Table of Contents. Our Mission, Vision and Values Board of Directors Goals & Objectives Board of Directors

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3 Table of Contents Our Mission, Vision and Values... 1 Board of Directors Goals & Objectives Board of Directors Officers... 4 Directors... 4 Message from the Chairperson... 5 Message from the President and Chief Executive Officer... 6 Message from the Chief of Staff... 9 Message from the West Nipissing General Hospital Foundation Chair Statistics... 12

4 Our Mission, Vision and Values M I S S I O N S T A T E M E N T THE WEST NIPISSING GENERAL HOSPITAL is committed to the delivery of quality primary healthcare to the people of West Nipissing and surrounding areas by utilizing innovative skills, technology and best practices. V I S I O N THE WEST NIPISSING GENERAL HOSPITAL will improve the health status of our population through integration of service and in cooperation with our partners. We Value: C O R E V A L U E S Patient Centered Care; Care, compassion and integrity; Respect; Patient and employee safety; Quality of worklife; and Multiculturalism 1

5 Board of Directors Goals & Objectives Enhance organizational effectiveness 1. Review and trend the West Nipissing General Hospital (WNGH) Quality Improvement Plan (QIP) indicators to ensure an efficient & effective delivery of health care. 2. Implement leading practices in the ER to improve customer service. 3. Provide customer service training for employees and physicians. 4. Maintain strong financial health with adequate measures and controls in place through the Excellent Care for All Act (ECFAA), the Broader Public Sector Accountability Act (BPSAA), Accountability Agreements, etc. 5. Support current Capital Plan and the Health Infrastructure Renewal Fund (HIRF). 6. Support major infrastructure planning as needed. Develop a culture of quality 1. Board members will promote an environment that supports quality. 2. Ensure a strong Quality Committee of the Board of Directors. 3. Best practices will be encouraged and supported by the Board of Directors. 4. The Board of Directors will complete a quality survey. 5. The Board of Directors will support and approve a Quality Plan of Action (QIP) for the (WNGH with an Executive Pay for Performance indicator. Provide quality services to the patients and residents of West Nipissing 1. Monitor bilingual patient satisfaction survey results. 2. Trend sentinel events, near misses and adverse events biannually. 3. Ensure a fair and equitable complaints process. 4. Ensure a fair and equitable credentialing process. 5. Support and enhance our role in patient experience and customer service at all levels within the organization WNGH will become a workplace of choice 1. Support a Human Resource plan. 2. Review employee satisfaction survey results. 3. Review Exit Interview survey results. 4. Support the Health & Wellness program for employees. 5. Encourage strong relationships with internal and external partners. 6. Promote and encourage both patient and employee safety initiatives. 7. Support the implementation of an enhanced employee attendance Management Program. 2

6 Promote information technology enhancement and system integration 1. Continue with implementing Phase II of the Information Technology (IT) Meditech Project over the next 12 months. 2. Maintain a membership in good standing with the North Eastern Ontario Network (NEON) group. 3. Work in partnership with Health Sciences North, e-health Ontario and the NELHIN s for Information Technology implementation. 4. Participate in the North East Local Health Integrated Network (NE LHIN), NEON and Meditech meetings. 5. Work in collaboration with district and regional partners to review and plan for partnerships and integration opportunities. Develop the Volunteer program 1. Promote the WNGH Volunteer program with hospital staff, Board of Directors and the community with respect to the role of volunteers. 2. Support and promote the recruitment for volunteers. 3. Support a volunteer Greeter Program for ER. Foster a culture of mutual respect and safety at WNGH 1. Advocate a culture of mutual respect within the community and hospital for staff, visitors, patients, physicians, Board of Directors and volunteers. 2. Support a mutual respect program in conjunction with all parties to ensure a buy-in is obtained. 3. Promote a safe environment for employees, patients, physicians, students and volunteers. 4. Support the OHA Safety Group Initiative. Professional development for WNGH Board of Directors 1. New board members will attend Ontario Hospitals Association (OHA) training sessions as feasible. 2. Board members will regularly attend board meetings and board committee meetings as applicable. 3. Board members will participate at the governance level with districts partners, regional partners and with the North East Local Health Integrated Network (NE LHIN), as required. 3

