Président Vice-présidente Trésorier POINT À L ORDRE DU JOUR PRENDRE

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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 : SECRÉTAIRE DE SÉANCE : INVITÉS : PROCÈS-VERBAL de la réunion du conseil d administration tenue le 8 mai 2013 au Carleton Place & District Memorial Hospital Michael Ennis Denise Alcock Ralph Moxness Célestin Abedi Lynn Graham Diane Hupé Melody Isinger Barbara Lajeunesse Anne Noonan Colette Rivet Sherryl Smith Gilles Lanteigne Patrice Connolly Kim Peterson Deryl Rasquinha Ashley Haugh Ashley Haugh Mike Coxon Gordon MacNabb Toni Surko Bill Skinner Président Vice-présidente Trésorier Directeur général Vice-présidente, Personnel et Mobilisation des intervenants Vice-présidente, Soins cliniques Vice-président, Rendement et Stratégies Adjointe à la direction Adjointe à la direction Mills Corporation Carleton Place & District Memorial Hospital Carleton Place & District Memorial Hospital Candidat - conseil d administration du CASC de Champlain 1.0 OUVERTURE DE LA SÉANCE POINT À L ORDRE DU JOUR MESURE À PRENDRE 1.1 Mot de bienvenue Le président du conseil, Michael Ennis, souhaite la bienvenue à toutes les personnes qui participent à la réunion et il remercie le Carleton Place & District Memorial Hospital d être l hôte de la réunion du conseil. Procès-verbal conseil d administration du CASC de Champlain, le 8 mai 2013 Champlain Community Care Access Centre Centre d accès aux soins communautaires de Champlain

2 2 1.2 Déclaration de tout conflit d intérêts Diane Hupé déclare avoir un conflit d intérêts à l égard du point 3.7 (Rapport sur les services en français) et quitte la pièce pendant la discussion. 2.0 DISCUSSION GÉNÉRATIVE CARLETON PLACE HEALTH VILLAGE INTEGRATION PROJECT Des représentants du Carleton Place & District Memorial Hospital, Toni Surko et Gordon McNabb, ont été invités à la réunion du conseil pour participer à une discussion générative concernant le réaménagement de l hôpital. On fait un survol de la ville de Carleton Place, de la population et des services fournis par l hôpital. L hôpital a été construit en 1955 et il ne répond plus aux besoins de la population actuelle. La nécessité de réaménager l hôpital a été soulevée il y a bon nombre d années. Les projets de réaménagement en sont au stade embryonnaire phase 1 l analyse de rentabilité a été envoyée au ministère de la Santé et des Soins de longue durée (MSSLD) en 2008 et révisée en 2012; elle doit maintenant être examinée et approuvée par le gouvernement. Le Réseau local d intégration des services de santé (RLISS) de Champlain a approuvé le réaménagement en juin Le réaménagement est fondé sur un modèle de carrefour ou de village et, nous l espérons, rassemblera bon nombre de partenaires en santé sous un seul toit p. ex. médecins de premiers recours, CASC de Champlain et services de santé mentale. La discussion porte sur les points ci-dessous. Carleton Place n a pas de difficulté à attirer de nouveaux médecins; toutefois, les nouveaux médecins veulent des possibilités de mentorat. Le médecin-chef sert actuellement de mentor à deux nouveaux médecins. L hôpital retiendra les services d un expert-conseil financier au moment d entreprendre la planification du réaménagement. Dans Champlain, les petits hôpitaux et les hôpitaux ruraux reçoivent des fonds affectés à la mise en œuvre de la philosophie Chez soi avant tout. Carleton Place n a pas d équipe de santé familiale (a fait plusieurs demandes) et espère qu une telle équipe fera partie du projet de réaménagement. La technologie et les dossiers de santé électroniques faciliteront l intégration d un bout à l autre du spectre de soins de santé. On envisage un modèle collaboratif de gouvernance pour le réaménagement de l hôpital ou le carrefour. On a discuté des soins palliatifs; il y a un groupe à Almonte qui étudie ce dossier. Procès-verbal conseil d administration du CASC de Champlain, le 8 mai 2013

3 3 3.0 BLOC DE RÉSOLUTIONS Anne Noonan, avec l appui de Melody Isinger, propose que soit approuvé le bloc de résolutions de la réunion du conseil d administration du CASC de Champlain du 8 mai 2013, qui contient les motions et les renseignements suivants : 3.1 Que le conseil du CASC de Champlain approuve le procès-verbal de la réunion du conseil tenue le 10 avril 2013; 3.2 Que le conseil du CASC de Champlain approuve le plan de travail du conseil; 3.3 Que le conseil du CASC de Champlain approuve la déclaration de conformité à l ERS-M; 3.5 Fiche de rendement du CASC de Champlain. ADOPTÉE Motion adoptée Les points ci-dessous ont été déplacés du bloc de résolutions à l ordre du jour : 3.2 Rapport du Comité de gouvernance renfermant des renseignements et des mises à jour sur les sujets suivants : o Recrutement de membres du conseil o Membres du Comité de direction, présidents des comités et membres des comités ( ) On tient compte de la planification de la relève au moment de former les comités du conseil et dans le cadre du recrutement des membres du conseil. o Évaluations des membres du conseil o Plan de travail du conseil o Planification des journées de réflexion du conseil o Orientation du conseil 3.3 Rapport du Comité des finances états financiers o À la fin de l exercice se terminant le 31 mars 2013, le CASC de Champlain affichait un excédent préliminaire et non vérifié de 1,9 million de dollars par rapport à un excédent prévu de 1,6 million de dollars; il y a donc un écart excédentaire cumulatif net de $. o Les sommes excédentaires doivent être rendues au ministère de la Santé et des Soins de longue durée. o On remercie l équipe des finances de l excellent travail qu elle a accompli concernant le budget Rapport du Comité des services à la clientèle, de la qualité et de la sécurité (SCQS) renfermant des renseignements et des mises à jour sur les sujets suivants : o Consentement éclairé à l évaluation et à l amélioration de la qualité o Plan de travail du comité o Rapport sur les indicateurs de violence et de harcèlement au travail o Histoire d un client Procès-verbal conseil d administration du CASC de Champlain, le 8 mai 2013

4 4 o Fiche de rendement du conseil; améliorer l accès et réduire les listes d attente Un des principes clés de l amélioration de l efficacité et de l expérience du client consiste à réduire le nombre d évaluations auxquelles ce dernier doit se soumettre. En utilisant l outil RAI-PS pour évaluer (évaluation préliminaire) les clients qui nécessitent des soins personnels, certains de ces clients peuvent être immédiatement orientés vers le secteur des SSC. On s attend à une réduction des risques pour les clients grâce aux évaluations opportunes et à l utilisation du bon outil d évaluation, au bon endroit. 3.6 Rapport sur la santé et la sécurité au travail o En mai, l évacuation, vers Cornwall, de plus de 350 personnes des régions inondées du Nord-Est a mis à l épreuve le système d intervention d urgence du CASC de Champlain. De concert avec des partenaires locaux, le CASC a fourni aux évacués des soins communautaires et du matériel et il les a orientés vers les services nécessaires. 3.7 Rapport sur les services en français (Diane Hupé quitte la pièce pour la discussion) o En décembre 2012, le CASC de Champlain a soumis au Réseau des services de santé en français de l Est de l Ontario son plan de désignation aux termes de la Loi sur les services en français. o La soumission a été approuvée moyennant deux recommandations, que le CASC de Champlain a mises en œuvre. o Il existe une «offre active» de services et de communications dans les deux langues officielles. Les clients du CASC de Champlain peuvent recevoir les services dans la langue officielle de leur choix. o On compile des statistiques sur la langue dans laquelle les services sont fournis pour s assurer que le CASC de Champlain compte le bon nombre d employés bilingues. 4.0 APPROBATION DE L ORDRE DU JOUR Diane Hupé, avec l appui de Sherryl Smith, propose que l ordre du jour de la réunion du 8 mai 2013 soit approuvé tel qu il a été modifié. ADOPTÉE Motion adoptée RÉSOLUTIONS EN VUE DE L ASSEMBLÉE GÉNÉRALE ANNUELLE DE L ACASCO Le CASC de Champlain ne présentera aucune résolution à l AGA de l ACASCO. On fait remarquer que la soumission budgétaire à l ACASCO traite déjà de sujets tels que le financement pluriannuel des CASC. Procès-verbal conseil d administration du CASC de Champlain, le 8 mai 2013

5 6.0 MISE À JOUR DE LA FICHE DE RENDEMENT DU CASC DE CHAMPLAIN Mise à jour de la fiche de rendement du CASC de Champlain : 5 Diane Hupé et Colette Rivet, en tant que représentantes du conseil, ont collaboré avec l équipe de direction du CASC à la mise à jour de la fiche de rendement du conseil. La nouvelle fiche de rendement sera prête pour les réunions du mois de mai des comités et pour la réunion de juin du conseil. Les mises à jour décrivent les indicateurs révisés ou les nouveaux indicateurs liés à diverses sources notamment : o L Entente de responsabilisation en matière de services multisectoriels (ERS-M) ; o Le rapport sur le rendement et les paramètres du RLISS; o Le plan d amélioration de la qualité des soins communautaires faisant l objet d une surveillance par Qualité des services de santé Ontario; o Les directives concernant le Modèle d allocation fondée sur la santé (MAS). À l interne, tous les paliers de direction sont responsables des indicateurs ou des objectifs pertinents. La discussion porte sur les sujets suivants : Dans le cadre de la mise à jour de la fiche de rendement du conseil, le groupe de travail a examiné les indicateurs pour déterminer lesquels il est préférable de surveiller au niveau de la gouvernance ou au niveau opérationnel. Les indicateurs de la fiche de rendement sont fonction des normes d agrément. Les objectifs visés par les indicateurs sont établis par diverses sources, notamment le MSSLD et l ERS-M. 7.0 PLAN STRATÉGIQUE Les membres du conseil discutent de l élaboration du plan stratégique Le conseil entreprendra la planification et l élaboration du plan immédiatement et ces activités seront au cœur des journées de réflexion du conseil, en novembre prochain. On aura recours à un processus d approvisionnement pour retenir les services d un expert-conseil indépendant qui aidera le conseil à élaborer le plan stratégique et qui pourrait collaborer à l animation des journées de réflexion. Un plan stratégique de trois ans cadre avec le Plan de services de santé intégrés (PSSI) du RLISS de Champlain et reconnaît l évolution du secteur des soins de santé communautaires. Les trois orientations stratégiques présentées dans le plan stratégique Procès-verbal conseil d administration du CASC de Champlain, le 8 mai 2013

