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2016 06 13_Board CSQS Committee _DRAFT Agenda_v4
Acc
BOARD CLIENT SERVICES, QUALITY & SAFETY COMMITTEE MEETING
DATE: June 13, 2016
TIME: 9:00 – 11:00am
PLACE: Labelle Boardroom
AGENDA
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9:00-9:05 1.0 Welcome; Declaration of Conflict Melody Isinger √
Core Business
2.0 Approval of Agenda for June 13, 2016 Melody Isinger √
9:05-9:10 3.0 Review and Approval of May 9, 2016 Minutes Melody Isinger √
4.0 Business Arising Melody Isinger √
Consent Agenda – assumed approved unless any member of CSQS wishes to discuss
5.0 Consent Items 5.1 Quarterly Events Report 5.2 Quarterly Complaints Report 5.3 Accreditation Update
Jennifer Proulx
√
Standing Items
9:10–9:30
6.0 Quality Reports 6.1 Adverse Events (Verbal)
6.2 FY 2015-16 Q4 QIP Update 6.3 CCEE Semi-Annual Update
Jennifer Proulx /
Caroline Guimond √
Strategic Discussion
9:30-9:50 7.0 Champlain CCAC Action Plan Update Marc Sougavinski/ Catherine Butler
√
9:50-10:00 8.0 Medical Assistance in Dying (MAID) Update (Verbal) Catherine Butler √
10:00-10:10 9.0 Special Needs Strategy (SNS) Update (Verbal) Catherine Butler √
10:10-10:30 10.0 Semi-Annual People Services and Organizational
Development Update Patrice Connolly √
Joint Meeting with Finance & Audit Committee
10:30-11:00
11.0 Board Scorecard Discussion/Review Deryl Rasquinha /
Catherine Butler √
12.0 Full Management Scorecard (Informational item) Deryl Rasquinha / Catherine Butler
√
CONFIDENTIAL
DRAFT
Minutes – Champlain CCAC Client Services, Quality and Safety Committee – May 9, 2016
Champlain Community Care Access Centre Centre d’accès aux soins communautaires de Champlain
Head Office
4200 Labelle Street Suite 100 Ottawa ON K1J 1J8 Siège social 4200, rue Labelle Bureau 100 Ottawa ON K1J 1J8
Tel/Tél : 613 745 5525 866-994-8124 Fax/Téléc : 613 745 1422
www.champlain.ccac-ont.ca
MINUTES
Client Services, Quality & Safety Committee (CSQS)
Held May 9, 2016
Champlain CCAC Head Office
BOARD COMMITTEE
MEMBERS (CSQS):
Melody Isinger
Denise Alcock
Andrée Durieux-Smith
Abebe Engdasaw
Sherryl Smith
Chair
Ex-officio member
By phone
REGRETS (CSQS):
BOARD COMMITTEE
MEMBERS
(FINANCE):
Maria Barrados
Robert D’Aoust
Sherryl Smith
Chair
By phone
FINANCE REGRETS
STAFF PRESENT
(CSQS):
Marc Sougavinski
Paul Boissonneault
Catherine Butler
Christian Gagnon
Ashley Haugh
Claire Ludwig
Jennifer Proulx
Deryl Rasquinha
Catherine Richard
Jamie Stevens
Chief Executive Officer
Director, Information Systems & CIO
Vice-President, Clinical Care (by phone)
Systems Specialist
Executive Assistant
Director, Program Development & Clinical Care
Director, Quality & Program Evaluation
Vice-President, Performance and Strategy
Manager, Occupational Health and Safety Program
Director, Business Intelligence
FINANCE STAFF
PRESENT FOR JOINT
PORTION OF
MEETING:
Jimena Martinez Acting Corporate Controller
RECORDER: Ashley Haugh Executive Assistant
GUEST(S):
2
Minutes–Champlain CCAC Client Services, Quality & Safety Committee, May 9, 2016
AGENDA ITEM ACTION TO BE TAKEN
1.0 Declaration of Conflict of Interest
There were no declarations of conflict
2.0 Approval of Agenda
It was moved by Abebe Engdasaw, seconded by Andrée Durieux-Smith and agreed
to approve the agenda for the May 9, 2016 meeting.
CARRIED
3.0 Approval of Minutes
It was moved by Andrée Durieux-Smith, seconded by Abebe Engdasaw and agreed
to approve the minutes of the April 11, 2016 meeting.
CARRIED
4.0 Business Arising
There was no business arising.
5.0 Quality Reports 5.1 Adverse Events There were no adverse events to report.
6.0 IMPACT Centre Update and Tour
The Committee received an update and tour of the IMPACT Centre:
People want to remain in their homes as long as possible. Technology is one way to assist patients, caregivers and families meet this goal.
The IMPACT Centre is working with health care technology developers and vendors to test, evaluate and recommend new technologies with patients and caregivers in real-life situations. The IMPACT Centre is set up to resemble a typical apartment with a kitchen, living area, bedroom and bathroom.
The goals of the IMPACT Centre are to: o Enhance patient safety o Enable patients and caregivers o Enable the circle of care o Enhance service quality
There are technologies that support socialization, monitoring, safety, etc. It allows authorized caregivers and members of the circle of care to monitor activities – e.g., sensors to see if the patient has gotten out of bed, opened the front door, opened the fridge, etc.
Want technology that is easy to use out of the box for the patient and the circle of care/families.
3
Minutes–Champlain CCAC Client Services, Quality & Safety Committee, May 9, 2016
AGENDA ITEM ACTION TO BE TAKEN
Staff is working with Bruyère and Carleton University on a potential research project to use data from the use of technology to be able to predict if a patient is at risk of a fall. Funding is required for this project.
Discussion included:
Started looking for vendors by reaching out and issued a Request for Proposal. There are a variety of business models possible to roll out the technologies, that are currently under review
Technologies can enable new practices. Where feasible, these practices will be evaluated in planned pilot sites looking at new models of care and enhanced care coordination
7.0 Employee Health and Wellness Annual Report The Committee reviewed the annual Employee Health and Wellness report:
The Employee Health and Wellness Program consists of: o Occupational Health and Safety Program o Infection Prevention and Control (IPAC) Program o Wellness Program o Mental Health Strategy
Overall, the CCAC is performing well in employee health and wellness. However, there are areas for improvement.
In 2016-2017, quarterly meetings of the six Joint Heath and Safety Committees (JHSC) at the Champlain CCAC will be scheduled in advance to ensure meetings are taking place in all locations. Inspections and follow-ups required will also be closely monitored.
The health and safety of employees and the workplace is important and this will continue to be a priority during this time of health system transformation.
Joint CSQS and Finance and Audit Committees
8.0 Scorecard Review
The Committees discussed the April scorecard (March data); the last scorecard for
the 2015-2016 year:
Overall, the Champlain CCAC has performed well.
Referral volume continues to remain higher than a year ago.
Significant progress has been made on service wait times in the community
over the past year and it is currently around 25 days; from close to 120 days
a year ago. Work continues to meet the provincial target of 21 days (90%
receiving service within 21 day).
The five day wait time for complex PSS continues to improve.
Patient complaint resolution time has generally increased, however, it is due
to the delay in the administrative closure of files not in the resolution of the
actual complaints. Work was done in April to administratively close the
4
Minutes–Champlain CCAC Client Services, Quality & Safety Committee, May 9, 2016
AGENDA ITEM ACTION TO BE TAKEN
complaints and ensure this process is completed in a timely manner in the
future.
A report on absenteeism is being brought to the Board in June.
Ended the year with a deficit of approximately 1.8M, less than 1% of
budget.
The performance agreement completion rate has increased as this is the time
of year when they are being completed.
The Committees discussed the format of the 2016-2017 scorecard:
Overall, the 2016-2017 scorecard is similar to the 2015-2016 scorecard,
however, it has a focus on metrics related to our Action Plan for supporting
complex patients. Any metrics not carried over from the 2015-2016
scorecard are still being monitored internally by staff. If there are significant
changes in any of these indicators it will be reported to the Committee.
Patient capacity is being tracked on the new scorecard, this is also being
communicated to partners on a monthly basis as part of the new Care
Report.
Many of the metrics and targets are determined by the Multi-Sector Service
Accountability Agreement or the Quality Improvement Plan.
It was moved by Melody Isinger, seconded by Robert D’Aoust and agreed to
recommend the Board approve the new scorecard.
CARRIED
The meeting was adjourned by consent.
ACTION: Headings to be
updated (both scorecards),
as discussed.
ACTION: Examine
possibility of year over
year comparisons,
especially for end of year
reporting.
ACTION: Staff will report
back to the Committee if
there are any significant
changes in metrics not
carried over to 2016-2017
scorecard.
CONFIRMED: ________________________________________________ MELODY ISINGER, CHAIR
Champlain CCAC CSQS Committee of the Board, June 13, 2016
Item 5.1– Quarterly Events Report PAGE 1
Submission to the CSQS Committee of the Board
Quarterly Events Report: January 2016-March 2016 (Q4)
June 13, 2016
EVENT REPORTING
Adverse Events: The last Adverse Event occurred on January 3, 2016 (Q4, 15-16). Top 5 Reported Events in CELS: Within CELS, the event categories and definitions include those required internally and by the OACCAC reporting requirements and data collection needs. In Q4, the top five reported events were:
1. Patient Fall - Unwitnessed fall resulting in injury, recommendation to call 911 and/or additional healthcare resources
2. Compliment about Service Provider 3. Quality of Services Provided by SPO- general 4. Quality of Services Provided by SPO- responsiveness 5. Infusion Pump Issues AND Abuse/Threat/ Harassment/ Injury to Staff
02468
101214161820
Jun
-14
Jul-
14
Au
g-1
4
Sep
-14
Oct
-14
No
v-1
4
Dec
-14
Jan
-15
Feb
-15
Mar
-15
Ap
r-1
5
May
-15
Jun
-15
Jul-
15
Au
g-1
5
Sep
-15
Oct
-15
No
v-1
5
Dec
-15
Jan
-16
Feb
-16
Mar
-16
NU
MB
ER O
F EV
ENTS
DATE
CLIENT FALL-UNWITNESSEDJUNE 2014-MARCH 2016
Median= 1
Champlain CCAC CSQS Committee of the Board, June 13, 2016
Item 5.1– Quarterly Events Report PAGE 2
0
5
10
15
20
25
30
Jun
-14
Jul-
14
Au
g-1
4
Sep
-14
Oct
-14
No
v-1
4
Dec
-14
Jan
-15
Feb
-15
Mar
-15
Ap
r-1
5
May
-15
Jun
-15
Jul-
15
Au
g-1
5
Sep
-15
Oct
-15
No
v-1
5
Dec
-15
Jan
-16
Feb
-16
Mar
-16N
UM
BER
OF
EVEN
TS
DATE
COMPLIMENT ABOUT SPOJUNE 2014-MARCH 2016
0
5
10
15
20
25
30
35
40
Jun
-14
Jul-
14
Au
g-1
4
Sep
-14
Oct
-14
No
v-1
4
Dec
-14
Jan
-15
Feb
-15
Mar
-15
Ap
r-1
5
May
-15
Jun
-15
Jul-
15
Au
g-1
5
Sep
-15
Oct
-15
No
v-1
5
Dec
-15
Jan
-16
Feb
-16
Mar
-16
NU
MB
ER O
F EV
ENTS
DATE
QUALITY OF SERVICES BY SPO-GENERALJUNE 2014-MARCH 2016
Median= 9
Median= 8
Champlain CCAC CSQS Committee of the Board, June 13, 2016
Item 5.1– Quarterly Events Report PAGE 3
0
10
20
30
40
50
60
70N
UM
BER
OF
EVEN
TS
DATE
QUALITY OF SERVICES BY SPO-RESPONSIVENESSJUNE 2014-MARCH 2016
02468
101214161820
Jun
-14
Jul-
14
Au
g-1
4
Sep
-14
Oct
-14
No
v-1
4
Dec
-14
Jan
-15
Feb
-15
Mar
-15
Ap
r-1
5
May
-15
Jun
-15
Jul-
15
Au
g-1
5
Sep
-15
Oct
-15
No
v-1
5
Dec
-15
Jan
-16
Feb
-16
Mar
-16N
UM
BER
OF
EVEN
TS
DATE
INFUSION PUMP ISSUESJUNE 2014-MARCH 2016
Median= 21
Median= 0
Champlain CCAC CSQS Committee of the Board, June 13, 2016
Item 5.1– Quarterly Events Report PAGE 4
Improvement Activities Patient Fall – Unwitnessed fall resulting in injury, recommendation to call 911 and/or additional healthcare resources Patient Falls are captured in CELS by witnessed falls as well as those that though not witnessed, do have an impact on the patient and require an intervention. Patient falls continue to be addressed by Champlain CCAC and is an indicator on our annual Quality Improvement Plan. Compliment to Service Provider Through continued efforts, the Quality team is able to more accurately capture and categorize events, including events related to positive aspects of care for patients. Quality of Services Provided by Service Provider – General Quality of Service, for both CCAC and SPO staff, is captured through the subcategories: professionalism, responsiveness, time management and cleanliness. Quality of Service- General are those complaints which have an impact on the quality of services provided but do not fall into the identified subcategories. Continued review of these events have helped determine two new categories, specifically, Quality of Service- consistency of care, and Quality of Service- continuity of care. Quality of Services Provided by Service Provider – Responsiveness Quality of Service, for both CCAC and SPO staff, is captured through the subcategories: professionalism, responsiveness, time management and cleanliness. The area of responsiveness, which encompasses complaints regarding the quality of service provided or arranged – related to timeliness and consistency in addressing care needs, requests, inquiries – will be a particular focus for the upcoming year as identified in the
02468
101214161820
Jun
-14
Jul-
14
Au
g-1
4
Sep
-14
Oct
-14
No
v-1
4
Dec
-14
Jan
-15
Feb
-15
Mar
-15
Ap
r-1
5
May
-15
Jun
-15
Jul-
15
Au
g-1
5
Sep
-15
Oct
-15
No
v-1
5
Dec
-15
Jan
-16
Feb
-16
Mar
-16N
UM
BER
OF
EVEN
TS
DATE
ABUSE/THREAT/HARASSMENT/INJURY TO STAFFJUNE 2014-MARCH 2016
Median= 10
Champlain CCAC CSQS Committee of the Board, June 13, 2016
Item 5.1– Quarterly Events Report PAGE 5
Action Plan and FY 16/17 QIP, and will be the focus of a new SPO Monitoring initiative currently under development. Abuse/Threat/Harassment/ Injury to Staff A workgroup was initiated in FY15/16, with representation from all three Quality subcommittees (Nursing, Personal Support Services and Allied Health), to work on educating CCAC and SPO staff about how to recognize and respect professional boundaries, how to build effective communication skills when working with patients and caregivers, and effective documentation of challenging situations and behaviours. This work will continue into FY 16/17. Infusion Pump Issues Issues related to the use of infusion pumps in the community is a focus area for Accreditation- Home Care Standards and has been identified as a work plan item for the Nursing Quality Subcommittee. As such, data specific to events involving infusion pumps are now captured in CELS. Key issues include supplies and equipment, patient and staff education, referrals and the communication of medical orders. Ellen Alie Manager, Quality, Risk and Patient Experience Sponsoring Executive: Deryl Rasquinha, VP, Performance & Strategy
Champlain CCAC Board CSQS Committee, June 13, 2016
Item 5.2–Quarterly Complaints Report PAGE 1
Submission to the CSQS Committee of the Board
Quarterly Complaints and Compliments Report:
January 2016-March 2016 (Q4)
June 13, 2016
COMPLAINT AND COMPLIMENT REPORTING
Complaint categories: There are six complaint categories captured in CELS 2.0. Compliments provided to both CCAC and SPO staff are also reported:
Amount of services: Complaint regarding the CCAC’s decision about the amount of any particular service included in the plan of service
Eligibility for services: Complaint regarding the CCAC’s decision regarding eligibility for service
Exclusion of Services: Complaint regarding the CCAC’s decision to exclude a particular service from the plan of service
Quality of services: Complaint regarding the quality of service provided or arranged
Termination of services: Complaint regarding the decision to terminate service
Violation of rights: Complaint about violation of patient rights: Client Bill of Rights (LTC Act) or the Human Rights Act.
Compliments about CCAC: Expression of appreciation, praise, or commendation of a CCAC staff member.
Compliments about SPO: Expression of appreciation, praise, or commendation of a Service Provider staff member.
Compliment about Health Care Team: Champlain CCAC category; expression of appreciation, praise, or commendation of both CCAC and SPO staff.
Each of the complaint categories are continuously reviewed and broken down into subcategories to better capture the actual area of concern.
