de la province à conclure un protocole d entente avec les Forces canadiennes relativement aux services de soins à domicile. En suivant le modèle du CASC de Champlain, cinq autres CASC ont à leur tour signé un protocole d entente de la sorte avec les FC. En plus des excellents soins médicaux d urgence reçus par les soldats blessés sur le terrain, les soldats des FC qui reviennent en Ontario recevront, au besoin, des services de soins à domicile. Ceux-ci sont rendus possibles grâce aux partenariats établis entre les Forces canadiennes et les centres d accès aux soins communautaires. 2.0 ÉDUCATION À L INTENTION DU CONSEIL D ADMINISTRATION ET DISCUSSION GÉNÉRATIVE 2.1 Visite de la Fondation du cancer de la région d Ottawa (Centre Maplesoft) La présidente-directrice générale de la Fondation du cancer de la région d Ottawa, Linda Eagen, nous fait visiter le Centre Maplesoft et nous en donne un aperçu. Le Centre Maplesoft a ouvert ses portes à l automne 2011 pour répondre aux besoins sans cesse croissants des survivants du cancer et de leur famille. Le personnel du centre a étudié des pratiques exemplaires de partout dans le monde pour mettre au point des techniques de «coaching», des programmes et des ateliers à l intention des patients atteints du cancer et de leur famille. Grâce au «coaching» et à d autres programmes, les patients acquièrent des Procès-verbal - conseil d administration du CASC de Champlain, le 7 mars 2012

3 connaissances et des ressources qui leur donnent les moyens de se prendre en charge pendant le traitement, et après. Au nom du conseil, Lynn Graham remercie Linda Eagen de la visite, de la discussion et d avoir accepté de tenir la réunion du conseil du CASC de Champlain. 3.0 BLOC DE RÉSOLUTIONS 3.1 Approbation du bloc de résolutions 3 Melody Isinger, avec l appui de Colette Rivet, propose que le bloc de résolutions de la réunion du conseil d administration du CASC de Champlain du 7 mars 2012, qui contient les motions et renseignements suivants, soit approuvé tel qu il a été modifié : Que le conseil du CASC de Champlain approuve le procès-verbal de la réunion du conseil tenue le 1 er février Rapport du Comité de gouvernance renfermant des renseignements et des mises à jour sur les sujets suivants : o Assemblée générale annuelle (AGA) et assemblé extraordinaire des membres; o Rapport annuel du CASC de Champlain; o Quorum aux réunions des comités; o Code de conduite du conseil; o Éducation à l intention du conseil/discussion générative; o Comité de direction du conseil, présidents des comités et membres des comités ( ) Mise à jour sur l agrément Mise à jour sur les directives budgétaires Loi sur l accès à l information et la protection de la vie privée et rapport d information des CASC Rapport de la présidente du conseil renfermant des renseignements et des mises à jour sur les sujets suivants : o Assemblée générale annuelle de la Coalition pour des soins de fin de vie de qualité du Canada (CSFVQC); o Hôpital général d Almonte et Hôpital Memorial de Carleton Place et du district; o Conseil consultatif sur la gouvernance du comté de Renfrew; o Le Rapport Drummond Rapport du directeur général renfermant des renseignements et des mises à jour sur les sujets suivants : o Communications externes; O Surveillance des opérations; O Habilitation du personnel; O Surveillance stratégique; O Fiche de rendement du conseil. ADOPTÉE Motion adoptée Procès-verbal - conseil d administration du CASC de Champlain, le 7 mars 2012

4 Les points ci-dessous ont été déplacés du bloc de résolutions à l ordre du jour : Rapport du Comité des services à la clientèle et de la qualité (passé au point 5.1) o Politique antidiscriminatoire; o Définitions gestion des événements; o Comité de la santé et de la sécurité du CASC de Champlain (personnel); Rapport du Comité des finances états financiers (passé au point 6.1) 4.0 APPROBATION DE L ORDRE DU JOUR 4.1 Approbation de l ordre du jour de la réunion du conseil du 7 mars Denise Alcock, avec l appui de Sherryl Smith, propose que l ordre du jour de la réunion du conseil du CASC de Champlain du 7 mars 2012 soit approuvé tel qu il a été modifié. ADOPTÉE 5.0 ECELLENCE EN MATIÈRE DE PRESTATION DE SERVICES Motion adoptée Rapport du Comité des services à la clientèle et de la qualité (CSCQ) On présente un rapport du Comité des services à la clientèle et de la qualité renfermant des mises à jour sur les sujets suivants : Agrément; Stratégies de priorisation des ressources pour les thérapies; Plan d amélioration de la qualité; Politique et procédures antidiscriminatoires; Gestion des événements; Structure de gouvernance pour la qualité et la sécurité; Mise à jour de la fiche de rendement du conseil; Fiche de rendement du conseil Politique antidiscriminatoire Denise Alcock, avec l appui d Anne Noonan, propose d approuver la politique antidiscriminatoire et visant le harcèlement telle qu elle a été modifiée. ADOPTÉE Définitions gestion des événements Motion adoptée Pour assurer la clarté des politiques, la définition d incident critique approuvée antérieurement sera modifiée pour cadrer avec la définition qui se trouve dans le cadre de gestion des événements. Denise Alcock, avec l appui de Melody Isinger, propose que les définitions gestion des événements, soient approuvées. ADOPTÉE Motion adoptée Procès-verbal - conseil d administration du CASC de Champlain, le 7 mars 2012

5 5.1.3 Comité de la qualité et de la sécurité du CASC de Champlain (personnel) La discussion concernant le Comité porte sur les points suivants : On mettra sur pied divers sous-comités, y compris un comité sur l éthique et un comité sur les services paramédicaux, entre autres. Le directeur, Qualité et Élaboration de programmes, siège au Comité de la qualité et de la sécurité et agit aussi à titre d agent de liaison entre le personnel et le Comité des services à la clientèle et de la qualité du conseil. Par conséquent, il pourra assurer l échange de renseignements entre les deux comités. Le mandat peut faire l objet d un examen dans 6 à 12 mois. 5 Denise Alcock, avec l appui de Melody Isinger, propose que la mise sur pied du Comité de la qualité et de la sécurité du CASC de Champlain (personnel) soit approuvée. ADOPTÉE 6.0 CAPACITÉ ET RENDEMENT ORGANISATIONNELS Motion adoptée Rapport du Comité des finances Pour les 10 mois se terminant le 31 janvier 2012, le CASC de Champlain affiche un déficit de 1,47 million de dollars. En raison de la demande accrue de services, le personnel continue à discuter avec le Réseau local d intégration des services de santé (RLISS) de Champlain de la possibilité d accroître son financement. 6.2 Discussion sur le Cadre de priorisation des ressources Le conseil discute de la mise en œuvre du cadre de priorisation des ressources déjà approuvé : Le nombre de renvois de clients de la communauté et des hôpitaux continue à augmenter. Tous les secteurs du spectre des soins de santé des hôpitaux aux organismes de soutien communautaire en passant par les CASC sont des partenaires essentiels en prestation de soins de qualité et chaque secteur doit avoir la capacité et les ressources nécessaires pour fournir les services. Le cadre de priorisation des ressources tient compte du risque pour le client au moment de déterminer la priorité et les besoins en matière de services. o On tient compte de l accès des clients à d autres services dans la communauté. Bien que le CASC de Champlain soit chef de file en matière d intégration du système, c est le Réseau local d intégration des services de santé (RLISS) de Champlain qui s occupe de la coordination pour la région et qui fournit le financement pour assurer la prestation d un continuum de soins dans tous les domaines du secteur des soins de santé. Procès-verbal - conseil d administration du CASC de Champlain, le 7 mars 2012

6 6 Il faut atteindre un équilibre entre les besoins des clients mis en congé de l hôpital et ceux des clients dans la communauté, sinon les hôpitaux pourraient être perçus comme la porte d accès aux services du CASC de Champlain. En ce qui concerne les postes budgétaires auxquels le RLISS de Champlain affecte des fonds (p. ex. hanches et genoux, maximums établis pour les services et Chez soi avant tout), le CASC de Champlain dépensera le budget. Si le CASC est obligé de fournir d autres services dans ces domaines, il devra recevoir plus de fonds du RLISS. Il est proposé que le conseil tienne une discussion générative, à une date ultérieure, sur l attribution équitable des ressources. 6.3 Directives budgétaires et budget provisoire pour Les directives budgétaires et le budget provisoire sont présentés au conseil : Conformément aux indications du RLISS de Champlain, le budget du CASC de Champlain est fondé sur une augmentation de 0,5 % du budget de base. Toutes les augmentations connues des fournisseurs de services sont incluses dans le budget. Le CASC de Champlain ne dépensera que les fonds prévus au budget - p. ex. les fonds réservés aux maximums établis pour les services peuvent couvrir environ 50 admissions par mois au programme Chez soi avant tout. Il reste des facteurs à l égard desquels on ne peut pas faire d estimation; ces facteurs ne sont pas inclus dans le budget p. ex. les employés qui peuvent choisir de travailler ou non il y a trop de variables pour fournir une estimation fiable. De plus, le gouvernement provincial pourrait fournir des fonds au besoin. Bien que le budget ait été établi en fonction d une augmentation de 0,5 % du budget de base, il y aura une baisse des fonds consacrés aux services à la clientèle (5 millions de dollars) en raison de l allocation unique reçue en Les coûts administratifs augmenteront légèrement par rapport à , mais demeureront inférieurs aux objectifs visés par l Entente de responsabilisation en matière de services multisectoriels (ERSM). Le budget est équilibré, mais il reste peu de place pour les dépenses imprévues. Le solde du déficit de l ordre de 1,47 million de dollars pour à reporter n est pas inclus dans le budget provisoire de Le personnel du CASC de Champlain continue d informer le RLISS de Champlain des coûts permanents liés aux Autres niveaux de soins et à Chez soi avant tout ainsi que de l incidence du budget sur le CASC de Champlain. Le CASC de Champlain appuiera les initiatives gouvernementales entreprises en cours d exercice dans la mesure où son budget le lui permet. Procès-verbal - conseil d administration du CASC de Champlain, le 7 mars 2012

7 7 Ralph Moxness, avec l appui de Michael Ennis, propose que les directives budgétaires et le budget provisoire pour soient approuvés. ADOPTÉE Motion adoptée Au nom du conseil, le trésorier, Ralph Moxness, remercie le vice-président, Services généraux et qualité, Deryl Rasquinha, ainsi que son équipe du travail qu ils ont consacré aux documents budgétaires. 7.0 LEADERSHIP EN SOINS À DOMICILE ET COMMUNAUTAIRES DANS UN SYSTÈME DE SANTÉ INTÉGRÉ 7.1 Fiche de rendement du CASC de Champlain Examen de la fiche de rendement Les faits saillants de la fiche de rendement ont été fournis dans le rapport du directeur général au conseil Mise à jour de la fiche de rendement Comme la fiche de rendement a été élaborée avant l adoption du plan stratégique, le temps est venu de la mettre à jour afin de s assurer que le conseil reçoit les renseignements dont il a besoin pour prendre des décisions stratégiques en ce qui concerne les politiques. On demandera à chacun des comités du conseil de nommer un représentant pour examiner la fiche de rendement mise à jour et de fournir des commentaires. Une fois que la nouvelle fiche de rendement aura été élaborée, le conseil recevra un aperçu approfondi des nouveaux indicateurs. Denise Alcock, avec l appui de Melody Isinger, propose qu on approuve la nomination d un représentant de chacun des comités du conseil pour contribuer à la mise à jour de la fiche de rendement du conseil. ADOPTÉE 8.0 DIVERS Motion adoptée Questions et commentaires du public Il n y a aucune question ni aucun commentaire du public. 9.0 À HUIS CLOS Barbara Lajeunesse, avec l appui d Abdourahamane Diallo, propose que la réunion se poursuive à huis clos. ADOPTÉE Motion adoptée Procès-verbal - conseil d administration du CASC de Champlain, le 7 mars 2012

8 LEVÉE DE LA SÉANCE Barbara Lajeunesse, avec l appui de Sherryl Smith, propose que la séance soit levée. ADOPTÉE Motion adoptée CONFIRMÉ : APPROUVÉ VOIR LA SIGNATURE ORIGINALE LYNN GRAHAM, PRÉSIDENTE APPROUVÉ VOIR LA SIGNATURE ORIGINALE GILLES LANTEIGNE, DIRECTEUR GÉNÉRAL ET SECRÉTAIRE DU CONSEIL Procès-verbal - conseil d administration du CASC de Champlain, le 7 mars 2012

9 HEURE POINT ORATEUR RENVOI À LA POLITIQUE PRISE DE DÉCISIONS INFO. / EDUC./ SURVEILLANCE À HUIS CLOS RÉUNION DU CONSEIL D ADMINISTRATION DATE : Le 7 mars 2012 HEURE : 12 h ENDROIT : Fondation du cancer de la région d Ottawa (Centre Maplesoft), 1500, prom. Alta Vista, Ottawa ORDRE DU JOUR SUJET 1.0 Ouverture de la séance 12 h 12 h Mot de bienvenue 1.2 Déclaration de tout conflit d intérêts 1.3 Présentation du ministère de la Défense nationale et des Forces canadiennes Lynn Graham Lynn Graham Capt(N) Cyd Courchesne V- B h h Éducation à l intention du conseil d administration et discussion générative 2.1 Visite du Centre de cancérologie Linda Eagen, Fondation du cancer de la région d Ottawa 3.0 Bloc de résolutions (N importe quel membre du conseil d administration peut demander qu on déplace un article du bloc de résolutions à l ordre du jour ordinaire.) 12 h h Approbation du bloc de résolutions Lynn Graham Procès-verbal de la réunion du conseil d administration tenue le 1 er février Rapport du Comité de gouvernance Agrément 1