7 Board of Directors Officers 1. Chair (Roch Pilon resigned Sept. 2012) Collin Bourgeois 2. Vice-Chair Jean-Luc Rivet 3. Treasurer Janet Parsons 4. Secretary, President and CEO Cynthia Désormiers Directors 5. President, Professional Staff Dr. André Béhamdouni 6. Sylvie Bélanger 7. JoAnne Beninger 8. Chief of Staff Dr. Klère Bourgault 9. Priscille Desjardins 10. Charles Goulard 11. Howard Longfellow 12. Municipal Council Léo Malette 13. Vice-President, Professional Staff Dr. Quy Duong Nguyen 14. Daniel Richard 15. Chief Nursing Officer Thérèse Savignac 16. Nipissing First Nation Eric Stevens 4

8 Message from the Chairperson This report tells a story of an extraordinary year at the West Nipissing General Hospital (WNGH). On behalf of the West Nipissing General Hospital Board of Directors, I am honoured to present the Annual Report. The WNGH is a true leader in health care and an important partner in the provision of healthcare services for the community of West Nipissing and surrounding areas. had another very successful year. Care was provided and delivered under a balanced budget and within a framework of a strong fiscal, accountable and high quality care environment. Given the changing healthcare environment, this is a significant accomplishment. Hospitals are complex organization dealing with the business aspect (finance), as well as caring for people. As a hospital, we are committed to positive health outcomes for our patients and the community. Over the past year, there are several accomplishments worth noting: a balanced budget with a healthy surplus, solid capital plan focused on equipment and infrastructure, OHA Silver Quality HealthCare Workplace Award, positive patient and staff surveys, Quality Improvement Plan, Accountability Agreements and the implementation of a new Health Information System. We are putting WNGH on the provincial map with membership and presence on the OHA Provincial Leadership Council for French Language Services. Additionally, our foundation is proceeding at an exciting pace with great fundraising activities and an increased awareness in the community. Moving forward, the Board of Directors will embark on a Strategic Planning exercise that will include employees consultation, physicians input and open communication. We are undertaking the task of a Strategic Planning re-fresh that will set the future direction for patients, employees and the hospital. We are looking to not only be the hospital of choice but also an employer of choice. The updated Strategic Plan will be finalized and acted upon in the upcoming year and will be shared publically. Although the West Nipissing General Hospital had another excellent year, the future will be challenging. Ongoing changes with legislation, reporting requirements and a zero-based budget will be challenging, coupled with our aging workforce, aging complex patients and increasing costs. Despite the challenges, we will continue to think strategically, proactively address issues and remain efficient and effective as healthcare providers. We are delighted to welcome Daniel Richard and Howard Longfellow to the Board of Directors. We also extend a sincere thank you to Roch Pilon and Jean-Luc Rivet for their commitment to the hospital and community. Roch spent six (6) years on the board with three years as Board Chair and Jean-Luc provided nine (9) years of service as a board member and Vice- Chair. Additionally, I extend sincere appreciation on behalf of the board to Dr. André Béhamdouni for his role as Chief of Staff over the past two years. I would also like to thank the many talented and passionate physicians, nurses, allied health care professionals, volunteers and the management team who are dedicated and work hard each and every day to make the WNGH a trusted place for health care. Best regards, Collin Bourgeois WNGH Board of Directors, Chair 5