Complaints and Compliments Reported in CELS
Total Number Reported
(FY 2014/15)
Number Reported Q4 (FY 2015/16)
Number Reported Year
to Date (FY 2015/16)
Average Days to Resolution (FY 2014/15)
Average Days to Resolution
Q4 (FY 2015/16)
Average Days to Resolution
Year to Date (FY 2015/2016)
Complaints
584 115 724 36.83 37.6 30.41
Compliments
205 33 169 N/A N/A N/A
Champlain CCAC Board CSQS Committee, June 13, 2016
Item 5.2–Quarterly Complaints Report PAGE 2
Total Number of Complaints Reported in CELS (By Month):
Total Number of Complaints and Compliments Reported in CELS (By Theme)
Note: There are no reports under Violation of Rights.
0102030405060708090
100A
pr-
14
May
-14
Jun
-14
Jul-
14
Au
g-1
4
Sep
-14
Oct
-14
No
v-1
4
Dec
-14
Jan
-15
Feb
-15
Mar
-15
Ap
r-1
5
May
-15
Jun
-15
Jul-
15
Au
g-1
5
Sep
-15
Oct
-15
No
v-1
5
Dec
-15
Jan
-16
Feb
-16
Mar
-16
NU
MB
ER O
F C
OM
PLA
INTS
DATE
NUMBER OF COMPLAINTS BY MONTHAPRIL 2014-MARCH 2016
value UCL LCL Median
050
100150200250300350400450500550600
NU
MB
ER O
F C
OM
PLA
INTS
AN
D
CO
MP
LIM
ENTS
THEME
NUMBER OF COMPLAINTS AND COMPLIMENTS BY THEMEAPRIL 2014-MARCH 2016
Median= 51
Champlain CCAC Board CSQS Committee, June 13, 2016
Item 5.2–Quarterly Complaints Report PAGE 3
0123456789
10
Jan
-14
Feb
-14
Mar
-14
Ap
r-1
4
May
-14
Jun
-14
Jul-
14
Au
g-1
4
Sep
-14
Oct
-14
No
v-1
4
Dec
-14
Jan
-15
Feb
-15
Mar
-15
Ap
r-1
5
May
-15
Jun
-15
Jul-
15
Au
g-1
5
Sep
-15
Oct
-15
No
v-1
5
Dec
-15
Jan
-16
Feb
-16
Mar
-16
NU
MB
ER O
F C
OM
PLA
INTS
DATE
AMOUNT OF SERVICEJANUARY 2014-MARCH 2016
02468
101214161820
Jan
-14
Feb
-14
Mar
-14
Ap
r-1
4
May
-14
Jun
-14
Jul-
14
Au
g-1
4
Sep
-14
Oct
-14
No
v-1
4
Dec
-14
Jan
-15
Feb
-15
Mar
-15
Ap
r-1
5
May
-15
Jun
-15
Jul-
15
Au
g-1
5
Sep
-15
Oct
-15
No
v-1
5
Dec
-15
Jan
-16
Feb
-16
Mar
-16
NU
MB
ER O
F C
OM
PLA
INTS
DATE
ELIGIBILITY FOR SERVICESJANUARY 2014-MARCH 2016
Median=2
Median=3
Champlain CCAC Board CSQS Committee, June 13, 2016
Item 5.2–Quarterly Complaints Report PAGE 4
0
1
2
3
4
5
Jan
-14
Feb
-14
Mar
-14
Ap
r-1
4
May
-14
Jun
-14
Jul-
14
Au
g-1
4
Sep
-14
Oct
-14
No
v-1
4
Dec
-14
Jan
-15
Feb
-15
Mar
-15
Ap
r-1
5
May
-15
Jun
-15
Jul-
15
Au
g-1
5
Sep
-15
Oct
-15
No
v-1
5
Dec
-15
Jan
-16
Feb
-16
Mar
-16
NU
MB
ER O
F C
OM
PLA
INTS
DATE
EXCLUSION OF SERVICESJANUARY 2014-MARCH 2016
0102030405060708090
100
Jan
-14
Feb
-14
Mar
-14
Ap
r-1
4
May
-14
Jun
-14
Jul-
14
Au
g-1
4
Sep
-14
Oct
-14
No
v-1
4
Dec
-14
Jan
-15
Feb
-15
Mar
-15
Ap
r-1
5
May
-15
Jun
-15
Jul-
15
Au
g-1
5
Sep
-15
Oct
-15
No
v-1
5
Dec
-15
Jan
-16
Feb
-16
Mar
-16
NU
MB
ER O
F C
OM
PLA
INTS
DATE
QUALITY OF SERVICES BY SERVICE PROVIDERJANUARY 2014-MARCH 2016
Median=0
Median=37
Champlain CCAC Board CSQS Committee, June 13, 2016
Item 5.2–Quarterly Complaints Report PAGE 5
0
5
10
15
20
25
Jan
-14
Feb
-14
Mar
-14
Ap
r-1
4
May
-14
Jun
-14
Jul-
14
Au
g-1
4
Sep
-14
Oct
-14
No
v-1
4
Dec
-14
Jan
-15
Feb
-15
Mar
-15
Ap
r-1
5
May
-15
Jun
-15
Jul-
15
Au
g-1
5
Sep
-15
Oct
-15
No
v-1
5
Dec
-15
Jan
-16
Feb
-16
Mar
-16
NU
MB
ER O
F C
OM
PLA
INTS
DATE
QUALITY OF SERVICES BY CCACJANUARY 2014-MARCH 2016
0
1
2
3
4
5
6
Jan
-14
Feb
-14
Mar
-14
Ap
r-1
4
May
-14
Jun
-14
Jul-
14
Au
g-1
4
Sep
-14
Oct
-14
No
v-1
4
Dec
-14
Jan
-15
Feb
-15
Mar
-15
Ap
r-1
5
May
-15
Jun
-15
Jul-
15
Au
g-1
5
Sep
-15
Oct
-15
No
v-1
5
Dec
-15
Jan
-16
Feb
-16
Mar
-16
NU
MB
ER O
F C
OM
PLA
INTS
DATE
QUALITY OF SERVICE BY HEALTH CARE TEAMJANUARY 2014-MARCH 2016
Median=4
Median=0
Champlain CCAC Board CSQS Committee, June 13, 2016
Item 5.2–Quarterly Complaints Report PAGE 6
Days to Resolution for Complaints Reported in CELS
0
2
4
6
8
10
12
14
Jan
-14
Feb
-14
Mar
-14
Ap
r-1
4
May
-14
Jun
-14
Jul-
14
Au
g-1
4
Sep
-14
Oct
-14
No
v-1
4
Dec
-14
Jan
-15
Feb
-15
Mar
-15
Ap
r-1
5
May
-15
Jun
-15
Jul-
15
Au
g-1
5
Sep
-15
Oct
-15
No
v-1
5
Dec
-15
Jan
-16
Feb
-16
Mar
-16
NU
MB
ER O
F C
OM
PLA
INTS
DATE
TERMINATION OF SERVICESJANUARY 2014-MARCH 2016
-20
0
20
40
60
80
100
120
140
Ap
r-1
4
May
-14
Jun
-14
Jul-
14
Au
g-1
4
Sep
-14
Oct
-14
No
v-1
4
Dec
-14
Jan
-15
Feb
-15
Mar
-15
Ap
r-1
5
May
-15
Jun
-15
Jul-
15
Au
g-1
5
Sep
-15
Oct
-15
No
v-1
5
Dec
-15
Jan
-16
Feb
-16
Mar
-16
NU
MB
ER O
F D
AY
S
DATE
COMPLAINTS: DAYS TO RESOLUTION APRIL 2014-MARCH 2016
value UCL LCL Median
Median= 26
Median=1
Champlain CCAC Board CSQS Committee – June 13, 2016
Item 5.3 – Accreditation Update PAGE 1
Submission to the CSQS Committee of the Board
Accreditation Update
June 13, 2016
INFORMATION ITEM
The purpose of this briefing note is to provide the Board CSQS Committee with an update on the status of accreditation.
BACKGROUND/ISSUE
In March 2015, the Champlain CCAC began preparing for its next accreditation on-site survey visit scheduled for early December 2016. As a part of this process, self-assessments were completed in April and May 2015 and an action plan for improvement was developed in the following areas: • Governance; • Leadership; • Infection Prevention and Control; • Medication Management; • Case Management; • Mental Health and Addictions; and • Home Care. Following the release of the white paper, “Patients First - A Proposal to Strengthen Patient-Centred Health Care in Ontario”, the Board discussed the issue of accreditation in late 2015. It was decided then that Champlain CCAC should continue preparing for the site visit in December 2016, but that the Board should revisit the discussion in the spring 2016 to validate the appropriateness of the decision. In March 2016, the Board revisited its decision to proceed with accreditation in 2016. While more clarity was hoped for regarding the transformation of home and community care by spring 2016, there still remained many unknowns on the magnitude and timing of the change. As a result, it was decided that the Champlain CCAC would formally submit a request to Accreditation Canada to postpone its site visit for 12 months. It was further agreed that the organization would continue with work on Required Organizational Practices (ROPs) and High Priority areas and that the accreditation standards should be leveraged where applicable in the design and implementation of processes to support the “Champlain CCAC Action Plan: Maintaining Increasingly High Needs/Complex Patients at Home.”
Champlain CCAC Board CSQS Committee – June 13, 2016
Item 5.3 – Accreditation Update PAGE 2
STATUS OF ACCREDITATION
In April 2016, Accreditation Canada granted the Champlain CCAC’s request to postpone the site visit. New dates have now been confirmed and the site visit has been set for December 11-14, 2017. Based on an extensive review of the action plan for improvement and the Champlain CCAC’s strategic priorities for 2016/2017, the following table provides a summary of the current areas of focus for accreditation for this fiscal year and an update on progress to date. Table 1: Proposed Accreditation Work Activity for the Fiscal Year 2016/17
Standards Set Current Areas of Focus Progress to Date
Leadership Prospective Analysis (ROP)
Disclosure of Events (ROP)
Event Reporting and Feedback (ROP)
Workplace Violence (ROP)
Staff engagement (Requirement)
Prospective analysis (Transition to Rapid Response Nursing (RRN) from Hospital) for 2015 has been completed. Current emphasis placed on progressing with areas for improvement. Event Reporting: Care Coordinator, Manager, and SPI Reports have been streamlined. The CCAC continues to develop new ways to share data on events as well as how this information is used for improvement. Processes have been refined to close the loop between staff reporting and outcome of the event.
Infection Prevention and Control (IPAC)
Continue as planned Work has continued to progress on the action plan for improvement. Policy revisions nearing completion. Revisions to IPAC scorecard complete. Current work underway on Hand Hygiene Audits.
Medication Management
Continue as planned
Medication Reconciliation (ROP)
Work has progressed as planned. Revised policies and procedures are nearing completion. Medication reconciliation has been added to the Board Scorecard for 16/17. The indicator has also been built into team operational reports. A refresher will take place in the fall of 2016.
Case Management
All ROPs/Patient and Family Centred Care standards to align with action plan pilots
Continue with pediatric development work
Priorities for action have been built into the Champlain CCAC Action Plan (See Action Plan for more detail). Pediatric development work currently underway.
Home Care All ROPs Accreditation work related to infusion pumps has been included in the 2016/17 Nursing quality work plan. Policies and procedures have been reviewed,
Champlain CCAC Board CSQS Committee – June 13, 2016
Item 5.3 – Accreditation Update PAGE 3
updated, and implemented for medication reconciliation.
Mental Health & Addictions
Continue as planned Action plan for improvement progressing as planned. Current area of focus: student experience and medication reconciliation.
Governance On hold Progress on hold. Work plan to be revisited late fall 2016.
NEXT STEPS
Progress on addressing identified areas for improvement will continue to be monitored over the summer. A more fulsome review of accreditation status and next steps will take place mid to late fall 2016 (once more detailed and specific information is obtained regarding the transformation of home and community care). An update on progress will be brought forward to the CSQS Committee in the fall 2016. Paula Greco Senior Lead Program Evaluation Sponsoring Executive: Deryl Rasquinha, VP, Performance and Strategy
CASC de Champlain CCAC
FY 15-16 Quality Improvement Plan (QIP) –
Q4 Update
Client Services, Quality and Safety CommitteeJune 13, 2016
Jennifer Proulx – Director, Quality & Program EvaluationEllen Alie, Manager, Quality, Risk and Patient Experience
CASC de Champlain CCAC
Reduce % of adult long-stay home care patients who record a fall on their follow-up RAI-HC assessment
TARGET ≤36.0% HQO DATA: Q3 14/15 - Q2 15/16= 39.3%
SAFETY
Improvement Activity Target Status
Collaboration with Ottawa Public Health, Primary Care and Community Partners to address fall prevention and support exercise programs with PSWs in the community
All SPOs implement by
March 31 2016
Delayed due totimelines for e-
module completion; will be implemented
in 2016-2017.
Implement training and education with Clinical Teams and SPOs re: Falls awareness with patients
Improvementon CCEE
Safety KPI
Most recent data from NRC: Q1-Q2 FY
15/16=75.5%; improvement over FY 14/15 score of 73.5%
CASC de Champlain CCAC
ACCESS
Increase the % of complex patients who received their first personal support service with in 5 days of the service authorization dateTARGET ≥95% CCAC DATA: Q4 FY 15/16= 78.6%HQO DATA: Q3 14/15 - Q2 15/16= 73.8%
Increase the % of patients who received their first nursing visit within 5 days of the service authorization TARGET ≥95% CCAC DATA= Q4 FY 15/16= 93.6%HQO DATA: Q3 14/15 - Q2 15/16= 93.6%
Improvement Activity Target Status
Collaboration to develop processes for 24 hours discharge notification
% of new referrals with 24 hour notice of
hospitaldischarge
Replaced with eNotification pilot
(Kemptville District Hospital & Arnprior Hospital)
Implement Neighborhood Care 100% of SPOsOn hold; under
review
Review process of time to SPO/Internalprovider offer to first service date
Identify improvement opportunities
Improvement of service
authorization date completion rates;
Waitlist releases for PSS/Therapies
CASC de Champlain CCAC
Improvement Activity Target Status
**Additional Action:Reinforce first visit date field in CHRIS
Improvement in Access metrics access for PSW
and Nursing
Complete & Ongoing
**Additional Action:Use “Client on Hold” feature in CHRIS more effectively
Improvement in Access metrics access for PSW
and Nursing
Complete & Ongoing
Increase the % of complex patients who received their first personal support service with in 5 days of the service authorization dateTARGET ≥95% CCAC DATA: Q4 FY 15/16= 78.6%HQO DATA: Q3 14/15 - Q2 15/16= 73.8%
Increase the % of patients who received their first nursing visit within 5 days of the service authorization TARGET ≥95% CCAC DATA= Q4 FY 15/16= 93.6%HQO DATA: Q3 14/15 - Q2 15/16= 93.6%
ACCESS
CASC de Champlain CCAC
Reduce % of home care patients with an unplanned, less-urgent ED visit within the first 30 days of discharge from hospital. TARGET ≤7.0% HQO DATA: Q2 14/15 - Q1 15/16=7.0 %
Reduce % of home care patients who experienced an unplanned readmission to hospital within 30 days of discharge from hospital. TARGET ≤ 18.2% HQO DATA: Q2 14/15 - Q1 15/16= 18.8%
Improvement Activity Target Status
Collaboration with TOHIdentify improvement
opportunitiesNo longer
active
Implement Community Health Evaluation completed using Paramedicine Services (CHECUPS) with Renfrew County Paramedics
Establish baselineperformance
Pilot phase completed;
Evaluation of pilot completed
March 2016
EFFECTIVENESS
CASC de Champlain CCAC
Improvement Activity Target Status
**Continuation: Rapid Response Nurse Program
Continuation from 14-15 QIP
Prospective Analysis at QCH completed, improvement work
underway.
** New Project:Integrated Discharge Planning Model
10% decrease in readmissions and ED visits at TOH
Pilot completed; TOH evaluation of project
underway
Reduce % of home care patients with an unplanned, less-urgent ED visit within the first 30 days of discharge from hospital. TARGET ≤7.0% HQO DATA: Q2 14/15 - Q1 15/16=7.0 %
Reduce % of home care patients who experienced an unplanned readmission to hospital within 30 days of discharge from hospital. TARGET ≤ 18.2% HQO DATA: Q2 14/15 - Q1 15/16= 18.8%
EFFECTIVENESS
CASC de Champlain CCAC
Percentage of patients who have reassessment on time, per population standards of care.