6 demeurent très pertinentes et le personnel ainsi que les partenaires du CASC de Champlain en prennent de plus en plus conscience, les acceptent et s y conforment de mieux en mieux. Ces orientations pourraient servir de point de départ au plan stratégique Le processus de consultation servira à déterminer si certains des éléments du plan stratégique resteront en place. La consultation avec les partenaires, les clients et le personnel, entre autres fera partie du processus. Bon nombre de structures existantes faciliteront les consultations, par exemple le forum des fournisseurs de services et le comité consultatif communautaire. Les priorités du MSSLD et celles du RLISS, l apport des clients et les changements qui se manifestent chez les partenaires du système de santé, entre autres, guideront largement le processus. La mission, la vision et les valeurs feront l objet d un examen dans le cadre du processus. Le Comité de gouvernance a demandé qu un représentant de chaque comité (à déterminer une fois que les nouveaux comités auront été créés) collabore à la planification des journées de réflexion du conseil. Ce groupe participera aussi au processus de planification stratégique pendant l été et durant les semaines précédant les journées de réflexion. 8.0 DIVERS 6.1 Questions et commentaires du public Il n y a aucune question ni aucun commentaire du public. 9.0 À HUIS CLOS 6 Melody Isinger, avec l appui de Célestin Abedi, propose que la réunion se poursuive à huis clos. ADOPTÉE Diane Hupé, avec l appui d Anne Noonan, propose que la séance soit levée. ADOPTÉE Motion adoptée Motion adoptée CONFIRMÉ : APPROUVÉ VOIR LA SIGNATURE ORIGINALE MICHAEL ENNIS, PRÉSIDENT APPROUVÉ VOIR LA SIGNATURE ORIGINALE GILLES LANTEIGNE, DIRECTEUR GÉNÉRAL ET SECRÉTAIRE DU CONSEIL Procès-verbal conseil d administration du CASC de Champlain, le 8 mai 2013

7 HEURE POINT ORATEUR RENVOI À LA POLITIQUE RÉSULTAT ORIENTATION STRATÉGIQUE À HUIS CLOS RÉUNION DU CONSEIL D ADMINISTRATION DATE : Le 8 mai 2013 HEURE : 12 h ENDROIT : Salle du conseil du Carleton Place & District Memorial Hospital (sous-sol) 211, avenue Lake Est, Carleton Place SUJET ORDRE DU JOUR 12 h 12 h Ouverture de la séance 1.1 Mot de bienvenue 1.2 Déclaration de tout conflit d intérêts Michael Ennis Michael Ennis V- B h 5 13 h 2.0 Discussion générative - Carleton Place Health Village Integration Project Michael Ennis DS TOUTES 13 h 13 h 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.) Michael Ennis PD 3.1 Procès-verbal de la réunion du conseil d administration tenue le 10 avril Rapport du Comité de gouvernance IE PD Plan de travail du conseil d administration 3.3 Rapport du Comité des finances États financiers Entente de responsabilisation en matière de services multisectoriels Déclaration de conformité 3.4 Rapport du Comité des services à la clientèle, de la qualité et de la sécurité (SCQS) 3.5 Fiche de rendement du CASC de Champlain 3.6 Rapport sur la santé et la sécurité au travail PD IE PD IE IE IE TOUTES LEAD TOUTES EPS TOUTES ORG Résultat : PD Prise de décisions DS Discussion IE Information et éducation 1 Orientation stratégique : EPS Excellence en prestation de services LEAD Leadership en soins à domicile et communautaires dans un système de santé intégré ORG Capacité et rendement organisationnels

8 HEURE POINT ORATEUR RENVOI À LA POLITIQUE RÉSULTAT ORIENTATION STRATÉGIQUE À HUIS CLOS SUJET 3.7 Rapport sur les services en français IE TOUTES 13 h h Approbation de l ordre du jour Michael Ennis PD 13 h h Résolutions de l Assemblée générale annuelle de l ACASCO 13 h h Mise à jour sur la fiche de rendement du CASC de Champlain Michael Ennis IE TOUTES Deryl Rasquinha IE TOUTES 13 h h Plan stratégique Deryl Rasquinha PD TOUTES 13 h h 8.0 Divers 6.1 Questions et commentaires du public IE 9.0 À huis clos PD Levée de la séance Michael Ennis PD Résultat : PD Prise de décisions DS Discussion IE Information et éducation 2 Orientation stratégique : EPS Excellence en prestation de services LEAD Leadership en soins à domicile et communautaires dans un système de santé intégré ORG Capacité et rendement organisationnels

9 02/05/2013 Stage 1 Capital Redevelopment Proposal Update Share information about the proposed innovative model for a New Hospital Discuss the Role of CCAC within this model Respond to your questions 1

10 02/05/2013 Situated in the Champlain LHIN North Lanark/North Grenville Community of Care Current population of 9,800 in Carleton Place Last census (2012 underestimated our growth) Hospital catchment population over 29,000 (**Beckwith, Mississippi Mills, Carleton Place, Lanark Highlands, **west Ottawa) Highway 7 expansion to 4 lanes resulting in industry and housing growth and increased numbers of West Ottawa patients Large retirement community over 300 beds with expansion plans ** Fastest growth in catchment Vision The Communities Leading Partner in the Provision of Integrated HealthCare Services 2

11 02/05/2013 Accreditation Canada Recognition Exemplary Standing or 99% Healthy Food Options and Fitness at Work Community and Hospital Infection Control Association Award Top Performer in Emergency Satisfactions Registered Practical Nurses - Full Scope of Practice including OR Palliative Care Nurse presentation in Jerusalem 2012 :The End of Life Journey In a Rural Hospital and accepted for the 2013 conference in Ottawa Largest small hospital provider of Telehealth services-450 events/year to increase to 550 this year 6 Focus on Improving the safety and quality of our programs and services by adopting expert regional standards of practice Improving access by bringing more services closer to home; a focus on responsible growth Sustaining the cost effectiveness of our programs and services. Patient experience by engaging patients in both strategic directions and care decisions Playing a network role to facilitate the effectiveness of the whole health system 3

12 02/05/2013 Population is aging- 13.3% are 65 and over In residents with chronic disease Arthritis, High Blood Pressure, Asthma, Diabetes Hospitalization rate for chronic disease 19% above Champlain average, 45% above Champlain average for respiratory disease (Chronic obstructive lung disease) Many of residents aged 12 and over have activity limitation related to a health problem Repeat mental health readmissions within 30 days through Emergency well above LHIN average CPDMH ALC percentage average 26%, represented by 11% palliative days, 15% placement Emergency Visits per year-21,490 Inpatient Days -5,855 census days Ambulatory Care Visits -11,227 Diagnostic Imaging Exams -17,461 (increasing) Surgical Procedures

13 02/05/ Today Single elevator Surgical Patients are transitioned along the same corridors as Emergency patients Significant access challenges for patients with mobility issues Operational efficiencies rising utility costs To Grow Patient Services Facilitate a Team Approach with Partners 5

14 02/05/2013 Stage 1 Business Case Proposal submitted in 2008 Updated 2012 to better align with: a vision of hospital and community integration LHIN Integrated health services plan, Ministry Action Plan and priorities A natural Health Links Fit Our community s needs and values Growing Population Renovation vs. Rebuild service disruption, site constraints, parking, helicopter Cost Analysis Partner Accommodation This site will be sold and $$ applied to new hospital 6

15 02/05/2013 Preferred Option Development of two buildings on one site (land donated by the Town of Carleton Place): A re-developed acute care building with Emergency department, surgical suite, Diagnostic Imaging and inpatient unit. An Ambulatory care centre where the hospital s ambulatory and administrative services reside with regional partner agencies. The acute care hospital is linked to this building A locally developed campus of care within a system of care Hospital s ambulatory and administrative services reside with regional partner agencies Centre is linked to the Hospital building Will facilitate clinical and administrative synergies. Will create a unique one-stop shopping model for clients 7

16 02/05/2013 The Ambulatory Care Building a P3 build with a private developer, partner portion funded through leases The hospital portion of ambulatory care building funded by MOH Capital planning branch. Preferred option to condo ambulatory space from the developer. The acute care building funded through the MOH 8

17 02/05/2013 Carleton Place Hospital as a Hub Hospital to support the following integration strategies: Optimize access in the most appropriate care environment Guide residents and caregivers as they navigate the care journey Create both clinical and operational synergies Communicate easily across sectors Opportunities to share talent management and succession planning Support training, education of students Offer an environment conducive to research and adoption of best practices Emergency Strategies Diversion, a catalyst for referrals, clinical pathways and case management support programs Mental Health Strategies Reduce the numbers needing support in ED, improve access to community services, create transition pathways between acute and community based services, engaged specialized services Senior Friendly Care Strategies Fall prevention, Supportive environment, Table of service providers to improve transition of care, clear access points, end of life support Chronic Disease Strategies Complex and chronic disease models of care 9

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19 Item 3.0 Consent Agenda MOTION WEDNESDAY MAY 8, 2013 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 May 8, 2013 meeting. 3.1 Minutes from the April 10, 2013 Board meeting (approval) 3.2 Report from the Governance Committee (info) Board Work Plan (approval) 3.3 Report from the Finance Committee Financial Statements (info) MSAA Declaration of Compliance (approval) 3.4 Report from the CSQS Committee (approval) 3.5 Champlain CCAC Scorecard (info) 3.6 Occupational Health and Safety Report (info) 3.7 French Language Services Report (info) Carried Defeated

20 No. Goal Responsibility Board Resp. 1 Managing to a balanced annual budget Finance 4 C Board Role Staff Support Target Date Committee Target Date Board Date Completed Sr Director - Finance Monthly Reporting; Annual compliance 2 Monitor implementation of annual Quality and Client Safety plan (inclusive of new Accreditation standards goals & action plans, Risk plan, Ethics plan, etc) CSQS 1 C VP, Performance & Strategy Ongoing 3 Strategic guidance on key Clinical care, and Quality trends (eg Health system partnership/integration, Evolving CCAC Role, Safe client transitions, Client experience survey results, resource prioritization & shift to community, etc) CSQS 1 C VP,Clinical Care; VP, Performance & Strategy Ongoing Joint Management with CSQC subcommittee of Client Service & Quality demands balanced against Financial demands Review and approval of procurement arrangements at levels requiring Board authorization (as required) Joint Management with Finance subcommittee of Client Service & Quality demands balanced against Financial demands Manage process, action items from Board Client Story discussions Provide guidance to Program Development, Research programs Provide guidance, review quality improvement plans from Program Evaluations (eg Client care model phase 1 implementation; RAI 0-7; etc) Managing to MSAA targets & monitoring Champlain's progression to HBAM goals Finance, CSQC 3,4 C Finance 4 C Finance, CSQC 3,4 C CSQS 2,5 C CSQS 3 C CSQS 3 A Finance 4 C VP, Clinical Care; VP, Performance & Strategy Sr Director - Finance VP,Clinical Care; VP, Performance & Strategy VP,Clinical Care; VP, Performance & Strategy VP,Clinical Care; VP, Performance & Strategy VP,Clinical Care; VP, Performance & Strategy Sr Director - Finance; VP, Performance & Strategy Ongoing Ongoing Ongoing Quarterly Quarterly Quarterly Quarterly Reporting

