1 Raising the Bar for Healthcare Governance and Leadership in Canada Wendy Nicklin, President and CEO, Accreditation Canada
2 Overview Accreditation Canada Governance and Leadership Standards Governance Functioning Tool Strengths and opportunities for improvement identified through accreditation results Revisions to Qmentum 2
3 Accreditation Canada National accreditation body for organizations across all health sectors in Canada, incorporated in 1958 International presence, including in Bermuda, Brazil, Italy, Saudi Arabia, and Kuwait Over 1000 active client organizations An independent, non-governmental, non-profit organization funded by its members Accredited by ISQua
4 Governance and Leadership in Qmentum Qmentum released in 2008, first cycle completed end of 2010 Governance standards address the governing body s role and responsibilities, enabling excellence in health care governance and organizational performance Leadership standards address leadership functions across and throughout all levels of the organization Revised in 2011
5 Governance Standards (formerly Sustainable Governance) Built on the five key functions and framework of Denis et al. (2005): Developing the mission, vision and values Collecting and using knowledge and information Developing the organization Building relationships with stakeholders Demonstrating accountability Supported by the Governance Functioning Tool, which assesses the knowledge of the board regarding composition and processes of the board
6 Governance Functioning Tool Helps the boards of health care organizations monitor and assess their performance and identify areas of success and areas for further development 33-question survey helps the governing body examine its own functioning by focusing on: Composition of the governing body Recruitment and renewal cycles Roles and responsibilities Orientation and ongoing education Meeting processes (e.g. mechanisms to make group decisions and resolve conflict) Completed anonymously by board members Supports consistent measurement of standards compliance
7 Leadership Standards (formerly Effective Organization) Focus on: Operations, decision-making structures, and infrastructure Worklife and a healthy and safe work environment Performance management Maintaining a culture of safety Based on best practice: A Framework for the Analysis of Management in Health Care Organizations and Proposed Standards of Practice (Denis et al., 2006, University of Montreal)
8 Accreditation Results The application of the Qmentum accreditation program across Canada and the resulting data that is collected provides a unique opportunity for identifying of the strengths and opportunities for improvement across Canada A clear link: governance and patient safety Key finding from the 2011 Canadian Health Accreditation Report High performing organizations in governance demonstrate higher performance in patient safety (statistically significant difference) 8
9 Strengths in Governance Having an effective system of financial planning and control Using strategic information to make decisions Allocating resources effectively Data from , 428 organizations 9
10 Opportunities for improvement in Governance Evaluating performance regularly Defining the vision and setting the strategic plan, goals, and objectives Fostering and supporting a culture of safety throughout the organization 10
11 Strengths in Leadership Planning and designing services to meet community needs Allocating and controlling financial resources to maximize efficiency and meet needs Investing in human resources development Data from , 554 organizations 11
12 Opportunities for Improvement in Leadership Delivering services according to the organization s values and ethics Having an integrated quality risk management and quality improvement system Monitoring and improving client safety culture on an ongoing basis Preparing for disasters and emergencies 12
13 Developments in governance best practice Baker et al. (2010) Effective Governance for Quality and Patient Safety in Canadian Healthcare Organizations and resulting Effective Governance for Quality and Patient Safety: A Toolkit for Healthcare Board Members and Senior Leaders Increasing need to put greater clarity between the role of the governing body and the role of the leadership team Greater focus on the governing body s effectiveness and its own functioning Recognition within the standards that in some jurisdictions, governing body is appointed by government 13
14 Developments in leadership best practice LEADS in a Caring Environment framework Valuable, comprehensive resource for responding to the challenges associated with striving for excellence in health care leadership Referenced in standards introduction and in specific guidelines CSA standards for Emergency management and business continuity programs Resource addressing the requirements for a comprehensive emergency management program Key reference for new standard on preparing for disasters and emergencies: prevention and mitigation; and preparedness planning, including business continuity plans
15 Standards Working Group Broad representation Health organization leaders Health care board members Professionals Academia Stakeholders Accreditation Canada surveyors Government Pan-Canadian membership 15