TARGET ≥ 80% Q3 FY 15-16: 86.7%
Improvement Activity Target Status
Increase the percentage of completed in-home assessments as per guidelines of care
80%Target met;
sustain improvements
7
EFFECTIVENESS
CASC de Champlain CCAC
PATIENT-CENTRED
Improvement Activity Target Status
Implement AIDET (Acknowledge, Introduce, Duration, Explanation, Thank You)
All CCAC and SPO Staff
CCAC TAs trained; Training of SPO staff
under review
Define Care Plan FlexibilityDefine; Educate Staff
and SPOs
On Hold pending patient experience
plan
Implement Client Check-In across all Congregate Care Teams
100% of CongregateCare Teams engaged
in client check ins
Pilot complete; implementation in
development
Patient Caregiver Council engagement in specific workplan activities
Council activelyconsulted on 2 key
organizational initiatives
Complete
Increase the % Positive Response to KPI 1 “Overall Experience” on the client experience survey.
TARGET ≥94% CCAC DATA: Q4 15-16: 91.2%HQO DATA: FY 14-15: 92.8% Q1 5-16 = 92%
CASC de Champlain CCAC
Improvement Activity Target Status
Trial IVR Technology as a means of obtaining real-time patient satisfaction data
Develop and trial survey
Complete
Reduce average number of calendar days to resolve patient complaints
20 daysFY 15/16= 30.41
days
Reduce the occurrence of missed careDetermine baseline missed care rate
Focus of prospective analysis changed to focus on the Rapid Response Nurse
**New Initiative:Automated Provider Reports
Improve communication
between CCAC and Service Provider Organizations
In progress; Allied Health to be
completed in 2016-17
Patient Centred Appointments 85%Not addressed this
fiscal year
Increase the % Positive Response to KPI 1 “Overall Experience on the client experience survey.
TARGET ≥94% CCAC DATA: Q4 15-16:91.2%HQO DATA: FY 14-15: 92.8% Q1 5-16 = 92%
PATIENT-CENTRED
CASC de Champlain CCACCASC de Champlain CCAC
Client and Caregiver Experience Evaluation (CCEE)
FY 2015-16 Results and Action Plan Focus Areas
Client Services, Quality and Safety Committee
June 13, 2016
Jennifer Proulx – Director, Quality & Program Evaluation
Caroline Guimond – Patient Experience & Risk Specialist
CASC de Champlain CCACCASC de Champlain CCAC
• Provincial tool used by all 14 CCACs
• Available in English and French
• Conducted over the phone with patients or their designated caregivers
• 47 Questions and 9 Key Performance Indicators
• Statistically relevant data across:
• Regions
• Service Providers
• Service Type (nursing, social work (SW), occupational therapy (OT), physiotherapy (PT))
• Clinical Care Teams
• Approximately 2200 completed surveys per year
Background
2
CASC de Champlain CCACCASC de Champlain CCAC 3
Scope
CASC de Champlain CCACCASC de Champlain CCAC
KPI 1 - OverallExperience
KPI 2 - ClientCentred Care
KPI 3 - ClientCentred CareAppointments
KPI 4 - Qualityof Care
KPI 5 - BuildingRelationships
and Trust
KPI 6 - Linkingto otherservices
KPI 7 -Willingness toRecommend
KPI 8 -Expectations
of QualityKPI 9 - Safety
Champlain CCAC 91.4 86.6 91.5 93.8 91.0 79.2 97.1 59.5 75.1
Provincial CCAC 91.6 88.4 90.8 93.5 91.7 77.0 96.6 59.2 76.3
50.0
55.0
60.0
65.0
70.0
75.0
80.0
85.0
90.0
95.0
100.0
Champlain vs the Province FY 2015-16 Q1-Q2
KPI Comparison
4
CASC de Champlain CCACCASC de Champlain CCAC
46.7%
36.4%41.4% 39.3%
46.1% 45.7%40.2% 38.7%
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
Nursing PSS PT OT Nutrition SLP SW Placement
Excellent Very Good Good Fair Poor
Overall Satisfaction by Service, by Response (FY 2015-16 Q1-Q3)
5
CASC de Champlain CCACCASC de Champlain CCAC
Year of Survey FY 12-13 FY 13-14 FY 14-15 FY 15-16
KPI 1 - Overall Experience 93.2 92.8 92.5 91.5
KPI 2 – Client-Centred Care 89.5 88.6 88.4 86.1
KPI 3 – Client-Centred Care Appointments 92.4 92.4 91.7 91.5
KPI 4 - Quality of Care 93.9 93.1 92.2 93.4
KPI 5 - Building Relationships and Trust 92.1 91.6 92.5 91.1
KPI 6 - Linking to other services 49.7 74.1 77.6 77.9
KPI 7 - Willingness to Recommend 96.5 97.0 96.8 96.7
KPI 8 - Expectations of Quality 61.6 61.8 60.1 59.0
KPI 9 - Safety 74.4 73.5 75.3 75.1
Key Performance Indicators Year over Year
6
CASC de Champlain CCACCASC de Champlain CCAC
Year of Survey FY 12-13 FY 13-14 FY 14-15 FY 15-16
Nursing 96.5 96.2 93.6 92.7
PSS 92.8 91.6 92.2 92.6
PT 94.2 93.4 93.9 91.1
OT 91.5 92.2 91.7 89.4
Nutrition 95.3 95.2 95.8 92.2
SLP 92.3 95.4 97.0 91.5
SW 87.1 94.1 89.0 86.8
Placement -- 91.3 87.8 88.7
Overall Services Year over Year
7
CASC de Champlain CCACCASC de Champlain CCAC
Priority Matrix – Apr. to Sept. 2015
8
CASC de Champlain CCACCASC de Champlain CCAC
Patient Experience Action Plan: Areas of Focus
Alignment with FY 2016-17 QIP:
• KPI 1: Overall experience – % Positive
• KPI 2: Patient-centred appointments – On Demand pilot project
• KPI 6: Integrated care and support of transitions – Onboarding of complex patients pilot project
• Establish VOICES baseline performance
9
CASC de Champlain CCACCASC de Champlain CCAC
Patient Experience Action Plan: Areas of Focus
• KPI 9: Safety – based on our improvement work from 2014-15, the province has adopted 2 new questions:
• Q23: You are satisfied with the support received from [care coordinator] to address safety concerns at home.
• Q31: You are satisfied with the support received from this agency to address safety concerns at home.
• Monitor highest correlated CCEE item to Overall Experience and identify related improvement opportunity
10
CASC de Champlain CCACCASC de Champlain CCAC
New Survey Offerings
NRC is offering additional modules:
• Clinic survey
• VOICES survey for caregivers of palliative patients
• Hospital discharge survey (for Rapid Response Nurse (RRN) patients and hospital to home)
• Mental Health and Addiction Nurse (MHAN) survey (under development)
11
CASC de Champlain CCACCASC de Champlain CCAC
Clinic Survey:
• Interactive Voice Response (IVR) survey launched in May
VOICES Survey:
• Mail out & web based surveys administered Dec-Feb
MHAN Survey:
• Exploring in-house development
12
Champlain CCAC Strategy
CASC de Champlain CCACCASC de Champlain CCAC
Hospital Discharge Survey:
• Exploring in-house development
Personal Support Services (PSS) Patient Experience Survey:
• IVR survey conducted in 2015
Service Provider Monitoring: IVR survey and process under development
13
Champlain CCAC Strategy
CASC de Champlain CCACCASC de Champlain CCAC
Appendix
CASC de Champlain CCACCASC de Champlain CCAC
86
88
90
92
94
96
98
100
% P
osi
tive
KPI 1 – Overall Experience
15
CASC de Champlain CCACCASC de Champlain CCAC
80
82
84
86
88
90
92
94
96
98
100
% P
osi
tive
Rate management/handling of case by case manager Rate services Rate services provided by agency
KPI 1 – Overall Experience, by Question
16
CASC de Champlain CCACCASC de Champlain CCAC
KPI 1 - Overall Experience
Date Long Stay Short Stay
2012-13
Q1 91.1 93.6
Q2 94.3 93.5
Q3 93.2 94.7
Q4 92.7 93.8
2013-14
Q1 92.5 94.1
Q2 94.2 94.2
Q3 91.1 94.7
Q4 93.5 94.8
2014-15
Q1 92.1 94.3
Q2 91.9 92.9
Q3 91.6 92.8
Q4 92.7 94.5
2015-16
Q1 92.0 92.0
Q2 90.4 92.0
Q3 92.0 91.3
17
CASC de Champlain CCACCASC de Champlain CCAC
80
82
84
86
88
90
92
94
96
98
100
% P
osi
tive
* No data available for
Q2 of FY 2015/16.
KPI 2 – Client-Centred Care
18
CASC de Champlain CCACCASC de Champlain CCAC
70
75
80
85
90
95
100
% P
osi
tive
Felt involved in developing care plan Given needed information about CCAC services
* No data available for
Q2 of FY 2015/16.
KPI 2 – Client-Centred Care, by Question
19
CASC de Champlain CCACCASC de Champlain CCAC
KP1 2 – Client-Centred Care
Date Long Stay Short Stay
2012-13
Q1 95.7 88.7
Q2 93.1 91.2
Q3 92.3 84.6
Q4 88.2 85.3
2013-14
Q1 90.1 86.9
Q2 91.5 84.5
Q3 92.3 90.6
Q4 89.4 91.9
2014-15
Q1 90.4 86.4
Q2 91.0 84.7
Q3 89.3 86.3
Q4 90.1 87.6
2015-16
Q1 88.9 86.7
Q2 No data No data
Q3 85.6 85.6
20
CASC de Champlain CCACCASC de Champlain CCAC
40
50
60
70
80
90
100
% P
osi
tive
* As of April 2013, a second question was added to KPI 6.
KPI 6 – Linking to Other Services
21
CASC de Champlain CCACCASC de Champlain CCAC
40
50
60
70
80
90
100
% P
osi
tive
CCAC link to other community services after discharge CCAC linked to other community services
* As of April 2013, a second question was added to KPI 6.
KPI 6 – Linking to Other Services, by Question
22
CASC de Champlain CCACCASC de Champlain CCAC
KPI 6 - Linking to Other Services
Date Long Stay Short Stay
2012-13
Q1 35.0 52.4
Q2 38.9 57.1
Q3 71.4 45.1
Q4 66.7 54.6
2013-14
Q1 79.8 67.7
Q2 80.5 61.6
Q3 76.2 72.2
Q4 79.0 72.0
2014-15
Q1 80.4 68.6
Q2 81.2 72.3
Q3 78.4 75.7
Q4 76.4 65.0
2015-16
Q1 84.0 73.9
Q2 80.4 71.8
Q3 79.3 66.7
23
CASC de Champlain CCACCASC de Champlain CCAC
60
65
70
75
80
85
90
95
100
% P
osi
tive
KPI 9 – Safety
24
CASC de Champlain CCACCASC de Champlain CCAC
60
65
70
75
80
85
90
95
100
% P
osi
tive
Case manager discusses safety issues Told how to set up home to move around safely
KPI 9 – Safety, by Question
25
CASC de Champlain CCACCASC de Champlain CCAC
KPI 9 - Safety
Date Long Stay Short Stay
2012-13
Q1 77.9 66.5
Q2 78.5 61.9
Q3 81.4 63.1
Q4 77.8 62.3
2013-14
Q1 80.4 60.6
Q2 78.7 61.4
Q3 79.8 63.5
Q4 76.0 67.8
2014-15
Q1 81.0 67.9
Q2 78.5 66.0
Q3 78.8 66.0
Q4 78.6 58.9
2015-16
Q1 79.8 67.8
Q2 78.8 64.2
Q3 81.3 63.2
26
CASC de Champlain CCACCASC de Champlain CCAC
70.0
75.0
80.0
85.0
90.0
95.0
100.0
Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3
2012-13 2013-14 2014-15 2015-16
% P
osi
tive
Long Stay Short Stay All
Ease of Contacting Case Manager
27
CASC de Champlain CCACCASC de Champlain CCAC
Ease of Contacting CM
Date Long Stay Short Stay
2012-13
Q1 78.0 77.8
Q2 83.3 79.6
Q3 80.9 88.2
Q4 81.6 85.0
2013-14
Q1 82.2 81.0
Q2 83.0 87.9
Q3 81.1 78.1
Q4 86.3 89.2
2014-15
Q1 84.3 91.0
Q2 84.6 79.6
Q3 81.2 85.7
Q4 82.4 84.9
2015-16
Q1 81.6 83.7
Q2 80.6 80.0
Q3 76.7 74.0
28
CASC de Champlain CCACCASC de Champlain CCAC
Discussion
29
Work Status CodePlanned activity Work in progress, proceeded as expected Delays or issues encountered and being Escalations required to address issuesCompleted
Project Name Action Status Q1 Update (Apr, May, June) Q2 Planned Activities
Enhance the Care Coordinator Role: through role depth, role intensity, role scope and role expertise
1.1 Workforce and resource planning – support optimal 2015 caseload size
recommendations
Completed. Confirmed previously defined Care Model caseload sizes are
applicable. Identified additional resources required to address current
situation.
none - will address Action Plan item 1.2.
1.2 Care model restructuring to reduce large caseloads
Opportunities for caseload size reduction identified (short stay, intake,
placement and resource care coordinator). Resourcing analysis
conducted to support planning work.
Further work to develop implementation plan.
1.3 Develop evaluation framework for assessing caseload size n/a Develop evaluation framework to support implementation plan
2.1 Identify common CCAC & Health Links patients & ensure CC duplication is
minimized
Align this work with new Enhanced Care Model Pilot where CCAC is HL lead and more
work required
2.2 Support LHIN-identify/rationalize/reduce CC duplication Retreat planned with LHIN June 9 Discussions planned with LHIN.
2.3 Develop CC standards & build into evaluation/educ & tools Completed: National Case Management standards are in place Care coordinator education planned will combine IHI and refresher .
2.4 Establish clinical resources to ensure staff have appropriate skills / tools to
assist patients to access care across all Health, Community and Social Service
sectors
Refresher education referenced in 2.3 will include education on community services
via The HealthLine.
2.5 Redefine CC roles/responsibilities within an integrated team, multi-discipline
team & SPOLinkage to the new Enhanced Care Model Pilot.
2.6 Pilot shared decision making framework & tools such as Coordinated Care
Plan Tool ….
Adoption of the Consolidated Care Plan in CHRIS by a number of the
Champlain Health Links has grown and seems to be accelerating, During
May, CCAC added organizations and users from Seaway Valley CHC (UC
HL); Pinecrest-Queensway CHC, Arnprior District FHT, and Greenbelt FHT
(SONG HL); and West Carleton FHT (AROW).
Further work will link to the new Enhanced Care Model Pilot. (Note: The Ministry still
has to decide what of the 5 tool options they use for CCP - it is hopefully CHRIS, but
may not be)
2.7 Implement new std protocols/tools for transitions, DIVERT, Falls Prevention
and Med Mgmt Linkage to the new Enhanced Care Model Pilot.
2.8 Implement AcuteNet Completed; May 2016
Champlain CCAC Action Plan – Prioritization
Coloured cells indicate priority work for action in F2016-17Clinical care work related to patient experience QI
Other Work-in-progress OR Previously Planned
Mandatory work
To Maintain Increasingly High Needs Complex Patients at Home, we need to:
1 Review/balance caseload sizes
2
Streamline care coordination
initiatives in the region &
standardize care coordination
practices
Page 1 of 6
Project Name Action Status Q1 Update (Apr, May, June) Q2 Planned Activities
2.9 Improve SPO outcome reporting – SPR/APR
Completed automated provider reporting (APR) system enhancement for
outcomes and goal focused content reports in Nursing and PSS from 3
large Providers;
Implement APR with Peds in Aug 2016. Planning for further implementation into
Allied Health and all Providers started.
2.10 support CCAC/CSS reform strategies
Two new agencies were brought onto the SSO client information system
platform, Olde Forge and South East Ottawa CRC, (Total of 44 supported
agencies and over 600 user)s.
Completed client transfers and developed with LHIN a shared client and
escalation process between CCAC and CSS.
SSO client information system has two more small providers and a very large one in
the pipeline for future implementation planning.
. Awaiting further LHIN
direction/engagement.
3.1 develop strategy & materials to mentor clinical best practices Completed initial set of work focused on Palliative. Work will be leveraged for the first set of Clinical Audits planned for fall across
Nursing/PSS with 3 Providers.
3.2 strengthen CCAC professional practice/educ structures to align with clinical
needs
3.3 create advanced nursing & therapy roles within professional practice to
support educ, clinical best practice development and clinical protocols
3.4 Develop standardized processes and expectations, including performance
metrics for direct care clinical staff
Work in progress and has been linked and driven by Accreditation
preparations.Work will continue.