10 HEURE POINT ORATEUR RENVOI À LA POLITIQUE PRISE DE DÉCISIONS INFO. / EDUC./ SURVEILLANCE À HUIS CLOS SUJET Rapport du Comité des finances états financiers Directives budgétaires Rapport du Comité des services à la clientèle et de la qualité (CSCQ) Politique antidiscriminatoire Définitions gestion des événements Comité de la qualité et de la sécurité du CASC de Champlain (personnel) Loi sur l accès à l information et la protection de la vie privée et les CASC Rapport de la présidente du conseil d administration Rapport du directeur général 4.0 Approbation de l ordre du jour 12 h h Approbation de l ordre du jour de la réunion du conseil d administration prévue pour le 7 mars h h h h Excellence en matière de prestation de services 5.1 Discussion sur le Cadre de priorisation des ressources 5.2 Directives budgétaires et budget provisoire pour Leadership en soins à domicile et communautaires dans un système de santé intégré 6.1 Fiche de rendement du CASC de Champlain Examen de la fiche de rendement Mise à jour de la fiche de rendement 7.0 Divers Deryl Rasquinha Deryl Rasquinha Deryl Rasquinha 13 h h 7.1 Questions et commentaires du public 8.0 À huis clos 15 h Levée de la séance Lynn Graham 2

11 Submission To The Board DND Presentation March 7, 2012 INFORMATION The Canadian Forces Health Services Group will be presenting an appreciation plaque to the Champlain CCAC. It is through the partnership and efforts of the Champlain CCAC that there is now a successful model for the collaboration/coordination and Memoranda of Understanding with 6 CCACs in Ontario for the delivery of Home Care services to our Canadian Forces (CF) Members. Attendees for CF: Capt(N)Cyd Courchesne, Director Primary Care, CF Health Services Group (senior exec representative - she will make the presentation) Ms Charlene Langlais, National Manager Home Care L Col Arshad Saeed, NCR Surgeon (senior physician/clinician Ottawa region) Maj Cher Goulet, Deputy Commanding Officer, Ottawa clinic CPO2 Mario Richard, Unit Sergeant Major, Ottawa clinic Maj Brandy McKenna, Clinic Manager, Petawawa MWO John Gallant, Company Sergeant Major, Petawawa Clinic Ms Brenda Tilander-Masse, Primary Care Services Manager, Petawawa Maj Sheila McLean, Deputy Commanding Officer (previously Clinic Manager Petawawa) Ms Gillian Wheeler, Health Services Civilian Military Cooperation Champlain CCAC Board March 7, 2012 Item 1.3 Presentation from Department of National Defence and the Canadian Forces PAGE 1

12 Item 3.1 Consent Agenda MOTION WEDNESDAY MARCH 7, 2012 Champlain CCAC Board of Directors Consent Agenda For all presentations and reports on the entire agenda (i.e., not just the consent agenda), presenters have been asked to assume that the Board has read all of the material in advance. Time with the Board will focus on questions and discussions rather than repetition of the written material. Any one Board Member may request that any item be removed from the consent agenda and moved to the regular agenda for discussion. By approving the consent agenda, the Board will be approving and accepting the material on the consent agenda. The minutes of the meeting will reflect that the consent agenda passed and note all of the items and full motions approved as part of the consent agenda. Moved by: Seconded by: Be it resolved, That the Champlain CCAC Board approves the consent agenda for the March 7, 2012 meeting Minutes from the February 1, 2012 Board meeting (approval) Report from the Governance Committee (information) Accreditation (information) Report from the Finance Committee Financial Statements Budget Guidelines (information) Report from the Client Services and Quality Committee (information) Anti-Discriminatory Policy (approval) Events Management Definitions (approval) Champlain CCAC (staff) Quality and Safety Committee (approval) Freedom of Information and Protection of Privacy Act (FIPPA) and CCACs (information) Report from the Board Chair (information) Report from the CEO (information) Carried Defeated

13 Submission To The Board Report from the Governance Committee March 7, 2012 ISSUE To provide an update to the Board regarding the February 23 Governance Committee meeting. BACKGROUND Annual and Special Meeting of Members (AGM) Planning continued for the June 6, 2012 AGM. Diane Hupé is the Board representative on the AGM planning group and she will emcee the AGM which also includes facilitating a stakeholder panel discussion. Champlain CCAC Annual Report The Annual Report is in production and will be released at the AGM on June 6. The Annual Report will focus on the strategic directions, key priorities and outcomes. Quorum at Committees In December 2009 and May 2011, the Governance Committee discussed and determined that the Board Chair, as an ex-officio voting member of all Board committees, should be included in determining quorum. This was subsequently presented to the Board at the December 2009 Board meeting and has been in practice since then. Now with more than two years of experience with this format, the Governance Committee has reviewed this practice and recommends that the Board Chair not be included in determining quorum or if quorum is present at a Committee meeting. Having the Board Chair counted in quorum counts puts undue pressure on the Board Chair to be present at all Committee meetings. The Board Chair not being included in quorum counts complies with Robert s Rules of Order. When present at Committee meetings, the Board Chair is a voting member. Board Code of Conduct As is required to meet Accreditation standards, the Governance Committee is drafting a Board Code of Conduct. A first draft has been reviewed and revisions will be incorporated into a revised draft to be tabled at the March Governance meeting. If endorsed, it is expected to be tabled with the Board at the April meeting. Champlain CCAC Board - March 7, 2012 Item Report from the Governance Committee PAGE 1

14 Board Education/Generative Discussion The Governance Committee reviewed the frequency and format of the Board generative discussion. Feedback on the generative discussions has been very positive. However, it is recommended that full generative discussions (approximately 60 min to 75 min in length) take place every other Board meeting. The alternating meetings will allow time for other discussion items (e.g., accreditation preparation). As an update to the February 2012 Governance Committee report, upcoming Board generative and/or education discussion will include: March the Board meeting will be held at the Cancer Survivorship Centre (Maplesoft Centre) and Board education/generative discussion will include: o a tour of the Centre and discussion o Resource Prioritization Framework discussion April Accreditation preparation - information, background and readiness for accreditation onsite survey May the Board meeting will be held at the Cornwall CCAC office and education/generative discussion will also include local community and partner engagement June the Annual and Special Meeting of Members Board Officers, Committee Chairs, Committee Membership ( ) As a reminder, Board Members were sent a survey regarding their interest in officer, committee chairs and committee membership positions. Responses are due to Ashley Haugh, Executive Assistant, by April 9, Anne Noonan Chair Sponsoring Executive Patrice Connolly, VP, HR, OD and Communications Champlain CCAC Board - March 7, 2012 Item Report from the Governance Committee PAGE 2

15 Submission to the Board Accreditation March 7, 2012 BACKGROUND Work continues to progress to prepare the Champlain CCAC for accreditation. A work plan has been put in place to meet accreditation standards and the accreditation teams are progressing on projects. Both the Board Governance Committee and the Client Services and Quality Committee continue to monitor accreditation projects related to the Board. SUMMARY OF CURRENT ACTIVITIES Timing of on-site accreditation visit Given other high priority demands and the availability of human resources to complete the work as well as the critical importance of staff engagement during the process, the Executive Committee is investigating deferring the on-site survey from September 2012 until December Discussion is currently underway with Accreditation Canada to determine whether this request can be accommodated. Board Code of Conduct As is required to meet Accreditation standards, the Governance Committee is drafting a Board Code of Conduct. A first draft has been reviewed and revisions will be incorporated into a revised draft to be tabled at the March Governance meeting. If endorsed, it is expected to be tabled with the Board at the April meeting. Board Evaluations At the March 2012 Governance Committee meeting, the Committee will be discussing potential methods of Board evaluation including self-assessment, peer to peer evaluations, Board assessments and officer evaluations. Sponsoring Executive: Gilles Lanteigne, CEO Champlain CCAC Board March 7, 2012 Item Accreditation PAGE 1

16 Submission to the Board CCAC Budget Guidelines Updated February 20, 2012 Purpose: To seek input from the Finance Committee of the Champlain CCAC Board, on key principles and assumptions with regard to F Budget. Background: The desired objective is to end each year in a balanced financial position. However, in meeting its financial objectives, it is important that Champlain CCAC also meet key business objectives including: fulfilling its mission by finding and serving all the clients requiring CCAC service; having no service waitlists; having excellent quality results; and investing in building operational efficiency to enhance future sustainability. In achieving these objectives, it is challenged by the inherent complexity of the business, the rate of business transformation necessary in community care to support the ministry s transformation from institutional to community care, and finances being confirmed in a timely fashion. Budget Guidelines for Revenue Growth in revenue o Jan /24/2011 0% revenue growth assumption Directive from the LHIN was to assume a 0% revenue growth for F 11. Base F 11 funding dollar amount to be inclusive of F 10 service max funding received of $3.1M on Sept/15, and $1.8M growth funding received Nov/4 o Apr/26/2011 3% revenue growth assumption While not confirmed by a funding letter from the LHIN, three credible sources have provided indications that CCACs should expect a 3% increase in funding in They include: Update received from OACCAC CEO, to CCAC CEO Council, at March end meeting Update received from LHIN CEO, to Champlain CCAC Board & Senior Management, at board retreat Apr/13 Attached letter from Deputy Minister Saad Rafi, to OACCAC CEO, Apr/8/2011 o Aug/29/2011 The 3% funding letter from the LHIN was received Aug/26/2011 Based on this, Champlain CCAC has recast the budget with the 3% increase Operationally, Champlain CCAC may proceed to spend beyond the 3% increase (i.e., not waitlist), keeping the LHIN informed on a regular basis on monthly costs, and cost projections for year end o Sept/26/2011 Sept 13, Directed Funding for Mental Health and Addiction Nurses for School Board Program - $696K in 2011/12; $1, 169K in 2012/13 to hire 1RN Lead, 14 RN/RPN s. Sept 8, Directed funding for Nurse Practitioners for Integrated Palliative Home Care Program - $340K in 2011/12; $583K in 2012/13 to hire 5 NP s Sept 14, Directed funding for Registered Nurses for Rapid Response Nursing Program - $545K in 2011/12; $935K in 2012/13 to hire 11 RN s Aug 18, Directed Funding for PSW Training (Flow Through to Service Providers); One time funding of $717K Sept 6, Directed funding, one time, for CARESS planning- $190K o Oct/20/2011 Champlain CCAC Board March 7, 2012 Item CCAC Budget Guidelines PAGE 1

17 o o o o o o o o o 471K Funding for Admin expenses to move to the centre of the health system/ handle additional Client demand (against $1.5M of identified need) NOTE: Funding letter still pending 144K to support Long Stay Expert Panel (flow through funds) Nov/3/2011 LHIN Letter requesting Champlain CCAC present a deficit recovery plan of no more than $3M deficit for YE, and a balanced budget for F2012/13. Nov/10/2011 LHIN Letter notifying Champlain CCAC that they will be recovering $70,000 funding for Champlain Hospice End-of-Life Coordinator position (no longer staffed) as part of funding for Champlain Hospice Palliative Care Program. Nov/24/2011 LHIN Letter notifying Champlain CCAC that they will be providing one-time funding of $275,000 for 2011/12 and an additional $200,000 for 2012/13 for ALC initiatives Nov/21/2011 LHIN Letter notifying Champlain CCAC that they will provide one-time funding of $57,500 to support the Construction of Community Education and Resource Center at Hospice Renfrew. Dec/16/2011 LHIN Letter notifying Champlain CCAC that they will provide one-time funding of $2,120,000 for the implementation of the Sustainability Plan. Jan/10/2012 LHIN Letter notifying Champlain CCAC that they will provide one-time funding of $11,000 for additional Renfrew Preschool Speech and Language services. Jan/24/2012 LHIN Letter notifying Champlain CCAC that they will provide one-time funding of $877,500 for additional Home First clients. Feb/7/2012 LHIN Letter notifying Champlain CCAC that they will provide one-time funding of $1,000,000 for the implementation of the Sustainability Plan. Feb/17/2012 LHIN Letter requesting an amended Sustainability Plan that results in a balanced position at yearend with the $3,997,500 identified above: ($2,120,000; $877,500 and $1,000,000)) Hips & Knees: o Jan/24/2011 Sept 18, 2011: Assume Wait Time funding for cases above a baseline of 150. This will generate $1.275M $1,417K of additional revenue. (Confirmation of acceptance of baseline value and funding received Sept 18, 2011). o Apr/26/2011: Letter from ADM of MOHLTC, to LHIN CEO & OACCAC CEO indicating reconciliation process for F 11to be provided in F 11/12 Hips/Knee funding letter Expense Government directive is a zero net increase for salaries Government funding to support Service Provider rate increases assumed to be 0% o However, any pre-negotiated rate increases in 2011 needs to be supported by Champlain CCAC from its 0% revenue growth base Compensation Restraint Act determines management compensation until 2012 Investments required to support ongoing CCAC priorities including: o Client Services o Quality & Performance Management o Communications and Corporate Image Champlain CCAC Board March 7, 2012 Item CCAC Budget Guidelines PAGE 2

18 Update Apr/26/2011: Letter received from Champlain LHIN indicating need to reduce Executive Office Expenses by 10% over 2 years (5 %/year) (Updated February 20, 2012) Champlain CCAC Board March 7, 2012 Item CCAC Budget Guidelines PAGE 3