21 11 Annual and Special Meeting of Members Working group 5 C VP, People&SE/ E.A. Jan-13 Jun Develop work plan; present to full Board for approval Governance 5 B E.A. Apr-13 May Canvass Members for their interest in being considered for an officer role, Board Committee Chair Governance 5 B CEO Apr-13 May Develop Board orientation and development written material/check-list Governance 5 C E.A. Apr-13 n/a 15 Develop Board in-person orientation outline Governance 5 C E.A. Apr-13 n/a 16 Propose a slate of Officers Governance or sub-comm 5 B CEO May-13 Jun Prepare and Conduct Board and Board Member assessments Governance 5 C E.A. May-13 May VP, Approval for revised Board Scorecard items related to CSQS 3 B Performance & Client Services, Quality, and Safety Strategy Q1 VP, 19 Revised Board Scorecard Finance 4 B Performance & Strategy Q1 F Plan Board retreat Working group 1 & 5 C E.A. Jun-13 Nov Develop Action Plan from Board Assessments Governance 5 C CEO Aug-13 Sep Quarterly Board education schedule Governance 5 & 6 C E.A. Aug-13 n/a 23 Set Board and Committee meeting dates for 2013 Governance / Board 5 B E.A. Sep-13 Oct Update and Approval of CSQS Policies CSQS 2 A VP, Clinical Care Q2 25 Update & Approval of Finance Policies Finance 4 A VP, Performance & Q2 F2013 Strategy 26 Annual Review of Board policies Governance 5 C E.A. Nov-13 Jan Board recruitment Governance 5 B VP, People &SE/ E.A. Dec-13 Jan Non - Client Services Contracts Management & Controls Sr Director - Finance 4 C of expenditures Finance Q3 F VP, Clinical Education Item - scorecard performance items related to Care; VP, Champlain practices that are non-standard across CCACs Finance 4 C Performance & and/or influenced by partner strategies Strategy Q3 F2013

22 30 Finalize Board skills metrics and distribute to returning Board Members Governance 5 C E.A. Jan-14 Feb Review By-law No. 3 Governance B E.A. Jan-14 Feb Development/approval of the CAPS and M-SAA submissions Finance 4 B Sr Director - Q4, F Establish Strategic Direction 2. Provide for Excellent Management 3. Ensure Program Quality and Effectiveness 4. Ensure Financial Viability 5. Ensure Board Effectiveness 6. Build Relationships A. Policy Formulation B. Decision-Making C. Oversight Initial Board approval: Revision Dates:

23 Submission To The Board Report from the Governance Committee May 8, 2013 Board Recruitment Advertisements resulted in a number of candidates submitting applications; interviews were conducted April 24 with two candidates selected to fill the Renfrew vacancies. Recruitment continues to fill one Ottawa based vacancy on the Board. If you are aware of possible candidates please let Sherryl Smith or Ashley Haugh know. 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 for the upcoming year. Responses are due to Ashley Haugh by May 17, Board Evaluations Board evaluations governance functioning tool, self-assessment, peer-to-peer assessment and board chair assessment are being distributed by . Please ensure you complete the anonymous electronics surveys by May 22. Board work Plan (see item 3.2.1) All committees reviewed their work plans at the April committee meetings. The compiled results represent the Board work plan for which is presented for Board approval. Board Retreat Planning The Annual Board retreat is scheduled for November 12-13, The Governance Committee is seeking a member from each Board committee to sit on the Board retreat planning group. Meetings will take place monthly and will be by teleconference or in-person. Board Orientation All Board orientation material was reviewed and will be available through the Board portal. Board orientation will be planned for our three new Board members in June/July. All Board members are highly encouraged to take part in the in-person orientation session which will be approximately half a day (date to be determined). As well, Board members are always welcome to take part in client visits with front line staff care coordinators, therapists, geriatric assessors, nurses. If you would like to schedule a client visit please contact Ashley Haugh. Champlain CCAC Board - May 8, 2013 Item 2.2 Report from the Governance Committee PAGE 1

24 Annual General Meeting Update Dr. Sinha will be the guest speaker at the Annual General Meeting (AGM) on June 13. The agenda for the AGM will be as follows: AGM Schedule at a Glance 11:45 am to 12:30 pm 12:30 pm to 1:00 pm Business portion of the meeting plus CEO and Board highlights to be presented by the Chair of each Committee Lunch and networking, media briefing 1:00 pm 1:45 pm Presentation by Dr. Sinha and Q&A 1:45 pm Media interviews and follow up The Board meeting will follow the AGM and will finish by 3:30pm. Board Education/Generative Discussion Please forward any suggestions for generative discussion for the fall to Ashley Haugh. The Governance Committee will maintain a rolling list of ideas so you are welcome to suggest topics at any point. Ideas currently in the queue for discussion/education include (in no particular order): Governance /Management Ethics E-health, technology solutions OACCAC CEO, Dan Burns Evolving role of CCAC Current Projects or Papers being delivered by Champlain CCAC staff. Sherryl Smith Chair Sponsoring Executive Patrice Connolly, VP, People and Stakeholder Engagement Champlain CCAC Board - May 8, 2013 Item 2.2 Report from the Governance Committee PAGE 2

25 Item MSAA Declaration of Compliance MOTION WEDNESDAY MAY 10, 2013 Champlain CCAC Board of Directors MSAA Declaration of Compliance Per the terms of the MSAA, the Champlain CCAC Board is required to submit a MSAA Declaration of Compliance to the Champlain Local Health Integration Network (LHIN) Board on a semi-annual basis. The Declaration of Compliance asks if the Champlain CCAC has complied with: Article 4.8 of the MSAA concerning applicable procurement practices The Local Health System Integration Act, 2006 The Champlain CCAC is in compliance with these sections. In addition, the Champlain CCAC submits monthly reports to the Champlain LHIN on the MSAA metrics and progress towards achievements. This is also included in the monthly Board Finance report. The Finance committee recommends that the Board authorize the Board Chair to sign the semi-annual MSAA Declaration of Compliance. Moved by: Seconded by: Be it resolved, That the Champlain CCAC Board approves the semi-annual MSAA Declaration of Compliance. Carried Defeated

26 DECLARATION OF COMPLIANCE Issued pursuant to the MSAA effective April 1, 2011 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 : To: The Board of Directors of the Champlain LHIN From: The Board of Directors of the Champlain CCAC Date: May 8, 2013 Re: October 1, 2012 March 31, 2013 (the Applicable Period ) Unless otherewise defined in this declaration, capatalized terms are the same meaning as set out in the MSAA between the Champlain LHIN and the Champlain CCAC effective April 1, la The Board has authorized me, by resolution dated May 8, 2013, to declare to you as follows: After making inquiries of Gilles Lanteigne, Champlain CCAC Chief Executive Officer, and other appropriate officers of the Champlain CCAC and subject to any exceptions identified on Schedule G, to the best of the Board s knowledge and belief, the Champlain CCAC has fulfilled its obligations under the service accountability agreement (the MSAA ) in effect during the Applicable Period. Without limiting the generality of the foregoing, the Champlain CCAC has complied with: i. article 4.8 of the MSAA concerning applicable procurement practices; and ii. the Local Health System Integration Act, Michael Ennis, Board Chair Champlain Community Care Access Centre Centre d accès aux soins communautaires de Champlain

27 Champlain CCAC Executive Summary Financial and Performance Results Preliminary and Unaudited For the Year Ended March 31, 2013 Item 3.3 Report from the Finance Committee Summary This executive summary covers Champlain CCAC s preliminary financial results for the YEAR ended March 31, These financial statements are subject to final adjustments and external audit. Financial Results Summary For the year ended March 31, 2013, Champlain CCAC is in a preliminary and unaudited surplus position of $1.9M, against a planned surplus view of $1.6M, for a net YTD surplus variance of $0.3M against plan. There is a deficit in the month of March in the amount of $0.9M as anticipated by the CCAC due to the timing of expenditures and revenue recognition. Client Care expenditures and Administration expenses were above plan for March. Revenue was above plan as well. Budget numbers reflect a base increase of $2.4M announced by the Ministry of Health and Long Term Care in 2011/12, as well as a planning increase of 1.25% as directed by the LHIN. At the end of September, the LHIN confirmed additional funding representing an additional $4.7M above our original plan. The additional funding is being recognized over the remainder of the fiscal year but is slightly offset by an HBAM-related funding reduction totalling $0.4M. Several project-specific funding requests have also been accepted through the LHIN that are recognized as those projects are implemented. PRELIMINARY FINANCIAL RESULTS: Year ended March 31, 2013 Preliminary Total Preliminary Variance % REVENUE Actual Budget Variance of budget Base Funding 197,553, ,635,225 (2,082,021) (1.0%) One-Time Funding 5,138,508 3,425,145 1,713, % BTI 491, ,574 14, % Other 115, ,000 11, % TOTAL REVENUE 203,298, ,640,944 (342,511) (0.2%) EXPENSES CHRIS 132,603, ,124, , % Non-CHRIS 4,904,776 4,545,608 (359,168) (7.9%) Internal Therapies 3,917,354 4,133, , % Care Coordination & I&R 41,083,257 41,216, , % Total Nursing Initiatives 457,157 2,224,618 1,767, % Total Administration 18,402,044 16,744,455 (1,657,589) (9.9%) TOTAL EXPENSES 201,368, ,988, , % TOTAL SURPLUS/(DEFICIT) 1,929,926 1,652, , % Page 1 of 5 March 2013