3.5 Train clinical staff/mgmt in the execution of their new rolesDiscussion paper developed to help document enhanced care
coordination roles/responsibilitiesLinkage to the new Enhanced Care Model Pilot.
4.1 provide CC services to HL where contracted (4 different HL) Work in progress
4.2 become lead agency for HL Work in progress
4.3 improve collaboration & integration with HL CC / CCAC CC Work in progress for alignment where CCAC is lead. Linkage to the new Enhanced Care Model Pilot.
4.4 serve as lead agency for HL 1 VP is clinical lead for this new HL. Work in progress.
4.5 identify resource req'ts and advocate for equitable distribution of CCAC CC
and admin resources in all HL
5.1 explore opportunities to change the NP / RPCT model & have NP provide
direct care or symptom mgmt with non-attached ptsDiscussions with Bruyère are in-progress. Discussions will continue.
5.2 revise Bruyère MOU to reflect expanded NP role & new model
6.1 Re-establish relationships with Primary Care providers
6.2 Explore opportunities to embed CCAC care coordination activities within PC
team processes and improve/ standardize expectations for communication with
primary care team / interdisciplinary team members overall
Linkage to the new Enhanced Care Model Pilot where care coordinator is integrated
with Primary Care.
3
Improve the training and clinical
support for CCAC Care
Coordinators, Therapists and
Nurses and development and
support for Clinical Care
Managers
6
Enhance development and
leadership with Health Links
5
4
Increase scope of practice and
role for Nurse Practitioners in
Palliative program and improving
the Central Referral and Triage
(CRT) processes (in partnership
with Bruyère)
2
Streamline care coordination
initiatives in the region &
standardize care coordination
practices
Advance Integration with Primary
Care across Champlain region
Page 2 of 6
Project Name Action Status Q1 Update (Apr, May, June) Q2 Planned Activities
7.1 ensure pt/caregiver perspective informs initiatives
Completed; all programs/initiatives are engaging patient advisors and
will continue to leverage this resource throughout (e.g.. Enhanced Care
Coordination, Equipment and Supplies Delivery Service
Enhancements/Waste Reduction, etc. (I would not say COMPLETE - track
as green - in progress)
7.2 improve how patient experience is measured & apply to QI
8.1 engage Patient/Caregiver Council role in developing/guiding caregiver
support program
8.2 inventory resources for caregivers; identify gaps / needs
8.3 engage private sector/govt to participate in foundation
9
Adopt Self-Directed Care funding
models9.1 implement SDC funding program
1 SDC Agreement implemented as of June 3, 2016. 2 other potential SDC
Agreements may be completed prior to end of Q1.
Developing a list of all potential candidates for SDC and working through Ministry SDC
program rollout, timeframe, expectations and budget for further implementations.
10.1 develop SPO care team continuity guidelines (# of PSW or nurses per team
per care plan hours)
Collaboratively working with Provider to define many aspects of service
expectations and service delivery standards; planning committee set
up/active
Leverage Onboarding Patient Improvement Pilots to implement and evaluate
outcomes.
10.2 implement patient communication and checklist materials for patients to
understand care plan, expectations, contacts
10.3. Conduct LEAN analyses of current processes and service delivery
expectations to identify and prioritize quality initiatives to address offer/referral
content of care plan, impact of acceptance metric, transition planning/case
conferencing, >1 SPO per patient, pathways & self-mgmt care, reduce Ax
duplication of CC/SP, direct communication CC/PSW & current process of when
Ax visits are complete at initial onboarding, delegated task changes, patient
status reporting to CC
Lean analysis planned mid-June; this work will support Onboarding
Patient Improvement Pilot Pilot launch in Q2.
10.4 define/pilot solutions to RH service delivery challenges
Meet with RHRA for clarity on regulations/expectations to identify
potential impacts to CCAC/Providers. Meeting and collaboratively
working through issues with individual retirement homes, providers and
CCAC. Some QI is evident. Will carry over into Q2.
Work planned to define problems/solutions and pilots.
10.5 modernize delivery of MES as per RFP new capabilitiesMeet with OMS supplier, patient advisor and provider representations to
identify problems and prioritize action plans.
Develop project plans for detailed work actions around 1st priorities of Waste
Reduction, Electronic Catalogues, Delivery Tracking Status
11.1 collaborate with colleges to establish an enhanced PSW curriculum related
to medical conditionsEstablished communication lines with college. Additional meetings planned with college and LHIN to discuss further.
Implement new service standards
for patient centered clinical care
and service delivery and develop
new practices to improve “On-
Boarding” of Complex Patients
Engage providers to enhance the
knowledge, skills and technical
expertise of front line health care
workers
To Modernize the Home and Community Care Delivery Models: through more continuity, more consistency, more quality of care, we need to:
Advance the engagement of Patients and Caregivers and provide services to support caregivers
8. Develop a “Champlain
Caregiver Initiative” to create a
fund exclusively focused on
caregivers’ needs
11
10
8
7Adopt & apply Carman Patient
Engagement Framework
Page 3 of 6
Project Name Action Status Q1 Update (Apr, May, June) Q2 Planned Activities
11.2 standardize PSW training/competency testing in medical diagnosis
education and technical skills (lifts) and reduce delegations & have SPO
demonstrate they have sufficient # of staff with skills/capabilities
11.3 support development of knowledge and skills with SPO nurses through
work of clinical care advanced practice staff and CCAC professional practice
structure where possible
12.1 increase events tracking of events/complaints/incidents & do trending
analysis & develop relevant action plans Analysis and planning work to begin
12.2 increase engagement with patients/caregivers for feedback on quality and
experience using IVR
Initiated work to use IVR to verify care delivery issues such as scheduling,
communicating and delivery of care (e.g.. late, missed, appointment
options, communications/awareness of status)
Develop tracking to identify time spent by clinical care on related issues brought to
their attention. Develop IVR survey plan. Initiate calls. (Q3 - may look to further refine
survey by leveraging actual Provider appointment scheduling system data)
12.3 complete palliative & clinic model evaluations
Clinic model evaluation started May 27 2016 with IVR calls to clinic
patients. Palliative model continues to generate data for future
evaluation purposes.
13.1 implement new provincial standards of Missed Care (MC) Contracts adjusted to reflect new MC KPI. Continue to work with providers to meet the new MC KPI.
13.2 augment current SPO performance metrics with new metrics
Contracts adjusted to reflect other new performance and QI metrics that
support Champlain focuses in palliative, clinics, congregate care billings,
wound care and more.
Continue to work with providers to implement processes and measure outcomes
associated with the new metrics. Continue to refine the mathematical calculations for
improved accuracy/relevancy.
13.3 develop/implement outcome-based & clinical best practice metrics in falls,
palliative and infection rates related to vascular access in home infusionsWork in progress Leverage work for Clinical Audit initiatives
13.4 add a clinical-based audit framework into inspection plans Developed clinical best practices/outcomes to be used in clinical audit
framework for palliative services. Planning for clinical audits of 3 providers of palliative care in fall.
13.5 complete 3 more SPO audits (clinical & contractual view)Contractual audit planning for 1 SPO in spring started; audit delayed from
June to July date due to new Contracts Manager. Planning for additional contractual Q3 audits of PSS providers
13.6 improve regular audit of SPO events/complaints & correlate to CCAC info
14.1 complete NBC - patient transitions to new SPO for region
14.2 pilot in RH a single SPO for nursing & PSS2 RH with nursing primes are identified. Natural patient attrition will
continue until nursing provider has all patients.
14.3 explore NBC for new rural regions, therapy or nursing
15.1 implement new practices/processes for more flexibility in duration of time
(45 min) associated with care plan visitCompleted May 9 2016.
13
Engage providers to enhance the
knowledge, skills and technical
expertise of front line health care
workers
Increase our ability to measure
and improve on quality of
patient/caregivers’ experiences
To Create Sustainability for Growth through effectiveness and innovation, we need to:
15
Optimize cost of service and care
delivery by aligning service
delivery times and durations with
patient needs
12
11
Increase and improve
performance oversight of
providers through better clinical
and contractual audit program
14
Continue to restructure our care
delivery programs and
relationships between providers
and the geographical areas they
serve (“Neighbourhood” Care)
Page 4 of 6
Project Name Action Status Q1 Update (Apr, May, June) Q2 Planned Activities
15.2 pilot new practices for flexibility of care over 30 dy vs weekly Exploring options for pilot within Peds groups.
16.1 Pilot On-Demand care delivery (scheduled and unscheduled care and
integrated enhanced care coordination)Planning work initiated with one provider. Pilot launch in Q2.
15.2 support reform & future state - Arnprior Rural Health Hub Discussions ongoing as appropriate.
17.1 Investigate potential options against a cost-benefit analysis to determine
feasibility
17.2 Issue a report and recommendation to meet this need
18
Clarify and communicate CCAC
actual capacity and occupancy
rates against our programs for
external partners and
stakeholders in the region
18.1 Develop mechanisms and report monthly our capacity vs occupancy rate
to hospitals /othersCompleted June 2016. Further refinements/improvements as identified.
19.1 pilot new Enhanced Care Coordinator model with other processes/services
and new technologies that enhance services and support care needs
2 Pilots being planned. (1) On-Demand care delivery and Enhanced Care
Coordinator. (2) Enhanced Care Coordinator and Integrated Primary
Care/HealthLinks.
Pilot launch in Q2.
19.2 incubate technology solutions / services that support tighter integration ,
improved clinical care monitoring, electronic sharing of patient information,
cost savings, etc.
RFP responses closed and evaluation and decisions are in-progress. Further planning work.
19.3 support hospitals with CCAC IS/IT resources for ED Notification
Completed 2 hospital implementations - Renfrew Victoria Hospital May
18; Arnprior Regional Hospital June 7.
19.4 Leverage IVR to reach patients for feedback on QI
Linked to 12.2. - Initiated work to use IVR to verify care delivery issues
such as scheduling, communicating and delivery of care (e.g.. late,
missed, appointment options, communications/awareness of status)
19.5 Assess & pilot new technologies/products/services to improve falls
prevention and more
May 26 the Champlain CCAC became the first health service provider in
the Champlain region to begin contributing patient data to the
cNEO/ConnectingOntario Clinical Data Repository or, as it has been
branded, the ConnectingOntario EHR.
dependent of 19.2 and more
19.6 Monitor implementations/opportunities to support patient monitoring &
intervention ( eShift, CDSM tool) and/or other
May 26 the Champlain CCAC became the first health service provider in
the Champlain region to begin contributing patient data to the
cNEO/ConnectingOntario Clinical Data Repository or, as it has been
branded, the ConnectingOntario EHR.
19.7 Chronic disease self-management monitoring & alerts to unusual /
negative trends
19
15
Optimize cost of service and care
delivery by aligning service
delivery times and durations with
patient needs
16
Pilot new models of care delivery
that improve patient-centered
care through new service
capabilities, integrated care
teams, enhanced care
coordination
17
Research and analyze alternative
residential care possibilities for
patients with needs between
home and long term care
Support innovation and research
in home care through IMPACT
Program
Page 5 of 6
Project Name Action Status Q1 Update (Apr, May, June) Q2 Planned Activities
20.1 develop/implement strategies to address 2015 Employee Engagement
survey resultsMeetings with department and directors to review survey results. Director level engagement with staff for further analysis/planning.
20.2 support staff through change management and communication initiatives
throughout transformation
Multiple Staff Conversations have been held and more planned to
communicate and do Q&A on transformation Continue communication work with staff and plan other work as appropriate.
20.3 engage front line staff in discussions & planning for implementation of key
strategies identified with Action Plan
Review of Action Plan done at Leadership meetings and with all front line
staff at Staff Conversations.
20.4 identify new / reinforce programs & strategies for employee wellness work in progress.
20.5 develop prof training & prgms that correspond with changing roles &
environment
Links to 2.3 - Care Coordinator education developed - case management
roles/responsibilities, standards and overall refresher.
Links to 10.3, 16.1, 19.1 - will continue to engage and support Pilot work and
Transformation work as appropriate.
Increase stability and engagement
of our employees 20
Page 6 of 6
CASC de Champlain CCAC
People Services & Organizational Development
Update
Client Services, Quality and Safety CommitteeJune 13, 2016
Martin Hajek – Director, People ServicesDan Merritt – Director, Organizational Development
CASC de Champlain CCAC 2
Table of Contents
Integrated HR-OD Talent Management Framework
Indicators
• Employee Headcount
• Full Time Equivalents
• Age of Employees
• Length of Service
• Employee Turnover
• Absenteeism
• Labour and Employee Relations
• Exit Interviews
• Performance Development
• Education Hours
• Other Learning and Development
• Employee Engagement Survey
Highlights
CASC de Champlain CCAC 3
Integrated HR-OD Talent Management Framework
Rewards & Recognition
Workforce Planning &
Management
Talent Acquisition
Onboarding
Performance Management
Learning & Development
Organizational Effectiveness
& DesignLabour
Relations
Health, Safety & Wellness
Compensation & Benefits
Employee Engagement
CASC de Champlain CCAC
0
100
200
300
400
500
600
700
800
Employee HeadcountApril 2015 to March 2016
Full Time Part Time Job Share Casual Temp
• Headcount increased from 698 to 727 over the past 12 months (+29)
• Growth occurred in permanent full time (+13) and temporary employees (+21). Decline occurred part time employees (-5).
• Permanent, full time employees continue to be the foundation of our work force
• Casual and temporary employees are used only for absence replacement and short term projects
4
Employee Headcount
CASC de Champlain CCAC
0
100
200
300
400
500
600
700
800
Number of BudgetedFull Time Equivalent Positions
April 2015 to March 2016• Although headcount increased,
budgeted FTE remained constant over the past 12 months
• Budgeted FTE has remained relatively stable since staff reductions in February 2015
5
Full Time Equivalents
CASC de Champlain CCAC
0
50
100
150
200
250
0-25 26-35 36-45 46-55 56-65 65+
Regular Employees by AgeMarch 31, 2016
• Average age of regular employees is 46, unchanged from previous year
• Age distribution does not indicate any immediate issue. The number of employees aged 55+ is noteworthy, but not a significant concern at this time.
• Older employees may be more likely to retire in the face of significant organizational changes
6
Age of Employees
CASC de Champlain CCAC
• Significant number of highly experienced employees in the organization
• Average length of service is 10.3 years
• Median length of service is 8.4 years
7
Length of Service
0
20
40
60
80
100
120
140
160
180
0-2 2-5 5-10 10-15 15-20 20-25 25+
Regular Employees Length of Service
March 31, 2016
CASC de Champlain CCAC
• Turnover is within target range (below 10%)
• Turnover is being closely monitored since introduction of the Patients First white paper
• There has been an increase in MPE departures, with uncertainty about the future of CCAC being cited as a contributing factor
• High turnover rates in Q1-Q3 reflected the voluntary early retirements offered in 2015
8
Employee Turnover
0%2%4%6%8%
10%12%14%16%18%20%
2014/15Q1
2014/15Q2
2014/15Q3
2014/15Q4
2015/16Q1
2015/16Q2
2015/16Q3
2015/16Q4
Annualized Turnover RateApril 2014 to March 2016
Rate
CASC de Champlain CCAC
• Employees with 1-5 years make up the largest portion of employee departures
• 92% of employees leaving for a “better job opportunity” had tenure of 5 years or less
9
Departures by Length of Service
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
< 1 yr 1 - 5 yrs 6 - 10 yrs 11 - 20yrs
21 + yrs
CASC de Champlain CCAC
• Continuing to experience high levels of sick leave among Team Assistants and Care Coordinators
• Mental health issues are the primary diagnosis for sick leave. Mental health strategy continuing through 2016-17.
• Increasing the level of organizational expertise in managing disability and return to work
• Focusing on employee engagement and attendance management strategies
10
Absenteeism
0
2
4
6
8
10
12
14
Days of AbsenceApril 2015 to March 2016
Rate Target
CASC de Champlain CCAC
• Relationships with both Unions remain positive. Union-Management meetings are held regularly.
• Grievance rates remain very low, with no grievances currently outstanding. Only one arbitration hearing in 2015-16, which was settled by the Parties.
• One employment related human rights complaint was filed in 2015-16. Mediation with Ontario Human Rights Commission is scheduled for mid-June 2016.
• There were no complaints lodged or infractions cited with respect to any employment legislation in 2015-16.
• One wrongful dismissal claim was settled in 2015-16. There were no other employment related legal proceedings initiated.