19 Submission to the Board CCAC Budget Guidelines Updated February 20, 2012 Purpose: To seek input from the Finance Committee of the Champlain CCAC Board, on key principles and assumptions with regard to F Budget. Background: The desired objective is to end each year in a balanced financial position. However, in meeting its financial objectives, it is important that Champlain CCAC also meet key business objectives including: fulfilling its mission by finding and serving all the clients requiring CCAC service; having no service waitlists; having excellent quality results; and investing in building operational efficiency to enhance future sustainability. In achieving these objectives, it is challenged by the inherent complexity of the business, the rate of business transformation necessary in community care to support the ministry s transformation from institutional to community care, and finances being confirmed in a timely fashion. Budget Guidelines for Revenue Growth in revenue o Jan /24/2011 0% revenue growth assumption Directive from the LHIN was to assume a 0% revenue growth for F 11. Base F 11 funding dollar amount to be inclusive of F 10 service max funding received of $3.1M on Sept/15, and $1.8M growth funding received Nov/4 o Apr/26/2011 3% revenue growth assumption While not confirmed by a funding letter from the LHIN, three credible sources have provided indications that CCACs should expect a 3% increase in funding in They include: Update received from OACCAC CEO, to CCAC CEO Council, at March end meeting Update received from LHIN CEO, to Champlain CCAC Board & Senior Management, at board retreat Apr/13 Attached letter from Deputy Minister Saad Rafi, to OACCAC CEO, Apr/8/2011 o Aug/29/2011 The 3% funding letter from the LHIN was received Aug/26/2011 Based on this, Champlain CCAC has recast the budget with the 3% increase Operationally, Champlain CCAC may proceed to spend beyond the 3% increase (i.e., not waitlist), keeping the LHIN informed on a regular basis on monthly costs, and cost projections for year end o Sept/26/2011 Sept 13, Directed Funding for Mental Health and Addiction Nurses for School Board Program - $696K in 2011/12; $1, 169K in 2012/13 to hire 1RN Lead, 14 RN/RPN s. Sept 8, Directed funding for Nurse Practitioners for Integrated Palliative Home Care Program - $340K in 2011/12; $583K in 2012/13 to hire 5 NP s Sept 14, Directed funding for Registered Nurses for Rapid Response Nursing Program - $545K in 2011/12; $935K in 2012/13 to hire 11 RN s Aug 18, Directed Funding for PSW Training (Flow Through to Service Providers); One time funding of $717K Sept 6, Directed funding, one time, for CARESS planning- $190K o Oct/20/2011 Champlain CCAC Board March 7, 2012 Item CCAC Budget Guidelines PAGE 1

20 o o o o o o o o o 471K Funding for Admin expenses to move to the centre of the health system/ handle additional Client demand (against $1.5M of identified need) NOTE: Funding letter still pending 144K to support Long Stay Expert Panel (flow through funds) Nov/3/2011 LHIN Letter requesting Champlain CCAC present a deficit recovery plan of no more than $3M deficit for YE, and a balanced budget for F2012/13. Nov/10/2011 LHIN Letter notifying Champlain CCAC that they will be recovering $70,000 funding for Champlain Hospice End-of-Life Coordinator position (no longer staffed) as part of funding for Champlain Hospice Palliative Care Program. Nov/24/2011 LHIN Letter notifying Champlain CCAC that they will be providing one-time funding of $275,000 for 2011/12 and an additional $200,000 for 2012/13 for ALC initiatives Nov/21/2011 LHIN Letter notifying Champlain CCAC that they will provide one-time funding of $57,500 to support the Construction of Community Education and Resource Center at Hospice Renfrew. Dec/16/2011 LHIN Letter notifying Champlain CCAC that they will provide one-time funding of $2,120,000 for the implementation of the Sustainability Plan. Jan/10/2012 LHIN Letter notifying Champlain CCAC that they will provide one-time funding of $11,000 for additional Renfrew Preschool Speech and Language services. Jan/24/2012 LHIN Letter notifying Champlain CCAC that they will provide one-time funding of $877,500 for additional Home First clients. Feb/7/2012 LHIN Letter notifying Champlain CCAC that they will provide one-time funding of $1,000,000 for the implementation of the Sustainability Plan. Feb/17/2012 LHIN Letter requesting an amended Sustainability Plan that results in a balanced position at yearend with the $3,997,500 identified above: ($2,120,000; $877,500 and $1,000,000)) Hips & Knees: o Jan/24/2011 Sept 18, 2011: Assume Wait Time funding for cases above a baseline of 150. This will generate $1.275M $1,417K of additional revenue. (Confirmation of acceptance of baseline value and funding received Sept 18, 2011). o Apr/26/2011: Letter from ADM of MOHLTC, to LHIN CEO & OACCAC CEO indicating reconciliation process for F 11to be provided in F 11/12 Hips/Knee funding letter Expense Government directive is a zero net increase for salaries Government funding to support Service Provider rate increases assumed to be 0% o However, any pre-negotiated rate increases in 2011 needs to be supported by Champlain CCAC from its 0% revenue growth base Compensation Restraint Act determines management compensation until 2012 Investments required to support ongoing CCAC priorities including: o Client Services o Quality & Performance Management o Communications and Corporate Image Champlain CCAC Board March 7, 2012 Item CCAC Budget Guidelines PAGE 2

21 Update Apr/26/2011: Letter received from Champlain LHIN indicating need to reduce Executive Office Expenses by 10% over 2 years (5 %/year) (Updated February 20, 2012) Champlain CCAC Board March 7, 2012 Item CCAC Budget Guidelines PAGE 3

22 CHAMPLAIN CCAC Item 3.1.4B - Report from the Finance Committee - Financial Statements Financial Statements for the Ten Months Ending Tuesday, January 31, Month YTD YTD Total 1 Month Budget Variance YTD Budget Variance Budget REVENUE Base Funding 15,769,338 15,447, , ,693, ,394, , ,161,456 One-Time Funding 1,994, ,592 1,860,219 5,243,935 1,345,917 3,898,018 1,615,100 BTI 36,468 36, , , ,620 Other 66,677 30,416 36, , , , ,988 Assisted Living 19,875-19, , , ,495 Total Revenue 17,867,293 15,669,145 2,198, ,844, ,608,078 4,236, ,817,659 CLIENT CARE Purchased Services Personal Support Services 5,914,928 5,004, ,618 57,212,643 50,851,953-6,360,690 60,290,814 Visit Nursing (includes dialysis) 2,540,145 2,446,895-93,250 25,333,738 24,879, ,882 29,498,179 Visit Nursing - Clinic 247, ,104 20,677 2,300,130 2,685, ,254 3,193,164 Nursing Shifts 776, ,592-56,372 7,649,087 6,972, ,495 8,337,333 Community - OT 280, ,693 7,830 2,581,761 2,961, ,011 3,505,382 Community - PT 248, ,888 28,737 2,427,645 2,838, ,257 3,360,263 Community - Speech 11,932 22,633 10, , ,129 78, ,767 School - OT 174, ,179 62,406 1,654,589 2,042, ,018 2,493,991 School - PT 40,977 59,352 18, , ,061 43, ,017 School - Speech 134, ,346 47,578 1,343,066 1,571, ,037 1,918,125 Social Work 22,262 44,633 22, , , , ,947 Nutrition 28,918 41,046 12, , ,135 51, ,579 Hospice 284, ,913-70,721 2,904,037 2,139, ,907 2,566,953 Aphasia 20,833-20, , ,330 Medical Supplies 1,061, ,304-84,705 10,309,726 9,934, ,025 11,777,045 Medical Equipment 98, ,564 6,650 1,073,692 1,072,463-1,229 1,271,628 Laboratory Services ,011 5,086 7,135 Other 3,934 6,129 2, ,172 61, , ,554 Total Purchased Services 11,891,457 10,895, , ,424, ,629,967-6,794, ,367,876 Internal Therapies Wages 232, ,766 38,409 2,348,582 2,683, ,466 3,232,650 Benefits 70,469 64,946-5, , ,287 83, ,180 Travel 23,137 23, , ,604 43, ,945 General Administration Costs 170 1,667 1,496 10,918 16,667 5,749 20,000 Total Internal Therapies 326, ,550 34,417 3,174,458 3,641, ,148 4,370,775 Page 1 of 7

23 CHAMPLAIN CCAC Item 3.1.4B - Report from the Finance Committee - Financial Statements Financial Statements for the Ten Months Ending Tuesday, January 31, Month YTD YTD Total 1 Month Budget Variance YTD Budget Variance Budget Case Management Wages 2,555,738 2,416, ,642 24,605,826 23,941, ,236 28,862,121 Benefits 718, , ,758 6,160,849 6,360, ,139 7,521,227 Travel 31,483 43,244 11, , ,511 51, ,000 Professional Service 15,000 15,000 64, ,000 85, ,000 Office Supplies 3,752 10,888 7,136 63, ,880 45, ,660 Photocopy Charges 2,258 9,761 7,503 69,545 97,610 28, ,128 Delivery & Courier 3,871 5,400 1,529 31,480 54,000 22,520 64,800 Courses/Training/Conferences 87 6,667 6,580 41,686 66,670 24,984 80,000 Equipment Maintenance ,569 2, ,500 Minor Equipment 4,167 4,167 41,670 41,670 50,000 Printing 15,334 9,167-6, ,055 91,670-34, ,000 Wireless Service 4,970 4, ,779 46,250-2,529 55,500 Other 2,924 1,417-1,507 15,571 14,170-1,401 17,000 Total Case Management 3,339,297 3,106, ,537 31,607,557 31,404, ,469 37,705,936 Information & Referral Wages 76,201 72,000-4, , ,468 7, ,578 Benefits 19,833 16,718-3, , ,897 6, ,333 Course Registrations Travel 12,403-12,403 Total for Information & Referral 96,034 88,718-7, , , ,077,911 Total Client Care 15,652,922 14,451,203-1,201, ,103, ,573,026-6,530, ,522,498 ADMINISTRATION Executive Office Wages 80,679 96,622 15, , ,607 43,886 1,150,851 Benefits 23,295 22,045-1, , ,496 44, ,585 Travel 608 2,446 1,838 18,695 24,238 5,543 29,132 Legal Services 2,952 4,188 1,236 25,588 41,880 16,292 50,250 Consultants 6,704 6,704 11,226 67,040 55,814 80,450 Membership (OACCAC) 30,794 33,333 2, , ,330 21, ,000 Minor Equipment Meeting Expenses ,560 3, ,750 Printed Matter & Subscriptions ,214 3,960 1,746 4,750 Board Expenses 637 2,625 1,988 22,707 26,250 3,543 31,500 Other 1,156 1,156 11,560 11,560 13,875 Page 2 of 7

24 CHAMPLAIN CCAC Item 3.1.4B - Report from the Finance Committee - Financial Statements Financial Statements for the Ten Months Ending Tuesday, January 31, Month YTD YTD Total 1 Month Budget Variance YTD Budget Variance Budget Total for Executive Office 139, ,911 30,906 1,508,178 1,712, ,143 2,052,143 Corporate Services Business Intelligence Wages 33,340 29,601-3, , ,369-17, ,571 Benefits 9,503 6,752-2,751 76,272 74,272-2,000 87,774 Travel ,252 7,737 6,485 9,300 Total for Business Intelligence 42,843 37,134-5, , ,378-13, ,645 Quality & Risk Wages 25,388 36,491 11, , , , ,626 Benefits 9,920 8,364-1,556 59,565 92,004 32, ,728 Travel ,223 6,241 3,018 7,500 Other 5,061 5,061 28,575 50,610 22,035 60,728 Total for Quality & Risk 35,380 50,546 15, , , , ,582 Project Management Office Wages 23,043 20,624-2, , ,404-22, ,652 Benefits 6,345 4,706-1,639 47,227 51,764 4,537 61,172 Travel ,578 4,074 5,500 Other 18,583 18, , , ,000 Total for Project Management Office 29,388 44,375 14, , , , ,324 Finance Wages 31,970 40,980 9, , ,088 48, ,962 Benefits 10,246 9, , ,520-12, ,521 Travel ,079 2,069 2,500 Insurance 6,021 5, ,833 50,750-8,083 60,900 Audit Services -2,719 3,708 6,427 32,651 37,080 4,429 44,500 Other 250 1, ,878 10,000 7,122 12,000 Total for Finance 45,769 60,475 14, , ,517 41, ,383 Page 3 of 7

25 CHAMPLAIN CCAC Item 3.1.4B - Report from the Finance Committee - Financial Statements Financial Statements for the Ten Months Ending Tuesday, January 31, Month YTD YTD Total 1 Month Budget Variance YTD Budget Variance Budget Contracts & Procurement Wages 47,461 56,074 8, , ,732 95, ,880 Benefits 13,985 12,818-1, , ,998 29, ,632 Travel ,701 4,994-4,707 6,000 Total PMA 61,800 69,396 7, , , , ,512 IT & System Communications Wages 111, ,700-10,205 1,008,793 1,007, ,216,114 Benefits 31,488 23,499-7, , ,488 10, ,486 Travel 1,526 2, ,465 24,963 7,498 30,000 Telephone & System Communications 31,226 35,400 4, , ,802 39, ,602 Telephone Supplies 571 2,500 1,929 40,423 23,214-17,209 28,214 Telephone Maintenance & Licenses 6,614 1,850-4,764 75,964 89,162 13,198 92,862 Telephone System Consultant 5,000 5,000 18,544 35,000 16,456 45,000 Equipment Maintenance 2,100 2,100 17,281 23,269 5,988 28,000 Software Maintenance & Licenses 9,133 15,500 6, , ,700 67, ,000 System Development Consultant/CHRIS Development 12,000 12,000 78, ,012 87, ,012 Computer Supplies 3,839 8,500 4,661 48,408 82,500 34, ,000 Other Equipment Rentals 5,000 5,000 5,000 BTI 32,020 39,715 7, , ,145 77, ,574 BTI Refresh/Growth 8,076-8,076 65,010 38,862-26,148 44,000 CCAC ehealth Program 1,270,396 1,277,345 6,949 1,703,126 Renovations 216 2,000 1,784 18,248 20,827 2,579 25,000 Other 4,408 10,000 5,592 34, , , ,000 Equipment Purchases (Capital Asset) 40,581-40,581 Net Gain or Loss on Disposal Total for IT & System Communications 241, ,283 21,260 3,797,134 4,202, ,974 5,274,990 Health Records Wages 24,494 25, , ,808-17, ,661 Benefits 6,413 5, ,816 64, ,834 Travel ,227 5,993 3,766 7,200 Equipment Maintenance ,670 1,670 2,000 Shredding & Document Destruction 1,667 1,667 17,013 16, ,000 Scanning Services ,670 6,670 8,000 Storage 3,750 3,750 33,758 37,500 3,742 45,000 Total for Health Records 30,954 37,898 6, , ,475-2, ,695 Page 4 of 7