28 Key Revenue Assumptions Assumptions and funding updates are shown in the Current Budget Guidelines document. March Results March Financial Results The results for the month of March show a $0.9M deficit. For the month of March 2013: Revenues are higher than Plan by 1.3M: o o o Base funding is under budget by ($0.1M). One time funding is over budget by $1.2M. BTI and other revenue is over budget by $0.2M. Revenues were higher than Plan due primarily to recognition of one-time funding for project timing of various CCAC initiatives as well as various projects authorized by the LHIN in the fourth quarter. Unspent program funding, such as unspent Nursing Program funds or underspent HSIP investments are assumed to be returned to the Province. Those funds are not recognized in revenue. Expenses are in a deficit position against Plan of ($2.3M): Client Services and Client Care ($ 0.1 M) Mental Health and Rapid Response Nursing Initiatives $ 0.1 M Administrative expenditure (including project spend) ($ 2.3 M) Expenses were anticipated to be significantly higher than Plan due to the increases of various client care activities (e.g., growth of the Home First program), project implementations, and projects funded through HSIP funds from the LHIN in the fourth quarter. In addition, some year-end adjustments are accounted for in March, such as reasonable expectations of grievances and legal liabilities of the organization. Preliminary Year-End Financial Results For the year ended March 31, 2013: Revenues are in a deficit position of ($0.3M). o o o Base funding is under budget by ($2M) due primarily to the Nursing Initiatives, as anticipated. One time funding is over budget by $1.7M primarily due to additional system funding related to quality, efficiency improvements, and the evolving role of the CCAC. BTI revenue is on budget and is matched with associated expense. Expenses are in a surplus position of $0.6M. o o o o Client Services (Purchased Services and Internal Therapies) are under budget by $0.4M due to efficiencies in service delivery, constraints placed on the CCAC early in the year, and system capacity constraints in some areas. Nursing Initiatives are under budget by $1.8M. Care Coordination and I&R are under budget by $0.1M. Administration is over budget by ($1.7M) as previously referenced. Year End Carryover The CCAC ended with a $1,652,174 deficit in 2011/12. To offset this deficit, the 2012/13 budget results in a surplus of $1.65M and assumes that it will be realized equally ($137,682/month) throughout the year. That surplus is reflected in our Plan numbers. Page 2 of 5 March 2013

29 Overall Analysis The year-end financial outlook overall remains a small Surplus of $0.28M above the planned level of financial surplus. The surplus represents less than a 0.15% variance compared to budgeted revenue. These results are subject to audit and potential year end final adjustments. With the program to shift RAI 0-7 clients to CSS, the total number of clients served has remained balanced to the budget view, but the acuity of the client population served has increased. The Operations Improvement Plan has delivered savings well beyond expectations (YTD anticipated was $5.2M; YTD actual estimates are $7.3M) due to its quicker ramp up. The CCAC has exceeded the Year End Operational Improvement Plan requirements. Operations Improvement Plan Results: Savings Initiative Metric Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Wound Care % of Wound Clients Achieving Q3 Monthly Target 0% 0% 0% 40% 70% 100% 100% 100% 100% 100% 100% 100% Frequency Change Visits Actual 74.3% 81.9% 82.0% 82.9% 83.3% 74.8% 76.6% 75.7% 77.7% 77.9% Cluster Care: Rate Monthly Lost Savings if Clients at Baseline $15,500 $14,820 $14,140 $13,460 $12,780 $12,100 $11,420 $10,740 $10,060 $9,380 $8,700 $8,020 Reduction Cluster Care not serviced at Shared Actual $19,021 $18,237 $19,218 $17,245 $16,792 $18,556 $22,290 $23,256 $23,120 $23,574 $22,838 $29,928 Retirement Home: Average PSS Monthly Utilization Baseline Utilization Reduction (Retirement homes) Actual Clinic Achieving 20% % Clinic Nursing Units of Total Visit-Monthltype Target 17.5% 17.5% 18.0% 18.0% 18.5% 18.5% 19.0% 19.0% 19.5% 19.5% 20.0% 20.0% Nursing Units Actual 17.7% 18.7% 21.2% 21.3% 21.4% 21.5% 20.7% 20.6% 19.6% 18.4% 17.6% 18.3% Discharging RAI-HC 0-5 Count of paid clients with PSS, Monthly Target (Number 2,400 2,220 2,020 1,880 1,740 1,540 1,340 1,140 1, Clients Clients where RAI Score 0-7 of clients receiving PSS with scores of 0-7) Overall Estimated Savings $1,350,000 Actual 2,277 2,161 1,886 1,551 1,249 1, Administrative Reduction in administration costs Monthly Target $119,167 $119,167 $119,167 $0 $0 $0 $0 $0 $0 $0 $0 $0 $357,500 Savings* per savings schedule Actual $142,624 $234,498 $255,000 $267,485 $287,904 $116,826 $0 $0 $0 $0 $0 $0 * no longer reported after Q2 Total Savings $ 5,015,500 $54,000 $319,000 $335,000 $2,600,000 Page 3 of 5 March 2013

30 Performance Results 2012/13 Summary M-SAA Performance Metrics Accountability Indicators Target Standards Performance Standard Measure Type Q1 Q2 Q3 Q4 % Total Margin 0% >=0% YTD 0.69% 2.3% 1.42% 0.96% Balanced Budget 0 0 YTD $ 344,512 $ 2,303,495 $2,126,143 1,929,927 Proportion of budget spent on Administration 9% <10% YTD 7.3% 7.5% 8.0% 9.1% Variance Forecast to Actual Expenditures 0.0% <5% YTD 0.14% 2.54% 1.48% 0.14% Variance Forecast to Actual Units of Service 0.0% <5% YTD -2.3% 2.3% -1.1% -0.9% Number of Individuals Served 52,000 +/- 5% YTD 33,894 41,113 48,186 54,814 Wait Time th Percentile from hospital discharge to service Not available from OA at this time Not available from OA at this time initiation (Hospital clients) 1 <=1 Quarterly 1 1 Wait Time th Percentile from hospital discharge to service Not available from Quarterly 7 6 initiation (Hospital clients) OA at this time Wait Time th Percentile wait time from community setting to community home care services Quarterly Clients placed in LTCH with MAPLE scores high and very high as a proportion of total clients placed 78 <=78 Quarterly 81.3% 85.1% 82.4% 83.0% Falls for long stay home care clients N/A N/A Quarterly 31.5% 34.8% 38.0% Medication Safety N/A N/A Quarterly 1.1% 1.2% 1.2% Cost Per Episode Turnover Rate Explanatory Indicators Wait Time 1: From Hospital Discharge to service initiation (Hospital clients) Short Stay Acute Wait Time 1: From Hospital Discharge to service initiation (Hospital clients) Short Stay Rehab Wait Time 1: From Hospital Discharge to service initiation (Hospital clients) Long Stay Complex Wait Time 2: 90 th percentile wait time from community setting to community home care services Short stay acute Wait Time 2: 90 th percentile wait time from community setting to community home care services Short Stay Rehab Wait Time 2: 90 th percentile wait time from community setting to community home care services Long Stay Complex Home First Admitted Home First Discharged Others Service Max Expenditure (EPSS, SAH,WAH/H2H, EOL incremental, CM costs estimated) Adult Short Stay Acute (episode) N/A N/A Quarterly $645 $604 Adult Long Stay Complex (monthly) N/A N/A Quarterly $941 $917 End of Life (episode End Life portion) N/A N/A Quarterly $5,167 $5,060 End of Life in the 3 months Not available Not available from immediately preceding death N/A N/A Quarterly from OA at this OA at this time time Children Medically Fragile (Monthly) N/A N/A Quarterly $3,344 $3,553 10% Annually YTD 1.94% (7.78% Annualized) 2.3% (8.4% Annualized) N/A Quarterly 5 3 N/A Quarterly N/A Quarterly 4 10 Not available from OA at this time Not available from OA at this time Not available from OA at this time Not available from OA at this time Not available from OA at this time 0.9% (7.3% Annualized) Not available from OA at this time Not available from OA at this time Not available from OA at this time N/A Quarterly N/A Quarterly N/A Quarterly Number of new hospital clients admitted to home first program per month (Yr. 1 Explanatory; Yr. 2 Accountability) Number of Home First clients discharged by destination within 90 days per month (Yr. 1&2 explanatory ; Yr. 3 Accountabil ity) Quarterly 56 Avg. 61 Avg. 78 Avg. Not available from OA at this time Not available from OA at this time Not available from OA at this time Not available from OA at this time Not available from OA at this time Not available from OA at this time Not available from OA at this time Not available from OA at this time Not available from OA at this time 1.9% (7.6% Annualized) Not available from OA at this time Not available from OA at this time Not available from OA at this time Not available from OA at this time Not available from OA at this time Not available from OA at this time 74 Avg. ALS-HRS YTD CCAC Enhanced Services YTD CCAC Palliative Services YTD CCAC Regular Services YTD ,107 1,962 Died YTD Hospital Stay, Returned to CCAC Services YTD Hospital Admission > 14 days YTD LTCH YTD Other YTD YTD $4,066,771 $8,155,947 $12,031,913 $16,820,697 Total joint funding (hips & knees) 1,333 clients/year YTD ,381 Dialysis clients 85 clients per year YTD Page 4 of 5 March 2013

31 Schedule E-3-CCAC OHRS Description Total Case Management ( ) Total Primary Care ( ) Total In-Home Visits ( ) Total In-Home Hours of Care ( ) Total In-Home Individuals Served ( ) Total In-Home Support ( ) Total COM Residential Services ( ) Total CSS In-Home & Community Services ( ) Health Service Activity Visits (s450,s451) Individuals Served (s ) Visits Face-to-Face (s449,s450,s453,s454) Individuals Served (s455) Visits Face-to-Face (s449,s450) Hours of Care (s453,s454) Individuals Served (s455) Hours of Care (s453,s454) Individuals Served (s455) Hours of Care (s453,s454) Individuals Served (s455) Visits Face-to-Face (s449,s450) Hours of Care (s453,s454) Individuals Served (s455) Performance Target Performance Standard Q1 Q2 Q3 Q4 Min Max 133, , ,990 42,076 75, , ,903 52,000 49,400 54,600 33,894 41,113 48,186 54,814 75,000 72,750 77,250 20,872 42,088 62,202 79,552 6,200 5,890 6,510 2,413 4,245 5,465 6, , , , , , , , , , ,100 55,189 98, , ,858 39,000 37,050 40,950 17,866 24,931 31,908 39,082 1,899,156 1,842,181 1,956, ,654 1,082,371 1,644,458 2,197,159 13,497 12,822 14,172 10,755 12,324 14,172 16,141 49,100 47,627 50,573 Not available 38,835 55, , Not available ,078 7,756 7,368 8,144 Not available 4,250 7,482 9,063 8,610 9,516 Not available 6,938 10,214 4,090 3,681 4,499 Not available 2,723 3,495 Not yet available from CSS Not yet available from CSS Not yet available from CSS Page 5 of 5 March 2013