11
Labour and Employee Relations
CASC de Champlain CCAC
Exit Interviews: SummaryFiscal Year 2015-2016
CASC de Champlain CCAC
Number of
Departures
Not Eligible
for Exit
Interviews
Eligible for Exit
Interviews
Exit Interviews
Conducted
63 18 45 27
Offer rate: 100%
Participation rate: 60%
Participation profile: 23 full time and 4 part time employees
Exit Interviews 2015-2016 at a glance…
13
CASC de Champlain CCAC
Primary Reason for Leaving
RetirementsBetter Job
OpportunityOther
25% 44% 14.8%
Exit Interviews 2015-2016 at a glance…
14
CASC de Champlain CCAC
• 33% of interviewees stated that continuous change was a cause for departure.
• Overall lowest rating continues to be “I had career advancement opportunities with the CCAC” followed by “The amount of work I was expected to do was reasonable.”
• 73% of employees would recommend the CCAC as a good place to work, down from 85% last fiscal year.
• Positive themes were with regards to work drawing on skills, abilities and experiences, respect and teamwork, and flexible work arrangements.
Exit Interview 2015-2016 Trending
15
CASC de Champlain CCAC
Enablement 2015-2016
16
CASC de Champlain CCAC
Work Life 2015-2016
17
CASC de Champlain CCAC
Total Compensation & Recognition 2015-2016
18
CASC de Champlain CCAC
Communication & Senior Leadership 2015-2016
19
CASC de Champlain CCAC
Organizational Effectiveness 2015-2016
20
CASC de Champlain CCAC
Comments
I believe the therapists on staff are often forgotten in our
Ottawa-centric organization and it's a
shame.
The current climate of uncertainty significantly influenced decision.
Potential for a more strategic opportunity may have convinced me to stay along with a compensation
re-evaluation and increase.
Very heavy and needed to learn to identify priorities and boundaries. Amount of work is tremendous- very hard to
have work life balanceOn call adds to the heavy workload often very busy.
Good feedback from manager and team. We support
one another.
There has to be more opportunity for growth and development within corporate services. Part of that is for regular staff to feel that leadership actively cares about this aspect of the
workplace.
Working from home was a big asset.
Flexibility. I put more time in from home
(less social interruptions).
21
CASC de Champlain CCAC
Performance Development (performance management) activities include the evaluation and appraisal of work objectives, goal setting, learning & development planning, and ongoing feedback and coaching.
Unionized staff – 2015-16 fiscal year
98% completion.
MPE staff – process currently open
40% completion (as of June 3).
100% completion is expected.
22
Performance Development
%
MPEUnionized
98%
40%
CASC de Champlain CCAC 23
Education Hours
• Documentation Standards
• Engagement
• CCAC Rounds / Professional Practice
• Learning Cafés
• Service Offers
• Ethics
• AcuteNet system
• Patient Safety
• Workplace Violence & Harassment
• Self-defense and situational awareness
• Person Driven Care techniques: AIDET
• Self-care and mindfulness
• Leadership
• Health and Safety
• Orientation programs
• CHRIS & RAI training
• Responding to conflict
• Dementia care
CASC de Champlain CCAC 24
Other Learning and Development
• # Orientation sessions: 29
• # new employees trained: 77
• # employees trained related to internal movement: 44
• # employees trained related to return-to-work: 28
• # eLearning courses deployed: 7 (excluding Orientation-related courses)
CASC de Champlain CCAC 25
Employee Engagement
The December 2015 Employee Engagement Survey
Results were communicated to the Board in March 2016.
The Engagement Action Plan will be presented to the Board
in June 2016.
CASC de Champlain CCAC
• Ongoing enhancements to recruitment and selection processes
• MPE job evaluation
• 5th Champlain Summit
• Introduction of the “Inspire” recognition program
• CUPE job evaluation
• Implementation of Coaching and Peer Support program for new hires
• AcuteNet training and implementation support
• Mentoring and support for new leaders
• 2015 Employee Engagement Survey – 87% participation rate
• 2016 National Capital Top Employer award
• 2016 Platinum Quality Healthcare Workplace Award
26
Highlights
Champlain
Board Scorecard
May 2016
(Data as of April 2016)
Champlain
Operational Dashboard
2
Patient
Financial
Quality
People
Patient Trends Apr-15 FY 2015/16Target (T) / Baseline (B)
Local (L) / Provincial (P)Mar-16 Apr-16 FY 2016/17
Referra l Volume 4790 4585 B: 4600 (L) 4809 4762 4762
Monthly CCAC Patient Capacity 102% 102% T: 100% (L) 105% 110% 110%
% of Patients Reassessed Within
Guidel ines of Care71% 71% T: 80% (L) 73% 73% 73%
Total PSS Patients Ful ly Waitl i s ted 1511 315 T: 0 (L) 1 0 0Total PSS Patients Partia l ly Waitl i s ted 558 255 T: 0 (L) 62 0 0Total PT Patients Waitl i s ted 189 102 T: 0 (L) 34 17 17
Total OT Patients Waitl i s ted 476 174 T: 0 (L) 17 24 24
Quality Trends Apr-15 FY 2015/16Target (T) / Baseline (B)
Local (L) / Provincial (P)Mar-16 Apr-16 FY 2016/17
Service Wait-time Community (90th
Percentile Days Waiting)**78 57 T: 21 days (P) 25 29.8 29.8
2014/15 Q4 FY 2015/16 Target / Baseline 2015/16 Q3 2015/16 Q4 FY 2016/17
5 day wait time – Complex PSS* 72.9% 78.8% T: 95% (P) 83.7% 82.0% 75.6%Adjusted 5 day wait time - Complex PSS N/A N/A T: 95% (L) 91.7% 89.2% 84.9%5 day wait time – nursing* 93.6% 96.6% T: 95% (P) 93.9% 92.7% 93.8%% of Care Visits Delivered 99.85% 99.79% T: 99.95% (P) 99.79% 99.77% 99.78%
2014/15 Q3 FY 2015/16 Target / Baseline 2015/16 Q2 2015/16 Q3 FY 2016/17
Patient Experience* 91.4% 91.5% T: 94.5% (L) 90.9% 91.7% 91.5%*QIP Metrics
** MSAA Metrics
People Trends 2014/15 Q4 FY 2015/16Target (T) / Baseline (B)
Local (L) / Provincial (P)2015/16 Q3 2015/16 Q4 FY 2016/17
Staff Turnover 11.0% 11.0% T: 8.5% (L) 8.6% 13.7% 13.7%
% of Performance Agreements completed on
time
316/348
90.8%
316/348
90.8%
T: 217 (L)
100%
109/144
76%
188/217
87%
188/217
87%
Apr-15 FY 2015/16Target (T) / Baseline (B)
Local (L) / Provincial (P)Mar-16 Apr-16 FY 2016/17
Absenteeism annualized rate 10.6 10.6 T: 9 days (L) 12.5 12.7 12.5
Financial Trends Apr-16
FY 2015/16
Variance vs.
Plan
FY 2015/16
Variance vs.
Plan %
FY 2015/16
Projected Deficit
Tracking to Budget Targets -$1,571k -$1,571k -7.89% TBD
FYTD Target
+$0k
Champlain
3
Financial People
Metric Definition Discussion Questions
Referral Volume
The count of new referrals to the CCAC during the time period. Only referrals that initiate Case Management intake Assessments are counted in this indicator.
Is CCAC demand increasing? Is it from hospitals, physicians, or community?
Monthly CCAC Visit Capacity
The count of patients, by population groups, who received direct care visits or S&E as compared to the budgeted number of patients.
Are care plans efficient, ensuring creating additional capacity? Are there alternate parts of the health system to address particular care needs?
% of Patients Reassessed Within Guidelines of Care
Percent of patients (per population coding), who receive their RAI reassessments within guidelines. E.g. Complex Population patients are to receive a reassessment every 3-6 months, whereas Community Independence patients are to receive reassessments every 12 months.
Are Care Coordinators focusing their time on assessing patients? Are processes and tools in place to ensure efficiencies in processes, allowing time for Care Coordinators to assess their patients?
Total Personal Support Services (PSS) Patients Waitlisted
A snapshot view of the count of the number of PSS patients on the waitlist as at the end of the month, divided by those who are fully waitlisted (having no PSS service), and those that are partially waitlisted (having some PSS service, but assessed for needing more).
What is being done to manage patient risk?
Total Physiotherapy (PT) Patients Waitlisted
A snapshot view of the count of the number of PT patients on the waitlist as at the end of the month
How are patient risks being managed?
Total Occupational Therapy (OT) Patients Waitlisted
A snapshot view of the count of the number of OT patients on the waitlist as at the end of the month
How are patient risks being managed?
Metric Definition Discussion Questions
Tracking to Budget targetsNet surplus/deficit as calculated by Revenue minus Expenses, as per plan.
Are we tracking to budget plans? Are our cost/patients to plan? Is demand for service to expectations? What additional actions if any, are required at this time?
Metric Definition Discussion Questions
Staff Turnover Rate at which employees leave an organization. Calculated as number of permanent employees who terminate or cease employment, divided by the average number of permanent employees on staff
If not as expected, what is the underlying cause and mitigating action plan?
% of Performance Appraisals Completed on Time
FYTD percent of staff whose performance appraisal is completed on time.
Is staff development being appropriately managed?
Absenteeism annualizedRate
Total number of sick hours, paid and unpaid for all permanent and temporary staff (excludes casuals), divided by number of permanent staff.
If not as expected, what is the underlying cause and mitigating action plan?
Patient Quality
Operational Dashboard: Glossary
Metric Definition Discussion Questions
Service Wait-timeCommunity (90th
Percentile Days Waiting)
Wait time from patient intake / application date for referrals sourced from the community (e.g. Family, Self) to receiving the first direct care service visit, where the patient is an adult patient on Home Care services. The 90th percentile focuses on ensuring that 90% of patients will receive a visit in the targeted time frame, or better.
Should service eligibility or service guidelines be reviewed/reduced? What advocacy should the Board engage in?
5 day wait time –Complex PersonalSupport Services (PSS)
Measures the percent of patients whose 1st PSS visit was achieved within 5 days, from Service Authorization Date to the 1st PSS Visit Date for the episode of care. patients with an “On-Hold” episode between the authorization and 1st visit, are excluded from the measure. (On hold is used, for example, if a patients discharge is delayed from hospital due to complications)
How have Quality Improvement Plan (QIP) action plans improved performance?
Adjusted 5 Day Wait Time-PSS
Measures the percent of patients whose 1st PSS visit was achieved within 5 days, from Service Authorization Date or Patient Availability Date to the 1st PSS Visit Date for the episode of care.
Where are the remaining areas of focus to improve the performance? Is the target achievable?
5 day wait time -Nursing
Measures the percent of patients whose 1st Nursing visit was achieved within 5 days, from Service Authorization Date to the 1st Nursing Visit Date for the episode of care. patients with an “On-Hold” episode between the authorization and 1st visit, are excluded from the measure. (On hold is used, for example, if a patients discharge is delayed from hospital due to complications)
How have QIP action plans improved performance?
% of Care Visits Delivered
Measures the percent of visits provided to patients, of all scheduled visits, for direct care visits. The metric is self reported by SPOs on a quarterly basis.
Are there variances amongst providers or services? Are there adverse affects on patients due to missed care?
Patient Experience
Measures the percent positive rating for overall satisfaction with care. How have Person Driven Care action plans improved patient experience?
Champlain
Supporting Complex Patients Sustainable Health Care
4
Strategic Dashboard
Supporting Complex Patients Apr-15 FY 2015/16Target (T) / Baseline (B)
Local (L) / Provincial (P)Mar-16 Apr-16 FY 2016/17
Reassessment of Complex Patients within
Guideline94% 88% T: 90% (L) 86% 90% 90%
% of Complex Patients with a Care
Coordinator Contact (tel./FtoF) within 3
months88% 83% T: 85% (L) 79% 81% 81%
% of Complex Patients with 1 Care
Coordinator in past 12 Months95% 92% B: 95% (L) 90% 91% 91%
% of Patients with Targeted Number of SPO
Staff Within Past 3 MonthsNote: Feasibility being explored
% of Complex Patients With a Completed
Mediconciliation88% 74% T: 90% (L) 77% 81% 81%
Sustainable Health Care Trends Feb-15 FY 2015/16Target (T) / Baseline (B)
Local (L) / Provincial (P)Jan-16 Feb-16 2015/16 YTD
ALC Rate 12.9% 12.4% T: 12.7% (P) 12.5% 12.9% 12.6%
2014/15 Q3 FY 2015/16 2015/16 Q2 2015/16 Q3 FY 2016/17
Very High and High MAPLe Score %
supported by Champla in CCAC,
compared to Provincia l Averages
58%
(2)56.3% T: Top Quartile (L)
61.2%
(1)
62.0%
(1)
61%
(1)
2.0 1.0 T: 'Long Stay (L)Top Quarti le*
1.3 1.3 1.3
7.3 7.3 T: 'Short Stay (L)Top Quarti le**
7.0 7.0 7.0
Apr-15 FY 2015/16 Mar-16 Apr-16 FY 2016/17
% Cl inic Vis i t Uti l i zation 25.5% 29.3% T: 25% (L) 29.0% 28.5% 28.5%
Ranking relative to other CCACs for
average cost/Patient across a l l
Patient groups
*Champla in i s ranked cons is tently amongst the highest MAPLe proportion provincia l ly; Long Stay populations us ing provincia l
reference rates .
** Champla in continues to increase specia l programs, such as NPWT and CHIPP programs, impacting avg. cost; Short Stay
Population costs are ca lculated us ing loca l CCAC rates .
Champlain
Supporting Complex Patients Sustainable Health System
Metrics Definition Discussion Questions
Reassessment of Complex Patients within Guidelines
Percent of patients (per population coding), who receive their RAI reassessments within guidelines. E.g. Complex Population patients are to receive a reassessment every 3-6 months,.
Are Care Coordinators focusing their time on assessing patients? Are processes and tools in place to ensure efficiencies in processes, allowing time for Care Coordinators to assess their patients?
% of Complex Patients with a Care Coordinator Contact (tel./FtoF) within X Months
Count of the number of complex population patients who have had a Care Coordinator contact within last 3 months out of all complex population patients.
Are complex patients being monitored closely? Are there risks for some patients? If patients do not have a contact within last 3 months, what are the potential impacts?
% of Complex Patients with 1 Care Coordinator in Past 12 Months
Percent of complex patients active in the current month, who have had 1 Care Coordinator consistently assigned to the patient in the past 12 months.
When there are transitions, are Care Coordinators briefing peers effectively? What may cause higher number of assigned Care Coordinators (turnover, reassignments, etc.)?
% of Complex PSS Patients with Targeted Number of SPO Staff Within Past 3 Months
Percent of complex patients active in the current month, who have had the appropriate number of SPO staff assigned to the patient, within the past 3 months.
Is there consistency in care within the PSS care team? Do high numbers of SPO assigned staff create risk or a need for constant retraining? How do SPOs ensure consistency of care within the care team?
% of Complex Patients With aCompleted Medication Reconciliation
% of Complex Population patients with a BPMH completed within 30 days of either a RAI-HC completed with triggers for needing a Medication Reconciliation, or within 30 days of an initial face to face visit by a RRN or MHAN nurse.
Are there risks to patients if the CCAC is not completing a medication reconciliation? Are there other health professionals completing the Med Rec? Are there barriers to completing a Med Rec. ?
Metrics Definition Discussion Questions
ALC Rate New Indicator: Counts the total ALC bed days as a percentage of Total Bed days, during the period. Includes sub-acute (rehab and complex care bed and counts patients not yet discharged).
Are our programs appropriately supporting LHIN-Wide ALC targets? What if any additional actions are required to improve performance?
Very High & High MAPLe Score % supported by Champlain CCAC
The proportion of CCAC patients assessed by a RAI-HC, with a MAPLe Score of High or Very High, out of the total number of patients with a RAI-HC assessment.
What is the financial impact of sustaining higher needs patients? What effects does this have for provincial HBAM funding/
Ranking relative to other CCACs for average cost/patient across all patient groups
Using the LHIN Benchmark report, average costs per patient are reported by population group. Ranking can be achieved through the comparison of average cost per patient, across peers.
Are we delivering appropriate service levels to different patient populations (HBAM neutral or positive) and properly balancing cost & patient risk/safety?
% Clinic Visit Utilization Percent of Clinic Visits out of total Visit Nursing and Clinic Nursing Visits
Strategic Dashboard: Glossary
Champlain
OPERATIONAL METRICS
Champlain
Patient Trends 2: Referrals
7
Owner(s):Sophie Parisien
Variance Explanation
N/A
Actions and Status
Referral Source for New Referrals
Apr2015
FY 2015/16
Avg. BaselineMar 2016
Apr 2016
FY 2016/17
Avg.