26 CHAMPLAIN CCAC Item 3.1.4B - Report from the Finance Committee - Financial Statements Financial Statements for the Ten Months Ending Tuesday, January 31, Month YTD YTD Total 1 Month Budget Variance YTD Budget Variance Budget Facilities Wages 16,700 19,383 2, , ,082-15, ,856 Benefits 4,868 4, ,285 49, ,239 Travel ,853 8,324 4,471 10,000 Office Supplies & Services 694 3,000 2,306 12,140 30,000 17,860 36,000 Postage, courier & photocopy services 7, ,434 40,100 23,330-16,770 30,000 Building Occupancy 218, ,941-17,709 2,149,012 2,009, ,601 2,411,295 Office Renovations ,833 18,033 59, , , ,000 Utilities 19,788 4,464-15, ,669 44,640-73,029 53,558 Building & Grounds - Other Misc Supplies/Repairs/Cleaning 7,368 8, ,533 80,000-11,533 96,000 Equipment Maintenance-Plant 2,782 4,750 1,968 43,244 47,500 4,256 57,000 Furniture & Equipment Purchases (Capital Asset) 126, ,964 Leasehold Improvement Purchases (Capital Asset) 69,549-69,549 Other 1,718 4,000 2,282 25,826 40,000 14,174 48,000 Total for Facilities 280, ,524-11,161 2,996,163 2,712, ,266 3,257,948 Total Corporate Services 767, ,631 63,788 9,259,696 9,942, ,478 12,163,079 HR/OD & Communications Human Resources Wages 68,797 67,398-1, , ,966 24, ,762 Benefits 17,929 18, , ,437 39, ,901 Travel 839 2,099 1,260 14,079 20,801 6,722 25,000 Consultants - HR 4,755 8,750 3,995 37,514 87,500 49, ,000 Labour Relations 21,525 12,083-9,442 81, ,830 39, ,000 Courses/Training/Conferences 3,689 5,000 1,311 51,639 50,000-1,639 60,000 Occupational Health & Safety 261,957 2, , ,189 20, ,359 25,000 Employee Assistance Plan 3,333 3,333 17,301 33,330 16,030 40,000 Staff Appreciation 103 5,000 4,897 42,544 50,000 7,456 60,000 Advertising 2,917 8,017 5,101 5,365 80,170 74,805 96,200 Other 43,450 50,000 6,550 65,000 Total Human Resources 382, , ,013 1,374,146 1,383,864 9,718 1,663,863 Page 5 of 7

27 CHAMPLAIN CCAC Item 3.1.4B - Report from the Finance Committee - Financial Statements Financial Statements for the Ten Months Ending Tuesday, January 31, Month YTD YTD Total 1 Month Budget Variance YTD Budget Variance Budget Inservice Educators Wages 25,608 29,181 3, , ,171 17, ,164 Benefits 8,110 6,750-1,360 68,092 74,250 6,158 87,750 Course Registrations Travel ,960-9,960 Total for Inservice Educators 34,085 35,931 1, , ,421 13, ,914 Payroll Wages 10,481 25,901 15, , , , ,505 Benefits 4,067 5,910 1,843 37,504 65,008 27,504 76,824 Travel ,378 2, ,500 Total for Payroll 14,548 32,021 17, , , , ,829 Public Relations Wages 28,727 22,406-6, , ,062-42, ,874 Benefits 8,931 5,112-3,819 66,746 56,232-10,514 66,457 Travel ,165 7,489 2,324 9,000 Public Relations 5,147 19,313 14, , ,374 55, ,000 Translation 696 1, ,476 16,639 3,163 20,000 Total Public Relations 44,073 49,266 5, , ,796 7, ,331 Total HR/OD & Communications 475, , ,502 2,380,618 2,564, ,253 3,079,937 Total Administration 1,382,063 1,251, ,807 13,148,492 14,219,366 1,070,874 17,295,159 Capital Assets - Offset -1,152,757 1,152,757 Current YTD Depreciation 1,152,757-1,152,757 Total Capital Assets/Depreciation Total Expenses 17,034,985 15,702,459-1,332, ,251, ,792,392-5,459, ,817,657 Revenue less Expenses 832,309-33, ,622-1,407, ,314-1,222,967 2 Page 6 of 7

28 CHAMPLAIN CCAC Item 3.1.4B - Report from the Finance Committee - Financial Statements Financial Statements for the Ten Months Ending Tuesday, January 31, Month YTD YTD Total 1 Month Budget Variance YTD Budget Variance Budget Additional Programs : French Language Funding 11,082 11, , , ,000 Expenses 11,680 11, , ,948-2, ,000 Total French Language , ,411 Preschool Funding 35,906 24,907 10, , ,068 11, ,881 Expenses 25,567 24, , , ,881 Total Preschool 10, ,071 9, ,195 Palliative Care Funding 7,202 7, ,028 70,940 1,088 85,128 Expenses 7,094 7,094 29,960 70,940 40,980 85,128 Total Palliative Care 7,202 7,202 42,068 42,068 CSS (AIP) Funding 118, ,714 1,750 1,184,643 1,167,143 17,500 1,400,571 Expenses 154, ,714-37,311 1,011,629 1,167, ,513 1,400,571 Total CSS (AIP) -35,561-35, , ,013 PSW Funding -549, , ,000 Expenses 549, , ,000 Total PSW Total Additional Programs -18, , , ,866 1 Total as per Trial Balance 813,690-32, ,677-1,185, ,963 1,000,102 3 Page 7 of 7

29 Submission to Board of Directors Client Services and Quality Committee Report March 7, 2012 BACKGROUND/ISSUE Accreditation Update Detailed review of the Accreditation gap analysis and self-assessment questionnaire was presented. Thirty-one projects or tasks have been identified to address the gaps. Given other high priority demands and the availability of human resources to complete the work as well as the critical importance of staff engagement during the process, the Executive Committee is investigating deferring the on-site survey from September 2012 until December Discussion is currently underway with Accreditation Canada to determine whether this request can be accommodated. Resource Prioritization Strategies for Therapies The Assistant Director Client Services, presented an overview of the resource prioritization strategies for therapies. The current context and challenges of providing timely care without a corresponding increase in resources to meet growing demands was discussed. Initial analysis of the current waitlist suggests that a different approach to prioritizing clients is required, these include: targeting key clinical conditions, realigning current waitlist priority scores from subjective ratings to more objective assessment scores obtained from the RAI-CAL (Resident Assessment Instrument - Calculator (to ensure that those clients with highest acuity have their needs addressed in a timely manner). Further work is scheduled to ensure that practice is standardised across the Champlain region and that practice is measured against provincial bench-marks; additionally, a complete service delivery model review is planned and will investigate strategies such as increased use of pathways, shared care approaches and inter-professional models of care. Update on Quality Plan An update on the Quality Improvement Plan was provided. Written status updates on all items included in the Quality Improvement Plan were provided to the CSQC; additional attention was directed to the Anti-Discrimination Policy, the Events Management System and the Governance Structures for Quality and Safety (see details below). Anti-Discrimination Policy & Procedure (see separate motion ) An updated draft of the Anti-Discrimination Policy was presented to the committee. Considerable work was undertaken to ensure congruency with the Ontario Human Rights Code and a legal opinion was obtained to ensure that the policy is in compliance with the code. The committee reviewed the legal opinion which addresses the unique nature of care provision in the home care setting and the balance of protecting the rights of the client with the rights of the worker to employment without discrimination. The impact to the service providers was Champlain CCAC Board March 7, 2012 Item Client Services and Quality Committee Report PAGE 1

30 discussed with reference to the permissible request for specific gender. The service providers have been engaged throughout the development of the policy and the legal opinion will be shared. Minor revisions were suggested by CSQC and the revised policy will be presented to the Board of Directors for approval. Events Management (see separate motion ) An update was provided on the implementation of the Events Management System. Deployment is on target; staff training will be completed by February 28, 2012 and Go-Live is scheduled for March 01, The committee discussed the launch of the system as the beginning of cultural change and a movement towards increased compliance and comfort in reporting of events. It is anticipated that there will be a significant increase in reporting over the coming fiscal year. The operational definitions of the event category and types were reviewed and approved by the committee and will provide staff with standardised definitions that are congruent with the provincial framework. The CSQC recommends Board approval of the definitions. Governance Structure for Quality and Safety (see separate motion ) The committee reviewed the Terms of Reference and the reporting accountabilities for the proposed staff Quality & Safety Committee. Feedback was provided on the roles and responsibilities of the committee with the recognition that a primary goal of the committee s initial work is to engage the front-line staff and raise awareness of the pivotal role they play in promoting quality and safety within the organization. The importance of an integrated systems approach was discussed and the recommendation was to ensure service provider representation on the group earlier rather than later. Articulation of the governance structure for quality and safety was also presented in the draft Champlain CCAC Quality & Client Safety Management Plan. The plan also addresses safety improvement target and initiatives for and will be presented to the Board of Directors for approval. Board Scorecard Refresh (see item 6.1.2) The committee reviewed the recommendation to refresh the organization s scorecard. Best practice suggests an annual review of the scorecard to ensure that it adequately captures the information required to determine the performance of the organization. Given the evolution and expansion of the CCAC mandate and the initiatives discussed as part of the Strategic Plan refresh it would be an ideal opportunity to engage in a refresh in order to ensure the organization is capturing metrics of most value. The committee concurred with the recommendation to have the involvement of one committee member from each of the Board subcommittees, i.e. CSQC, Finance Committee and the Governance Committee with the goal of bringing a draft set of indicators to the Champlain CCAC Board for approval in July Board Scorecard (see item 6.1.1) The Board Scorecard was presented to the committee. Discussion occurred with respect to CE-1 and a decline in paid services over the last two months partially accounted for by the holiday season. CE-2 (intake efficiency) and CE-3 (service wait-time community) were also discussed in the context of implementing resource prioritization; it is anticipated that these trends will continue. A further Champlain CCAC Board March 7, 2012 Item Client Services and Quality Committee Report PAGE 2

31 recommendation was that it would be prudent to breakdown the data by acuity in CE-3. Wait times for therapies CE-7 (adult therapy services) and CE-8 (school therapies) will be addressed with the work currently underway in the resource prioritization strategies for therapies (presented earlier in the meeting to CSQC). Attention was directed to OH-1 and the trend in the deficit position; discussion is underway between the CEO and the LHIN to address this gap. Home First admissions were discussed in S1- with additional funding the revised target for admissions is 70 clients. Denise Alcock Chair Sponsoring Executive: Deryl Rasquinha Vice-President, Corporate Services Champlain CCAC Board March 7, 2012 Item Client Services and Quality Committee Report PAGE 3

32 STATEMENT of POLICY and PROCEDURE Policy Name Anti- Policy Number: Discrimination Client Related Date Issued/Revised: New Revised Effective Date: Replaces Policy Number: Next Review Date: Approved by: Responsibility: Corporate Services & Quality Overview Statement Our policies are intended to support our staff in achieving the value promise of Trusted Quality Care Connector. Canada is known for having one of the most diverse populations in the world. This mosaic of individuals and cultures presents unique and evolving challenges for human relations (Ontario Human Rights Commission). The Ontario Human Rights Code gives each of us an equal opportunity to work and live without being hindered by discriminatory practices. Guiding Principles The Champlain CCAC recognizes the inherent dignity and worth of its clients, employees, and service providers and is committed to provide for equal rights and opportunities to these stakeholders, without discrimination; The Champlain CCAC recognizes the value and diversity of its clients, employees, and service providers and endeavors to protect them from discrimination and harassment; specifically in the realms of access to services, service provision and employment; In accordance with the Ontario Human Rights Code, the Champlain CCAC prohibits discrimination with respect to: race, ancestry, place of origin, color, ethnic origin, citizenship, creed (religion), sex, sexual orientation, age, marital status, family status or disability; The Champlain CCAC recognizes that there can be situations where the issue of fluency of language or a person s accent or manner of speech may be used to mask discrimination based on race or ethnicity. At the same time, it is Policy No. Page 1 of 9 Anti-Discrimination Client Related

33 recognized that in some circumstances, proficiency in a certain language, e.g. Cantonese, Arabic etc., would be a reasonable and bona fide occupational requirement. 1. Policy 1.1. The Champlain CCAC supports an environment free of discrimination, interference, intimidation, restriction or coercion exercised or practiced by any person (i.e. employee and service providers) with respect to all clients, as it relates to access to services and service provision. All clients must be treated with respect and dignity The Champlain CCAC supports a work environment free of discrimination, interference, intimidation, restriction or coercion exercised or practiced by any person with respect to any employee carrying out his/her duties and rights as employees. All employees and service providers must be treated with respect and dignity. 1.3 Every person in the workplace must be dedicated to preventing discrimination with clients, employees and service providers Any individual found to have engaged in behavior that constitutes or supports discrimination with Champlain CCAC clients, employees or service providers may be subject to corrective action up to and including: Regarding employees: termination of employment or contract with CCAC; Regarding service providers: termination of contract of service; Regarding clients: alteration of service arrangements. 2. Purpose 2.1. The purpose of this policy is to support a work environment that is free from discrimination by establishing the following: Discrimination is not tolerated toward employees in the workplace, toward clients or service providers; Measures are in place which promote employee awareness of and sensitivity to potential discrimination and to prevent incidents of discrimination; Policy No. Page 2 of 9 Anti-Discrimination Client Related