16 Governance Standards Revisions Greater focus for the governing body on quality Role of the governing body and its members must be identified, written, and shared Role in developing mission, vision, values, and strategic plan Promoting ethical behaviour and decision-making Education regarding the organization s ethics framework Role of governing body in understanding, reviewing, and addressing patient safety and quality issues 16
17 Revisions to Governance Functioning Tool - 4 new items The board receives ongoing education on how to interpret information on quality and patient safety performance The governing body oversees the development of the organization s strategic plan The governing body hears stories about clients that experienced harm during care The governing body tracks performance measures that provide a good understanding of organizational performance 17
18 Leadership Standards Revisions Creating and sustaining a caring culture Identifying and disseminating culture and values A culture that supports a safe and healthy work environment and ongoing quality improvement New requirements to monitor and improve safety Enhancements to integrated risk management approach and emergency preparedness requirements Assessing and improving client flow Supporting a no-blame culture 18
19 Leadership Standards Revisions (cont d) New requirements: culture of quality improvement Supporting leaders at all levels to develop knowledge and skills for ongoing quality improvement and participation in collaborative quality improvement initiatives Promoting and supporting spread and sustainability of quality improvement results Promoting consistent use of standardized protocols and best practice guidelines 19
20 National Consultation Feedback In partnership with the Canadian College of Health Leaders to gather broad feedback Sent to clients, surveyors, and stakeholders Circulated revised standards for feedback regarding clarity, importance, measurability Over 200 responses Positive feedback and support for the new requirements 20
21 Moving Forward Revised standards and governance functioning tool introduced in September 2011, to be rated in accreditation surveys beginning in September 2012 To support leaders of Canadian healthcare organizations and governing bodies to meet the growing demand for excellence in governance and leadership practice To reflect best practices identified through recent research and standards working group Feedback on standards accepted on ongoing basis 21
22 Raising the Bar for Healthcare Governance and Leadership in Canada Ray Racette, President and CEO, Canadian College of Health Leaders
23 LEADS in a Caring Environment The framework represents the key skills, abilities, and knowledge required to lead at all levels of the health system in Canada. Lead Self Engage Others Achieve Results Develop Coalitions System Transformation 23
24 LEADS as a model for change Outcomes Achieve Results Engage Others Relationships Develop Coalitions Future Vision Lead Self Change Dynamics Systems Transformation
25 Governance Standards Clarity improved between the role of governing body and the role of senior management Ethics expanding beyond code of conduct Board competencies important to assess for ensuring Board has skills set to govern effectively Board literacy in quality improvement identified as key development need to address Talent management added as new area of oversight 25
26 Governance Standards Governing body fosters and supports a culture of safety throughout the organization Governing body takes constructive action to address recommendations made in the organization s safety reports Governing body identifies quality improvement as a strategic goal for the organization The governing body promotes learning from results, making decisions based on research, evidence and ongoing quality improvement 26
27 Leadership Standards Increased accountability on leadership to develop strategic goals and objectives that are aligned with mission and values and clearly communicated within the organization at all levels Increased focus on execution of strategic actions, monitoring of performance and communication of results More diligence on training staff and service providers on safe operation of medical devices 27
28 Leadership Standards Increased accountability on leadership to promote and be actively involved in creating a healthy work environment and supporting a positive quality of worklife Leadership support to ensure there is continuing professional development and learning throughout the organization Leadership supports staff at all levels within the organization in developing competencies that will promote a healthier work environment 28
29 Raising the Bar for Healthcare Governance and Leadership in Canada Tom Philpott, Executive Director, Community for Excellence in Health Governance
30 Why the Governance Standards are important 1. Introduce consistency to governance practices 2. Set the stage for gradual implementation of recognized good practices 3. Provide practical guidance for boards and senior management 4. Help alleviate ministerial concerns about board capacity inconsistencies
31 Commission of Inquiry on Hormone Receptor Testing (2009) The Hon. Margaret A. Cameron was appointed commissioner in 2007 by an Order in Council. It was an investigation into incorrect estrogen and progesterone receptor (ER/PR) tests performed in Newfoundland and Labrador from 1997 to More than 100 of those wrongly tested patients had died by the time the mistake was discovered.