Hospital 2,351 2313 2300 2439 2,469 2,469
Community-Physicians
541 564 550 711 609 609
Community-Other
1,898 1708 1700 1659 1,684 1,684
Total 4,790 4585 4600 4809 4,762 4,762
Indicator Characterization
Definitions Referrals: Count of new referrals to the CCAC within the period, broken down by source of the referrals, and outcome of the referral (admit to CCAC or Non-Admit to CCAC).
Reliability High
Frequency Monthly
Target Informational
Champlain
Patient Trends Patient Capacity
8
Owner(s):Jamie Stevens
Variance Explanation
N/A
Actions and Status
MonthlyPatient Capacity
Apr2015
FY 2015/16
YTD TargetMar2016
Apr2016
FY 2016/17
YTD
OverallPatient Capacity Percentage
101.8% 101.7% 100% 105.2% 110.3% 110.3%
Indicator Characterization
Definitions The count of patients, by population groups, who received direct care visits or S&E as compared to the budgeted number of patients.
Reliability High
Frequency Monthly
Target 100%
<99% 99-99.4% 99.5-100.5% 100.6-101% >101%
Champlain 9
9
Indicator Characterization
Definitions 1) Proportion of patients who are within population RAI-HC reassessment guidelines at the end of the month
2) Average number of RAI-HC completed per month per community Care Coordinator FTE.
Reliability High
Frequency Monthly
Target:% patients within Reassessment
80%
<70% >=70% to <80% >=80%
Target:Average number of RAI-HC completed per month per CC-FTE
28
<15 >= 15 to <28 >=28
Owner(s):Kevin Babulic (RAI-HC)Glenda Owens (RAI-PC)
Variance Explanation
Actions and Status
MetricApr
2015
FY 2015/16
Avg.Baseline
Mar 2016
Apr 2016
FY 2016/17
Avg.
% of patientswith RAI-HC reassessment within guidelines
71.0% 71.3% 69.6% 72.8% 72.8% 72.8%
% of patientswith RAI-PC reassessment within guidelines
59.8% 61.1% 60.8% 56.1% 46.7% 46.7%
Average number of RAI-HC completed per month per community carecoordinator
19.9 19.6
Baseline11
Target30
18.4 19.1 19.1
Average number of RAI-PC completed per month per community carecoordinator
19.0 17.1
Baseline 17
TargetNA
16.2 18.7 18.7
Person Driven CareRAI-HC Assessment Completion
Champlain
Patient Trends PSS Waitlist
(Month end Snapshot)
RAI ScoreApr
2015
FY 2015/16 Avg.
TargetMar
2016Apr
2016
FY 2016/17
Avg.
16+
Fully Waitlisted 372 80.7 N/A 0 0 0
Partially Waitlisted 159 71.3 N/A 21 0 0
11-15
Fully Waitlisted 1080 217.4 N/A 1 0 0
Partially
Waitlisted377 201.2 N/A 39 0 0
8 -10
Fully Waitlisted 56 30.1 N/A 0 0 0
Partially
Waitlisted18 8.1 N/A 2 0 0
0 -7
Fully Waitlisted 2 2.0 N/A 0 0 0
Partially
Waitlisted1 1.0 N/A 0 0 0
To
tal
Fully Waitlisted 1511 315 N/A 1 0 0
Partially
Waitlisted558 255.4 N/A 62 0 0
% patients Assessed within Target
87.6% 43.1% 85% 100% 0.0% 0.0%
Indicator Characterization
Definition % of patients on the PSS waitlist who have been reassessed while on the waitlist within target days
# of PSS patients on the waitlist as at the end of the month
Reliability High
Frequency Monthly
Target 85%
Less than 75% between 75%-85% 85% or more
Owner(s):Kevin Babulic
Variance Explanation
# patients • on Full waitlist = 0; • on partial waitlist = 307
Partially waitlisted fall under assessment standards fall of active patient standards and as such do not follow waitlisted patient reassessments
Actions and Status
% patients on PSS waitlist Ax within target: is of little value given partially waitlisted patients do not receive this, and is marked blue, not red as no action is required
Champlain 11
MetricApr
2015
FY 2015/
16Avg.
TargetMar
2016Apr
2016
FY 2016/17
Avg.
Total Waiting 189 101.5 N/A 34 17 17
% DelayedStart patients Reassessed on Time
98.9% 96.7% 85% 91.1% 94.1% 94.1
Owner(s):Glenda Owens
Variance Explanation
Actions and Status
Patient Trends Adult PT Waitlist
11
Indicator Characterization
Definition % of patients on the PT waitlist who have been reassessed while on the waitlist within target days
# of PT patients on the waitlist as at the end of the month
Reliability High
Frequency Monthly
Target 85 % Assessed on Time
< 75% 75-85% >= 85%
Champlain
Patient Trends Adult OT Waitlist
12
Owner(s):Glenda Owens
Variance Explanation
Working to ensure we see this metric maintained or surpassed. Work with Short Stay Rehab CC’s to conduct re-assessment calls for Retirement Home patients and LTC home patients
Actions and Status
MetricApr
2015
FY 2015/16
Avg.
TargetMar
2016Apr
2016FY 2016/17
Avg.
Total Waiting 476 174.0 N/A 17 24 24
% DelayedStart patients Reassessed on Time
88.6% 91.3% 85% 70.5% 100.0% 100.0%
Indicator Characterization
Definition % of patients on the OT waitlist who have been reassessed while on the waitlist within target days
# of OT patients on the waitlist as at the end of the month
Reliability High
Frequency Monthly
Target 85 % Assessed on Time
< 75% 75-85% >= 85%
Champlain
Patient Trends 7: School Therapy Waitlist
(Month end Snapshot)
13
Indicator Characterization
Definition Number of pediatric patients on School Waitlists for OT, PT, and SP
Reliability High
Frequency Monthly
Target N/A
patientsWaiting
Apr 2015
FY 2015/
16 Avg.
Target
Mar 2016
Apr 201
6
FY 2016/
17 Avg.
OT 682 384.6 279 271 271
PT 37 33.9 28 27 27
SP 220 186.9 124 139 139
Champlain 14
Indicator Characterization
Definition 90th percentile days waited from the patient’s referral date to the date of the Intake Assessment.
Reliability Medium – Indicator is directional
Frequency Monthly
Target 10 Days
<= 10 days > 10 Days or <= 15 Days
> 15 Days
Metric
Apr2015
FY 2015/16
Avg. Target
Mar 2016
Apr 2016
FY 2016/17
Avg.
90th
Percentile Days Waiting for Ax
22 13.6 10 Days 11 13 13
Patient Trends 3: Intake Efficiency (All teams)
14
Champlain15
Indicator Characterization
Definition Average number of days to initial assessment, measured from the patient application date to the initial assessment completion date.
Reliability Medium – Indicator is directional
Frequency Monthly
Target N/A
Metric
Apr2015
FY 2015/
16Avg.
Mar2016
Apr2016
FY 2016/17
Avg.
Average Days to InitialAssessment 10 8.5 10 12 8.5
Median Days to InitialAssessment 1 1 1 1 1
Patient Trends 3: Intake Efficiency (All teams vs Hospital/Intake)
15
Champlain16
Patient Trends 1st RAI-HC/PC Efficiency
16
Indicator Characterization
Definition Average number of days to initial HC/PC assessment, measured from the initial assessment date on the referral, to the first HC or PC assessment in the home.
Reliability Medium – Indicator is directional
Frequency Monthly
Target 3 Days
<= 3 days > 3 Days and <= 5 Days > 5 Days
Metric
Apr2015
FY 2015/16
Avg. Target
Mar2016
Apr2016
FY 2015/16Avg.
Complex: Average Days to Initial HC/PC Assessment
22.0 14.6 7 Days 12.3 13.3 13.3
Chronic: Average Days to Initial HC/PC Assessment
28.1 18.610 Days
15.1 16.6 16.6
Comm. Independence: Average Days to Initial HC/PC Assessment
25.0 19.4 14 Days 16.1 16.1 16.1
Champlain
Patient Trends 1: Paid Service patients by Population
17
Indicator Characterization
Definition Distinct count of patients, where a paid unit of service, equipment, or supplies occurred within the period, broken down by Patient Population Groups. This excludes Case Management only patients, LTCH placement only patients
Reliability High
Frequency Monthly
Target Informational
Population Apr2015
FY 2015/16YTD Avg.
FY 2014/15
Avg.
Mar2016
Apr2016
FY 2016/17YTD Avg.
Total patients 18,385
Non-Summer:19,836
Summer:17,615
Non-Summer:17,655
Summer:14,884
21,039 21,323
Non-Summer:21,323
Summer:-
Detail
Short Stay-Acute 856 890 679 899 891 891
Short Stay-Wound 1,496 1,631 1196 1,568 1,577 1,577
Short Stay-Rehab 973 1,042 762 1,098 1,057 1,057
Short Stay-Oncology
721 720 642 768 766 766
Community Independence
1,726 1,603 4538 1,563 1,556 1,556
Chronic 6,327 7,593 3890 8,277 8,401 8,401
Complex 2,919 2,925 2494 2,943 2,957 2,957
Enhanced 525 547 535 580 589 589
Paeds 3,276 3,005 2957 3,878 4,057 4,057
Uncategorized 118 84 365 83 73 73
Champlain
Quality 1: Service Wait Times
(Community)
18
Indicator Characterization
Definition Wait time from patient intake / application date for services from the community, to receiving the first paid service (excludes patients receiving Case Management services, LTCH placement assistance, and any patient waiting over 1 year)
Reliability High
Frequency Monthly
Target 21 Days
21 days or less 21.1 to 30 days More than 30 days
Apr2015
FY 2015/1
6Avg. Target
Mar2016
Apr2016
FY 2016/17
Avg.
90th
Percentile Community Wait Time
78 57 21 25 29.8 29.8
Median Wait Time
6 7.3 N/A 6 7 7
Average CommunityWait Time
27 21.4 N/A 12 14 14
Owner(s):Penny Sands/ Brenda Toonders
Variance Explanation
Mar. Comment : We will continue working with the Service Providers to bring this down
Actions and Status
Champlain
% of Completion
within 5 days
2014/15Q4
FY 2014/15
Avg.
Target 2015/16Q3
2015/16Q4
FY 2015/16
Avg.
Combined Hospital & Community
PSS 72.9 78.8 95 83.7 82.0 75.6
Adjusted PSS TBD TBD 95 91.7 89.2 84.9
Nursing 93.6 93.6 95 93.9 92.7 93.8
Hospital
PSS 79.9 82.3 82.8 85.0 86.4
Nursing 93.9 94.0 93.1 94.3 92.4
Community
PSS 65.6 75.2 65.9 82.6 79.0
Nursing 92.9 92.8 82.8 93.3 93.1
Quality1-b : 5 Day Wait Time : Complex Patients
(Community & Hospital)
19
Indicator Characterization
Definitions Reliability Frequency Target
Percent of complex patients receiving their first PSS or Visit Nursing within 5 days from the authorization of the service to the first visit.
High Monthly Nursing: 95% PSS Complex: 95%
< 90% 90-95% 95% or
greater
< 90% 90-95% 95% or
greater
Owner(s):Kevin Babulic (PSS)Sophie Parisien (NUR)
Variance Explanation
Mar. Comment :
NURSING: Reports reviewed with Managers who are following up with staff individually.
Jan. Comment :
PSS: Dec at historical highest percentage ever 93%. Manager follow with individual successful
Actions and Status
Mar. Comment :
NURSING: Continue to monitor and follow-up with staff to ensure everyone is entering first service start date within 5-day timeframe.Sophie reviewing 5-day target with teams at Jan/Feb roadshow
Jan. Comment :
PSS: Education complete. +++ rigor re follow up on individual basis and monitor
Clients Percent Accumulated
111 90% 90%
1 1% 91%
1 1% 92%
3 2% 94%
Client Unavailable per SPR/APR 0 0% 94%
CC Data Entry 3 2% 97%
SPOs 4 3%
123Total Clients
Patient has chosen to delay service initiation
Clinical need for service to begin on a specific date
Patient is currently
available for service
Complex-PSS Clients
Met the Target
This service is being pre-planned
Champlain
% of Direct Care Visits Delivered
2014/15Q4
FY 2015/16
Avg.*
Target 2015/16Q3
2015/16
Q4
FY 2016/1
7Avg.
Overall99.85% 99.79% 99.95%
99.79%
99.77%
PSS99.80% 99.75% 99.95%
99.74%
99.72%
Visit &Clinic Nursing 99.99% 99.98% 99.95%
99.99%
99.98%
Shift Nursing99.99% 99.91% 99.95%
99.84%
99.94%
Therapies99.99% 99.69% 99.95%
99.85%
99.93%
*Note: FY 2015/16 Targets where at 99.5%
Quality% of Direct Care Visits Delivered
20
Owner(s):Brenda Toonders
VarianceExplanation
Actions and Status
Indicator Characterization
Definition
Reliability High
Frequency Monthly
Target 99.95%
<=99.49 99.5-99.94 >=99.95
Champlain
Metric 2014/15Q3
FY 2013/14
Avg
Target 2015/16Q2
2015/16Q3
FY 2016/17
Avg.
Patient Experience: Overall Satisfaction
91.4% 91.5%94.5%
90.9% 91.7%
QualityPatient Experience
21
Indicator Characterization
Definition % positive rating for overall satisfaction with care.
Reliability Moderate – Quarterly results are Interim until full year results are available
Frequency Quarterly
Target 94.5%
< 92.5% 92.5 – 94.5% >= 94.5%
Owner(s):Jennifer Proulx
Variance Explanation
Actions and Status
Champlain
% of Service Authorizations with Required 1st Visit Date
Entered
Apr2015
FY 2015/16Avg. Target
Mar2016
Apr2016
FY 2016/17Avg.
Overall Organization
81 87 100% 95 96 96
Intake Team 94 94 100% 97 98 98
Hospital Teams 82 84 100% 91 92 92
Community Teams 69 82 100% 95 96 96
PSS 79 81 100% 91 93 93
Nursing 69 80 100% 92 94 94
Therapies 99 100 100% 100 100 100
Quality% of Service Authorizations with Required 1st
Visit Date Entered
22
Indicator Characterization Definitions Reliability Frequency Target
% of Service Authorizations with Required 1st Visit Date Entered
High Monthly 95%
< 90% 90-95% 95% or greater
Champlain
% of Service Authorizations with Required 1st Visit Date
Entered
Apr2015
FY 2015/16Avg. Target
Mar2016
Apr2016
FY 2016/17Avg.
Overall Organization
88 85 95% 84 87 87
External PSS 86 78 95% 79 82 82
External Nursing 90 88 95% 87 90 90
External Therapies 78 78 95% 76 75 75
Internal Nursing 93 93 95% 86 92 92
Internal Therapies 83 83 95% 71 79 79
Quality% of SPO 1st Visits Achieved within Required 1st
Visit Date
23
Indicator Characterization Definitions Reliability Frequency Target
% of Service Authorizations with Required 1st Visit Date Entered
High Monthly 95%
< 90% 90-95% 95% or greater
Note: To be included in the metric, the Service Requested by or Required 1st Visit Date fields must
be populated, in order to measure SPO performance against these dates. Therapies, MHAN, and
RPCT may have very few authorizations with these dates filled in, due to past
practice/expectations, causing potentially large swings in performance for Therapies and Internal
Nursing.
Champlain24
Indicator Characterization
Definitions Number of high and adverse risk events reported and recorded within Champlain Event Learning System. Top five events by volume and by risk provided for information purposes.
Reliability Moderate
Frequency Monthly
Target Informational
Numberof events
Mar 2015
FY 2015/
16 Avg.
BaselineFeb
2016Mar
2016
FY 2016/17
Avg.
Number of Events
32 34 34 33 31 31
Number ofComplaints
58 57.2 57.2 42 34 34
Quality 2: Patient Events & Complaints
24
Champlain 25
Indicator Characterization
Definitions The number of days for a complaint to be resolved with the patient, from the time the complaint was recorded.
Reliability Moderate
Frequency Monthly
Target 20 days
<=20 days 21-30 days >=31 days
MetricMar
2015
FY 2015/16
Avg.Target
Feb2016
Mar2016
FY 2016/17Avg.
Average ResponseTime (days)
20.9 30.8 20 days 17.8 49.2 49.2
Percent of complaintsresolved in 20 days
66.6% 65.9%N/A
70.9% 44.6% 44.6%
Number of unresolved complaints at the end of the month
N/A TBD
Quality 3: Patient Complaints Resolution Time
25
Champlain26
MetricApr
2015
FY 2015/16
Avg.
