Vision Mission BOARD OF DIRECTORS MEETING A ......Draft Revised June 2016cv Charter Section #4 Action (Italics-comments) Committee Responsible Sep Nov Jan Feb May Jun Corporate Performance

BOARD OF DIRECTORS MEETING Tuesday, June 28, 2016

1900h-2000h CMH Boardroom OPEN SESSION

h

Board Members: Rita Westbrook (Chair), Don McIntyre, Denise Smith, Josephine McMurray, Joseph Kane, Al Van Leeuwen, Elaine Habicher, Ian Miles, Larry Kron, David Pyper, Tim Edworthy, Suren Rao

Ex-Officio Members: Patrick Gaskin, Sandra Hett, Dr. Kunuk Rhee, Dr. Winnie Lee, Dr. Francois Flamand

Page 1 of 1

Vision To provide exceptional healthcare by

exceptional people

Mission A progressive acute care hospital and

teaching facility committed to quality and integrated patient centered care

Values

Caring, Respect, Innovation, Collaboration, Accountability

*Agenda Item (* Indicates attachment) (TBC- to be circulated) Time Responsibility Purpose

1. CALL TO ORDER 1900 R. Westbrook 1.1 Confirmation of Quorum (7)

1.2 Declarations of Conflict

1.3 Consent Agenda 1.3.1 Minutes of May 25, 2016* 1.3.2 Board Work Plan* 1.3.3 Strategic Plan Scorecard*

If there are no requests to move an item the consent agenda business is approved by the Board.

1.4 Confirmation of Agenda R. Westbrook Approval 2. DISCUSSION ITEMS

2.1 Chair’s Report 2.1.1 Upcoming Events Calendar* 2.1.3 Board Evaluations*

1905

R. Westbrook R. Westbrook

Information Information

2.2 Resources Committee (June 27, 2016) 2.2.1 May Financial Statements*

1910

D. McIntyre

Information

2.3 Quality Committee 2.3.1 June 15, 2016 Meeting Summary*

1915

L. Kron

Information

2.4 Medical Advisory Committee 2.4.1 June 8, 2016 Meeting Summary*

1930

Dr. K. Rhee

Information

2.5 CEO/COS Update 2.5.1 2015/16 Year in review and 2016/17 – The Year Ahead (TBC)

1935 P. Gaskin/ K. Rhee

Information

3. ADJOURNMENT 1955

4. DATE OF NEXT MEETING: September 28, 2016

BOARD OF DIRECTORS MEETING Wednesday, May 25, 2016

OPEN SESSION Minutes of the open session of the Board of Directors meeting, held in the CMH Boardroom on May 25, 2016. Present:

Ms. R. Westbrook Dr. J. McMurray Ms. E. Habicher Ms. D. Smith Mr. P. Gaskin Mr. L. Kron Mr. D. Pyper Dr. W. Lee Dr. K. Rhee Mr. S. Rao Ms. S. Hett Mr. A. Van Leeuwen Mr. I. Miles Mr. J. Kane

Regrets: Mr. D. McIntyre, Dr. F. Flamand, Mr. T. Edworthy Staff Present:

Mr. M. Prociw

Mr. S. Beckhoff

Guest: Recorder: Ms. C. Vandervalk 1. CALL TO ORDER

Ms. Westbrook called the meeting to order at 1935 hours.

1.1. Confirmation of Quorum Quorum requirements having been met, the meeting proceeded, as per the agenda.

1.2. Conflict of Interest

Board members were asked to declare any known conflicts of interest regarding this meeting.

1.3. Consent Agenda 1.3.1 Minutes of February 24, 2016

1.3.2 CEO Report 1.3.2(a) Media Tracker 1.3.3. Governance Committee

• 2-B-10 Succession Plan CEO and Executive • 2-B-12 Succession Plan for COS and Chief of Departments • 2-D-6 Board Meeting Agenda • 2-D-22 Board and Non-Director Committee Members Declaration • 2-D-40 Board Evaluation

1.3.4 Quality Committee • 2-C-10 Quality and Patient Safety Policy

1.3.5 Resources Committee • HSAA scorecard • Resources Scorecard • Liability Insurance – year end claims activity

1.3.6 Board Scorecard 1.3.7 Quality Scorecard 1.3.8 MAC Scorecard

Board of Directors Meeting (Open Session) May 25, 2016 Page 2

1.3.9 Board Work Plan

1.4 Confirmation of Agenda

MOTION: (Kane/Habicher) that, the agenda be approved as circulated. CARRIED

2. DISCUSSION ITEMS 2.1. Chair’s Report

2.1.1. February Evaluations

The evaluations were reviewed. No action taken.

2.1.2. Upcoming Events Calendar The events calendar was reviewed. Ms. Westbrook reminded the Board of the upcoming Board and City Council meeting being held on June 22, 2016.

2.1.3. Follow up from MSAA Submission

Ms. Westbrook confirmed that the M-SAA submission was completed on behalf of the board and submitted on time.

2.2. Resources Committee 2.2.1 Declaration of Compliance BPSAA

As part of the accountability requirements from the Broader Public Sector Accountability Act 2010 (BPSAA), the hospital is required to prepare reports concerning the use of consultants, using a prescribed template.

Mr. VanLeeuwen brought forward a motion MOTION: (VanLeeuwen/Habicher) that, the Board receive

and approve the attestation prepared by the President and CEO in accordance with section 15 of the Broader Public Sector Accountability Act 2010 for the period April 1, 2015 to March 31, 2016. CARRIED

2.3 Quality Committee

Dr. McMurray provided an update on the activity of the Quality Committee. Dr. McMurray spoke specifically to the Best practices update. Dr. McMurray, Ms. Hett, Ms. Habicher and Mr. Edworthy, conducted a review of the Excellent Care for All Act (ECFAA) that provides the legislative authority for the Quality Committee to ensure the annual work plan and regular updates to the Board of Directors were aligned with ECFAA requirements. A literature search was done to identify any innovative best practices to support the effectiveness of the Quality Committee.

