Multi-Sector Accountability Agreement Compliance Reporting to Board of Directors

Transcription

1 Date: March 31, 2014 Multi-Sector Accountability Agreement Compliance Reporting to Board of Directors Time Period Covered in Report: October 1, March 31, 2014 This report is organized by the Sections outlined in the Multi-Sector Accountability Agreement (M-SAA). Provision of Services (Section 3.1) BQWCHC is meeting its Performance Standards as identified in Schedule E and has not reduced, stopped, started, expanded, transferred or ceased to provide services or changed its Service Plan. Please refer to the tables at end of report for further details as to progress on targets. Subcontracting for the Provision of Services (Section 3.2) The Health Centre does not contract out for the provision of services as defined under the M-SAA. Conflict of Interest (Section 3.3) The Health Centre has not identified any conflicts of interest in the performance of its contractual obligations. E-health / Information Technology Compliance (Section 3.4) The Health Centre is in compliance with the technical standards related to architecture, technology, privacy and security set for health service providers by the MOHLTC and the LHIN. This includes the use of Nightingale on Demand ( NOD) which meets the technical standards provided by the Ministry of Health. Procurement of Goods and Services (Section 4.8) The Health Centre is in compliance with the procurement and Broader Public Sector Accountability Agreement. Community Engagement and Integration Activities (Section 6.2) During the above mentioned time period, the Health Centre has undertaken the following engagement of our clients and community stakeholders. This information is used in the development and improvement of health services. Community Engagement Project The Centre embarked on a community engagement project. We conducted phone interviews, held focus groups and distributed written surveys to our clients and the pubic to learn how we can best involve and serve them. In all, we consulted with more than 300 people who have provided us with valuable insight on awareness for the Centre within the community and how we can reach more people. The information will be integrated into a plan for community engagement. Client Satisfaction Survey We completed a client satisfaction survey in the winter of Results indicate a 99% satisfaction rate. Respondents provided suggestion for new programs and areas of improvement.

2 Planning and Integration Activity (Section 6.3) During the above mentioned time period the Health Centre has participated in the following opportunities to plan and integrate the services available to the local health system: We functioned as the administrative lead for Quinte Health Link. All sectors are represented on the Steering Committee and working groups as well as over 80 members on the broader Collaborating group. We participate on a number of planning bodies including Mental Health Planning Group; Children s Services Planning Group; Military Family Resources Group; Food Security Network; Women s and Girls Own Network; and, Harm Reduction Network. We participated in regional CHC programs including telemedicine, Dental, pharmacy and Thrive French Language Services (Section 8.1 c) The Health Centre is not designated to provide services under the provisions of the French Language Services (FLS) Act. Transparency (Section 8.5) Compliance Declaration is required by June 30, By June 30, 2014 the Health Centre will post an electronic copy of the signed M-SAA posted on its website. Paper copies are available upon request. Governance (Section b 1) A Performance Review with the Executive Director with the compensation plan tied to the Executive Director s performance was completed. Commercial General Liability Insurance (Section 11.4) The Health Centre meets the requirements of liability insurance and has on record a letter verifying that our insurer meets the required clauses. Performance Standards Schedule E As you review the status of the charts, most of our targets are being met. There are a few targets that are flagged for concern. Yellow Status we are below the low end range of our performance targets, but not so far that we might not achieve target. Close monitoring is required. # Active Clients We are slightly below target. The rate of intake was impacted by our transition to a new EMR as we only accepted high risk clients for a 2 month period. Red Status - we are significantly below the low end range of our performance targets. We are unlikely to meet our performance targets. A performance improvement plan or resolution plan is in place. Reporting will change to monthly reports. The following targets are in the red zone: % Spent on administration is slightly over target, however 4 % of the variance is due to contract for Health Links so once that is factored in we are within the performance standard. Influenza - We have not achieved our targets and are providing training to providers to ensure the information is being entered correctly into our EMR. We had set a very aggressive target. These results are consistent with our peer CHC s in the South East.

3 Accountability Indicators - Core Indicators for all Health Service Providers Targets Performance Standard 1 ST QTR 2 ND QTR 3 RD QTR 4 TH QTR % of total margin 0% >= 0% % 6 % Balanced Budget 0 0 0% 6 % * % spent on administration 24% < 29% 30% 32 % * Turnover Rate N/A N/A 4% n/a Vacancy Rate for NP s /Physicians Variance forecast to actual expenditure 33% % 14% 5 % 0% < 5% * 0.6 % * $ 360,000 surplus was related to Health Links *4 % of variance relates to Contracts for Health Links actual % spent on admin is 28% which is within the performance standard Community Health Centre Indicators Targets Performance Standard Cumulative 1 ST 2 ND 3 RD 4 TH # of active clients N/A # individual face to face encounters Individual Encounters (Telephone)

4 Consultations btw providers with client Consultations btw providers no client * 670* *Estimated NOD does not track tasks, messages and communications between providers. This has been identified to the regional reporting groups as well as the vendors by several CHC s Clinical Indicators INDICATOR Cervical Cancer Screening Colorectal Screening TARGET Performance Standard 1 ST 2 ND 3 RD 4 TH 60% >48% 51% 56% 60% 64% 45% 36-54% 47% 50% 50% 51% Diabetes 90% % 94% 91% 87% 89% Influenza 68% % 29% 27% 28% 30% Breast Cancer 40% 32-48% 46% 48% 50% 56% Periodic Health Exams 40% 32-48% 49% 49% 49% 49% Local Indicators Description Back office integration project ALC reduction Reduction of ER demand Excellent Care for All Act E Health /IT Progress towards target Participating in HR, IT and purchasing initiatives No activity at this time No formal activity at this time. Working with QHC to identify opportunities. QI framework developed and QI committees established at the Board and staff level Provincially CHC s are involved in a number of

5 e-health alignment strategies ( new EMR, OHRS and NORA) Information on this initiative has been previously submitted Integration Activities Contained in this report Section 6.2 CHC s work with hospitals to ensure standardized & comprehensive discharge & ER information No activity at this time specific to obtaining information from QHC. Schedule Reporting Submission Deadlines OHRS / MIS Trial Balance Submission for CSS and CHC funding Quarter Due Date submitted 1 st Not required 2 nd October 31, 2013 Filed October 29, rd January 31, 2014 Filed January 28, th May 31, 2014 Filed May 30, 2014 Supplementary Reporting (WERS and other) for CSS and CHC funding Quarter Due Date submitted 1 st Not required 2 nd November 7, 2013 Filed November 7, rd February 7, 2014 Filed February 7, th June 7, 2014 Supplementary Report June 30, 2014 Annual Reconciliation Report June 30, 2014 Board Approved Audit Financial Statements N/A Submitted June 30, 2014 Approved at AGM June 19, 2014 Submitted June 20,2014 Additional Reporting Requirements Report Due Date submitted Compliance Report October 30, 2014 June 30, 2014 French Language April 30, 2012 Services November 1,2014 June 30, 2014 n/a

6 This report has been prepared by the Executive Director as of June 14, I certify this to be a true and accurate report on the compliance items covered under our Multi-Sector Accountability Agreement. Marsha Stephen, Executive Director BQWCHC