9 Message from the President and Chief Executive Officer It is with great pleasure that I present the Annual Report for the West Nipissing General Hospital. In looking back over the past four (4) years, I confidently say great things are happening at WNGH! Hospitals are at the forefront of the changing health care landscape, despite increasing data collection, increasing reporting requirement and funding challenges, the WNGH has come out on top once again. A team approach is what make the WNGH work successfully in such a climate, the management team are dedicated and committed to do what it takes while our employees are filled with care and compassion and provide health care second to none. Despite the health system changes we have seen, endured and struggled with, we are stronger and more focused on quality patient care. All activities, improvements and changes at WNGH directly correlate to improved quality patient care. Despite the ambiguity, adversity and challenge of our ever changing health care system, our employees, physicians, students, volunteers and governance put patients first. In accordance with the Canada Health Act, we do our best to ensure that healthcare needs are accessible, portable, comprehensive, universal and publically administered. Interestingly, the Conference Board of Canada provided a briefing report that quantifies the role of healthcare delivery as an economic growth engine. WNGH contributes greatly to the community of West Nipissing by improving health outcomes and creating employment as the second largest employer in the community. Unlike most other sectors of the economy, the demand for healthcare does not fall during a recession. Our Quality Improvement Plan (QIP) developed in compliance with the Excellent Care for All Act (ECFAA) provides strategic direction, accountability, transparency and outcome, all of which lead to better patient care. The QIP is a driving force for changes to policies and procedures and is in keeping with the LHIN and the Ministry of Health direction. Improving patient satisfaction and quality care is a priority, with goals and objectives at the board and departmental levels supporting the following quality dimensions: Safety: Collection of accurate medication administration data, reduced patient falls in CCC and LTC, improved hand hygiene compliance, development and implementation of a surgical (endoscopy) safety checklist, reduce the incidence of new pressure ulcers and improved management of residents with response behaviors. Effectiveness: Maintain a healthy financial position and a balanced budget for a third consecutive year with an improved total margin. Access: Continue to meet and exceed provincial ER wait times. Patient and Family Centered Care: Continuous improvement of patient satisfaction, experience and customer service. Integration: Improve alternate level of care (ALC) percentages and reduce unnecessary hospital readmissions. Winning a Silver OHA Quality Award in 2012 is a prime example of our position and focus on quality patient care throughout the organization. 6

10 The WNGH has seen significant infrastructure changes in 2012 and The most significant implementation is that of our Hospital Information System (HIS) Meditech. Under the leadership of Kathie Smith we have successfully implemented Phase I. Kathie along with our super users have changed and improved the way we access, store and share patient data. As part of the North East Ontario Network (NEON), we are now connected with our regional hospital Health Science North and numerous other hospitals in Northern Ontario, all of which improves quality patient care. The physical environment is better and safer over the past year with safe roof access, replacement of domestic hot water pipes, new security system, loading docks improvements, new flooring, fire protection system, emergency generator, dishwasher, IT equipment, zambonie floor washer and other equipment. Our infrastructure improvements are a result of a solid capital plan, the Hospital Infrastructure Reform Funding (HIRF) and generous donations. Our capital plan permitted nearly $700,000 in various equipment and infrastructure purchases, while the WNGH Foundation under the strong leadership of Mike Page donated more than $70,000 for patient equipment. As a result of due diligence at all levels, revised vendor contracts, improved purchasing and tight internal controls, the hospital is once again ending the 2012 fiscal year in a healthy financial position. The hospital has seen general wage increases for CUPE, ONA and OPSEU and a wage review for the management team post a legislative wage freeze. Salary increases were awarded to address wage compression issues and to ensure a fair and equitable internal compensation process. We will continue to operate in a transparent fiscally responsible manner. Our challenges over the past year continue to be consistent with other hospitals in Ontario, with respect to the recruitment and retention of family physicians, ER physicians, and qualified health professionals. Health Force Ontario estimates that the shortage of family medicine physicians will end by Although there continues to be a higher allotment of family physicians in southern Ontario, we are hopeful that the Northern Ontario School of Medicine (NOSM) and the commitment of provincial bodies to Northern Ontario will happen sooner than later. An ongoing challenge in West Nipissing and northern communities is our aging population, Alternate Level of Care (ALC) patients and their need for long term care beds and additional community support. We continue to work with local, district and regional partners on this issue to ensure the right patient is getting the right care in the right location. I would like to take the opportunity to welcome Mrs. Brenda Lennon, Diagnostic Imaging and Therapeutics Coordinator, Mr. Danny Putman Infrastructure Coordinator, and Ms. Brenda Rochon Administrative Assistant (Medical Staff) to our team. Additionally, I would like to extend a warm welcome to Dr. Alexandre Anawati, Dr. Jeffrey Middaugh and Dr. Idowu Oyeniran, who compliment our team of ER physicians and Dr. Klère Bourgault, our new Chief of Staff. It is vital that I extend a thank you to Dr. André Béhamdouni for his past two years as Chief of Staff. His commitment and passion for health care at the WNGH will always be appreciated and has set us on the path for improved quality patient care. I would be remise if I did not thank the WNGH Board of Directors, dedicated members who are stronger than ever with a solid vision for the hospital as a true leader in health care and as an employer of choice. We bid farewell and extend our thanks to Mr. Jean- Luc Rivet who has served on the board for the past nine (9) years as member and vice-chair, and who has gratefully provided us with a wealth of knowledge. Furthermore, I would like to extend a personal thank you to our management team who are true leaders and professionals, who have endured ongoing changes and pressures while always maintaining a patient first commitment. 7