34 Service providers have measures in place for their employees which promote awareness and sensitivity to potential discrimination and prevent incidents of discrimination; Individuals have recourse to appropriate mechanisms for redress where an alleged incident of discrimination is shown to have occurred; An appropriate response will be made in a timely manner to each alleged incident of discrimination; Staff will make every effort to work with community and systems partners to address and resolve issues involving discrimination. 3. Scope 3.1. This policy applies to all employees, service providers acting with or on behalf of Champlain CCAC and clients. 4. Procedures A. General 4.1. Allegations of discrimination towards a Champlain CCAC employee will be received by Human Resources Director or delegate and handled in a confidential and expeditious manner An individual, who becomes aware of a situation where discrimination or harassment may be occurring, is expected to notify his/her Manager or designate immediately. B. Client Complaints 4.3. Any employee or service provider receiving a complaint from a client about alleged discrimination shall escalate the complaint to his/her Manager or designate immediately. The Manager will address the complaint and present a proposal for resolution. The Manager may seek further consultation with the Quality Department In the event that informal resolution is unsuccessful, a client or client representative may also submit a formal written complaint directly to the Policy No. Page 3 of 9 Anti-Discrimination Client Related

35 Quality Department. The complaint should include details of the incident/s of discrimination including dates, times, places, parties involved, names of witnesses, if any, and the remedy sought Where the client brings a complaint under this policy, the identified staff member will be informed of the complaint and presented with a written statement of allegations. He/she is expected to respond to the complaint and to offer his/her perspective regarding the allegations and present a proposal for resolution The Quality Department will, within five (5) working days of the alleged incidents or notification thereof, take the steps to initiate an investigation into the allegations and conduct a thorough and timely investigation. Information will be gathered and analyzed, and the findings will be reported without delay to the Vice President of Human Resources Organizational Development and Communications for staff, or to the Vice President of Corporate Services and Quality if the identified staff member is a service provider. The parties to the complaint will be informed, in writing, of the outcome of the investigation Where appropriate, the Champlain CCAC may engage the services of a third party investigator The Champlain CCAC will ensure the parties have a sense of well-being until a resolution of the matter is reached; on an interim basis, it may be necessary to restrict contact between the parties, up to and including reassignment of the employee. C. Employee or Service Provider Complaints 4.9. In situations where clients refuse to allow an employee, service provider or community partner to provide services on the basis of what may be discriminatory grounds, the CCAC employee, service provider or community partner should immediately contact the appropriate Case Manager or Manager to report the incident The Case Manager will notify his/her Client Services Manager or designate. The Client Services Manager will organize a meeting with the affected party to evaluate the situation and attempt to resolve the concern in a fair and appropriate manner and recommend appropriate remedial action. Policy No. Page 4 of 9 Anti-Discrimination Client Related

36 4.11. At the same time the client shall receive a copy of this policy and be advised by the Case Manager/Manager that: The Champlain CCAC is a public agency which does not tolerate or support discrimination and is bound by the requirements of the Ontario Human Rights Code; The client will be provided with a case manager / service provider / community partner who is qualified to provide the requisite services in keeping with the requirements of the Ontario Human Rights Code; The client shall not be permitted to determine his/her care provider based on discriminatory reasons; In the event that the client does not accept the care provider scheduled then he/she will be advised that he/she will be deemed to have refused the service for those particular day(s) In situations where a service provider or community partner providing services on behalf of the Champlain CCAC receives a request from a client which could potentially lead to discrimination in employment and would be contrary to the requirements of the Ontario Human Rights Code, the service provider or community partner, as the case may be, should immediately escalate the complaint to his/her Manager or designate immediately. The Manager will address the complaint and present a proposal for resolution. Should the resolution not be successful, the Manager may seek further consultation with the Quality Department, in assessing the request for the purpose of determining: Whether the request, if accepted, would lead to a discriminatory employment practice; and The appropriate response to the client in the circumstances. In its assessment of the request, the Quality Department shall have regard to a client s rights as set out in the Bill of Rights applicable to persons receiving community services pursuant to the Home Care and Community Services Act, 1994, S.O c.26 and the requirements of the Ontario Human Rights Code All incidents of discrimination or potential discrimination are documented in the client file, reported, tracked and trended with a view to identifying risk areas. Policy No. Page 5 of 9 Anti-Discrimination Client Related

37 5. Responsibilities 5.1. It is the responsibility of employees and service providers** acting on behalf of the Champlain CCAC to: Understand and comply with the relevant Anti-Discrimination Policy and Procedure; Participate in available education and training programs related to a healthy and respectful workplace and, specifically, the prevention of discrimination; Report incidents of alleged discrimination to Quality Department or to their Manager or designate; Make attempts to resolve incidents of discrimination, as appropriate; Cooperate in any investigation into allegations of discrimination. ** Service Providers are also subject to their direct employer s policies and procedures governing discrimination and conduct 5.2. It is the responsibility of the Client Services Management Staff to: Understand and monitor compliance with the Anti-Discrimination Policy and Procedure; Foster respect on a daily basis amongst all employees; Ensure that any client s, employee s, service provider s, and community partner s (acting on behalf of the Champlain CCAC) report of discriminatory treatment will be investigated and the client, employee, service provider and community partner will be protected against reprisals; Participate in available education and training programs related to a healthy and respectful workplace and, specifically, to the prevention of discrimination; Provide assistance and support to clients, employees and service providers who are confronted with conduct which might constitute discrimination. Policy No. Page 6 of 9 Anti-Discrimination Client Related

38 5.3 It is the responsibility of the Quality Department to: Assist supervisors/managers and individuals reporting issues of discrimination with the timely and thorough investigation of the allegation; Update the Anti-Discrimination Policy and Procedure, as required in accordance with legislation, research and best practice; Ensure all incidents of discrimination or alleged discrimination are reported, assessed, tracked and trended as necessary for purposes of risk identification. 5.4 It is the responsibility of the Senior Leadership Team to: Actively identify and challenge individual or systemic acts of discrimination in our workplace and service delivery; Ensure that management and all employees are responsible for challenging discrimination in our workplace and service delivery; Ensure that management staff understand their legal responsibilities as directing minds to act immediately to deal with situations of potential harassment or discrimination; Mitigate the resolution of discrimination incidents, when necessary; Equip management and all employees with knowledge and skills to recognize and challenge discrimination in our workplace and service delivery. 5.5 It is the responsibility of the Client Services Quality Committee of the Board to: Facilitate the discussion and resolution of identified trends in discrimination issues arising in client care; Review corrective plans with regard to negative variances and serious events; Improve care delivery and client outcomes through recognition of the needs, interests, and rights of clients and of all participants in the delivery of care throughout the Champlain CCAC. 6. References and Related Policies Policy No. Page 7 of 9 Anti-Discrimination Client Related

39 Ontario Human Rights Code Champlain CCAC Statement of Values Collective Agreements Client s Bill of Rights and Responsibilities Policy and Procedure Freedom from Harassment Policy and Procedures Occupational Health and Safety Act and Regulations 7. Definitions 7.1. Discrimination: Discrimination is any action or inaction that differentiates between individuals, imposes a disadvantage, or withholds an advantage on the basis of any of the protected grounds. Deliberately excluding an individual from participating in an initiative is a form of discrimination if the exclusion is based on one of the prohibited grounds Everyone has the right to be treated with respect and dignity in the workplace, and all individuals are expected to recognize and refrain from actions that offend, embarrass or humiliate others, whether deliberate or not Harassment: Harassment is any unwanted physical or verbal conduct that offends or humiliates. Such conduct can interfere with the ability to do a job or obtain a service Harassment is a type of discrimination. It can take many forms, such as: threats, intimidation, or verbal abuse; unwelcome remarks or jokes about subjects like your race, religion, disability or age; displaying sexist, racist or other offensive pictures or posters; Condescending or patronizing behavior which undermines self-respect sexually suggestive remarks or gestures; inappropriate physical contact, such as touching, patting, pinching or punching; physical assault, including sexual assault. Policy No. Page 8 of 9 Anti-Discrimination Client Related

40 Harassment can consist of a single incident or several incidents over a period of time Harassment can create a negative or hostile work environment which can interfere with job performance and result in someone being refused a job Harassment will be considered to have taken place if a reasonable person ought to have known that the behavior was unwelcome Racial Harassment: includes deliberate isolation or ostracism and overtly or covertly ridiculing, degrading, or expressing hatred, whether verbally, in writing, or physically, based on race, ethnic origin, skin colour, language, dress, citizenship, or religion Examples of behaviour that can constitute racial harassment include, but are not limited to: Racial slurs or jokes Displays, cartoons, or pictures degrading members of a particular racial group or religion Name-calling based on race, colour, citizenship, place of original, ancestry, ethnic background, or creed 7.4. Workplace: Workplace includes, but is not limited to the offices and buildings of Champlain CCAC. It also includes cafeterias, washrooms, work sites, clients homes, vehicles, training rooms, and any other environment, including schools, where the business of the Champlain CCAC is being conducted. Policy No. Page 9 of 9 Anti-Discrimination Client Related

41 Events Management Definitions Champlain Community Care Access Centre EVENTS MANAGEMENT FRAMEWORK Definitions

42 TABLE OF EVENTS Event Type Category Reportable Event Event Definition Reporting required by CCAC Reporting required by SP 1. Compliments N/A (i) Compliment CCAC staff Expression of appreciation, praise, or commendation of a CCAC staff member. (ii) Compliment SP staff Expression of appreciation, praise, or commendation of a Service Provider staff member. 2. Complaints 2 a) Source Client/Caregiver 2 b) Source External advocate 2 c) Source CCAC staff/sp staff (i) Eligibility of Service* (ii) Exclusion of Service* (iii) Amount of Service* Complaint regarding the CCAC s decision regarding eligibility for service (LTC Act 39.(1)1) Complaint regarding the CCAC s decision to exclude a particular service from the plan of service (LTC Act 39.(1)2) Complaint regarding the CCAC s decision about the amount of any particular service included in the plan of service (LTC Act 39.(1)3) (iv) Termination of Service* Complaint regarding the decision to terminate service (LTC Act 39.(1)4) (v) Quality of Service Complaint regarding the quality of service provided or arranged (vi) Availability of Service Client is eligible however; service is unavailable due to fiscal and/or HR resources. (vii) Ability to place in LTCH Complaint about wait-lists to enter facility (viii) Rights violation Complaint about violation of client rights: Client Bill of Rights (LTC Act) or the Human Rights Act. (ix) Business Process Complaint regarding CCAC organizational or business practice. Based on Event Mgmt Version 1.1 October

43 Event Type Category Reportable Event Event Definition Reporting required by CCAC Reporting required by SP 3. Risk Events 3 a) Client/ Caregiver Safety (i) Improper procedure / intervention As per College standards and CCAC contractual requirements or established practice. (ii) Medical Orders not followed As per medical order. (iii) Client injury Physical injury resulting from a causative factor other than a Client Fall or Medication Error. (iv) Client fall Where an individual makes contact with the ground or an object on the ground. (v) Medication error Incident related to prescribing, processing, dispensing, or administration of medication or IV fluids. Examples: missed or wrong medication, missed or wrong dose of medication, wrong time dose administered, missed or wrong delivery of medication, administration errors. (vi) Infectious disease not reported Infectious disease (as defined in the Health Promotion and Protection Act) that is not reported by client/caregiver, service provider, CCAC or other third party. (vii) Actual/potential abuse of client Mental, physical, emotional, verbal, or financial abuse or neglect directed towards the client. (viii) Alleged theft Client/caregiver identifies missing property or money. Based on Event Mgmt Version 1.1 October

44 Event Type Category Reportable Event Event Definition (ix) Unexpected death (x) Not Reported - Client not-seen-notfound (NSNF) Death not anticipated in view of client pre-existing condition or service plan. Neglecting to report a not seen not found visit. Reporting required by CCAC Reporting required by SP 3 b) CCAC/Service provider safety 3 c) Privacy & Security (i) Unsecured animals (ii) Unsecured weapons (iii) Unsafe client environment (iv) Abuse/threat/injury to staff **HROD placeholder (i) Consent to collect/use PHI not obtained (ii) Confidentiality/Privacy not maintained Animals that are not secured safely in the home. Weapons that are not secured safely in the home. Hazards identified in client s home. Abuse, threat or injury of service provider staff or CCAC staff from the client or any other individual present within the client s environment. Currently in development Knowledgeable consent to collect, use and disclose personal health information not obtained as required by Personal Health Information Protection Act, Actual or suspected loss/theft/ accidental or unauthorized access, use, disclosure copying, modification, destruction, disposal of Client Records or Client Information whereby personal client information is inappropriately disclosed. Based on Event Mgmt Version 1.1 October

45 Event Type Category Reportable Event Event Definition 3 d) Service Delivery **Business continuity placeholder (i) Missed visit (ii) Service refused by client (iii) Service refused by SP due to risk issue (iv) Service not delivered as requested (v) Lack of professionalism (vi) Discontinuity of providers (vii) Accidental damage to property Currently in development Any scheduled visit/shift/clinic where the service provider fails to attend, where the service provider has not provided advance notice or has provided notice but does not reschedule. Reporting required by CCAC Reporting required by SP Client declined to accept service. Service provider declined new referral due to identified risk issue. Deviation from service/care plan. Behaviours inconsistent with good customer service. Poor continuity of service provider staffing when inconsistency has negatively impacted client care. Damage to client/caregiver property due to service provider or CCAC employee. (viii) Unauthorized visit/billing Billing for visits provided without authorization or billing for visits not made. Based on Event Mgmt Version 1.1 October