32 Submission to Board of Directors Client Services, Quality and Safety Committee Report May 8, 2013 BACKGROUND/ISSUE Informed Consent for Evaluation & Quality Improvement The Committee was provided with information regarding the extent to which the organization is meeting requirements related to informed consent for program evaluation and quality improvement activities. Whilst the members acknowledged there are key differences between program evaluation, quality improvement and research, it was also noted that there are some areas of overlap that require ongoing reflection and clarification as the organization redefines its role in research activity. The following principles have been addressed by the organization with regard to informed consent for program evaluation and quality improvement: Privacy, Confidentiality, Security, Identifiable Information, Ethical Considerations in research. Significant discussion focused on the need to ensure that ethical considerations be captured in all three categories with a need to ensure justice is captured as a stand-alone principle. It was acknowledged that the ethical principle of justice (particularly for staff) is an important element when considering engaging in quality improvement activities which may impact one section of the organization more than another. The organization has made a commitment to ethical decisionmaking and meeting the procedural values in the Accountability for Reasonableness Framework; as such, it must ensure that when engaging in quality improvement activities (particularly involving large-scale business process changes) that it meets the test for transparency in informing key stakeholders about the potential impact of proposed changes. It was further acknowledged that this does not necessarily restrict the organization from engaging in change but it does affirm the obligation for transparency in what the change brings. The Committee concurred that an initial draft of the Briefing Note would be forwarded by one of the Committee members to solicit feedback and additional guidance from the Tri-Council Secretariat. Committee Work Plan (see item 3.2.1) The Committee reviewed a final draft of the work plan for The linkage to ethics was noted in several key areas of the work plan, including, but not limited to: the annual Quality and Safety Plan, client story, strategic guidance for clinical care programs.. Workplace Violence and Harassment Indicator Report F The Committee was provided with a report of the Workplace Violence and Harassment indicators. External incidents are described as those incidents where an employee is subjected to workplace violence and harassment from either a clientbased source or a person unrelated to the organization. Internal incidents are described as involving a colleague, employee or affiliated organization; or those involving domestic violence within the employee s family. It was noted that there were no incidents of physical injury reported in either external or internal incidents. Champlain CCAC Board May 8, 2013 Item 3.4 Client Services Quality and Safety Committee Report PAGE 1

33 Police involvement was noted in one incident of external threat. The report provides data on CCAC employees with client-based incidents tracked separately for contracted service provider personnel. The Committee acknowledged that incidents at both the employee and service provider level are likely under-reported. The Committee requested that with regard to client-based events, the data should be presented for both the CCAC staff and service provider personnel for the next reporting period. The importance of tracking client-based incidents will be stressed in the discipline-specific Quality Committees. The Committee also raised the issue of the need for an organizational position statement and procedure for managing video and audio surveillance of staff. Client Story The Committee revisited the proposal put forth at the last meeting that the Client Story be presented at the next Board meeting with a focus on a client with a RAIscore of 0-7 discharged from service; discussion will be facilitated by the Board Chair. It was agreed that this will be an opportunity to update the Board on the evaluation of the discharged clients with a RAI score of 0-7 as well as present an occasion to trial the Client Story template and process in order to provide recommendations for improvement as necessary. Board Scorecard; Improving Access and Reducing Waitlists (see item 3.5) A summary view of the Board Scorecard was presented with a focus on the areas where the organization is trending red, most notably intake efficiency and the intake waitlist. The organization has recently undertaken considerable efforts to address efficiency efforts through a recent review (Optimus) of key areas of the business impacting efficiency at point of referral and intake. The review mapped out business processes associated with information and referral, intake to CCAC services and referral to CSS. A future state was then presented based on promising practices across the sector as well as best practices identified in other jurisdictions. A key principle in improving both efficiency and the client experience is to reduce the number of assessments the client is subjected to. By utilizing the RAI-PS (preliminary screener) to screen clients at point of initial intake it is expected that risks to clients will be reduced through timely assessment, utilizing the right assessment tool at the right juncture of care. In addition to improved screening and assessment processes the organization will focus efforts on: navigation for community referrals; more effective partnership with CSS; and, the implementation of urgent assessment teams for higher needs clients. It is posited that urgent assessment will mitigate risks posed by wait for service and will identify where occupational therapy and physiotherapy interventions would serve to ensure home safety and early implementation of falls reduction strategies to facilitate better outcomes for the client. The Committee recommended that human resource impacts would require close monitoring particularly with regard to shifts in staffing needs and training impacts. Diane Hupé, Chair Sponsoring Executive: Deryl Rasquinha, Vice-President, Performance and Strategy Champlain CCAC Board May 8, 2013 Item 3.4 Client Services Quality and Safety Committee Report PAGE 2

34 Item 3.5 Board Scorecard April 2013 (Data as of March 31, 2013) Champlain

35 Service Delivery Excellence Core Metrics Client Trends Target / Baseline Feb-13 Mar-13 FY 2012/13 1. Client Population 17,770 Clients non-summer 15,550 Summer 17,375 17,597 17,655 Non- Summer 14,884 Summer 2. Referrals 3703 Referrals 3,369 3,612 3, Intake Efficiency 90% 80.5% 82.0% 82.4% 4. Intake Waitlist 760 Clients 1, , PSS Waitlist 0-25 clients (RAI 16+) N/A 6. Adult OT/PT Therapy Waitlist 7 days or less (RAI 16+) N/A 7. School Therapy Waitlist 28 days or less (RAI 16+) N/A 8: Community Clients Requiring Enhanced Services 36 Clients 15 4 N/A Quality Target / Baseline Feb-13 Mar-13 FY 2012/13 1: Service Wait Times: Community 19 days or less : Service Wait Times: Hospital 3 days or less : Client Events : Client Complaints : % of Wound Clients within target LOS 5: % Compliance to receiving Falls Prevention Intervention (Audit) 6: % of Clients that triggered RAI-Med. Cap with a Medication Review (Audit) 7: ED Registration/Hospital Admits (QCH) 80% 59% 62% 67% 80% 83% 97% 82% 85% 97% 100% 88% 444 clients/ 117 clients 310 / / / 124 Organizational Capacity and Performance Financials / Sustainability Target / Baseline Feb-13 Mar-13 FY 2012/13 1: Tracking to Monthly Financial + $138k per +$187k -875k +$1,930k Targets month 2: Tracking Against Operational Global Improvement Plan Champlain 3: Tracking to Avg. Cost/Client Expectations $639/client ($734 Summer) $596 $639 $641 Organizational Health Target / Baseline Q3 Q4 Q4 1: Staff Turnover Rates 10% 7.3% 7.6% 7.6% 12 mnts to 12 mnts to 2: Absenteeism Annualized Rate and 12 Feb Mar N/A Cost : Health & Safety Staff Events : % Education Hours 1.0% 0.8% 0.8% 0.9% 2

36 Enhanced Role Metrics Leadership in Home & Community Care in an Integrated Health System Acute Hospitals Target / Baseline Feb-13 Mar-13 FY 2012/13 1: Home First Enhanced Volumes 72 Clients : Initial Transitions within net 90 days 3. Total Days & Number of Clients Waiting for Home First Enhanced Clients 90% In Community % 95.9% 93.8% 0 clients 0 days avg. 0 clients 0 days avg. 1 clients 1.1 days avg. Sub Acute Hospitals Target / Baseline Feb-13 Mar-13 FY 2012/13 1: Volume of Placements to Other Settings : % of Spaces that CCAC is Managing NA 15% 15% 15% CSS Target / Baseline Feb-13 Mar-13 FY 2012/13 1: Referral Volumes TBD TBD TBD TBD 2: % of clients referred where CSS accepted the client TBD TBD TBD TBD Long Term Care Homes Target / Baseline Feb-13 Mar-13 FY 2012/13 1: % of LTCH placements with a MAPLe score of 4 or 5 78% or more 82.6% 81.0% 85.5% 2: Admission to LTCH from % Hospital Community/Hospital 48.8% 32.6% 34.3% 36.2% 3: Percent of Clients on LTCH Waitlist with CCAC Services 51% 60% 62% 59% ALS-HRS Target / Baseline Feb-13 Mar-13 FY 2012/13 1: % of clients placed into ALS-HRS with a Moderate or above MAPLe 63.9% 97.1% 95.5% 80.0% 2: Waitlist Volumes NA NA Adult Day Program Target / Baseline Feb-13 Mar-13 FY 2012/13 1: Waitlist Volume NA NA At Home Target / Baseline Feb-13 Mar-13 FY 2012/13 1: Number of Clients in Community (MAPLe 4,5) 4500 Clients Champlain 2: Number of Clients in Community 85 & Over 2012/13 Q3 5, /13 Q4 5, /13 Avg 5, clients 6,211 6,258 6,276 Primary Care Target / Baseline Feb-13 Mar-13 FY 2012/13 1: Number of Referrals from Physicians

37 Submission to Board of Directors Occupational Health & Safety Program Annual Report FY 2012/2013 May 8, 2013 INTRODUCTION This report is presented to the Board of Directors to provide information about the Occupational Health and Safety (OHS) Program at the Champlain CCAC during FY2012/13. The CCAC is committed to a culture of safety across the organization, which was supported and enhanced by its successful 2012 Accreditation Award. The requirements of the Occupational Health and Safety Act and its associated Regulations are the foundation of the OHS program and define the responsibilities of all workplace parties in our Health and Safety Management System. The OHS Program underwent significant changes during the 2012/13 fiscal year in order to meet standards and best practices for a health care organization. In addition to the OHS and Wellness components, the program now has responsibility for the Infection Prevention and Control (IPAC) Program. With the infrastructure complete, the OHS Program will continue with a plan of implementation and improvement of established processes as well as a system of data collection to evaluate the program and its targets. Program Components: The Executive accountable for the OHS Program is Patrice Connolly, Vice-President People and Stakeholder Engagement. The Director, People Services (currently vacant) is responsible for the management of the program. A new position, the OHS Program Manager, was created in Q2 to provide subject matter expertise for both OHS and IPAC. Occupational Health & Safety There are currently 5 Joint Health and Safety Committees (JHSC) across Champlain and 3 more in development. The smaller sites are covered by 6 Health and Safety Representatives. Infection Prevention and Control An IPAC committee was created in F12-13 with cross-organizational representation. The Chair of the Committee is the Director, People Services. In addition, there is a group of Infection Control Champions, consisting of 11 employees with an interest in infection control who act as a resource for their peers. These Champions report in to the OHS Manager and receive training in IPAC on an annual basis. Wellness The Wellness@Work committee is led by the OHS Program Manager, Catherine Richard, and is also comprised of 15 employees who volunteer to help promote wellness among their peers and within the organization. Champlain CCAC Board May 8, 2013 Item 3.6 Occupational Health & Safety Program Annual Report PAGE 1