11 Last but certainly not least, I would like to extend a thank you to the WNGH Foundation board members for their ongoing support and championship for fundraising and patient care. Over the past four (4) years, the foundation has grown substantially in membership, activities and fundraising. We thank Mike Page for having the courage to assist us four years ago to kick start this very important initiative for our patients and hospital. Although Mike s term is completed, we are eternally grateful for his assistance, guidance and vision. Despite times of fiscal constraint, we have grown sustained services and continued to build healthcare at WNGH. The Board of Directors encourages us to lead, be innovative and promotes continuous improvements. The board, physicians, employees are strong and passionate and advocate for better health care for our patients and community. Our Quality Improvement Plan, the Excellent Care for All Act (ECFAA), patient and staff satisfaction surveys will play a significant role in shaping the future direction for the hospital, employees and patients. Stay tuned, as exciting things will continue to happen at the West Nipissing General Hospital. Best regards, Cynthia Désormiers, RN BScN MHA President & CEO Together we can make a difference: this is your community hospital! 8

12 Message from the Chief of Staff To follow from the previous year s challenges, a focus on improving client services from all perspectives and at all levels has been an ongoing drive throughout Quality enhancement through the Health Care Quality Committee of the Board of Directors continues to report on quality indicators, such as monitoring of medication reconciliations, patient/resident falls and complaints. As well, a report card for physicians is being formalized to ensure that physicians are part of the process. During the year, lots of work and dedication has been committed to implement an integrated hospital information system. is also part of the North Eastern Ontario Network, which will enable us to communicate with our community hospitals in the region, and whereby patient information will be accessible to health care providers. Meditech, which is the product of this endeavor, has finally come to fruition and challenges are being met. Developing health links between community partners will certainly be facilitated by this system. Drug shortages were monitored and we have not had any patient related issues as a result of these shortages. Continued medical education continues to receive some formal priority through the Local Education Group (LEG). The Medical Staff continues to mentor medical students and residents through their affiliations with the Northern Ontario School of Medicine (NOSM). Continued focus on improving the following aspects: Documentation to enhance communication and quality health care; Reconciliation of medications to minimize errors; Standardization and formalization of discharge instruction to patients; Implementation of validated Patient Order Sets for the treatment of patients to ensure standardization of treatments; Communication between patients (clients) and staff (doctors and nurses) in not only the Emergency Department, but as well throughout the hospital where patient encounters take place. Some important feedback has been given by members of the Ethics Committee of the Board of Directors, as well as the Medical Staff regarding end of life directives to ensure that these are obtained and documented in a formalized way to adequately reflect the patient s wishes. On a final note, I would like to ask all of us to consider the challenge voiced by one of our Board members to become one of the 10 best hospitals in Ontario. I remain convinced that such a goal can be achieved through small steady incremental steps, with priority given to measures delineated above, among many others that will enhance patient quality care, service and satisfaction. 9

13 Once again, I would like to voice my appreciation to the distinguished Board members of the West Nipissing General Hospital who donate their time and expertise generously, all the support staff, nurses and physicians who through their daily, small but steady professional and respectful actions have made this year of 2012 one upon which we can build the next. Sincerely, A. Béhamdouni, M.D. Chief of Staff 10