2.3.1 Model of Care Evaluation Ms. Hett summarized CMH’s vision for nursing:

Collaborative teams comprise of Nursing Practitioner (NP), Registered (RN) and Registered Practical Nurse (RPN) and one Personal Support Worker (PSW)

Full scope of practice Best practices are apparent in daily work


Staffed to budget with surge capacity Providing support service that align with direct care providers Having strong linkages with community providers and partners

As reported in the Six Month Evaluation Report, call bell response times in the units have improved in both the actual response time and in the patients’ perceptions of these response times. Patient satisfaction has improved considerably and in the overall response to “would you recommend CMH to family and friends”.

2.4 MAC Update

2.4.1 Privileges for Ratifying and Granting Dr. Rhee confirmed due diligence was completed concerning the privileges and reappointments listed below.

New Medical Staff (April/May) Name Program Specialty Appointment Supervisor

Dr. George Yuan

Internal Medicine

Sleep Medicine Associate Privileges in the sleep clinic from a.s.a.p. to en of credentials process

NA

Dr. Glynn Martin

Surgery Orthopedic Surgery

Associate Privileges from Mar 1, 2016 to end of credentials process

Dr. J. Daly

Ms. Catherine Grant

Midwifery Midwifery Active Privileges from a.s.a.p. to end of credentials process

Ms. W. Pearle

Dr. Dennis Kim Surgery Urology Active Privileges from a.s.a.p. to end of credentials process

Dr. J. Daly

Name Program Specialty Appointment Supervisor

Dr. Carolynne Locke

Hospital Medicine

Family Medicine Associate Privileges from a.s.a.p. to end of credentials process

Dr. J. Mathew

Dr. Houman Khosravani

Internal Medicine

Internal Medicine

Associate Privileges from a.s.a.p. to end of credentials process

Dr. A. Nguyen

Locums/Temporary Staff for Approval (April/May)

MOTION: (Kron/McMurray) that, the Privileges for Ratification and Granting recommended to the Board be approved. CARRIED

Name Program Specialty Appointment Supervisor Dr. Louise Simms

Oncology Oncology Locum privileges from Jan 25, 2016- May 31, 2016 (covering Dr. Hahn and Dr. Evans)

Dr. E. Chouinard

Dr. Jonathan Rhee

Surgery Surgery Locum Tenens Privileges to assist all surgeons from Feb 11, 2016 to end of credentials process

Dr. Richard Johnstone


2.4.2 Hospital Standardized Mortality Rate (HSMR) As stated in the pre-circulated briefing note, Dr. Rhee provided details of HSMR for the first three quarters of Fiscal 2015/16. Since Fiscal 2014/15, Dr. Rhee reported the HSMR has improved from 111 to 77.

2.5 CEO Update 2.5.1 Safety Culture at CMH

Mr. Gaskin noted that a robust discussion ensued at the May Quality Committee based on presentation by Mr. Miles and the subsequent briefing note circulated at the May Quality meeting where Ms. Barefoot’s briefing note described the context of CMH’s current safety culture environment, illustrated the parallels between the two industries and the learning’s between sectors. Mr. Gaskin indicated that the Safety Culture will be part of the discussions in September and the development of the 2017-19 Strategic Plan.

2.5.2 Medical Assistance in Dying

Dr. Rhee updated the Board with regards to Medical Assistance in Dying (MAID), formerly known as Physician-assisted Death (PAD). The following is no longer a breach of the Criminal Code:

o Competent adult o Grievous and irremediable condition o Enduring intolerable suffering o Which cannot be alleviated by any treatment which the patient finds

acceptable o Consents for MAID

On April 13, 2016, a joint Ethics and MAC meeting was held, where an ethical framework facilitated discussion was led by Bioethicist, Dr. Abdool. The Executive Leadership of CMH informed by input from the MAC, Ethics Committee, Directors’ Council and Quality Committee recommends the development of a Medical Assistance in Dying (MAID) clinical service as part of the end-of-life care services at CMH. Dr. Rhee asked for a motion for the Board to approve the clinical service of MAID as part of end-of-life care services at CMH. Dr. Rhee added that the development of a process model and policy is currently in progress.

MOTION: (McMurray/Pyper) that, the Board of Directors approve the clinical service of MAID as part of end-of-life care services at CMH. CARRIED

2.5.3 Other items

Mr. Gaskin provided on update on the Common Hospital Information System RFP the due date for submissions is June 28, 2016. Mr. Gaskin directed the


Board to his briefing note where a presentation to the KW Chamber of Commerce was included.

3. MOTION to ADJOUN OPEN SESSION

The meeting adjourned at 2030hours. (Kane/Pyper) CARRIED Ms. Hett, Mr. Prociw, Dr. Lee and Dr. Flamand, Mr. Beckhoff left the meeting at 2035h

4. Discussion of Independent Directors and Management Discussion took place.

Dr. Rhee, Mr. Gaskin and Ms. Vandervalk left the meeting at 2040h 5. Discussion of Independent Directors

6. DATE OF NEXT MEETING

Next Meeting: The next scheduled meeting is June 28, 2016.

Rita Westbrook Patrick Gaskin Board Director Board Secretary CMH Board of Directors CMH Board of Directors

Agenda Item 1.3.2 BOARD WORK PLAN – 2015-16

= Due C = Complete I = In progress D = Delayed Draft Revised June 2016cv

Charter Section #4

Action (Italics-comments) Committee Responsible

Sep Nov Jan Feb May Jun

Tone at the Top

a-i, ii a-iii

Approve CEO goals and objectives Approve COS goals and objectives Mid-year/Year-end CEO report and assessment Mid-year/Year-end COS report and assessment CEO evaluation/feedback – mid-year COS evaluation/feedback – mid-year

CEO evaluation/feedback –year end and performance based compensation COS evaluation/feedback –year end and performance based compensation

Executive

Executive

Executive Executive

D D

D D

C C

C C

C C

√ √ √ √ √ √

Reviewing the performance assessments of the VPs – summary report provided to the Board (as per policy 2-B-10)

Executive √

Strategic Planning (b) Strategic Plan: approve process, participate in development, approve plan (done

in 2014; will be done again in 2017) Board

C

b Progress report on Strategic Plan

Board C

√

b-iii-c Approve annual quality improvement plan

Quality C

b-iii-c Review and approve the Hospital Services Accountability Agreement (H-SAA) Resources, Quality