38 OHS Indicators The following indicators will be used to evaluate the OHS Program and identify areas where improvements are needed. Comparative FY11/12 information will also be displayed, where available. The implementation of the Champlain Events Learning System (CELS) to report and track health and safety incidents and injuries occurred in September Prior to this data was collected manually using Excel. Indicator 2012/ /12 Number of incidents* Number of WSIB (Workplace Safety and 4 Health Care 2 Lost Time 2 Health Care 2 Lost Time Insurance Board) claims Employee flu shot rate 50% 38% Participation in Safety 90% - First training Participation in Hand 94% - Hygiene training Ergonomic consultant costs (for employee ergonomic assessments) $ $ *Incident details are listed below: Site 2012/ /12 Labelle 17 8 Hospitals 6 7 Client home 9 2 Eastern offices 9 3 Western offices 12 4 Roadway 4 3 Employee s home 2 0 Type of event 2012/ /12 Slips/Trips/Falls Harmful 13 3 substances/environmental Workplace 9 - violence/harassment Motor vehicle incident 4 3 Caught/struck 3 2 Overexertion 3 1 Repetition 2 1 Other (i.e. animal/pet attacks) 3 5 Champlain CCAC Board May 8, 2013 Item 3.6 Occupational Health & Safety Program Annual Report PAGE 2

39 WSIB NEER Statement NEER is the financial incentive program of the WSIB related to workplace injury claims. If our organizational performance in this program is good, the CCAC receives a rebate on the premium paid for this insurance. Poor performance results in payment of a surcharge in addition to the premium. For 2012, the CCAC received a rebate. Accident Year (calendar) Performance Index Rebate/Surcharge Rebate Rebate * Surcharge *subject to maximum surcharge Risk Analysis Although the overall incident rate has increased, this is due primarily to the change in incident reporting from a paper method to the electronic CELS method. There has not been a significant increase in injuries and the lost time WSIB claims are comparable to last year. Employees have also received training on reporting all hazards and near misses as it is important to identify areas of concern and correct them before an injury occurs. FY2012/13 should be considered a baseline moving forward so that future statistics can be benchmarked against the same reporting system. Slips, trips and falls remain the most common incident at the Champlain CCAC, with environmental complaints and workplace violence completing the top three most frequent events. This data was and will be used to guide hazard controls such as testing, training and procedures. Although musculoskeletal disorders (MSD) are the common type of injury among most health care workers in Ontario, our incidents in this area are low, mainly due to our proactive workstation review and ergonomic assessment process. By addressing employees complaints early on, long and expensive MSD claims are prevented. Our organization is vulnerable to even a small number of WSIB claims. For example, one expensive WSIB claim in 2010 resulted in a significant surcharge to the CCAC. By focusing on early reporting and prevention, the risk to the organization can be mitigated. Champlain CCAC Board May 8, 2013 Item 3.6 Occupational Health & Safety Program Annual Report PAGE 3

40 PROGRAM ACHIEVEMENTS FOR F12-13 Occupational Health & Safety: Development of OHS Manual stored on PPM (Policy and Procedure Manual) : 14 new policies, Health and Safety Management System Development of a Healthy Work Environment Framework Second year of participation in the Public Services Health and Safety Association Safety Group: CCAC will receive a WSIB rebate this fall based on the organization s participation in 2012 WSIB NEER rebate in 2012 of $33, Supervisor training for all management staff and others in October 2012 JHSC and Health and Safety Representative training in October 2012 Implementation of CELS reporting system Certification of 10 JHSC members First Aid training of 17 First Aiders Purchase of defibrillators for Labelle and Pembroke offices; agreement signed with City of Cornwall for existing defibrillator in Cornwall office Development of elearning modules for new employee orientation program related to OHS and IPAC Safety First training for all employees in October 2012 Participation in development of elearning OHS modules with Mississauga Halton CCAC for the following topics: WHMIS, Workplace Violence, Slips- Trips-Falls and Safe Home Visits Standardization of OHS forms and templates across Champlain Air quality testing performed at a Branch office in response to complaints from employees-results were negative for mold or other environmental hazards Infection Prevention and Control: Achieved 100% compliance in Accreditation Standard for IPAC Development of IPAC Policy and Procedure manual stored on PPM: total of 41 policies and procedures Development of Hand Hygiene elearning module Development of IPAC orientation elearning module 50% employee influenza immunization rate with onsite immunization clinics Development of employee immunization program to reflect best practice for health care organizations Development of reprocessing procedures for cleaning and disinfection of client care equipment Development of IPAC surveillance indicators for monitoring and improvement of program Fit testing of employees for N95 respirators Champlain CCAC Board May 8, 2013 Item 3.6 Occupational Health & Safety Program Annual Report PAGE 4

41 Wellness: Received Silver Quality Healthcare Workplace Award from the Ontario Hospital Association/Health Force Ontario Successful 10, 000 steps pedometer campaign with 240 participants 80 staff and family members benefitting from our corporate GoodLife fitness discount Conducted employee wellness needs assessment with 234 responses Committee planning meeting for 2013/14 wellness campaign based on survey results. The theme will be 12 Steps to Wellness. MOVING FORWARD INTO 2013/2014 A solid foundation for this program has been developed. Fiscal work plan will focus on the implementation of the many new and updated Policies and Procedures and improvements for a more streamlined data collection and reporting process. There is a FY13-14 work plan for the Occupational Health & Safety and Wellness components and the IPAC Committee is finalizing its work plan for 2013/14. In FY13-14, the OHS Program is collaborating with the Learning and Development team to plan education and training for all employees in such subjects as: Slips, Trips and Falls Prevention OHS related to Alternate Work Arrangements Workplace Violence and Harassment Prevention Safe Home Visits Safe Driving Workplace Hazardous Materials Information System (WHMIS) Hand Hygiene IPAC Routine Practices Supervisor Competency The implementation of a number of elearning courses will allow Champlain CCAC employees to easily access and complete courses on-line. The other significant advantage of on-line training is the Halogen tracking system which allows the Learning and Development /OHS teams the ability to monitor and report on training compliance. The accomplishments and achievements of 2012/13 provide an excellent opportunity for the OHS Program to continue to introduce and implement positive changes to maintain and improve the safety and health of employees and by doing so; improve the quality and safety of client care. Sponsoring Executive: Patrice Connolly Vice-President, People and Stakeholder Engagement Champlain CCAC Board May 8, 2013 Item 3.6 Occupational Health & Safety Program Annual Report PAGE 5

42 Submission To The Board of Directors French Language Services (FLS) May 8, 2013 ISSUE / PURPOSE As indicated in the FLS Committee Terms of Reference, the FLS Committee provides a report to the Champlain CCAC Board of Directors Governance Committee bi-annually. This report is presented provides a status update on the Champlain CCAC s French Language Services (FLS). BACKGROUND Since receiving the Board of Director s approval of the FLS Designation plan in September 2012, the final plan in both French and English versions were submitted to Le Réseau des services de santé en français de l Est de l Ontario in December Over the course of the past few months, le Réseau des services de santé en français de l'est de l'ontario designation committee reviewed thoroughly the submission and on April 17 th a letter was received stating approval pursuant to the following two recommendations. 1. That the Champlain CCAC reinforce the capacity of services in French in the Ottawa west area and the town of Pembroke in order to decrease the recourse to temporary measurements to offer the French services. 2. That the Champlain CCAC adopt the practical application of the new inclusive definition of a francophone (DIF) in order to standardize the terminology of the linguistic variable for the establishment of the geographical linguistic profile and for the provision of services. For this purpose, the following two questions should be taken into account a. What is your mother tongue? b. If your mother tongue is neither French, nor English, in which official language of Canada are you more at ease? In addition to the aforementioned recommendations, and as a standard of excellence to continued quality services, the Champlain CCAC is also acting on the Designation Committee s recommendation to have the FLS e-learning module translated for francophone staff. This material will also be integrated into orientation for new Board members. Champlain CCAC has clarified the recommendations with le Réseau and has prepared a response. The staff of Champlain CCAC are confident that this response will be positively received by le Réseau, and our plan will move on to the next level of Champlain CCAC Board May 8, 2013 Item French Language Services (FLS) PAGE 1

43 approval at the Champlain LHIN and ultimately at the Bureau des services de santé en français du Ministère de la Santé et des Soins de longue durée. Included for your review is the FLS Clients Report for fiscal 2012/2013. This document features data such as Clients Geo-Diversity French vs. English Clients and the number of clients whose first language is French per Age Group. At the end of May, the FLS Committee will meet to review its current mandate and membership, review reporting activities to the Board of Directors and develop a work plan for the year. As the first CCAC in the province to submit a FLS designation plan, we were approached by the SE CCAC to share our project work plan, processes used to determine designated bilingual positions and other resources for the submission of a thorough plan. Members of the SE CCAC FLS Committee will be onsite at the end of May to meet with key staff involved in the FLS designation project. Sponsoring Executive: Patrice Connolly Vice-President People and Stakeholder Engagement Champlain CCAC Board May 8, 2013 Item French Language Services (FLS) PAGE 2

44 FLS Designation Timelines: April 2011 to April 2013 June 2013 The Champlain CCAC with the support of a Réseau planning officer has developed a comprehensive FLS Designation Plan to ensure equitable and quality services to Francophones in the Champlain region. The plan to be submitted to the Boards of Directors of the Réseau and LHIN who will approve or make a recommendation to the organization for amendments. Status update April Board approval to move forward with FLS Designation request April Article informing staff of FLS Designation project showcased in Dialogue May 2011 FLS committee meeting Understanding the scope of the FLS Designation Project June 2011 Assignment of staff as leads for different areas of the FLS plan. Leads are responsible for the collection of data required. July 2011 FLS Committee meeting Understanding Human Resources data requirements and designated position assessment process September 2011 Amendment to CCAC Bylaw to ensure French language capacity and representation at the Board level approved at the 2011 Annual General Meeting September 2011 new Bylaw 3 sent to translation September 2011 FLS Committee Meeting Understanding FLS requirements for the procurement process and third party services November 2011 FLS Committee meeting Overview of FLS Communication Strategy and visual identity November 2011 FLS project update to the Governance Committee of the Board of Directors January /February 2012 FLS Committee meeting Implications of FLS on CCAC policies April 5/2012 FLS Committee meeting review draft Human Resources Plan, Selection Policy, Recruitment Policy and Staffing Policy May 16/2012 Information and Referral Policy changed to reflect FLS requirements May 29/ st draft of FLS Designation plan shared with FLS Committee for feedback June 13/2012 FLS Committee meeting discuss Draft FLS plan September 20/2012 FLS Designation Plan receives approval from the Board of Directors October 9/2012 Approved FLS Designation Plan sent to MoHLTC translator December 10/2012 translation received and reviewed December 12/2012 Final FLS Designation documents submitted to Le Réseau des services de santé en français de l'est de l'ontario for review April 17/2013 -Letter of approval with recommendations received. May/ Response to letter sent Champlain CCAC Board May 8, 2013 Item French Language Services (FLS) PAGE 3