BaselineMar
2016Apr
2016
FY 2016/17
Avg.
% of palliative / end
of life patients who
died in their
preferred place of
death
78.1% 75.1% 74.5% 70.6% 70.1% 70.1%
Quality Palliative Patients: Preferred Place of Death
26
Indicator Characterization
Definition Count the number of palliative / end of life patients who died in their preferred place of death. Patient must be discharged with a disposition of death in the period selected
Reliability Moderate
Frequency Quarterly
Target 85%
< 70% 70-84.9% >= 85%
Champlain27
Target Total Trend 2015-05 2015-06 2015-07 2015-08 2015-09 2015-10 2015-11 2015-12 2016-01 2016-02 2016-03 2016-04
90% 29.7% 19.2% 17.2% 32.3% 36.7% 27.1% 29.6% 34.0% 28.6% 39.3% 34.4% 29.6% 29.7%
90% 0.0%
90% 33.0% 15.7% 38.4% 54.5% 47.3% 57.7% 61.1% 54.3% 52.8%
8-10 Clients 6.4 4.1 7.3 4.6 5.2 7.4 6.6 7.3 7.4 7.3 7.3 7.9 6.1
5-10 Clients 4.2 3.0 1.7 2.4 4.1 5.7 4.4 3.7 5.7 7.5 7.9 6.6 3.7
5-10 Clients 19.1 20.7 25.4 37.6 40.8 30.0 15.0 17.1 13.2 10.0 10.5 8.1 7.9 • Average Number of Primary Care/Specialist/Care team
Consultations Per Nurse Per Week
• Percent of patients died in preferred place of death
• Percent of patients will have a medication reconciliation
Productivity
• Average Number of Face-To-Face Visits Per Nurse Per Week
• Average Number of Telephone Visits Per Nurse Per Week
Metric
Performance
• Percent of patients are seen within 5 days of referral
Quality HPCN / RPCT Provincial Metrics
27
Champlain28
Quality RRN Provincial Metrics
28
Champlain29
Quality MHAN Provincial Metrics
29
Champlain30
Apr2015
FY 2015/16
Avg. TargetMar2016
Apr2016
FY 2016/17Avg.
Total % 76 76 80 78 79 79
Arterial Ulcer
0 45 62 67 100 100
Diabetic Foot
73 65 65 71 66 66
Wound-Pilonidal
78 81 82 85 74 74
Pressure Ulcer
85 84 84 90 71 71
Surgical 78 80 83 85 83 83
Traumatic 71 74 76 72 84 84
Venous Leg 0 61 62 53 55 55
Quality 4: % OBC Wound patients within Target
Visits
30
Indicator Characterization Definitions Reliability Frequency Target
Total number of Outcome Based wound patients achieving a number of visits below or equal to wound pathways’ target visits over the total number of healable wound patients.
Moderate Monthly 80%
Less than 70% 70%-80% 80% or more
2015-05 2015-06 2015-07 2015-08 2015-09 2015-10 2015-11 2015-12 2016-01 2016-02 2016-03 2016-04
Arterial Leg Ulcer 0% 67% 75% 0% 67% 50% 43% 50% 67% 0% 67% 100%
Diabetic Foot Ulcer 60% 67% 71% 64% 55% 75% 53% 76% 50% 65% 71% 66%
Pilonidal Sinus 75% 93% 90% 60% 86% 65% 93% 93% 76% 80% 85% 74%
Pressure Ulcer 85% 92% 94% 87% 71% 88% 88% 85% 78% 70% 90% 71%
Surgical Wound 81% 78% 80% 81% 76% 86% 77% 79% 79% 79% 85% 83%
Traumatic Wound 67% 79% 86% 77% 73% 71% 70% 68% 74% 74% 72% 84%
Venous Leg Ulcer 0% 81% 65% 63% 63% 68% 70% 62% 73% 57% 53% 55%
Total 76% 80% 81% 75% 72% 78% 74% 76% 74% 73% 78% 79%
% OBC Wound Clients Within Target Visits
2015-05 2015-06 2015-07 2015-08 2015-09 2015-10 2015-11 2015-12 2016-01 2016-02 2016-03 2016-04
Arterial Leg Ulcer 0% 0% 0% 0% 0% 33% 0% 0% 0% #DIV/0! 0% 0%
Diabetic Foot Ulcer 0% 0% 5% 14% 12% 9% 18% 4% 15% 3% 8% 5%
Pilonidal Sinus 7% 14% 5% 0% 6% 8% 5% 4% 0% 16% 0% 0%
Pressure Ulcer 9% 20% 12% 27% 5% 5% 5% 18% 20% 0% 11% 8%
Surgical Wound 8% 11% 9% 6% 10% 5% 2% 6% 6% 3% 8% 7%
Traumatic Wound 5% 1% 4% 4% 4% 2% 4% 8% 5% 6% 3% 5%
Venous Leg Ulcer 0% 0% 5% 17% 14% 8% 21% 4% 7% 11% 0% 14%
Total 7.8% 7.8% 7.3% 7.4% 8.3% 5.0% 5.6% 6.9% 7.2% 4.7% 5.8% 6.4%
% of Discharged OBC Goal Met Clients Readmitted within 30 days
Champlain
People1: Staff Turnover Rates
31
Owner(s):Martin Hajek
Variance Explanation
High numbers in Q4 are the result of early retirement offers being given to Care Coordinators.
Only 2 MPE departures in Q4, being one in HR and 1 Executive.
Actions and Status
31
Indicator Characterization
Definitions Reliability Frequency Target
Rate at which employees leave an organization. Calculated as number of permanent employees who terminate or cease employment, divided by the average number of permanent employees on staff
High Quarterly Less than 10% Prorated annualized
10% or less 10%-11%12% or more
Employee Category
Q4 YTD2014/15Annualized
Q3 YTD2015/16Annualized
Q4 YTD2015/16Annualized
CM 13.4% 8.0% 12.9%
TA 1.3% 7.6% 9.5%
Other Union
8.7% 6.6% 13.0%
MPE 17.7% 16.7% 24.9%
Total 11.0% 8.6% 13.7%
Champlain
Employee Category
12 monthsending
Apr 2015
12 monthsending
Mar2016
12 monthsending
Apr2016
Annual cost based on 12
months ending
May 2015(thousands)
CM 11.6 12.7 13.2 $1,025k
TA 13.3 21.8 21.5 $385k
Other Union 9.4 10.0 10.0 $331k
MPE 4.1 3.1 3.2 $72k
Total 10.6 12.5 12.7 $1,813k
Owner(s):Martin Hajek
Variance Explanation
Increase in the number of employees absent for greater than 30 days. Climbing rate is primarily due to long term (>30 days) absences. Seeing related increase in Long Term Disability claims.
Actions and Status
Refresh of the Wellness program, including mental health initiatives, will occur at the beginning of new fiscal, with a focus on preventable health conditions.
Increase focus on first 30 days of absence, with a view to ensuring appropriate intervention and medical documentation to facilitate early return to work.
Revising Attendance Management program management to ensure that attendance is reviewed on a consistent, regular basis. Review of all employees’ attendance will occur with managers quarterly.
Indicator Characterization
Definition Total number of sick hours, paid and unpaid for all permanent and temporary staff (excludes casuals), divided by number of permanent staff. .
Reliability High
Frequency Monthly and Annually
Target 9 days or less annually
9 days or less– Above 9, up to
11 daysAbove 11 days
People2: Absenteeism
32
Champlain
Engaged & Proactive PeoplePerformance Agreement Completion
33
Indicator Characterization
Definition FYTD percent of staff whose performance appraisal is completed.
Reliability Moderate
Frequency Quarterly
Target 80%
<75% 75 – 79.9% >= 80%
Owner(s):Dan Merritt
Variance Explanation
The completed % is currently at 77%. There is strong evidence of progress within the process - many employees now have moved from the 1st step to the 2nd (middle) step in the process. This is a sign that managers and employees are engaged in completing the process. Only 6% remain at Step 1.
Actions and Status
Weekly reminders to Managers and Directors continue.
Source FYTD(as at end of 14/15-
Q4)
Target FYTD(as at end of 15/16-
Q3)
FYTD(as at end of 15/16-
Q4)
Performance Agreement
YTDCompletion
%
188/21790.8%
95%109/14450.2%
188/21786.6%
YTD Completion
Target100% 75% 100%
Champlain34
Number of Health & Safety
Events
Apr 2015
FY 2015/16
Avg.
Target / Baseline
Mar 2016
Apr 2016
FY 2016/17
Avg.
Number of WSIB Claims 1 0.76 1 1 1 1
Indicator Characterization
Definitions Reliability Frequency Target
Number of staff WSIB claims submitted per month.
Moderate Monthly
1 WSIB Claim or less
1 or less More than 1
People3: Staff WSIB Reported Incidents
34
Champlain
Financial / Sustainability1: Tracking to Monthly Financial Targets
35
Indicator Characterization
Definition Net surplus/deficit as calculated by Revenue minus Expenses
Reliability High
Frequency Monthly
Target Balanced Budget as annual aggregate target
Greater than
-2.5% variance
-1.5%To
-2.5%
-1.5% To
+1.5%
+1.5%To
+2.5%
Greater than
+2.5% variance
Owner(s):Sara Bisson / Jamie Stevens
Variance Explanation
Actions and Status
Financial Trends Apr-16
FY 2015/16
Variance vs.
Plan
FY 2015/16
Variance vs.
Plan %
FY 2015/16
Projected Deficit
Tracking to Budget Targets -$1,571k -$1,571k -7.89% TBD
FYTD Target
+$0k
Champlain 36
Sustainable Health SystemAvg. Cost/Patient
36
Indicator Characterization
Definitions Reliability Frequency Target
Average costs are calculated by summing all costs within the period (Services, supplies, equipment) divided by the sum of unique patients with costs. This is further divided into Lines of Business groupings. It excludes Case Management costsProvincial averages to be determined for comparison as they become available.
High MonthlyAt or below target Avg. Cost
0% 0-5% 5% or more
CCM Population
Apr2015
FY 2015/16
Avg.
Budget Target
Mar2016
Apr2016
FY 2015/16
Avg.
SS-Acute $460 $465 $501 $448 $479 $479
SS-Wound $597 $572 $494 $602 $558 $558
SS-Rehab $229 $239 $321 $273 $267 $267
Stable Oncology
$345 $335 $366 $320 $296 $296
Community Independence
$418 $440 $381 $491 $464 $464
Chronic $585 $613 $696 $660 $632 $632
Complex $1,089 $1,134 $1,124 $1,209 $1,144 $1,144
Enhanced $2,282 $2,380 $2,652 $2,314 $2,314 $2,314
Paeds$325 $453
$397(summer: $1400)
$280 $297$453
(Summer: $302)
Total
$651 $677
$639($734
summer due to Paeds)
$690 $662$678
(Summer: $666)
Champlain
STRATEGIC METRICS
Champlain
Indicator Characterization
Definition % of complex patients (per population coding), who receive their RAI reassessments within guidelines.
Reliability Moderate
Frequency Monthly
Target 90 % Assessed on Time
<= 79.9% 80-89.9% >= 90%
Supporting Complex PatientsReassessments within Guidelines
38
Owner(s):Kevin Babulic / Glenda Owens
Variance Explanation
Actions and Status
Population growth of the higher acuity segment of Champlain CCAC patients, as reflected in high and very high MAPLe scores, is significant and maintenance of this level of compliance is contingent on care coordinator staffing
MetricApr
2015
FY 2015/16
Avg.Target
Mar2016
Apr2016
FY 2015/16
Avg.
Reassessment of complex patients within Standards of Care guidelines
94% 88% 80% 86% 90% 90%
Champlain
Indicator Characterization
Definition % of Complex Patients with a Care Coordinator Contact (Te./FtoF/RAI) within 3 months
Reliability Moderate
Frequency Monthly
Target 85%
<75% 75-84.9% >=85%
Supporting Complex PatientsCare Coordinator Contacts
39
Owner(s):Kevin Babulic
Variance Explanation
Actions and Status
MetricApr
2015
FY 2015/16
Avg.Target
Mar2016
Apr2016
FY 2016/17
Avg.
% of Complex Patients with a Care Coordinator Contact (Te./FtoF/RAI) within 3 months
87.7% 82.6% 85% 79.2% 80.5% 80.5%
Champlain
Supporting Complex Patients Number of Care Coordinator Transitions within 1 year
40
Indicator Characterization
Definition The count of the number of Care Coordinator transitions that a patient experiences over the previous 12 months.
Reliability High
Frequency Monthly
Target 95%
<=89.9% 90-94.9% >=95%
Metric
Apr2015
FY 2015/16
Avg. TargetMar2016
Apr2016
FY 2016/17
Avg.
% of Complex
Patients with 1 CC in past 12 months
94.7% 91.5% 95% 89.6% 91.4% 91.4%
Average # of Caseload
Transitions1.0 1.1 TBD 1.2 1.1 1.1
Average # of Care
Coordinator Transitions
1.0 1.2 TBD 1.3 1.3 1.2
90th Percentile# of Care
Coordinator Transitions
1 1.8 TBD 2 2 1.7
Median # of Care
Coordinator Transitions
1 1 TBD 1 1 1
Owner(s):Kevin Babulic
Variance Explanation
Actions and StatusGraph a distribution
chart of the current
month (where it is a
reflection of the prior 12
months’ experience)
Champlain
Supporting Complex Patients Number of SPO Staff within 3 months
41
Indicator Characterization
Definition
Reliability High
Frequency Monthly
Target 95%
<=89.9% 90-94.9% >=95%
% of Patients
with Targeted Number of SPO Staff
Within Past 3 Months
Apr2015
FY 2015/16
Avg. TargetMar2016
Apr2016
FY 2016/17
Avg.
Owner(s):Brenda Toonders
Variance Explanation
Actions and Status
New metric: definition to
be determined. (e.g. PSS
only? All services?
Based on setting up a
reporting mechanism by
Providers to contracts…
likely audit based
Charts could be line chart
trend, plus second chart
could be YTD team
comparison
Champlain
Supporting Complex Patients Medication Reconciliation
42
Indicator Characterization
Definition % of Complex Population patients with a BPMH completed within 30 days of either a RAI-HC completed with triggers for needing a Medication Reconciliation, or within 30 days of an initial face to face visit by a RRN or MHAN nurse.
Reliability High
Frequency Monthly
Target 90%
<=79.9% 80-89.9% >=90%
Metric
Mar2015
FY 2015/16
Avg. TargetFeb
2016Mar2016
FY 2016/17
Avg.
% of Complex Patients With a
Completed Medication
Reconciliation
88.0% 73.5% 90% 77.3% 81.1% 81.1%
Owner(s):Glenda Owens
Variance Explanation
Actions and Status
Champlain
Sustainable Health SystemALC %
43
Indicator Characterization
Definition % of bed days used by ALC patients
Reliability Moderate – Reliant upon Hospital/LHIN reporting
Frequency Quarterly
Target 12.7%
<=12.7 >12.7 & <=13.3
> 13.3%
Owner(s):Sophie Parisien
Variance Explanation
Longer than average and more severe flu season impacting discharges to RHs and LTC. No significant changes to hospital practices re Home First/H2H practices.
Actions and Status
- Discuss with hospital partners and bring up to ED/ALC working group to look at various optimization opportunities (including Home First/H2H) to help decrease ALC % back to below target
- Continue to work with hospital teams to ‘case find’ and promote proactive discharge planning practices
Source Feb2015
2015/16 YTD
LHINTarget
Jan 2016
Feb 2016
2015/16 YTD
% of bed days used by ALC patients
12.9% 12.4% 12.7% 12.5% 12.9% 12.6%
Champlain
Metric Q3-2014/15
FY2014/15
Avg.
Target Q2-2015/16
Q3-2015/16
FY2015/16
Avg.