C

b-iii-C Monitor performance indicators and progress toward achieving the quality improvement plan

Quality C I I C



Charter Section #4



Corporate Performance

c-i-B c-i-B

Critical incidents report – (ECFAA). (Brought forward to Board as deemed necessary)

Monitor, mitigate, decrease and respond to principal risks

Quality

Audit

C

C

C

c-i-E c-i-F c-i-F c-i-F

Review the functioning of the Corporation, in relation to the objects of the Corporation the Bylaw, Legislation, and the HSAA

Governance

C

C

Receive and Review: • Resources Scorecard • Quality Scorecard • HSAA Scorecard • Board Scorecard

Note: Resources & Quality scorecards are available on the portal in the respective committee sections. HSAA & Board scorecards appear in the Board consent package

Resource Quality

Resource Board

C C C C

C

C C

C C C C

Declaration of Compliance with M-SAA Schedule G (due Oct 31 and Apr 30 to the WWLHIN)

Board

C C

Declaration of Compliance with BPSAA Schedule A (due May 31 to the WWLHIN) Board

C

Procedures to monitor and ensure compliance with applicable legislation and regulations

Audit C

Succession Planning

e-i-A CEO succession plan and process Executive C e-i-B COS succession plan and process Executive C e-i-C Succession plan for executive management and professional staff leadership

Receive summary report from Executive/CEO/COS on CEO & COS succession plans Executive Executive

C I

√

Professional Staff



Charter Section #4



f-i-A f-i-B/C

Ensure the effectiveness and fairness of the credentialing process

Monitor indicators of clinical outcomes, quality of service, patient safety and achievement of desired outcomes (MAC scorecard)

MAC/Quality

MAC

C

I

C

√

f-i-C Make the final appointment, reappointment and privilege decisions for Professional Staff

Oversee the Professional Staff through and with the MAC and COS

Board

COS

D

C

C

C

C

C

C

C

C

C

√ √

Financial Viability

h-i-A,C h-i-A,C h-i-A,C h-i-A, B

Review and approve multi-year capital strategy Review and approve multi-year information technology strategy

Resources Resources

I I

C C

Review and approve annual operating plan – service changes, operating plan, capital plan

Resources/ Quality

I

C

Approve the year-end financial statements

Board C

h-i-A i-i-C

Approve key financial objectives that support the corporation’s financial needs (including capital allocations and expenditures) (assumptions for following year budget)

Review of management programs to oversee compliance with financial principles and policies

Resources

Resources

I

C

Board Effectiveness i Establish Board Work Plan Board C



Charter Section #4



i-i-A Ensure Board Members adhere to corporate governance principles and guidelines Declaration of conflict agreement signed by directors annually Indemnity Agreement signed by directors annually

Governance C C

√ √

i-i-B Ensure the Board’s own effectiveness and efficiency, including monitoring the effectiveness of individual Directors and Board officers and employing a process for Board renewal that embraces evaluation and continuous improvement

Governance/ Board

√

i-i-C i-i-C

Ensure compliance with audit and accounting principles

Audit

C

i-i-D i-i-D

Periodically review and revise governance policies, processes and structures as appropriate

Governance

√

Annual review of committee Charters Board √ THREB Terms of Reference (to be reviewed every 3 years. Next review 2017) Board D C

Fundraising k Support fundraising initiatives including donor cultivation activities. (through

Foundation Report) Foundation C C C C C √

PHA required programs l-i-A l-i-B l-i-C

Ensure that an occupational health and safety program and a health surveillance program are established and require accountability on a regular basis

Quality

Ensure that Policies are in place to encourage and facilitate organ procurement and donation

Quality

√

Ensure that the Chief Executive Officer, Nursing Management, Medical/Professional staff, and employees of the Hospital develop plans to deal with emergency situations and the failure to provide services in the Hospital

Quality

Recruitment



Charter Section #4



n

Approve nominating committee membership (noted in By-law) Governance

C

Review recommendations for new directors, non-director committee members (2-D-20)

Governance

C

Conduct the election of officers (2-D-18)

Governance √

Review evaluation results and improvement plans for the board, the board chair

(by the Governance Chair), board committees, committee chairs (2-D-40)

Review Committee reports on work plan achievements (2-A-16)

Governance

Governance

√ √



ON GOING AS NEEDED Charter Section #4

Charter Item Action (Italics-comments) Committee Responsible

i-i-C Board Effectiveness Compliance with the By-Law Governance

c-i-D Corporate Performance Processes in place to monitor and continuously improve upon the performance metrics

Resources/ Quality

c-i-A, B Ensure there are systems in place to identify, monitor, mitigate, decrease and respond to the principal risks to the Corporation:

o financial o quality o patient/workplace safety

Audit, Resources Quality

c-i-C

Oversee implementation of internal control and management information systems to oversee the achievement of the performance metrics

Resources

c-i-G Policies providing direction for the CEO and COS in the management of the day-to-day processes within the hospital

Governance Executive

d CEO and COS Executive compensation strategy, philosophy Executive d-ii-A,B CEO and COS Select the CEO, delegate responsibility and authority, and require

accountability to the board Executive

d-ii-C CEO and COS Policy and process for the performance evaluation and compensation of the CEO

Executive

d-ii-D, E CEO and COS

Select the COS, delegate responsibility and authority, and require accountability to the board

Executive

d-ii-F CEO and COS Policy and process for the performance evaluation and compensation of the COS

Executive

h Financial Viability Approve collective bargaining agreements Board



ON GOING AS NEEDED Charter Section #4


h Financial Viability Approve salary increases, material amendments to benefit plans,

programs and policies (to be reviewed)

Board

h Financial Viability Approve capital projects Resources d-ii-C CEO and COS Policy and process for the performance evaluation and compensation of

the CEO Executive



ON GOING AS NEEDED – Led by CEO – reported in CEO report/Quality Presentations Charter Section #4


g Build Relationships Build and maintain good relationships with the corporation’s key stakeholders

Board oversight Led by CEO

j-i-A Communication and Community Relationships

Establish processes for community engagement to receive public input on material issues