45 June/July 2013 Up to 24 months from time submitted The plan will then be submitted to the French Language Health Services Office of the Ministry who will approve or makes a recommendation to the organization. The plan will then be submitted to the Office of Francophone Affairs who will approve or makes a recommendation to the organization. The final plan is then submitted to Cabinet who will pass a regulation officially designating the Champlain CCAC. Champlain CCAC Board May 8, 2013 Item French Language Services (FLS) PAGE 4

46 02/05/2013 French Language Service Clients 1 Clients Geo-Diversity French vs. English Clients 2 1

47 02/05/2013 Number of clients* whose first language is French per Age Group #Clients in #Clients in #Clients in #Clients in Total * Includes clients with a preferred Service Language as French or English & French 3 Of those whose service language is French, percentage of clients whose first language is French too % 21% 21% 22% % 25% 24% 23% % 87% 78% 74% Total 91% 86% 77% 75% 4 2

48 02/05/2013 Percentage of Clients per Service Language per MAPLe level French Clients % English Clients % English & French No MAPLe Level 10% 67% 2% High 0% 3% 0% Low 0% 0% 0% Mild 0% 0% 0% Moderate 0% 3% 0% Very High 0% 2% 0% Total 11% 75% 2% 5 Distribution of MAPLe within each language* French Clients % English Clients % English & French No MAPLe Level 88% 89% 85% High 4% 4% 5% Low 1% 1% 1% Mild 1% 1% 1% Moderate 4% 4% 5% Very High 2% 2% 3% Total 100% 100% 100% * The time scope is bound to the three fiscal years from 2009 to

49 02/05/2013 Volume and Cost of Services by Service Language per Year* Service Language Units Costs Units Costs Units Costs Units Costs French $ 352,939 $ 13,775,647 $ 311,246 $12,611,540 $ 340,853 $13,753,826 $ 308,973 $12,221,211 French & English $ 20,638 $ 802,201 $ 27,771 $ 1,192,351 $ 54,376 $ 2,543,538 $ 70,770 $ 3,262,769 English $ 2,216,951 $ 87,102,839 $ 2,042,071 $84,539,424 $ 2,353,681 $98,904,504 $2,313,029 $96,844,449 Total $ 2,590,527 $ 101,680,687 $ 2,381,088 $ 98,343,314 $ 2,748,909 $ 115,201,868 $ 2,692,772 $ 112,328,430 * Only includes clients that have incurred some service cost(s) in the 2009 to 2012 fiscal years 7 Proportion of French clients vs. expenditure percentage Service Language %Client %Units %Costs %Client %Units %Costs %Client %Units %Costs %Client %Units %Costs French 14.0% 13.6% 13.5% 13.5% 13.1% 12.8% 12.3% 12.4% 11.9% 11.6% 11.5% 10.9% French & English 0.8% 0.8% 0.8% 1.3% 1.2% 1.2% 2.8% 2.0% 2.2% 3.5% 2.6% 2.9% English 85.2% 85.6% 85.7% 85.2% 85.8% 86.0% 85.0% 85.6% 85.9% 84.9% 85.9% 86.2% Total 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 8 4

50 02/05/2013 Average Cost Per Client Service Language AVG Cost Per Client Per Year AVG Cost Per Client Per Year AVG Cost Per Client Per Year AVG Cost Per Client Per Year French 2,763 2,602 3,027 2,859 French & English 2,928 2,575 2,489 2,506 English 2,877 2,760 3,143 3,090 Total 2,862 2,736 3,111 3,043 Note: The CCAC has moving clients and practice towards standardized guidelines for service delivery. Past practise differences were primarily driven by historical guidelines within the former CCAC branches. 9 Average Cost Per Client in Eastern Counties Service Language AVG Cost Per Client Per Year AVG Cost Per Client Per Year AVG Cost Per Client Per Year AVG Cost Per Client Per Year French 2,236 1,984 2,344 2,303 French & English 2,527 1,533 1,566 1,460 English 1,681 1,703 2,052 2,071 Total 1,787 1,744 2,078 2,077 Note: This chart is basically the previous slide but drilled down to Eastern Counties region. This view gives more consistent numbers as they share the same business practice in Eastern Counties. 10 5

51 Submission To The Board OACCAC AGM Resolutions May 8, 2013 DISCUSSION To determine if the Champlain CCAC will submit any resolutions to the Annual General Meeting (AGM) of the Ontario Association Community Care Access Centres (OACCAC). BACKGROUND/ISSUE All CCACs are able to submit resolutions for the OACCAC AGM. While resolutions can be submitted at any point during the year, the OACCAC has asked for any resolutions for this year s conference to be submitted by May 26, The resolutions are tabled at the AGM and each CCAC s delegate votes on the resolution. For the Champlain CCAC, Michael Ennis is the delegate. Ashley Haugh Executive Assistant Champlain CCAC Board May 8, 2013 Item 5.0 OACCAC AGM Resolutions PAGE 1

52 Submission to the Board of Directors Champlain CCAC Scorecard Refresh May 8, 2013 BACKGROUND & PURPOSE Diane Hupé and Colette Rivet, as Board Representatives, have worked with Champlain CCAC management to refresh the Board Scorecard. The new scorecard will be produced for the May Committee meetings and the June Board meetings. The purpose of this briefing note is to outline the approach used to refresh the Scorecard, and to summarize the key changes made. APPROACH o o Since the creation of the F Strategic Plan, Champlain CCAC has taken steps to better align its Strategic Plan, to its Operating Plan, to its Scorecard. The Strategic Plan is updated on a 3 or 4 year cycle; The Operating plan and Scorecard measures to support the Strategic Plan, are updated annually or as needed. This Scorecard update is guided largely by: a) The recently board-approved Operating Plan which identifies areas of business emphasis for Champlain CCAC for F2013/14; and, b) An environmental scan where new measures have been introduced related to the CCAC s role, which would warrant consideration for Board and staff monitoring as well. Specifically these include: o o o The MSAA for F2013/14 the Multi Service Accountability Agreement (MSAA) is a legal agreement between the Champlain CCAC and the Champlain LHIN that outlines the obligations of the CCAC, and identifies service standards and service volume metrics that should be met; The recently introduced LHIN Performance & Benchmark report This report agreed to by the LHIN and CCAC CEOs, is a quarterly report meant to capture key strategic readout on performance as compared to other CCACs. They include indicators related to Client, Client Population, Budget, Access and Wait times, and Expanded Role rollout; And the Quality Plan related to Community care monitored by Health Quality Ontario (HQO) HQO has worked with the OACCAC to track some key quality measures related to CCAC performance, for provincial reporting. Note 1: The metrics found in the MSAA, LHIN Benchmarking, and HQO metrics are identified in summary in Appendix A; Note 2: Metrics are also being currently developed by the provincial Quality and Value in Home Care (QVHC) committees, to track Service Provider performance metrics, intended for public reporting by April/2014. They are not finalized at this time, and will be incorporated into the Board Scorecard, when appropriate. Champlain CCAC Board of Directors May 8, 2013 Item 6.0 Champlain CCAC Scorecard Refresh PAGE 1

53 o o o Indicators from the F2012/13 Scorecard that were largely informational and/or mostly green in status were removed; New indicators aligned with the F2013/14 Operating Plan and/or environmental scan were introduced; Targets were reviewed/refreshed as appropriate. Indicators were also better balanced between being operational and transformational (aligned with our strategic objectives). Indicators are also aligned with Health Based Allocation Model (HBAM) directions where possible. SCORECARD REVIEW PROCESS AT COMMITTEE AND BOARD MEETING o o The Scorecard will continue to be reviewed at the joint CSQS/Finance Committee meeting; Key Scorecard items requiring drill-down, will be reviewed and analyzed in greater detail, to support richer discussion by these Committee s and discuss appropriate mitigation plans. The full Board will see the Scorecard summary in the Consent Report, and will receive a trend analysis report on the Scorecard on a quarterly basis, together with an annual trend analysis report. NEW SCORECARD SUMMARY Champlain CCAC Board of Directors May 8, 2013 Item 6.0 Champlain CCAC Scorecard Refresh PAGE 2

54 Most changes made to the scorecard are shown though the tracked-changes above. Other changes made (e.g., going from developmental indicator to actual indicator) will be discussed during the review of this document at the board meeting Sponsoring Executive: Deryl Rasquinha Vice President, Performance and Strategy Champlain CCAC Board of Directors May 8, 2013 Item 6.0 Champlain CCAC Scorecard Refresh PAGE 3

55 External Metrics & their relationship to the Board Scorecard Legend for CCAC Scorecard Scorecard Summary Metrics Scorecard Detail Metrics List of Metrics (132) MSAA Accountability Indicators (20) Performance Standards Target Performance Standard Frequency MSAA (30) MSAA Scorecard (77) Scorecard QIP Indicator (16) QIP Indicator Reports (178 Touch Points) LHIN Benchmarking (19) LHIN Benchmarking Quality/Safety Dashboard (16) Quality/Safety Dashboard % Total Margin 0% >=0% YTD Fund Type 2- Balanced Budget 0 0 YTD Proportion of budget spent on Administration 9% <10% YTD Variance Forecast to Actual Expenditures 0.0% <5% YTD Variance Forecast to Actual Units of Service 0.0% <5% YTD Number of Individuals Served 52,000 +/- 5% YTD Paid Clients Wait Time th Percentile from hospital discharge to 1 <=1 Quarterly service initiation (Hospital clients) Wait Time th Percentile from hospital discharge to service initiation (Hospital clients) Quarterly Wait Time th Percentile wait time from community setting to community home care services Quarterly Clients placed in LTCH with MAPLe scores high an very high as a proportion of total clients placed 79% <=79% Quarterly Clients with MAPLe scores high an very high living in the Community Supported by CCAC TBD TBD Quarterly New Similar Falls for long stay home care clients N/A N/A Quarterly Similar Similar Medication Safety N/A N/A Quarterly Similar Similar Cost Per Episode Adult Short Stay - Acute N/A N/A Quarterly Avg Monthly Adult Long Stay Complex N/A N/A Quarterly Avg Monthly End of Life N/A N/A Quarterly Avg Monthly End of Life in the 3 months immediately preceding death N/A N/A Quarterly Children Medically Fragile N/A N/A Quarterly Avg Monthly Percentage People Registered with Health Care Connect 76% TBD Quarterly Who Are Referred New New Percentage ALC Days 12% 12%-13.2% Quarterly New Resource Prioritization Evaluation Dashboard (20) Resource Prioritization Evaluation Dashboard Champlain CCAC Board of Directors May 8, 2013 Item 6.0 Champlain CCAC Scorecard Refresh PAGE 4