46 Event Type Category Reportable Event Event Definition Reporting required by CCAC Reporting required by SP (ix) Late/Wrong delivery of Medical Equipment & Supplies Not delivered as ordered may cause extra visit or delay in service provision. (x) Equipment malfunctioned/soiled Client received equipment in disrepair or soiled, or equipment malfunctioned. (xi) Late pick up of equipment Equipment picked up after scheduled date/time. 3 e) Communication & Reporting (i) Risk event not reported (ii) Failure to communicate with client/caregiver CCAC or SP did not report or communicate a risk event CCAC or SP failure to communicate key information to client/family. (iii) Failure to relay change in health status As directed by CCAC within 24 hours of CCAC request verbally or within 4 hours from end of visit or shift. (iv) Claim/legal proceeding/police investigation involving client/caregiver Any claim/legal proceeding/police investigation involving client/caregiver 3 f)placement (i) Failed admission to LTCH Facility unable or unprepared to meet client care needs safely and/or appropriately due to incomplete/undisclosed information and/or missing documents. Based on Event Mgmt Version 1.1 October

47 Event Type Category Reportable Event Event Definition Reporting required by CCAC Reporting required by SP (ii) Failed to follow LTC legislation CCAC or other third party fails to follow required steps or provide accurate information/communication regarding placement (iii) Inappropriate admission to LTC Facility unable or unprepared to fully meet client care needs safely and/or appropriately due to incomplete/undisclosed information and/or missing documents. 4. Adverse Event Potentially all based on criteria Potentially all based on criteria Three Criteria Definition: -an unintended injury or complication AND -results in disability, death or increased use of health care resources AND -is caused by healthcare management 5. Near Miss Potentially all based on criteria Potentially all based on criteria Any event or deviation that is detected and remedied before a Risk Event occurs, avoiding harm/injury/impact to the client, CCAC, or to the service provider/organization *Indicates event is appealable to the Health Services Board Based on Event Mgmt Version 1.1 October

48 RISK SCALE Definition of RISK: A risk is the chance or possibility of danger, loss, or injury. For health services organizations, this can relate to the health and well-being of clients, staff and the public; property; reputation; environment; organizational functioning, financial stability, market share; and other things of value. (CCHSA, Accreditation Program, 5th Edition, 2006). Risk Scale: High Medium Low Rationale: Every event carries some risk. Risk levels are to be assigned to all Events except Compliment. Risk levels assist in determining the organizational resources required in responding Risk Levels may change through the course of investigation and resolution. Based on Event Mgmt Version 1.1 October

49 HIGH RISK MEDIUM RISK LOW RISK DEFINITION The event has actual or potential for significant harm/injury/ impact to the client, the CCAC, or to the service provider/ organization, has the potential for litigation and/or lack of confidence in CCAC services. The event has actual, or potential to result in some harm/injury/impact to the client, the CCAC, or to the service provider/organization. The event has caused a delay in service, or resulted in additional costs, or dissatisfaction with CCAC services. The event has actual, or potential for minimal harm/injury/ impact to the client, CCAC, or to the service provider/ organization OUTCOME Outcome has or may have a significant effect Safety of the client or any persons involved with the client s care The client s ability to receive services CCAC or service provider organizations ability to provide services The health or well-being of staff or clients Organizational functioning, financial stability or reputation Outcome has or may have some effect: Safety of the client or any persons involved with the client s care The client s ability to receive services CCAC or service provider organizations ability to provide services The health or well-being of staff or clients Organizational functioning, financial stability or reputation May require intervention to avoid a high risk situation Outcome does not affect: Safety of the client or any persons involved with the client s care The client s ability to receive services CCAC or service provider organizations ability to provide services The health or well-being of staff or clients Organizational functioning, financial stability or reputation Based on Event Mgmt Version 1.1 October

50 EVENT RESOLUTION Our Mission to support seamless client experience across the health system requires transitions from multiple origins to multiple destinations and providers. Not all events the CCAC will manage are solely within the CCAC scope to solve. Resolution data is an important measure of client experience as well as both CCAC and system effectiveness. Resolutions: Resolved Satisfied (from perspective of originator) Resolved Not Satisfied Unresolved Satisfied Unresolved Not Satisfied Appealed (Health Services Board) Unfounded (Not appropriate for complaints) Compliments Complaints Risk Events Adverse Events Near Miss Resolved- Satisfied N/A Applicable Applicable Applicable Applicable Resolved- Unsatisfied N/A Applicable Applicable Applicable Applicable Unresolved - Satisfied N/A Applicable Applicable Applicable Applicable Unresolved - Unsatisfied N/A Applicable Applicable Applicable Applicable Appealed - (HSAB) N/A Applicable Applicable Applicable Applicable Unfounded N/A N/A Applicable Applicable Applicable Based on Event Mgmt Version 1.1 October

51 Submission to the Board Champlain CCAC (staff) Quality and Safety Committee March 7, 2012 DESIRED OUTCOME This briefing note is intended to: The Client Service and Quality Committee recommends Board approval of the Interface and Reporting Accountabilities between the Champlain CCAC Quality and Safety Committee, and the Board of Directors Client Service Quality Committee DRAFT Terms of Reference for Champlain CCAC Quality & Safety Committee 1. Purpose To review operational issues identified and escalated by front line staff(*) via their managers related to Quality and Safety in order to o Provide resolution, o Develop and/or refine policies and procedures to better address field issues identified, and/or o Promote organizational learning s / training plans as required. o (*)Note: The issues also include those identified to Front Line Staff via SP staff/supervisors To review events reporting/trending, to proactively identify and address issues related to Quality and Safety To visibly support the transformation of the organizational culture focused on Quality and Safety, by being an effective support vehicle to staff dealing with Quality and Safety issues To identify and provide input into organizational wide annual Quality and Safety priorities 2. Values Blame free culture focus on Learning, and Quality improvement Orientation on support and learning Anonymity of Client, Service Provider, Staff, Partner, etc. involved in circumstance are strictly respected 3. Membership Initial Membership o Chaired by Director Quality o Representatives from Client Services, Contract Department, HROD Subsequent extension of membership o Service Provider agency representative o Community Support agency representative Resources to be accessed as needed: o External expertise on Ethics Champlain CCAC Board March 7, 2012 Item Champlain CCAC (staff) Quality and Safety Committee PAGE 1

52 4. Roles and Responsibilities To actively participate in discussions around quality of care and client safety from a corporate and systems perspective To offer ideas and perspectives to improve quality of care and client safety To serve as a vehicle to communicate and disseminate information discussed at the meeting to the organization at large and to the members respective programs and services To actively reflect and discuss the impact of issues and ideas on the members areas of line accountability and to action improvement ideas when applicable and able To participate in working groups as appropriate To provide input into organizational wide quality and client safety priorities 5. Meeting Structure The Committee shall meet no less frequently than monthly and at the call of the Chair. Meetings of the Committee are held on the pre-scheduled date and at the time and place set by the chair in writing. An unscheduled meeting may be called at any time by the Chair with appropriate notification no less than 24 hours prior to the time and date set for the meeting. 6. Interfaces & Reporting Accountabilities Champlain CCAC Executive Council Standing monthly agenda item to report key learnings and/or opportunities for Quality /Safety improvement programs that require executive support and/or prioritization Board Client Service Quality Committee Standing agenda item on Quarterly CSQC meeting for the purpose of: Identification of key Quality/Safety trends, and action plans to address gaps as found; Identification for policy amendments or new policy needs Quarterly Service Provider Forum meetings, and Community Advisory Committee meeting Identification for areas of collaboration for improvement of Quality and Safety objectives 7. Review Each committee member will be evaluated annually on the following criteria: Regular attendance at meetings of the committee. An attendance level of at least 75% is suggested.. Necessary background preparation and effective participation on the committee on which the member served. Champlain CCAC Board March 7, 2012 Item Champlain CCAC (staff) Quality and Safety Committee PAGE 2

53 Submission To The Board Report from the Board Chair March 7, 2012 Quality End-of-Life Care Coalition of Canada s (QELCCC) Annual General Meeting Respectfully submitted by: Melody Isinger, DHCE Member, Board of the Champlain CCAC. In late January, as the Canadian Medical Association (CMA) representative, I attended the Quality End-of-Life Care Coalition of Canada s (QELCCC) annual general meeting. The QELCCC is a group of 30 national organizations concerned about quality of end-oflife care. The QELCCC provides a forum for its members to share information, identify needs and gaps in end-of-life care, and advocate with federal and provincial governments -- for better hospice, palliative and end-of-life care for all Canadians. Recently the CHPCA, as QELCCC s secretariat, applied for and received Federal funding to advance the QELCCC s goal to ensure all Canadians have access to high quality hospice palliative end-of-life care that is seamless across all settings of care by [1.4 ] establish[ing] a multi-sectoral task force or working group that crosses health and social services (e.g., health, education, finance, human resources, First Nations, veterans, and non-governmental organizations, such as unions and insurance associations), whose role is to consult with communities and make recommendations to advance hospice palliative end-of-life care. On February 3, CHPCA was notified The Way Forward initiative was awarded Federal funding. To insure wheels are not re-invented, the Ontario Hospice Palliative Care Association presented to the QELCCC its initiative, Advancing High Quality, High Value Palliative Care in Ontario. Their initiative is the result of a collaborative effort from over 80 stakeholders from across Ontario [who] have achieved a common consensus on a vision for palliative care in Ontario. This work outlines the steps we need to take together to make that vision a reality. Almonte General Hospital and Carleton Place and District Memorial Hospital In late January, Sherryl Smith, CCAC Board member who resides in North Lanark/ North Grenville, attended the Almonte Hospital s Town Hall Meeting to obtain public input to their draft strategic plan. One of the directions identified for the next five years is to explore palliative care and she has been invited to participate in this process by acting as a resource to the organizing group, ensuring CCAC services are considered as the plans evolve; she has also been able to provide them with other contacts through the senior managers at the CCAC. In addition, Sherryl attended a meeting with the Hospital Case Manager in the Carleton Place office to orient herself to the discharge planning and transition processes and issues related to patients leaving both the Carleton Place and Almonte Hospitals. Champlain CCAC Board - March 7, 2012 Item Report from the Board Chair PAGE 1

54 Renfrew County Governance Advisory Council On February 9, CCAC Board member Bob Kulas attended the Local Health Integration Network s (LHIN) Governance Advisory Council (GAC) meeting held at the Ottawa Valley Health and Wellness Centre in Pembroke. In 2010 the Champlain LHIN established GACs across the district to enable health organizations to communicate with one another and advise the LHIN on system integration. Discussion at the February 9 meeting focussed on questions regarding the GAC s membership and mandate. The Drummond Report The report of the Commission on the Reform of Ontario s Public Services (the Drummond Report) was released publicly on February 15. This report will inform the 2012 Province of Ontario budget. Here is the link to the report s recommendations about community care, home care and long-term care: Lynn Graham, Board Chair Champlain CCAC Board - March 7, 2012 Item Report from the Board Chair PAGE 2

55 Submission to the Board Freedom of Information and Protection of Privacy Act (FIPPA) and CCACs March 7, 2012 INFORMATION UPDATE Does the Champlain CCAC fall under Freedom of Information and Protection of Privacy Act (FIPPA)? What are our obligations, if any? BACKGROUND/ISSUE FIPPA does not yet apply to the CCAC requests made under FIPPA would generally result in an answer indicating this to the requester. The Program that may receive requests under FIPPA would be the Health Care Connect program, a MOHLTC program but with staff working through the CCAC. There is a policy statement that has been developed by the Provincial Privacy Officer group and Privacy staff at the Ontario Association of Community Care Access Centres (OACCAC) regarding FIPPA and is available for use by each CCAC. Extract follows: SCOPE - This policy applies to any CCAC programs where information is governed under FIPPA due to contracts with FIPPA governed agencies and therefore subject to FIPPA. The policy also covers information that the CCAC has shared with FIPPA governed agencies/organizations which may become part of a Freedom of Information (FOI) request to that agency/organization. Requests for access to, or correction of, personal health information are governed by the Personal Health Information Protection Act (PHIPA) and are excluded from this policy. PROCESS All FIPPA requests should first come to the Privacy Officer to determine if it is, indeed, a FIPPA request or if it is a PHIPA request. FIPPA requests are to be forwarded to the MOHLTC with a standard response letter sent to the requester. The Champlain Privacy Officer has a great deal of resources and guidance available through the OACCAC and its Provincial Privacy Officer Group. Champlain CCAC Board March 7, 2012 Item FIPPA and CCACs PAGE 1

56 PREPARATION FOR FIPPA (IN THE FUTURE WHEN FIPPA APPLIES TO CCACS) Preparation for FIPPA would involve (from ehealth Ontario slide deck): Standardize record keeping procedures through the development of detailed policies and guidelines Review what documents should be stamped privileged Appropriate use of Standards for minute-keeping; record-keeping Proactively disclose on website where possible Sponsoring Executive: Deryl Rasquinha VP Corporate Services & Quality Champlain CCAC Board March 7, 2012 Item FIPPA and CCACs PAGE 2