Board Oversight Led by CEO

j-i-B Promote effective collaboration and engagement between the corporation and its community, particularly as it relates to organizational planning, mission and vision

Board Oversight Led by CEO and Chair

j-i-C Work collaboratively with other community agencies and institutions in meeting the healthcare needs of the community

Board Oversight Led by CEO Quality

j-i-D Maintain information on the website Board oversight Led by CEO

j-i-E Establish a communication policy for the corporation; review periodically (1-B-15 last reviewed Sept 30, 2015 reviewed every 3 years)


m Communications Policy Oversee the maintenance of effective stakeholder relations through the corporation’s communications policy and programs


Agenda Item 1.3.3

Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4

Guideposts Defining Our RolesDevelopment of a clinical services plan Due June 2016 ↑ NA NA NA NA NA NA NA NA NA NA

Advance Health Links ↑ NA NA 77 119 163 201 233 266 304 351

Clinical Integration in Waterloo Region - clinical

governance planDue June 2016 ↑ NA NA NA NA NA NA NA NA NA NA

Integrated Clinical Programs ↑ NA NA NA NA NA NA NA NA NA NA

Improving QualityResidents will experience a decreased rate of

hospital readmissions for chronic conditions15.5% ↓ 18.9% 13.3% 13.9% 12.4% 12.4% 10.5% 18.2% 17.2% 14.1% 9.2%

Percentage of days residents spend in acute care

hospital beds when they should be receiving

their care in a more appropriate location (ALC)

will be lower

9.5% ↓ 18.4% 15.8% 15.1% 18.8% 15.4% 22.0% 17.8% 15.9% 16.3% 15.4%

Would you recommend this hospital to family

and friend?70% ↑

66.7% 60.2% 68.1% 69.0% 51.7% 50.0% 65.2% 65.9% 69.0% 60.0%

Patients: ED - Recommended 57.6% ↑ 58.3% 39.0% 36.4% 60.0% 38.2% 53.5% 39.4% 38.6% 53.4% 41.3%

Patients: Medicine - Recommended 70.5% ↑ 59.4% 66.7% 60.0% 55.0% 52.2% 40.0% 48.0% 58.6% 62.5% 64.3%

Patients: Obs - Recommended 76.1% ↑ NA NA 50.0% 46.9% 62.5% 46.0% 54.2% 61.9% 51.6% 45.5%

Patients: Paed - Recommended 80.2% ↑ NA NA 61.9% 55.6% 50.0% 41.7% 35.3% 70.6% 65.2% 41.7%

Strength Through PeopleStaff: Overall, how would you rate your

organization as a place to work? (poor, fair)10.0% ↓ NA NA NA NA NA NA 18.8% NA NA NA

Staff: How satisfied are you with job? (very

satisfied, satisfied)90.0% ↑ NA NA NA NA NA NA

62.6%NA NA NA

MD: Senior leadership decision making is

transparent90.0% ↑ NA NA NA NA NA NA

55.2%NA NA NA

MD: Senior leaders are committed to providing

patients with high quality care90.0% ↑ NA NA NA NA NA NA

65.5%NA NA NA

Driving Value and Affordability

Cost per weighted case$5,223 in 13/14

$5,281 in 14/15↓ NA $5,245 NA NA NA $5,185 NA NA NA NA

Regional IT system ↑ NA NA NA NA NA NA NA NA NA NA

Target Desired

Direction

CAMBRIDGE MEMORIAL HOSPITAL - STRATEGIC PLAN - 2014-17

2013-2014 2014-2015 2015-2016 2016-2017

MEASURING OUR PROGRESS

Guideposts Say what we do Work with others

500 patients with coordinated care plans

(needs validation)

Council recommendations approved by CMH

Board

Guideposts Give patients a voice Build QI capacity Improved transitions

Guideposts Energizing climate for staff Physician engagement Expanded leadership development

Guideposts Partnerships with others Costs in line Board

endorsement

Agenda Item 2.1.1

Page 1 of 1

BRIEFING NOTE - OPEN SESSION ____________________________________________________________________________ Date: June 21, 2016 Issue: Upcoming Meetings & Upcoming Events Purpose: Information Prepared by: Cheryl Vandervalk, Executive Assistant Approved by: Patrick Gaskin, President & CEO September 2016 Governance Committee September 8, 2016 4:30pm-6:00pm Quality Committee September 14, 2016 7:00am-9:00am Resources Committee September 26, 2016 5:00pm-7:00pm Capital Projects September 26 2016 3:30pm-5:00pm Board of Directors Meeting September 28, 2016 5:00pm-8:00pm WWLHIN Board Meetings * no additional meetings listed at this time on WWLHIN website OHA Conferences Essentials Certificate for New Directors September 16, 2016 2016 Events, Summer/Fall:

Foundation Events Best Bites Sunday September 11, 2016 Shade’s Mills Conservation Area

700 Coronation Blvd, Cambridge, ON N1R 3G2 Tel. 519.621 2333 Fax 519.740.4934. www.cmh.org

http://www.cmh.org/

Q3 Please provide any comments,concerns, or feedback you have in regard tothe content and/or process of the meeting

you are commenting on.Answered: 4 Skipped: 1

# Responses Date

1 Thought the discussion was good for the most part and that it focused on some very important, challenging andstrategic areas for the CMH Board and staff. It was a big package, but the meeting was only an hour longer than usualso that is a small price to pay to reduce the number of meetings during the year. Well run and on time meeting. Greatsupper. Good to see nearly everyone involved in the discussions as well.

5/28/2016 7:46 AM

2 A packed agenda but overall a good meeting 5/27/2016 8:43 PM

3 Long meeting but excellent briefing notes really helped us get through a heavy agenda. 5/26/2016 8:47 AM

4 I found that we had a very good board meeting.. A number of topics generated questions and discussion that wasexcellent. One point was that it was a very full agenda with some important and heavy topics to be dealt with. Thematerial provided was very well done and much appreciated but because it was a heavy agenda, there was a lot ofmaterial to review. It seems that members are reviewing the material and that is very encouraging.