56 MSAA Explanatory Indicators (7) External Metrics & their relationship to the Board Scorecard Measure Type MSAA Scorecard QIP Indicator LHIN Benchmarking Quality/Safety Dashboard Turnover Rate 10% Annually YTD Wait Time 1: 90 th Percentile From Hospital Discharge to service initiation (Hospital clients) Short Stay Acute N/A Quarterly Wait Time 1: 90 th Percentile From Hospital Discharge to service initiation (Hospital clients) Short Stay Rehab N/A Quarterly Wait Time 1: 90 th Percentile From Hospital Discharge to service initiation (Hospital clients) Long Stay Complex N/A Quarterly Wait Time 2: 90 th percentile wait time from community setting to community home care services Short stay acute N/A Quarterly Wait Time 2: 90 th percentile wait time from community setting to community home care services Short Stay Rehab N/A Quarterly Wait Time 2: 90 th percentile wait time from community setting to community home care services Long Sty Complex N/A Quarterly MSAA Champlain Local Indicators (5) Measure Type MSAA Scorecard Home First Enhanced Admitted Number of new hospital clients admitted to home first program per month (Yr 1 explanatory; Yr 2 Quarterly Accountability Home First Discharged by destination Info YTD Service Max Expenditure (EPSS, SAH,WAH/H2H, EOL incremental, CM costs estimated) Info YTD Total joint funding (hips & knees) 496 Hips & 505 Knee clients/year YTD Dialysis clients 85 clients per year YTD Additional QIP Metrics (8) Measure Type MSAA Scorecard QIP Indicator QIP Indicator LHIN Benchmarking LHIN Benchmarking Rating of Handling of Care by CCAC Care Coordinator Info Quarterly CCEE-KPI-1: Overall Experience Rating Info Quarterly Hospital Readmissions Info Quarterly ED Readmissions Info Quarterly Percentage of Long Term Care placements from Hospital Info Quarterly Medication Safety for Long Stay Home Care Clients Info Quarterly Similar New Incidence of Skin Ulcers Info Quarterly New Falls for Long Stay Clients Info Quarterly Similar Quality/Safety Dashboard Quality/Safety Dashboard Resource Prioritization Evaluation Dashboard Resource Prioritization Evaluation Dashboard Resource Prioritization Evaluation Dashboard Champlain CCAC Board of Directors May 8, 2013 Item 6.0 Champlain CCAC Scorecard Refresh PAGE 5

57 Additional LHIN Benchmarking Metrics (7) External Metrics & their relationship to the Board Scorecard Measure Type MSAA Scorecard QIP Indicator LHIN Benchmarking $ and % spent on General Administration and IT Info Quarterly New $ and % spent on services including case CM & Program Services Info Quarterly New General Volume (# and %) for: SS-Acute; SS Rehab; Adult Long Stay Complex; End-of-Life; Long-Stay Medically Fragile Info Quarterly Similar Children Average Cost per episode for: SS-Acute; SS Rehab; Adult Long Stay Complex; End-of-Life; Long-Stay Medically Fragile Info Quarterly Similar Children Average Length of Stay (ALOS)/population for: SS-Acute; SS Rehab; Adult Long Stay Complex; End-of-Life; Long-Stay Info Quarterly New Medically Fragile Children % 85+ living in the community with support Info Quarterly Similar Progress against milestones for completed implementation of enhanced role Info Quarterly Additional Champlain CCAC Scorecard Metrics (55) Measure Type MSAA Scorecard QIP Indicator LHIN Benchmarking Quality/Safety Dashboard Quality/Safety Dashboard Paid Service Clients by Population Info Monthly Similar Volume of Referrals by Referral Source Category Info Monthly Current Referral Status by month Supporting Monthly Intake Efficiency: Percent of Clients waiting 19 days or less 90% Monthly Number of Clients by Days Waiting by month Supporting Monthly Intake Waitlist by Days Waiting Category 760 Clients Monthly PSS Waitlist < 25 Clients with RAI Monthly % compliance with waitlist reassessment Supporting Monthly # complaints related to wait listing Supporting Monthly Adult OT/PT Therapy Waitlist < = 7 days waiting for RAI Monthly % compliance with waitlist reassessment Supporting Monthly # complaints related to wait listing Supporting Monthly School Therapy Waitlist < = 28 days waiting Priority A & B Monthly % compliance with waitlist reassessment Supporting Monthly # complaints related to wait listing Supporting Monthly SAH Waitlist Info Monthly % compliance with waitlist reassessment Supporting Monthly Number of High Risk & Adverse Events Info Monthly Similar Top Five Actual Problems by Event Severity (FYTD) Supporting Monthly Top Five High Severity Actual Problems Supporting Monthly Resource Prioritization Evaluation Dashboard Resource Prioritization Evaluation Dashboard Champlain CCAC Board of Directors May 8, 2013 Item 6.0 Champlain CCAC Scorecard Refresh PAGE 6

58 External Metrics & their relationship to the Board Scorecard Number Additional of Complaints Champlain CCAC Quality & Safety Dashboard Info Monthly Similar Measure QIP LHIN Quality/Safety Top Five Complaint Types Metrics by Organization Type (FYTD) Supporting Monthly MSAA Scorecard Type Indicator Benchmarking Dashboard % clients with healable wounds (9) within target length of stay 80% Monthly % Wound clients who Clients die within in preferred Target place Visits of death Supporting Info Quarterly Monthly % Wound increase Clients in client Readmitted events reporting within 30 (vs. days prior with quarter) Same Info Supporting Quarterly Monthly Similar Wound Code % increase in client events reporting (comparable quarters) Info Quarterly Similar Client ED Registrations % of Clients in high risk groups whose medications are Info Info Monthly Client Hospital Admissions Info Quarterly reconciled upon admission Monthly Average % of Clients Daily in Registrations high risk groups by population whose medications type are Supporting Info Quarterly Monthly Annualized reconciled on Absenteeism transitions Rate per FTE in Days <= 12 Days Monthly % of Clients in high risk groups whose medications are Info Health & Safety (H&S) Staff Events Info Quarterly reconciled upon discharge Monthly Top # of Clients 5 Locations with a of known H&S Events risk (e.g. infectious Supporting Info Monthly Top diseases/environmental 5 H&S Event Types /safety) where risk was not identified Supporting Quarterly Monthly on the referral to CCAC or Service Provider Percent Education Hours Info Monthly # Appeals to HSARB Info Quarterly Number of Education Hours by Employee Group Supporting Monthly % of Clients who expressed that they received home health Info Annual Funding by Month Announced Info Quarterly care when they needed it Monthly Count Additional of paid clients Champlain with PSS, CCAC where Resource RAI Score Prioritization 0-7 OIP Monthly % of wound care clients Evaluation q3 days Dashboard OIP Monthly (5) Monthly Lost Savings if Clients at Cluster Care not serviced OIP Monthly at Average Shared PSS Care Monthly Rate Utilization Info Quarterly % Clinic compliance Nursing to Units population of Total assessment Visit-type guidelines Nursing Units OIP Info Quarterly Monthly Reduction # complaints administration related to discharge costs per or reduction savings schedule in service? OIP Info Quarterly Monthly Average % change Cost in referral per Month volumes per Client by Population $639 Info Quarterly Monthly Similar Similar Total Stakeholder Days & input Number of Clients Waiting for Home First Info Quarterly Info Monthly Enhanced Service Additional Champlain CCAC Board Functioning Volume of Placements to Other Settings Info Measure Monthly QIP LHIN Quality/Safety Scorecard Metrics MSAA Scorecard Percentage of Sub-Acute Spaces that the CCAC is Managing Type Indicator Benchmarking Dashboard (16) Info Monthly Volume Board Attendance of Admissions Percent to LTCH by Community/Hospital Supporting 75% Monthly Number Board Committee of Clients Attendance on LTCH Waitlist Percent with CCAC Services Info N/A Monthly Number Board Members of Clients ensure in Community compliance 85 & with Over applicable 100% Info Annually Monthly Similar Referrals legislation from Physicians by Month Info Monthly Board maintains subcommittee with defined roles 100% Annually Adult Day Program Waitlist by Region Board Members roles and responsibilities are clearly Info Monthly Adult Day Program Waitlist by Provider 90% Annually distinguished from Senior Management Supporting Monthly % Board Clients Members placed participate into ALS-HRS in orientation with a MAPLe 3, 4, or 5 100% Info Annually Monthly ALS-HRS Board bylaws Waitlisted and policies Clients cover by Source confidentiality and conflict of 100% Info Annually Monthly interest Number Board Members of Assessed regularly Clients review on ALS-HRS team functioning Waitlist & process Supporting Monthly # referrals to CSS 80% Annually improvement (Future) Monthly % Board of clients Members referred receive to CSS feedback where on CSS performance accepted the client (Future) 80% Annually Monthly Resource Prioritization Evaluation Dashboard Resource Prioritization Evaluation Dashboard Champlain CCAC Board of Directors May 8, 2013 Item 6.0 Champlain CCAC Scorecard Refresh PAGE 7

59 Board Members receive ongoing education on quality and patient safety 100% Annually Board Members have explicit criteria to recruit members 100% Annually Board composition meets stakeholder and community needs 85% Annually Board Positions Filled Percent 100% Monthly Regional Representation Proportions N/A Quarterly Francophone Representation Percentage 19% Quarterly Visible Minority/Aboriginal Representation Percentage 14.9% Quarterly External Metrics & their relationship to the Board Scorecard Champlain CCAC Board of Directors May 8, 2013 Item 6.0 Champlain CCAC Scorecard Refresh PAGE 8

60 Submission To The Board Of Directors Approach To Strategic Plan Development DECISION SOUGHT Board feedback is sought on the overall approach and timelines proposed for the Strategic Plan development. APPROACH 1. Timeframes to start and complete the Strategic Planning exercise It is recommended that we start the Strategic planning exercise in June, and complete the exercise at the Nov/13 board retreat. o This will allow the Champlain CCAC staff to work in parallel on the development of the supporting Operating Plans and Business Plan to allow for their progression sufficiently, to properly contextualize and inform the Budget & CAPS submission timelines for the LHIN. 2. Engagement of a Consultancy It is recommended that Champlain CCAC engage a consulting agency to support its strategic plan development, to promote fuller partner & staff engagement and consultation including facilitation at the Board retreat in November Strategic Plan Horizon It is recommended that the strategic plan address a 3-year horizon ( ) to align with the end date of the LHIN IHSP Plan horizon ( ), and in acknowledgement Champlain CCAC Board Of Directors May 8, 2013 Item Strategic Plan Development PAGE 1