32 Government Inquiry Cameron (2009) Statement of the board (Cameron p.426): the Board of Trustees of Eastern Health have developed a modified policy governance model and have taken great strides to adopt that model for the organization. Cameron s response : A board cannot limit its responsibilities, whether imposed by the Hospitals Act or otherwise, by the choice of governance model. A board may choose to delegate certain responsibilities. However, that does not make it any less accountable for them.
33 Government Inquiry Cameron (2009) While the management is responsible and accountable for the quality of the reports provided to the board, the board allowed the management of Eastern Health to provide less than adequate information relating to the ER/PR problem and for that they are accountable. (p. 430) -Commission of Inquiry on Hormone Receptor Testing (The Honourable Margaret A. Cameron 2009)
34 Sample standards New standard: 3.3 The governing body identifies and has access to the information it needs to support decision making. Replaces: 4.1 The governing body allocates resources and delegates authority to collect and analyze the information it requires to carry out its responsibilities.
35 Sample standards Revised: 12.1 The governing body identifies the data and information it needs to monitor the organization's performance. Replaces: 12.1 The governing body allocates resources and delegates authority to collect data about the organization's performance.
36 Investigation into the Governance and Management of Kingston General Hospital (2008) The review was prompted by a myriad of financial and service problems and other challenges being faced by the hospital in meeting the needs of patients including a mounting deficit, unsustainable growth of the working capital deficit, and an impasse between the hospital and the LHIN. Report by government appointed investigator Graham Scott.
37 Government Inquiry Scott (2008) The Board has, in a genuine desire to advance the interests of patients, lost its focus on its equal responsibility to effectively oversee management and to ensure financial viability of the organization. (page 2)
38 Sample standards New standards: 1.2 (!) The governing body has written documentation that identifies its roles and responsibilities and how those roles and responsibilities are carried out. 4.3 With the CEO, the governing body consults regularly with government or its stakeholders to confirm the appropriateness of the organization's mandate and core services and to develop a common understanding about performance expectations.
39 Sample standards Revised: 6.3 The governing body works with the organization's leaders to conduct an ongoing environmental scan to identify changes and new challenges, and ensures that the strategic plan, goals, and objectives are adjusted accordingly. Replaces: 12.3 The governing body completes an annual environmental scan to identify changes and new challenges, and adjusts its strategic plan, goals, or objectives accordingly.
40 Sample standards New: 8.1 The governing body approves the organization's capital and operating budgets. 8.2 The governing body ensures the integrity of the organization's financial statements, internal controls, and financial information systems.
41 Sample standards Revised: 8.5 The governing body oversees the organization's resource allocation decisions as part of its regular planning cycle. Replaces: 10.1 The governing body makes resource allocation part of its regular planning cycle.
42 Commission of Inquiry into Pathology Services at the Miramichi Regional Health Authority (2008) In 1995, Dr. Rajgopal Menon was hired as a pathologist and department head at the Miramichi Regional Hospital. Suspension by the College of Physicians and Surgeons in Public inquiry by the Hon. Mr. Justice Paul S. Creaghan. Menon fails to meet the current standards of surgical pathology. In 18 per cent of his cases, the diagnoses were deemed incomplete and in three per cent, they were considered to be wrong.
43 Government Inquiry Creaghan (2008) In the future, the laboratory at the Miramichi Regional Hospital must be operated under a culture of patient safety, rather than a policy of risk management in a situation where a problem arises (p.126) Recommendation 29: The Board of Directors of the Regional Health Authority has responsibility to grant, retain, limit or withdraw a physician s hospital privileges
44 Government Inquiry Creaghan (2008) Recommendation 30: The Board of Directors of the Regional Health Authority act promptly on a question of a physician s hospital privileges after receiving advice from the CEO and the Medical Advisory Committee reporting to the Regional Health Authority
45 Sample standards Revised: 9.4 The governing body regularly reviews the frequency and severity of adverse events and near misses and uses this information to understand trends, client and staff safety issues in the organization, and opportunities for improvement. Replaces: 15.3 The governing body regularly reviews the frequency and severity of near misses and adverse events.
46 Sample standards New: 11.3 The governing body ensures that an integrated risk management approach and contingency plans are in place.
47 Board Development Resources Saskatchewan Ministry of Health Canadian Patient Safety Institute Ontario Hospital Association Variety of excellent consultants Governance Development Program
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