14 Message from the West Nipissing General Hospital Foundation Chair Foundation has had an exceptional year in 2012 and I truly believe the best is yet to come. The WNGH Foundation has endured growth and building over the past four (4) years, and is certainly reaping the benefits this year. The volunteer Board of Directors is an independent board built on community members who believe in our mission and vision and fully support our efforts to fundraise for new equipment and patient care needs at the West Nipissing General Hospital. Thanks to the generosity of our donors and volunteer board, the West Nipissing General Hospital Foundation has raised over $89,000 and donated $72,000 to the WNGH. Our annual fundraising events included the Moe Mantha Jr. Charity Golf Classic, Girls Night In, Nevada Tickets sales in partnership with Giant Tiger, Trip for Two raffle, coin boxes, as well as personal donations, in memoriam donations and court ordered donations. The generous donations permitted the purchase of an ED ECHO for the Emergency Room, and oncology and palliative care room equipment and furnishings. What has made our events and fundraising so successful is the community sponsor, service groups, and residents who are building life-long relationship with the Foundation. The Foundation fundraising activities also give back to the community, as we partner with local businesses (Laurentide Golf Club, Comfort Inn, Canadian Tire, Giant Tiger, Michaud & Levesque, RBC, NBC, Caisse Populaire, Moose FM radio) to name a few. In 2013, we plan to continue with our annual fundraising events in addition to the unveiling of our new Walk-Run- Roll-a-Thon in September. We need to fully realize our strategies to continue to be sustainable in the future. The upcoming year will be exciting with By-Law revisions, Walk Run-Roll-a-Thon, Million Pennies Campaign, trip for two raffle, a Facebook page, a new long-term palliative care room, the recruitment of new board members and a new board chair. I would like to acknowledge and thank the hospital staff, volunteers, and physicians for their dedication, excellence and quality patient care. Additionally, I would like to acknowledge the WNGH Foundation Board of Directors who have been growing and building for the past four (4) years and continue to have a vision that will benefit patients for years to come. Going forward, as I bid the Foundation farewell, I would like to recognize Collette Anderson for her ongoing efforts as the Foundation Officer and I wish the foundation and hospital all the best. Sincerely, Mike Page West Nipissing General Hospital Foundation, Chair 11

15 Admissions Acute Enhanced Care Unit Complex Continuing Care Interim Long-Term Care Patient Days Acute Enhanced Care Unit Complex Continuing Care Interim Long-Term Care Average length of stay Acute Enhanced Care Unit Complex Continuing Care Interim Long-Term Care Average percentage of Occupancy Acute & Complex Continuing Care Interim Long-term Care Statistics , ,945 17, % 98.07% , ,328 17, % 99.0% Emergency visits 20,172 19,316 Ambulatory Care visits 1,746 1,370 Oncology visits Telehealth Visits Clinical Non-Clinical Surgical cases Laboratory tests 525, ,674 Radiology procedures 32,624 30,259 Mammography procedures 1,433 1,532 Ultrasound procedures 5,808 5,480 ECG procedures 5,085 4,289 Respiratory Therapy procedures 7,495 7,556 Other Therapeutic Services visits 3,213 5,140 Volunteer Hours 1, , Mental Health and Addictions visits 9,393 * 7,554 * Note: counts are lower because multiple visits per day per service recipient are now reported as one visit, in compliance with changes to the Ontario Healthcare Reporting Standards (OHRS) definitions as of April 1, 2012)

16 To all employees who celebrated their years of service! Frank Desbois Carole Levac Sarah Remillard Marie-Josée Morin Caroline Steele Lise St-Jacques Angela Gardiner John Meeuwse Brenda Rakebrandt-Morin Line Bergeron Jamie Cushing Deborah Edmunds Micheline Guénette Dr. Richard Katsuno Cynthia Mayer Debborah McMurray Gail Aubertin Bernard Dupras Cynthia Rainville Fleurette Tétreault 13

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