5/25/2016 9:21 PM

4 / 5

Board and Committees Meeting Evaluations 2015-2016new

Agenda Item 2.1

Page 1 of 3

BRIEFING NOTE – Resources Committee Date: June 22, 2016 Issue: May Financial Statements Purpose: Review of May Financial Statements Prepared by: Mike Prociw Approved by: Patrick Gaskin Summary CMH has a May year to date operating surplus of $18K after building amortization and related capital grants which represents a $ 168K positive variance from budget. In May, CMH had an operating deficit of $20K. The positive YTD variance is primarily due to higher then expected parking revenue and the timing of expenditures within supplies and medical remuneration offset by pressures within salaries, wages and related benefits. Revenue A brief summary of some of the major year to date revenue variances include: MOH Funding:

• For the elective QBPS, the knee replacements are 34% (22 procedures) above target and hips are 8% (3 procedures) below target. Cataracts are 11% above target. Within the HSAA recently received, CMH was allocated funding for 12 additional joints and 116 additional cataracts. The volume increase was in lieu of a funding increase. Additional elective QBPs in breast cancer are 12 procedures below target, thyroid cancer surgery is at target, knee arthroscopy is 17 procedures under target and tonsillectomy is at target.

• For the remaining QBPs, coded data is not available and revenue was recognized based on the previous year’s actual results.

• The MOH Onetime/Other funding is less than budget due to the timing of the implementation of the new grad program and the alignment of revenue with expenses for the Hospital On Call Coverage funding.


http://www.cmh.org/

Agenda Item 2.1

Page 2 of 3

Billable Patient Services • The negative YTD variance of $51K is primarily due to less than expected

revenue from out of country patients and semi-private accommodations.

Recoveries and Other Revenues • The year to date positive variance is primarily due to higher than expected

revenue from parking and interest.

Expenses Salaries and Wages

• There is a negative variance of $ 36K for the month and a negative variance of $157K year to date. The negative YTD variance is attributed to overtime discussed below, training costs for additional staff in the emergency department and registration, and sick time in medicine and housekeeping.

• Sick and overtime was under budget in the month by $11K (2015 – over budget $65K). The YTD sick and overtime is over budget by $96K (2015 – over budget $194K). The table below provides a summary in hours for sick and overtime.

A brief overview of the year to date over time variance is as follows:

• The emergency department has a YTD negative variance of $42K. The major cause of the overtime has been the length of time it has taken to recruit staff to fill vacant positions. It has been very difficult to attract and retain part time staff in the department. Overtime pressures are expected to continue over the remainder of the summer until staffing positions have been filled.

• The medicine units have a YTD negative variance of $17K which has resulted from a negative sick variance and a greater number than expected patients requiring one to one care. The average number of patient days has remained within the current compliment of beds.

A brief overview of the year to date sick variance is as follows

• The medicine units and housekeeping have a combined negative YTD variance of $37K. This variance is offset by savings in Women and Children, Labs and Mental Health. Work continues with the timely delivery of letters and meetings with staff with a high number of sick days and occurrences. Other variances in salaries and wages are

• The emergency department has a YTD variance of $ 104K which is due to

overtime and training costs of new staff hired.

May YTD HOURS Actual Budget 2015 Actual Budget 2015 Overtime 1’629 1,469 2,569 4,559 2,891 4,662 Sick 2,456 2,583 3,238 6,073 5,084 6,909

Agenda Item 2.1

Page 3 of 3

• The registration department has a negative YTD variance of $ 64K which is primarily due to additional costs resulting from the training of new staff hired.

Benefits • The YTD maternity top up expense has a $ 20 K negative variance. Past

practice was used to determine the budget allocation. The entire maternity top up is recognized at the inception of the leave and therefore the expense is subject to fluctuations during the year

Medical Remuneration • The positive YTD variance is mainly attributed to the timing of expenditures

within the office of the Chief of Staff.

Medical and Surgical Supplies • The majority of the negative YTD variance is attributed to the Operating Room.

The majority of the variance is a result of performing 21 knees greater than budget, 25 additional cataracts and more shoulders then the previous year.

Drug Expense • The previous year’s large negative variance has been reduced due to an

increase in budget for systemic treatment. The budget adjustment for volume appears to be tracking well year to date.

Other Supplies and Expenses • The clinical areas have a positive YTD surplus of K114K. This variance is

consistent with the previous years expenditures and is considered a timing difference which will be diminished throughout the year.

• $ 87K of the variance is a result of the timing of expenditures within the Lab and Diagnostic Imaging.

• Administration and HR contribute $53K of the positive variance. As in past years the variance will vary based on the need to engage professional services.

Amortization • The positive variance is due to the timing of capital purchases during the year

Balance Sheet and Statement of Cash CMH’s current cash position is $25 M and remains in strong position. The working capital ratio meets the requirements of the Working Funds Agreement. The Capital Redevelopment Project has increased to $59.6M. In accordance with the agreement with the Ministry of Health CMH will make a lump sum payment of $ 65M to the general contractor once CMH takes ownership of the building. $ 59M of the payment will be funded by the Ministry with the remaining amount, $6M, will be funded the CMH Foundation

Agenda Item 2.2.1

22-Jun-16

CAMBRIDGE MEMORIAL HOSPITAL

STATEMENT OF INCOME AND EXPENSE

16/17

Actual Plan Variance % var YTD Actual YTD Plan YTD Variance % var Plan May 14 YTD May 14 15/16 YE

Operating Income

MoH Funding

3,639,821$ 3,787,432$ (147,611)$ (3.9%) MoH Base $ 7,286,546 7,463,344$ (176,798)$ (2.4%) 44,610,517$ 3,834,377$ 7,612,430$ $ 44,362,011

2,453,388 2,543,107 (89,719) (3.5%) MoH HBAM 4,827,634 5,011,329 (183,695) (3.7%) 29,954,147 2,470,855 4,857,041 29,521,147

1,518,985 1,267,741 251,244 19.8% MoH QBP 2,910,985 2,509,877 401,108 16.0% 15,842,704 1,163,373 2,289,410 15,773,153

545,428 577,347 (31,919) (5.5%) MoH Onetime / Other 1,064,056 1,137,691 (73,635) (6.5%) 6,869,912 528,300 1,048,088 7,163,712