57 Submission To The Board Report from the Chief Executive Officer March 7, 2012 INFORMATION UPDATE CEO activity report from January 26, 2012 to February 29, BACKGROUND/ISSUE External Communications Ongoing meetings/conversations with hospital CEO and/or VPs Ongoing open communication and meetings with the Local Health Integration Network (LHIN) Interim CEO and staff Co-Chaired Champlain LHIN/Champlain CCAC Executive Teams meeting Participated in monthly CEO Council meetings as well as weekly teleconferences Participated in CEO Council post retreat follow-up working group meetings Participated in OACCAC Board meeting Participated in the Champlain ED/ALC Steering Committee Chaired the Champlain CCAC Community Advisory Committee Participated in the Hawkesbury General Hospital s Strategic Planning meeting Operations Oversight Bi-weekly meetings with VPs Chaired Champlain CCAC Senior Operation Committee Chaired Champlain CCAC Leadership Meeting Ongoing Accreditation preparation meetings Staff Empowerment Executive Committee meetings rotating to different location monthly and includes an open session with staff. In February, the Executive committee travelled to the Orelans Office. Strategic Oversight Ongoing negotiations with multiple hospitals to complete Memorandum of Understandings. Nine hospital MOUs are in progress or have been signed. Champlain CCAC Board March 7, 2012 Item Report from the CEO PAGE 1

58 Board Scorecard (see item 6.1.2) The Client Services and Quality Committee and Finance Committee reviewed the January 2012 Board scorecard at their monthly joint meeting. Highlights of the report include: CE-1 Clients Served, Paid Services: The number of clients declined in January. Some of this is accountable to the holiday period and some due to an unexpected reduction in hospital wound/therapy referrals. CE-2 Intake Efficiency: Despite the recent decline in the number of clients served, referral volumes continue to be high resulting in wait times at the intake point. Dedicated resources have been committed to intake and mandatory clients with very high needs receive services immediately. CE-3 - Service Wait Time (Community): Lower need clients (lower acuity/risk) are waiting longer at intake and initial service. With resource prioritization beginning implementation, this trend will continue. Staff will be examining reporting the wait time metrics by client acuity for future scorecards. CE-7 - Waitlist for Adult Therapy Service & CE-8 School Therapy Waitlist: There continues to be wait lists in adult therapy services and school therapy services (although, mandatory start clients are seen immediately). The Assistant Client Services Director presented a report to the Client Services and Quality Committee (CSQC) regarding therapy waitlists (see CSQC report item 3.1.5). A different approach to prioritizing clients is being reviewed as well as ensuring that practice is standardised across the Champlain region and that practice is measured against provincial benchmarks. Additionally, a complete service delivery model review is planned and will investigate strategies such as increased use of pathways, shared care approaches and inter-professional models of care. OH-1 Financial Management: the Champlain CCAC continues to project a year end deficit (approximately $1.47M). Discussions are continuing with the Champlain LHIN regarding the funding gap. SI-1 Home First-Admissions: Home First admissions have continued to climb in January and February. The Champlain LHIN has set a target of 70 Home First admissions a month for the remained of This amount is not sustainable in without additional funding. Champlain CCAC Board March 7, 2012 Item Report from the CEO PAGE 2

59 Submission To The Board Resource Prioritization Framework Discussion March 7, 2012 INFORMATION ITEM A discussion will take place on the implementation of the Resource Prioritization Framework. DISCUSSION ITEMS Themes for discussion include: Overview of the Resource Prioritization Framework including timing, importance, financial considerations, etc. The balance between different client groups, including wait time for services and acuity: o Community and hospital o Rural and urban Communication of the Framework to our partners and the community Capacity of our partners to support the Framework Relationship to other CCAC documents such as the ethical framework, strategic plan, etc. LHIN and other partners role in the development and/or implementation of the Framework Champlain CCAC Board - March 7, 2012 Item 5.1 Resource Prioritization Framework Discussion PAGE 1

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66 01/03/2012 Board Scorecard Champlain CCAC January 2012 Champlain Scorecard Framework Client Experience (CE) Access Client served Intake efficiency Wait time community setting to home service initiation* Wait time Hospital discharge to service initiation* Clients waiting for LTC placement (hospital/home) Waitlists by service Service activity by service type * Effective Clients with MAPLe H, VH living in community * Clients placed in LTCH with MAPLe H, VH as portion of total placement * Safe Case Management touch points with clients * Complaints/Occurrences (Once process is fixed) Falls - long stay CCAC clients (Developmental) * Medication Safety (Developmental) * Wait time Hospital discharge to service initiation (By client subgroups) (Developmental)* Wait time community setting to home service initiation (by client subgroups) (Developmental)* Person Centered Missed and cancelled visits (Once process is fixed) Service activity by functional center Champlain * Also an MSAA indicator Organizational Health (OH) Efficient Balanced budget *, Cost by client groups, Cost per Episode (Developmental) * Appropriately Resourced Absenteeism Vacancy rate Turnover * Governance BOD Attendance BOD - TBD Systems Integration (SI) Integrated Home First client trends (Developmental, local)* Community engaged Care Connector 2 2 1

67 01/03/2012 Scorecard Summary for January 2012 Scorecard Item Frequency Previous Period Current Period Tracking to YE CE-1: Clients Served CE-2: Intake Efficiency CE-3: Service Wait Time By Community* CE-4: Service Wait Time By Hospital* CE-5: LTCH Placement Wait Time CE-6: Waitlist for PSS Service CE-7: Waitlist for Adult Therapy Service CE-8: Waitlist for School Therapy Service CE-9: Appropriate placement in LTCH * CE-10: Maintaining Clients in the Community * CE-11: Client Contact * CE-12: Complaints & Occurrences CE-13: Falls Long Stay Clients * (Developmental) CE-14: Medication Safety * (Developmental) CE-15: Missed & Cancelled: CE-16: Service Wait Time By Community (By Client subgroups) (Developmental)* CE-17: Service Wait Time By Hospital (By Client subgroups) (Developmental)* CE-18 Service Activity by service type* PSS Visit Nursing Shift Nursing PSS Nursing, Therapy Monthly Monthly Quarterly Quarterly Monthly Monthly Monthly Monthly Quarterly Quarterly Monthly Monthly Quarterly Quarterly Monthly Monthly Monthly Quarterly Quarterly Monthly Scorecard generated 3 rd week of the month, to reflect previous month results Legend Caution May or may not require a mitigation strategy Champlain Attention Requires a mitigation strategy 3 * Expected 2011 MSAA scorecard measures 3 Good Info Only Developmental Information only Scorecard Summary for January 2012 Scorecard Item Frequency Previous Period Current Period Tracking to YE OH-1: Financial Management * OH-2: Length of Stay By Client Groups OH-3: Costs per Client Groups OH-4: Cost Per Episode * OH-5: Absenteeism OH-6: Turnover * OH-7: Vacancies OH-8: Board of Directors: Attendance OH-9: Board Of Directors: Profile SI-1: Home First Admissions * SI-2: Home First Next Referrals * SI-3: Care Connections Monthly Monthly Monthly Monthly Quarterly Quarterly Quarterly Quarterly Quarterly Monthly Monthly Monthly Scorecard generated 3 rd week of the month, to reflect previous month results Champlain * Expected 2011 MSAA scorecard measures Legend Good Caution Attention Info Only Developmental May or may not require a mitigation strategy Requires a mitigation strategy Information only

68 01/03/2012 Assigned to: Sharon CE - Access CE-1: Clients Served, Paid Services Non Admit I&R CCAC Clients CM Only Intake Queue Determine eligibility and manage waitlist (e.g. LTCH) Paid Services Indicator Characterization Time Period Fall 2009 Summer 2010 Known Issues or Events PSS waitlist institute Therapy waitlists ma have HR resourcing issues Pop_Code Jan-12 Fiscal YTD 1,960 10,499 Acute Rehabilitation 871 4,047 Maintenance 8,032 14,109 Long Term Supportive 3,384 5,922 Definition Reliability Frequency Target Distinct count of clients, where a paid unit of service, equipment, or supplies occurred within the period, broken down by Client Population Groups. This excludes Case Management only clients, LTCH placement only clients High Monthly Cumulative expenditure on paid services per month, as per the budget allocated EndLife 787 2,212 Service_Max Note: Client Counts reported for Previous Period may change if data is recorded in CHRIS after scorecard cut off date. Paeds 2,685 5,105 Total Clients 17,818 36,957 Previous Period Current Period Green if cumulative YTD expenditure on paid services is within the 0-1.5% range of what is budgeted Yellow if cumulative YTD expenditure on paid services is beyond 0% to 1.5% margin of what is budgeted, but is within -1% to + 2.5% Red if out side of the -1% to +2.5% corridor of YTD expenditure budget target Mitigation Strategy Prime Timing Champlain 5 5 Assigned to: Sharon Home Care School CE Access CE-2: Intake Efficiency CCAC Clients Non CM Determine eligibility and Admit Only manage waitlist (e.g. LTCH) I&R Intake Paid Services Queue Indicator Characterization Definition Count of clients assessed for initial eligibility determination, grouped into categories of the number of days waited. Note: Output of intake process could be that a client is not-admitted, admitted to Case Management only, or admitted to receiving services. Reliability Frequency Target Medium Indicator is directional Monthly 90% of clients waiting for home care, wait less than or equal to 19 days Note: Intake Counts reported for Previous Period may change if data recorded in CHRIS after scorecard cut off date. Referrals. Column Labels Service Type Feb-11 Mar-11 Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Trend Home Care School Champlain Previous Period 86.1% Current Period 85.6% Mitigation Strategy Prime Timing Green if 90% or more of assessed clients receive eligibility determined date within 19 days Yellow if 85% to less than 90% of assessed clients receive eligibility determined date within 19 days Red if less than 85% of assessed clients receive eligibility determined date within 19 days 6 6 3

69 01/03/2012 Assigned to: Juhee CE Access CE-3: Service Wait Time (Community) Time Period Fall 2009 Summer 2010 Known Issues or Events PSS waitlist institute Therapy waitlists ma have HR resourcing issues ssment to Service Referral ice referral to Initial First ld be on a Visit Date aitlist) ce Wait Time Indicator Characterization Definition Wait time from client intake / application date for services from the community, to receiving the first paid service (excludes clients receiving Case Management services, LTCH placement assistance, and any client waiting over 1 year) Reliability Medium - Indicator is Directional h - wait time arge to service nts) Frequency Target Quarterly to LHIN; Monthly To Board; NOTE: Sum of monthly results may not equal quarterly results 56 days, 90 th percentile Median = middle value in an ordered set of values; Average = mathematical average of set of values ; 90 th percentile = fits 90 percent of sample data Green 0-56 days Previous Period Current Period Yellow days Red Greater than 61 days Mitigation Strategy Prime Timing Champlain 7 7 Assigned to: Juhee CE - Access CE-4: Service Wait Time(Hospital) Indicator Characterization Time Period Fall 2009 Summer 2010 Known Issues or Events PSS waitlist institute Therapy waitlists ma have HR resourcing issues ssment to ice referral ld be on a aitlist) Service Referral to Initial First Visit Date Definition Wait time from client referral to CCAC services from the Hospital, to receiving the first paid service (excludes clients receiving Case Management services, LTCH placement assistance, and any client waiting over 1 year) ce Wait Time Reliability Medium Indicator is directional. Calculation of indicator is 20 weeks after reporting period (as data is required from hospital systems) Frequency Quarterly Target 8 days, 90 th Percentile h - wait time arge to service nts) Champlain Green - TBD Previous Period Current Period Yellow TBD Red - TBD Mitigation Strategy Prime Timing 8 8 4

70 01/03/2012 CE - Access CE-5: LTCH Wait Time Assigned to: Bobbak Monthly Graph - client wait time for LTC placement(hospital/home)* Indicator Characterization Definition Client Wait Time - Median days waiting for clients that were placed in LTC homes, in the previous month (Note: Includes only clients placed) Volume of Clients Waiting total number of clients waiting for LTCH placement in the previous month Volume of clients waiting for LTCH placement, broken down by region (may split by Community, Hospital, LTC by present location address) Reliability Frequency Target High Monthly Board Information Only Targets cannot be readily defined; LTCH supply not controllable by CCACs Jan-12 Community Hospital LTC Client Wait Time for LTCH Volume of Clients Waiting For LTCH 2, ,394 Champlain Previous Period Current 9 Period 9 Assigned to: Prasun CE - Access CE-6: PSS Waitlist Indicator Characterization Time Period Fall 2009 Summer 2010 Known Issues or Events PSS waitlist institute Therapy waitlists ma have HR resourcing issues Definition Reliability Frequency Target Count of clients waiting for PSS service. Includes all clients, whether on full or partial waitlist. The count is split by client priority groups. Snapshot taken at the end of the previous month High Monthly No High (H) and Very High (VH) needs PSS clients on waitlists Green if between 0-50 H & VH PSS clients waitlisted Previous Period Current Period Yellow if between H and VH PSS clients waitlisted Red if over 250 H and VH PSS clients waitlisted Mitigation Strategy Prime Timing Champlain