Percent of patients
58.0% 56.3%Top
Quartile61.3% 62.0% 61.0%
Rank 2 1Within
the top 41 1 1
Number of patients
6,690 6,917 4,500 7,547 7,748 7,527
At Home Percent of patients in Community
(MAPLe 4,5)
44
Indicator Characterization
Definition Count of CCAC patients with an open referral with a MAPLe (Method of Assigning Priority Levels) score of High or Very High
Reliability Medium – Indicator is dependent on when RAI assessment was last conducted
Frequency Quarterly
Target 75th Percentile Ranking
59th Percentile or less 60-75th Percentile75th Percentile or
more
Owner(s):Kevin Babulic
Variance Explanation
Actions and Status
Champlain
LHIN Benchmarking
Population
Cost Calculation
Provincial Average
ChamplainPercentile Ranking
Adult Short Stay Acute (Episode)
Local CCAC Rates
807 863 7
Adult Short Stay Rehab (Episode)
Local CCAC Rates
689 592 4
End of Life (Episode) Local CCAC Rates
5703 4727 2
Adult - Community Independence
(Monthly)
ProvincialRates
398 303 1
Adult – Chronic (Monthly)
ProvincialRates
712 603 2
Adult – Complex(Monthly)
ProvincialRates
1560 1421 5
Sustainable Health SystemRelative Ranking Avg. Cost/Patient
45
Indicator Characterization
Definition Average costs are calculated by summing all costs within the period (Services, supplies, equipment) divided by the sum of unique patients with costs. This is further divided into Lines of Business groupings. It excludes Case Management costsProvincial averages to be determined for comparison as they
Reliability High
Frequency Monthly
Target 75th Percentile Ranking
59th Percentile or less
60-75th Percentile75th Percentile or
more
Owner(s):Penny Sands
Variance Explanation
Short Stay Populations are compared without adjusting rates to a provincial reference rate. Champlain’s nursing rates are 14% higher than provincial average, affecting the current ranking. Furthermore, Champlain’s specialty programs, such as NPWT, DIALPD, Pleurx, etc., affect the short stay population average costs.
Actions and Status
Champlain
Sustainable Health SystemNursing Clinic Percent
46
Indicator Characterization
Definition Percent of Clinic Visits out of total Visit Nursing and Clinic Nursing Visits
Reliability Moderate
Frequency Monthly
Target 25%
< 20% >=20% to <25% >= 25%
Owner(s):Sophie Parisien / Brenda Toonders
Variance Explanation
N/A
Actions and Status
Jan. Comment: Maintain momentum to continue achieving 30%/month
Metric Apr2015
FY 2015/16
Avg. TargetMar2016
Apr2016
FY 2016/17
Avg.
% Clinic Visits
25.5% 29.3% 25% 29.0% 28.5% 28.5%
Champlain
Sustainable Health SystemLTCH Length of Stay
47
Indicator Characterization
Definition Average length of stay (in years) of patients in long stay LTC beds, based on patients who left LTCH in the past 12 months.
Reliability Moderate – Reliant upon Hospital/LHIN reporting
Frequency Quarterly
Target 2.5 Years
<=2.5 Years 2.6-3.0 Years > 3.0 Years
Note: Provincial data has been excluded from the above chart where there are
data points with missing data from 1 or more CCACs.
Source Sep 2014
Baseline Aug2015
Sep2015
LTCH LOS (Years)2.9 2.8 2.7 2.8
Champlain
Sustainable Health SystemCSS Referral Volumes
48
Indicator Characterization
Definition Count of referrals to the CSS Agencies within the period.
Reliability Moderate
Frequency Monthly
Target 400
< 350 350-400 >= 400
SourceApr
2015
FY 2015/16
Avg.
BaselineMar
2016Apr
2016
FY 2015/16
Avg.
Adult Day Program 166 199 182.8 179 205 205
Assisted Living 36 36 56.3 33 33 33
ABI - Personal Support/Independence
Training10 7 22 9 5 5
Respite/PSS for Seniors 157 109 20.5 80 118 118
Service Arrangement/Coordina
tion0 2 0 1 0 0
ABI Supportive Housing 2 3 11 2 0 0
Transportation -Patient 12 9 0 6 6 6
Personal Support CSSA Publicly Funded 0 63 0 17 0 0
Personal Support/Independence
Training0 0 0 0 0 0
Geriatric Mental Health 0 127 0 81 0 0
Total 383 435 273.8 408 367 367
Champlain
Indicator Characterization
Definition % of patients whose 1st visit occurred within 48 hours of the patient availability date to the 1st visit date
Reliability Moderate – Manual tracking of hospital discharge date
Frequency Monthly
Target 90 % Assessed on Time
< 70% 70-90% >= 90%
Person Driven CareHospital Transition: % RRN Patient Contact within 24
hrs
49
Metric Apr 2015
FY 2015/1
6Avg.
Target Mar2016
Apr2016
FY 2016/17
Avg.
% RRN (Face to Face) visits completed in 48 hrs. of patient availability date
81% 78% 90% 84% 90% 90.0%
Champlain
Engaged & Proactive PeopleHealthline Visits
50
Indicator Characterization
Definition The count of site visits during the period, to Healthline.
Reliability Moderate
Frequency Monthly
Target Informational
Source Apr2015
FYTD2015/16
Avg
Baseline Mar2016
Apr2016
FYTD2016/17 Avg
# of Healthline
visits49,030 46,917 28,792 49,028 48,642 48,642
% Variance from
Baseline70.3% 62.3% N/A 70.3% 68.9% 68.9%
Champlain
Engaged & Proactive PeoplePublic Website Visits
51
Indicator Characterization
Definition The count of site visits to the Champlain CCAC public website.
Reliability Moderate
Frequency Monthly
Target Informational
Source Apr2015
FYTD2015/16
Avg
Baseline Mar2016
Apr2016
FYTD2016/17
Avg
# of Public Website Visits
6,473 6,478 6,000 6,792 6,317 6,317
Champlain
COORDINATED ACCESS METRICS
Champlain
Acute Hospitals 1: Home First Volumes
53
Indicator Characterization
Definition Count of new hospital patients admitted to the Home First Program per month
Reliability Medium – Indicator is directional
Frequency Monthly
Target 90 Home First Enhanced patients per month
<80 80-89 90-105 106-110 >110
CategoryApr
2015
FY 2015/
16Avg. Target
Mar2016
Apr2016
FY 2016/17
Avg.
Enhanced 78 78 90 93 85 85
2015-05 2015-06 2015-07 2015-08 2015-09 2015-10 2015-11 2015-12 2016-01 2016-02 2016-03 2016-04
CCAC Enhanced Services 84 69 63 62 88 86 82 67 83 83 93 85
Adult - Complex-Adult 8 2 1 3 4 6 10 5 5 1 8 5
Adult - Complex-Palliative 12 11 15 14 22 15 19 11 18 16 20 17
Adult - Complex-Senior 64 56 47 45 62 65 53 50 60 65 64 63
Home First and Enhanced Service Client Count
Champlain
Long Term Care Homes1: % of LTCH placements with a MAPLe
score of 4 or 5, by Source
54
Indicator Characterization
Definition Percent of patients with a MAPLe (Method of Assigning Priority Levels) score of High or Very High, out of the total number of patients placed into LTC homes within the previous quarter (Note: MAPLe scores are determined from a RAI assessment on a patient) Note 1: Crisis placement designation from Hospital may impact this indicator; Note 2: Home First should help improve indicator results over time
Reliability High
Frequency Monthly
Target 78%
Less than 75% 75% -78% 78% or more
Prior Location Apr2015
FY 2015/16
Avg.
Baseline Mar2016
Apr2016
FY 2016/17
Avg.
Hospital 80.7% 80.3% 78% 71.4% 76.8% 76.8%
Private Dwelling
82.5% 84.8% 78% 86.2% 89.9% 89.9%
RetirementHome
89.2% 85.3% 78% 68.6% 87.8% 87.8%
Total 84.1% 83.7% 78% 74.7% 85.6% 85.6%
Champlain
Long Term Care Homes2: Admission from Community/Hospital
55
Indicator Characterization
Definition % Admission to LTCH by Community/Hospital: The count of patients placed into LTCH for their initial placement by location prior to placement, divided by the overall initial placements in the period.
Number of Admissions to LTCH by Community/Hospital: The count of patients placed into LTCH for their initial placement by location prior to placement..
Reliability High
Frequency Monthly
Target Hospital Percentage is 40% or less
40% or less 40.1% to 50% 50.1% or more
Apr 2015
FY 2015/1
6Avg.
Target Mar 2016
Apr 2016
FY 2016/
17Avg.
Hospital 36.5% 30.6% 40% 29.3% 27.5% 27.5%
Community 63.5% 69.4% 60% 70.7% 72.5% 72.5%
Champlain
At Home2: Number of patients in Community
85 & Over
56
Indicator Characterization
Definition Count of CCAC patients who are actively case managed by the CCAC during the period.
Reliability High
Frequency Monthly
Target 6276 patients
Less than 6276 6276 or more
Apr 2015
FY2015/16
Avg.
Target Mar2016
Apr2016
FY2016/17
Avg.
6,903 7,207 6,276 7,422 7,513 7,513
Champlain
Primary Care1: Referrals to CCAC by Physicians
57
Indicator Characterization
Definitions Referrals: Count of new referrals to the CCAC within the period, broken where the referral source is identified as physicians.
Reliability High
Frequency Monthly
Target 550 patients Referred per Month
499 or less 500 - 549 550 or more
Referral Source for New Referrals
Apr2015
FY 2015/16
Avg.
Target Mar2016
Apr2016
FY 2016/17
Avg.
Community-Physicians
541 564 550 711 609 609
Champlain
Sustainable Health SystemALS-HRS Unfilled Demand
58
Indicator Characterization
Definition Count of unique patients waiting to be placed into Assisted Living Services, by referral source category.
Reliability Moderate
Frequency Monthly
Target Informational
Source Apr2015
FY 2015/16
Avg. BaselineMar2016
Apr2016
FY 2016/17Avg.
Hospital 9 6 9.2 5 5 5
Community 121 112 59.7 94 85 85
Total 130 117 68.9 99 90 90
Champlain
Adult Day Program 1: Waitlists
59
Indicator Characterization
Definition Count of CCAC patients who are waiting for Adult Day Programs (ADP), by region and provider, as at the end of the period.
Reliability Moderate – New process with ADP partners
Frequency Monthly
Target Informational
Region Apr2015
Baseline Mar2016
Apr2016
Ottawa 328 127.0 359 362
Eastern 32 4.5 32 26
Renfrew 3 8.8 4 0
NLNG 18 NA 26 22
Total 381 140.1 421 410
Champlain
PROVINCIAL MIS EXPENDITURE COMPARATORS
Champlain
Provincial Comparators1: Cost per Patient Groupings
Patient Grouping
Data updated to compare: 2015/16-Q3
ChamplainCentral
EastCentral HNHB
SouthWest
Province
Adult Short Stay Acute/Oncology/Wound(Episode)
$863 $728 $771 $867 $932 $807
Adult Short Stay Rehab (Episode) $592 $702 $632 $646 $561 $689
End of Life (Episode) $4,727 $5,517 $5,414 $4,609 $5,546 $5,703
Long stay adult Complex (CCM Population)-Monthly $1,421 $1,410 $1,650 $1,593 $1,863 $1,560
Long stay adult Chronic (CCM Population) -Monthly $603 $558 $632 $933 $783 $712
Long stay adult Community Independence (CCM Population) -Monthly
$303 $322 $344 $508 $447 $398
Medically Fragile Children-Monthly $3,295 $3,159 $3,091 $2,475 $4,065 $2,912
Source: OACCAC
Excludes case management, equipment and supplies
Indicator Characterization
Definition Average costs are calculated by summing all costs within the period (Services) divided by the sum of unique patients with costs. This is further divided into Lines of Business groupings. It excludes Case Management costs
Reliability High
Frequency Quarterly
Target Target set against provincial average cost. Green: At or below target Avg. CostYellow: Between Target and 5% above TargetRed: Above 5% of target
Champlain
Provincial Comparators1: Cost per Service Unit
Data updated to compare: 2014/15-FY
Champlain Central East
Central HNHB SouthWest
Province
Personal Support 32.82(+1.9%)
31.60 31.91 30.82 36.19 32.19
Nursing – Visit 64.61(+13.8%)
56.78 56.02 50.14 53.44 56.78
Nursing – Shift 43.67(-7.0%)
51.00 49.78 48.18 38.52 46.98
Occupational Therapy 96.91(-15.7%)
122.0 112.86 112.47 129.48 114.92
Physiotherapy 101.95(+19.4%)
90.07 61.62 82.28 105.54 85.41
Speech 76.64(-34.2%)
128.86 129.32 101.69 144.87 116.53
Social Work 85.19(-36.0%)
128.40 162.94 138.68 139.71 133.18
Nutrition 119.87(+0.4%)
112.46 105.21 122.24 129.43 119.45
Source: OACCAC
Champlain
Provincial Comparators2: Proportion of Expenditures: (Admin,
CM, Patient Care)
Expenditures Category
Data updated to compare: 2014/15-Q4
Champlain Central East
Central Toronto Central
HNHB SouthWest
Avg of Peer
CCACs
Province(Avg.)
Total Expenditures 230,203k 272,247k 286,320k 246,802k 309,527k 208,557k
Patient Care 73.5% 70.3% 75.0% 73.7% 75.2% 69.6% 72.9% 70.5%
Case Management / I&R 19.3% 21.5% 17.7% 19.5% 18.6% 22.9% 19.9% 19.8%
Administration7.1%
(with SSO)7.6% 6.9% 6.5% 6.2% 6.7% 6.8% 7.2%
Other 0.1% 0.6% 0.4% 0.3% 0.0% 0.8% 0.4% 0.3%
Administration + Other 7.2% 8.2% 7.3% 6.8% 6.2% 7.5% 7.2% 7.5%
Total FTEs 613.4 794.2 651.8 604.6 740.2 599.9 667.4 483.0
Case Management / I&R 465.3 645.7 523.8 515.2 611.3 469.9 518.3 378.3
Direct Care Staff 65.4 23.2 20.9 14.0 34.5 29.3 31.2 29.7
Administration76.8
(including 6 SSO FTEs)
114.1 98.9 69.6 91.2 85.4 89.3 68.5
Other (e.g. In-service Education; Marketed
Services)5.9 11.2 8.2 5.8 3.2 15.3 8.3 6.3
Source: OACCAC Finance Reports
Champlain
Term Definition
ADP Adult Day Program Services: Adult Day Programs are funded by the LHIN, provided by community support services; provide supervised group programs to frail elderly and/or individuals with progressive cognitive disorders such as dementias
ALC Alternate Level of Care (ALC): A patient whose care is being provided in an acute care setting where the patient is no longer in an acute phase, and can be cared for in another area of the health care sector
ALS-HRS Assisted Living Services for High Risk Seniors: Program to provide patients with an enhanced level of personal support services through near on-call availability.
Ax Assessment, typically a RAI-HC or RAI-CA assessment, sometimes a local CCAC Assessment tool
CAP Patient Assessment Protocol: Identifies the MDS-HC items that alert the assessor to the patient’s potential problems or needs. Once flagged by a triggered condition, a more in-depth review of the relevant causes of the patient’s identified problems and needs is necessary
C.E.L.S. Champlain Events Learning System:
CCM Patient Care Model: Grouping patients into categories according to the needs of the patient
CM Case Manager
CSS Community Support Services: Community support services are intended for seniors or people with disabilities who prefer to stay at home. Services can be offered at the patient’s home or in the community.Funded via LHIN, local Cities and other sources for basic operation and salary costsOffer mostly fee based services
FTE Full Time Equivalent
LOS Length of Stay
LTCH Long Term Care Homes
MAPLe Method of Assigning Priority Levels (MAPLe) for community and/or facility services, as calculated by the RAI-HC assessment instrument
MPE Management and Professional Exempt
PSS / HOM Personal Support Services
RAI-CA Resident Assessment Instrument – Contact Assessment
RAI-HC Resident Assessment Instrument – Home Care
RAI Score A score derived from outputs from the InterRAI RAI-HC
SAH Stay at Home (SAH) program where patients require more than the legislated maximum of 60 hours of Personal Support Services (PSS) per month
TA Team Assistant
Therapies Aggregation of the therapy services provided by the CCAC, including: Occupational Therapy (OT), Physiotherapy (PT), Speech & Language Pathology (SLP), Nutrition (NUT), Social Work (SW)
64
Glossary of Terms
Champlain
Term Definition
AGH Almonte General Hospital
ADMH Arnprior District Memorial Hospital
Bruyere, BCC Bruyere Continuing Care Hospital
CCH Cornwall Community Hospital
CPDMH Carleton Place District Memorial Hospital
GMH Glengarry Memorial Hospital
HDMH Hawkesbury District Memorial Hospital
HM Hopital Montfort – Monfort Hospital
HNHB Hamilton Niagara Haldimand Brant Community Care Access Centre
KDH Kemptville District Hospital
PRH Pembroke Regional Hospital
QCH Queensway Carleton Hospital
ROMHC Royal Ottawa Memorial Health Centre
RVH Renfrew Victoria Hospital
SFMH St. Francis Memorial Hospital
SJCCC St. Joseph’s Continuing Care Centre
TOH-Civic The Ottawa Hospital – Civic Campus
TOH-General The Ottawa Hospital – General Campus
WDMH Winchester District Memorial Hospital
65
Glossary of TermsCont’d