8,157,622 8,175,627 (18,005) -0.2% Total MoH Funding 16,089,221 16,122,241 (33,020) -0.2% 97,277,280 7,996,905 15,806,969 96,820,023

1,235,046 1,227,027 8,019 0.7% Billable Patient Services 2,366,836 2,417,960 (51,124) (2.1%) 14,449,063 1,239,448 2,571,426 13,843,229

905,794 785,603 120,191 15.3% Recoveries and Other Revenue 1,695,320 1,548,065 147,255 9.5% 9,553,323 789,652 1,645,436 10,426,798

196,724 176,741 19,983 11.3% Amort'n of Deferred Equip Capital Grants 393,512 348,789 44,723 12.8% 2,089,611 168,185 336,476 2,303,745

288,499 289,683 (1,184) (0.4%) MoH Special Votes Revenue 563,113 570,844 (7,731) (1.4%) 3,441,458 264,313 558,582 3,430,094

10,783,685 10,654,681 129,004 1.2% Total 21,108,002 21,007,899 100,103 0.5% 126,810,735 10,458,503 20,918,889 126,823,889

Operating Expense4,882,964 4,847,090 (35,874) (0.7%) Salaries & Wages 9,672,804 9,515,991 (156,813) (1.6%) 57,226,102 4,734,288 9,409,104 56,564,531

1,354,903 1,358,854 3,951 0.3% Employee Benefits 2,732,317 2,679,942 (52,375) (2.0%) 15,026,882 1,302,768 2,600,902 15,369,312

1,516,211 1,529,323 13,112 0.9% Medical Remuneration 2,845,018 3,017,134 172,116 5.7% 18,010,751 1,517,952 3,036,445 17,868,159

873,014 703,173 (169,841) (24.2%) Medical & Surgical Supplies 1,644,086 1,382,801 (261,285) (18.9%) 8,285,150 735,009 1,388,519 8,428,593

496,136 497,090 954 0.2% Drug Expense 955,963 976,452 20,489 2.1% 5,782,859 466,924 942,406 5,650,439

927,101 1,067,578 140,477 13.2% Other Supplies & Expenses 1,771,533 2,083,129 311,596 15.0% 12,648,512 1,036,056 1,748,467 12,055,399

388,266 397,317 9,051 2.3% Equipment Depreciation 780,661 782,954 2,293 0.3% 4,672,148 331,021 662,147 4,648,403

302,859 301,744 (1,115) (0.4%) MoH Special Votes Expense 563,113 594,278 31,165 5.2% 3,536,992 264,313 558,582 3,430,094

10,741,454 10,702,169 (39,285) (0.4%) Total 20,965,495 21,032,681 67,186 0.3% 125,189,396 10,388,331 20,346,572 124,014,930

42,231 (47,488) 89,719 (188.9%) MOH Surplus (Deficit) 142,507 (24,782) 167,289 (675.0%) 1,621,339 70,172 572,317 2,808,959

Other income (expense):

(152,703) (157,104) 4,401 (2.8%) Building Depreciation (305,409) (309,587) 4,178 (1.3%) (1,850,462) (147,834) (296,468) (1,823,703)

90,409 93,316 (2,907) (3.1%) Amortization of Deferred Build Capital Grants 180,779 183,880 (3,101) (1.7%) 1,099,123 85,338 170,675 1,072,179

(20,063)$ (111,276)$ 91,213$ (82.0%) Net Surplus (Deficit) for the period 17,877$ (150,489)$ 168,366$ (111.9%) 870,000$ 7,676$ 446,524$ 2,057,435$

CONFIDENTIAL

Month of May 2016 For the Year Ending May 31, 2016 15/16 prior year actuals

Agenda Item 2.1

CAMBRIDGE MEMORIAL HOSPITAL 22-Jun-16

COMPARATIVE BALANCE SHEETMAY MARCH

2016 2016

ASSETS

Current Assets

Cash and short-term investments 21,593,450$ 22,450,973$

Due from Ministry of Health/LHIN 1,831,630 1,356,162

Other receivables 1,775,430 2,214,717

Inventories 1,855,870 1,775,585

Prepaid expenses 694,906 940,218

27,751,286 28,737,655

Non-Current Assets

Grant receivable - -

Cash and investments restricted - Capital 3,270,660 3,891,693

Endowment and special purpose fund cash & investments 187,427 187,427

Capital Assets 74,922,557 75,016,310

Capital Redevelopment Construction in Progress 59,903,936 51,690,998

TOTAL ASSETS 166,035,866$ 159,524,083$

LIABILITIES & EQUITY

Current Liabilities

Due to Ministry of Health/LHIN 450,719$ 490,879$

Accounts payable and accrued liabilities 20,275,712 21,592,823

20,726,431 22,083,703

Long Term Liabilities

Employee future benefits 4,117,603 4,090,000

Capital Redevelopment Construction Payable 59,584,322 51,371,669

Deferred Capital Grants Capital Redevelopment 59,889,352 60,278,429

Deferred Capital Grants and Donations 2,245,400 2,245,400

125,836,677 117,985,499

Net Assets:

Unrestricted 2,907,251 2,563,952

Externally restricted special purpose funds 187,427 187,427

Invested in Capital Assets 16,378,080 16,703,502

19,472,758 19,454,881

TOTAL LIABILITIES & EQUITY 166,035,866$ 159,524,083$

Working Capital Balance 7,024,855 6,653,952

Working Capital Ratio (Current Ratio) 1.34 1.30

Agenda Item 2.2.1

CAMBRIDGE MEMORIAL HOSPITAL 22-Jun-16

STATEMENT OF CHANGES IN FINANCIAL POSITION

For the Month Ending May 31, 2016

Cash Provided By (used in) Operations: YTD MAY16 YTD APR16 FY 2015/16

Excess (deficiency) of revenue over expenses 17,877$ 37,940$ 2,057,435$

Items not involving cash:

-Amortization 1,086,070 545,101 6,472,106

-Loss on Disposal of Assets - - (10,000)

-Amortization of deferred grants and donations (574,291) (287,158) (3,375,924)