71 01/03/2012 Assigned to: Prasun CE - Access CE-7: Adult Therapy Waitlist Indicator Characterization Time Period Fall 2009 Summer 2010 Fall 2010 Known Issues or Events PSS waitlist institute Therapy waitlists ma have HR resourcing issues Therapy waitlist rele approved, but provid resources are tight Average of Days Waiting Jan- 11 Feb- Mar Apr- 11 May Jun Jul- 11 Aug- 11 Sep- 11 Oct- 11 Nov- Dec- Jan Very High Definition Reliability Frequency Target Count of Adult clients waiting for Therapy services. Includes all clients, whether full or partial waitlist. The count is split by client priority groups. Snapshot taken at the end of the previous month; Average Wait Times for first visit for H and VH needs adult therapy clients High Monthly Under 28 days for H and VH needs adult therapy clients High Moderate Mild/Low Previous Period 67.6 Current Period 58.8 Green if H & VH waiting less than 28 days Yellow if H& VH waiting between days Red if H & VH waiting more than 60 days Mitigation Strategy Prime Timing Champlain 11 * Note: Waitlists were repatriated from SP in late Assigned to: Prasun CE - Access CE-8: School Therapy Waitlist Indicator Characterization Time Period Fall 2009 Summer 2010 Fall 2010 Known Issues or Events PSS waitlist institute Therapy waitlists ma have HR resourcing issues Therapy waitlist rele approved, but provid resources are tight Definition Reliability Frequency Target Count of School clients waiting for Therapy service. Includes all clients, whether full or partial waitlist. The count is split by client priority groups. Snapshot taken at the end of the previous month Average Wait Times for first visit for H and VH needs adult therapy clients High Monthly Under 28 days to first therapy visit for A & B needs school therapy clients Average of Days Waiting Jan- 11 Feb- 11 Mar- 11 Apr- 11 May Jun- Jul Aug- 11 Sep- 11 Oct -11 Nov- 11 Dec- Jan A-SHSS B-SHSS C-SHSS D-SHSS * Note: Waitlists were repatriated from SP in late 2010 Previous Period 49.9 Current Period 57.3 Green if A & B waiting less than 28 days Yellow if A & B waiting between days Red if A & B waiting more than 60 days Mitigation Strategy Prime Timing Champlain

72 01/03/2012 CE - Effective CE-9: Appropriate Placements in LTCH Assigned to: Bobbak Indicator Characterization Definition Reliability Frequency Percent of clients with a MAPLe (Method of Assigning Priority Levels) score of High or Very High, out of the total number of clients placed into LTC homes within the previous quarter (Note: MAPLe scores are determined from a RAI assessment on a client) Note 1: Crisis placement designation from Hospital may impact this indicator; Note 2: Home First should help improve indicator results over time High Quarterly Target 78% Green if 78% or greater Previous Period Current Period Yellow if between 75-78%% Red if below 75% Mitigation Strategy Prime Timing 13 Champlain 13 Assigned to: Bobbak Monthly Graph - Clients 85+ with Maple H, VH living in community CE - Effective CE-10: Maintaining Clients in the Community Indicator Characterization Definition Count of CCAC clients with an open referral with a MAPLe (Method of Assigning Priority Levels) score of High or Very High Reliability Frequency Target Medium Indicator is dependent on when RAI assessment was last conducted NOTE: Indicator is a count, and not a % based on census of clients living in Champlain territory Quarterly 4500 clients Green if 4500 clients or greater Previous Period Current Period Yellow if between clients Red if below 4320 clients Mitigation Strategy Prime Timing Champlain * Awaiting final definition from Ministry/LHIN

73 01/03/2012 Assigned to: Juhee Non Admit I&R Intake Queue CCAC Clients CM Only Determine eligibility and manage waitlist (eg LTCH) Paid Services CE Safe CE-11: Client Contact CM, Paid, and Eligibility/waitlist clients Indicator Characterization Time Period Feb 2009 Sept 2010 Known Issues or Events Discussions began w renewed push on recording workload CRAAFT reports now included Face to Fac Telephone and Ax co on reports. Definition Reliability Frequency Target Monthly count of RAI assessments, face-to-face visits, and telephone visits by Case Managers Medium use as Directional (Dependent on timing of CHRIS updates) Quarterly 130,000 (10,833/month)visits for F 10; 133,000 (11,083/month)visits for F 11; Note: Client Contacts reported for Previous Period may change if data recorded in CHRIS after scorecard cut off date. Face to Face and Telephone Q3 YTD Jan-12 (2011) Annual Target 14, , ,000 Previous Period Current Period Green within -1% of target, or above target Yellow within -1 to -3 % of target Red below -3% of target Mitigation Strategy Prime Timing Champlain Assigned to: CE Safe CE-12 Complaints & Occurrences Indicator Characterization Definition A) Number of high risk or sentinel risk events recorded during the month. B) Number of high risk or sentinel complaints recorded during the month Reliability Frequency Target Low: relies upon either service provider or client to report Monthly Developmental Indicator Complaints and Occurrences o Event Management System will be reimplemented with new DATI system. This may result in changes in the metrics and/or the values reported. Previous Period Current Period Champlain Mitigation Strategy Prime Timing

74 01/03/2012 CE Safe CE-13 Falls Long Stay CCAC Clients Assigned to: Indicator Characterization Definition Reliability Number of clients who reported a fall (self reported) on follow up client assessments, who were not completely dependent on bed mobility on previous assessment, and are SRC 93 and 94 clients Low Frequency Target Quarterly Developmental Indicator Note: Current Data provided by OACCAC. Previous Period Current Period Champlain CE Safe CE-14 Medication Safety Assigned to: Indicator Characterization Definition Reliability Number of clients whose medications have not been reviewed by a physician, nurse practitioner, or pharmacist within the last 180 days (where clients take at least 2 medications, and client has had RAI assessment within the last year) Low Frequency Target Quarterly Developmental Note: Current Data provided by OACCAC. Previous Period Current Period Champlain

75 01/03/2012 CE Patient Centred CE-15 Missed & Cancelled Assigned to: Sharon Indicator Characterization Definition Missed & Cancelled rate by SP Compare relative performance of Missed/Cancelled reported by each Service Provider to the CCAC, for Nursing and Personal Support Services (PSS). Reliability Frequency Target Low: Self reported by Service Provider staff Monthly Missed Visits less than 1.0%, as per contract agreements PSS Previous Period Current Period Champlain Visit Nursing Previous Period Current Period Shift Nursing Previous Period Current Period Mitigation Strategy Prime Timing Assigned to: CE Patient Centred CE-16 Service Wait Time, Hospital * By client subgroups Indicator Characterization Definition Wait time from client referral to CCAC services from the Hospital, to receiving the first paid service (excludes clients receiving Case Management services, LTCH placement assistance, and any client waiting over 1 year) (Broken down by short stay acute, short stay rehab, and long stay complex clients) Reliability Frequency Target Low - Directional Quarterly Developmental Previous Period Current Period Champlain

76 01/03/2012 Assigned to: Juhee CE Patient Centred CE-17 Service Wait Time, Community * By client subgroups Indicator Characterization Definition Reliability Frequency Target 90 th Percentile wait time from client intake / application date for services from the community, to receiving the first paid service (excludes clients receiving Case Management services, LTCH placement assistance, and any client waiting over 1 year) Broken down by short stay acute, short stay rehab, long stay complex clients Medium - Directional Quarterly Developmental Previous Period Current Period * Awaiting final definition from Ministry/LHIN Champlain Assigned to: Prasun CE Patient Centred CE-18 Service Activity by Functional Centre Indicator Characterization Definition Reliability Frequency Summation of the billed units of service grouped by PSS, Therapy and Nursing services. High Monthly Target For 10/11, PSS target is 1,925,000; Nursing / Therapy is 764,067; For 11/12, PSS target is 1,900,000; Nursing / Therapy is 755,000 Note: Service counts reported for Previous Month may change if SP s provide service invoices past the close of date for the previous month Service Categories Jan-12 YTD Annual Target PSS 182,160 1,777,254 1,900,000 Professional Services 63, , ,475 PSS Previous Period Current Period Mitigation Strategy Prime Timing Therapy, Nursing Green if cumulative YTD expenditure on (PSS) or (Therapy/Nursing) services is within the 0-1.5% range of what is budgeted per MSAA Targets Yellow if cumulative YTD expenditure on (PSS) or (Therapy/Nursing) services is Previous Period Current Period beyond 0% to 1.5% margin of what is budgeted per MSAA Targets, but is within -1% to + 2.5% per MSAA Targets Champlain 22 Mitigation Strategy Prime Timing Red if out side of the -1% to +2.5% corridor of YTD expenditure budget target 22 11

77 01/03/2012 Assigned to: Finance (Rick) OH - Efficient OH-1: Financial Management Indicator Characterization Definition Net surplus/deficit as calculated by Revenue minus Expenses Time Period Fall 2009 Summer 2010 Known Issues or Events PSS waitlist institute Therapy waitlists ma have HR resourcing issues Reliability Frequency Target High Monthly Balanced Budget as annual aggregate target Note: 3% Funding adjustment for Q1 posted to month of June ($1.4M), Additional Funding in Dec, resulting in single month surplus. Previous Period Current Period Green within 0 to % of cumulative YTD spend against budget Yellow Outside of Green corridor, but within 2.5 % of YTD spend against budget Red Outside of 2.5 % of YTD spend against budget Mitigation Strategy Prime Timing Champlain Assigned to: Juhee OH - Efficient OH-2: Length of Stay by Client Groups Indicator Characterization Time Period Fall 2009 Summer 2010 Known Issues or Events PSS waitlist institute Therapy waitlists ma have HR resourcing issues Definition Reliability Frequency Target Includes those clients who are actively receiving services in the previous month, and also those discharged in the previous month High Monthly Board Information No Provincial benchmark established for F 11/12 Previous Period Current Period Champlain

78 01/03/2012 Assigned to: Prasun OH - Efficient OH-3: Avg. Cost per Client Indicator Characterization Time Period Fall 2009 Summer 2010 October 2010 Known Issues or Events PSS waitlist institute Therapy waitlists ma have HR resourcing issues 91: Avg cost increas likely due to new # o VAC units in place Definition Reliability Frequency Target Average costs are calculated by summing all costs within the period (Services, supplies, equipment) divided by the sum of unique clients with costs. This is further divided into Lines of Business groupings. It excludes Case Management costs High Monthly Board Information No Provincial benchmark established for F 11/12 Avg_Cost_Per_Client Column Labels Client Population January 2012 Acute $ Rehabilitation $ Maintenance $ Long Term Supportive $ EndLife $1, Peads $ Service Max $2, Champlain 25 Previous Period Current Period 25 Assigned to: OH Efficient OH-4: Cost Per Episode Indicator Characterization Time Period Fall 2009 Summer 2010 October 2010 Known Issues or Events PSS waitlist institute Therapy waitlists ma have HR resourcing issues 91: Avg cost increas likely due to new # o VAC units in place Definition Average cost of purchased services per client episode, by client population: Adult Short Stay Acute End of Life End of Life in the 3 months immediately preceding death Children Medically Fragile Adult Long Stay Complex (RAI 17+) Adult Long Stay Chronic (RAI 11 16) Adult Long Stay Community Independence (RAI 1-10) Reliability Frequency Target Medium Monthly Developmental Previous Period Current Period Champlain

79 01/03/2012 OH Appropriately Resourced OH-5: Absenteeism Assigned to: HR/Payroll Emma Indicator Characterization Definition Total number of sick hours, paid and unpaid for all permanent and temporary staff (excludes casuals), divided by budgeted FTE of positions. Reliability High Frequency Target Monthly and Annually 12 days annually Previous Period Current Period Green 12 days or less annually Yellow Above 12, up to 13.8 days Red Above 13.8 days Mitigation Strategy Prime Timing Attendance Management System introduced in Q4-2010/11 Lynn Godding Ongoing Early Referral Services introduced in Q4-2010/11 Lynn Godding Ongoing Champlain 27 Performance Management Q3-2010/11 Lynn Godding Ongoing 27 OH Appropriately Resourced OH-6: Turnover Assigned to: HR/Payroll Emma Indicator Characterization Definition Reliability Frequency Target Rate at which employees leave an organization. Calculated as number of permanent employees who terminate or cease employment, divided by the average number of permanent employees on staff High Quarterly 10% Annually 2.5% Quarterly Previous Period Current Period Green Less than 10% Prorated annualized Yellow 10-11% prorated annualized Red Greater than 11% prorated annualized Mitigation Strategy Prime Timing Champlain

80 01/03/2012 OH - Appropriately Resourced OH-7: Vacancies Assigned to: HR/Payroll Emma Indicator Characterization Definition Reliability Frequency Number of vacant positions at a point in time in each reporting period divided by total number of positions at same point in time: expressed as a vacancy rate Moderate Quarterly Target 5% Previous Period Current Period Green 5% of less Yellow 5.1-7% Red Greater than 7% Mitigation Strategy Prime Timing Champlain OH Governance OH-8: Board of Directors Attendance Assigned to: Ashley/ Jamie Indicator Characterization Definition Percentage of Board members attending meetings or teleconferences throughout the year, in relation to the total number of Board seats filled Reliability Frequency High Monthly Target 75% Board Attendance Previous Period Current Period Green Over 75%, cumulative YTD Yellow Between 70-75%, cumulative YTD Red Below 70% cumulative YTD Mitigation Strategy Prime Timing Champlain

81 01/03/2012 OH Governance OH-9: Board of Directors Profile Assigned to: Ashley/ Jamie Indicator Characterizat Definition TBD Reliability Frequency Target TBD TBD TBD Mitigation Strategy Champlain 31 Those persons whose mother tongue is French, plus those whose mother tongue is neither French nor English but have a particular knowledge of French as an Official Language and use French at home. 31 SI Integration SI-1: Home First, Admissions Assigned to: Bobbak Champlain # of Referrals Total 04/ / / / / / / / / /2012 # of Clients With Home First Referral CCAC Enhanced Service Clients transitioned home CCAC Palliative Service Clients transitioned home CCAC Regular Service Clients transitioned home Non-admits Clients Pending Referrals Indicator Characterization Definition Count of new hospital clients admitted to the Home First Program per month Reliability Medium Indicator is directional Frequency Target Monthly 40 or more Home First Enhanced clients per month (April to November 2011) 60 or more Home First Enhanced clients per month (December 2011) 70 or more Home First Enhanced clients per month (January 2012 to March 2013) Previous Period Current Period Green 40 or more admissions to New Home First Enhanced Clients per month Yellow Between admissions to Home First Enhanced Clients per month Red Below 30 clients admitted to Home First Enhanced Clients per month Mitigation Strategy Prime Timing Champlain