Change in non-cash operating working capital (1,228,425) (2,329,581) 526,052

Change in employee future benefits 27,603 (3,477) 2,211

(671,166) (2,037,175) 5,671,880

Investing:

Acquisition of capital assets & CRP (9,205,255) (4,394,427) (53,465,062)

Grant receivable - - -

Endowment and special purpose investments - - 115,060

(9,205,255) (4,394,427) (53,350,002)

Financing:

Capital donations and grants & CRP 185,213 182,368 6,305,853

Construction payable 8,212,652 4,176,460 44,586,313

8,397,865 4,358,828 50,892,166

Increase (Decrease) In Cash for the period (1,478,556) (2,072,774) 3,214,044

Cash & Investments - Beginning of Year 26,342,666 26,342,666 23,128,622

Cash & Investments - End Of Period 24,864,110$ 24,269,892$ 26,342,666$

Cash & Investments Consist of:

Unrestricted Endowment and Special Purpose Investments 29,668$ 29,668$ 29,668$

Cash & Investments Operating 21,563,782 20,622,981 22,421,305

Cash & Investments Restricted 3,270,660 3,617,243 3,891,693

Total 24,864,110$ 24,269,892$ 26,342,666$

DATA POINT

M-14 J-14 J-14 A-14 S-14 O-14 N-14 D-14 J-15 F-15 M-15 A-15 M-15 J-15 J-15 A-15 S-15 O-15 N-15 D-15 J-16 F-16 M-16 A-16 M-16

Actual 3,056 3,170 2,991 2,337 2,454 2,567 2,637 3,650 3,642 4,299 5,350 3,671 3,238 3,682 4,631 4,091 3,815 4,447 3,803 3,847 3,935 3,685 3,337 3769 2456

Budget 3,103 2,992 2,903 2,879 2,797 2,894 2,814 2,911 2,911 2,630 2,930 2,403 2,510 2,419 2,353 2,282 2,205 2,283 2,244 2,337 2,310 2,160 2,232 2,589 2,686

-

1,000

2,000

3,000

4,000

5,000

6,000

CMH - Sick Hours - 24Month Actual vs. Budget


Actual 2,023 1,723 1,742 1,416 1,678 2,113 2,171 1,608 3,020 2,826 1,844 2,093 2,569 2,265 3,808 4,099 2,855 3,130 1,353 2,348 1,639 2,549 2,704 2,913 1,647

Budget 1,591 1,537 1,523 1,529 1,459 1,502 1,454 1,499 1,520 1,380 1,532 1,529 1,592 1,537 1,552 1,390 1,327 1,359 1,328 1,469 1,361 1,262 1,474 1,421 1,469

-

1,000

2,000

3,000

4,000

5,000

CMH Over Time Hours - 24Month Actual vs. Budget

Agenda Item 2.2.1


Series1 85,252 85,030 84,269 84,380 82,828 81,305 78,859 79,042 79,468 80,833 82,429 82,136 81,238 80,616 81,722 82,644 83,110 84,634 85,505 85,710 86,134 86,290 85,958 86,104 85,504

Series3 67,538 67,881 68,047 68,189 68,335 68,413 68,504 68,643 68,780 69,139 69,397 68,779 68,181 67,614 67,057 66,459 65,876 65,278 64,735 64,191 63,619 63,176 62,506 62,089 61,672

50,000

55,000

60,000

65,000

70,000

75,000

80,000

85,000

90,000

CMH - Sick Hours - Total 24Month Moving Average


Actual 51,509 50,556 50,484 50,232 49,066 48,164 47,771 46,436 46,860 46,702 45,044 45,066 45,719 46,453 48,240 50,639 52,580 54,638 55,024 56,267 56,273 55,912 55,372 56,489 56,113

Budget 34,833 35,065 35,239 35,420 35,573 35,736 35,886 36,047 36,200 36,333 36,483 36,433 36,397 36,371 36,371 36,200 36,040 35,868 35,714 35,655 35,466 35,322 35,235 35,127 35,005

20,000

25,000

30,000

35,000

40,000

45,000

50,000

55,000

60,000

CMH Over Time Hours - Total 24Month Moving Average

Agenda Item 2.3.1

Page 1 of 4

COMMITTEE MEETING SUMMARY - OPEN Date: June 18, 2016

Issue: Board Quality Committee Meeting, June 15, 2016

Prepared by: Iris Anderson, Administrative Assistant, Clinical Programs

Approved by: Sandra Hett, VP Clinical Programs & CNE

Attachments: Accreditation update H-SAA Scorecard PFAC update

Accreditation update As per attached briefing note.

H-SAA Quality Scorecard Mr. Meyette briefly spoke to the Quality Indicators #9 (Mental Health Weighted Cases) and #10 (Mental Health Weighted Cases), as noted in the previously circulated H-SAA Quality Scorecard. Since the time of this quality package reconciliation of data has occurred and the volumes for mental health and rehabilitation are in keeping with previous years volumes.

A question regarding progress on ED metrics was raised. S. Hett responded that this is a complex metric with many variables contributing to achieving the target goal. A value stream analysis was updated and focused attention to process improvement has occurred with some measurable improvements. The PIA time has dropped with process improvement strategies, eliminating up to 10 minutes from the process. Each clinical area focuses on their contribution to the goal and is able to celebrate continuous improvements that are measured and discussed. .

Patient Relations Process Ms. Barefoot welcomed Ms. Pavlic to the meeting.

Following the retirement of Ms. O’Connor, Ms. Pavlic was recruited to the position of Patient Experience Lead. The position title was deliberately changed, recognizing the core functions remain unchanged (complaints, compliments, negotiations, resolution) however a directional intent to approach patient experience in a forward proactive manner A more complete strategy will be shared with this committee in September 2016.


http://www.cmh.org/

Agenda Item 2.3.1

Page 2 of 4

As referenced in the Quality Workplan, the Patient Experience Lead will provide an update report to the Quality Committee twice a year.

Patient Family Advisory Council (PFAC) update Ms. Barefoot spoke to the previously circulated briefing note.

The last update on PFAC was presented to the Quality Committee in September 2015, where the Council had only six members. Since then, the total membership has reached nine members. Recruitment of two staff positions will start immediately, with the target of having them attend the September PFAC meeting.

Ms. Barefoot added that two PFAC members are involved with the Emergency Department Transitional Planning Team (CRP). Work continues to review the care of delivery in the new Emergency space. Feedback from Management and participants has been very positive.

As the PFAC matures, opportunities for updates to the Quality Committee by a PFAC member will be explored.

Board Oversight (presentations pre-circulated in package 2)

LDRP, including Patient Story Ms. Lywood, Manager Women & Children’s Services, Ms. Hauck, Director Surgical Programs, Dr. Rajguru, Chief of Pediatrics, and Ms. Doe, Midwife joined the meeting at 0702h. Ms. Hett welcomed the guests and requested of Ms. Lywood to provide highlights from the previously circulated presentation.

Ms. Lywood provided highlights from the previously circulated presentation: − In the new Build, the Birthing unit will be located on the first level of the hospital

adjacent to the OR; the nursery, post-partum and paediatrics will be located on another level, requiring new models of care.

− Moving towards the goal of Baby Friendly Designation − Receiving positive feedback of introduction of Skin-to-skin program for caesarian

moms and babes in the OR and in PACU − Current gaps in ability to provide timely access to epidurals for laboring moms &

working with Anesthesia to provide timely access to epidurals − With an increased incidence of Code Pink, monthly mock Code Pinks are held to

rehearse roles and skills. ensuring all nurses, midwives and physicians maintain competency

Ms. Lywood noted that with a model change in the new Build, there will be considerable education and cross training of nursing staff that will be required. This will support cross coverage and the ability to ensure adequate staffing levels and skillsets in each area.

Ms. Lywood continued by sharing a story regarding a patient of a midwife presented to the Birthing area requiring an epidural. As all budgeted RN’s were in 1:1 assignments with active labour cases, attempts to call in nurses occurred and unsuccessful. The midwives have this competency however it is not granted with their privileges at CMH.

Agenda Item 2.3.1

Page 3 of 4

This patient was discharged and travelled to another hospital to obtain access to this pain modality.

As a result, recommendations for improvement include working with the interprofessional team to facilitate midwives to work within their full scope of practice, allowing them to care for patients with epidurals. Discussions have occurred at MAC regarding this change. Mr. Kron opened the floor to questions and comments.

A discussion ensued regarding the scope of the practice of a midwife, and gaps within epidural services at CMH.

One Committee member commented that the patient experience results “Would You Recommend Obstetrics” at 53% were oddly lower than the “Overall Quality Care for Obstetrics” at 93%. Ms. Lywood reported that patients are happy overall, however would not recommend CMH Obstetrics due to the esthetics of the building, gaps in the baby-friendly services, and lack of lactation support.

Dr. Rajguru voiced concern of the lack of lactation support at CMH. Dr. Rajguru also expressed apprehension of separating of the Women & Children’s Services on two separate floors in the new build.

There being no further questions, Mr. Kron thanked the guests for their presentation.

Information Management Technology (IMT), including Health Information Management (HIM)

Mr. Winker, Manager of IMT, Mr. Prociw, Vice President, Finance & Corporate Services, and Ms. Martin, Manager of Health Records and Registration, joined the meeting at 0720h.

Mr. Kron directed the Committee members to the previously circulated presentation.

Mr. Winkler highlighted viruses and protection systems: − Virus protection system, such as eMail Gateway Filtering, Web Gateway

Filtering − Data backups − Under eEmail Gateway filtering, 1.2 million emails were assessed; only

42,000 of those emails were allowed through the CMH system − End user education

Mr. Kron opened the floor for questions and comments.

A discussion ensued, and Mr. Winkler responded to inquiries regarding the Ransomeware attacks and data backups.

Ransomeware is a malicious virus which encryptes files within an organization’s desktop and server. Detection often happens after it has been launched by the end user. CMH has had six Ransomeware attacks in the last six months. When detected, IT was alerted and the corrupted computers were removed from the network. The detection of the virus and recovery process was successful every time.

Agenda Item 2.3.1

Page 4 of 4

Mr. Winkler reported that data backups provide a final layer of protection for our network, and reviewed daily to ensure successful completion.

Ms. Martin introduced herself, and directed the Committee members to the previously circulated presentation.

Ms. Martin provided a brief overview of the following: • Scanning Inpatient Records as of April 2015; this improves patient information

availability for patient care.• Coding – audits in place; we engaged physicians to improve documentation to

accurately reflect our weighted cases; e.g. CHF and COPD.• Voice Recognition – Currently, CMH outsources dictation however has front end

dictation which allows practitioner via voice recognition software to produce aclinical record and authenticate in real time. This is a significant change tophysician workflow and while there are some champions and early adopters, thisis not mandatory. Going forward all new physicians will be set up on this systemas a standard. Work continues to promote this technology.

• Staff resources – working with Clerical teams to review errors, omissions, toimprove efficiencies, and provide staff with a better understanding that theircontributions add value and impact data integrity and funding.

Page 1 of 4

BRIEFING NOTE – Quality Committee

Date: June 7, 2016

Issue: Accreditation Update

Purpose: Information

Prepared by: Liane Barefoot, Director Patient Experience, Quality & Risk

Approved: Patrick Gaskin, President & CEO

Background Cambridge Memorial Hospital underwent our Accreditation Canada onsite visit in November 2015. At that time we received the following assessment of the quality dimension criteria:

Quality Dimension Met Unmet N/A Total

Population Focus 64 0 0 64

Accessibility 87 0 0 87

Safety 623 7 20 650

Worklife 142 0 1 143

Client-centred Services 187 0 3 190

Continuity of Services 62 0 2 64

Appropriateness 938 7 14 959

Efficiency 66 0 0 66

Totals 2169 14 40 2223

In summary we met 99.4% of the applicable criteria (2169/2183 = 99.4%).

In addition to the above criteria we achieved the following at our onsite visit on the Required Organizational Practices (ROPs) major and minor tests of compliance:


http://www.cmh.org/

Page 2 of 4

ROP Test for Compliance Rating

Major Met Minor Met

Medication reconciliation at care transitions (Ambulatory Systemic Cancer Therapy)*

0 of 7 0 of 0

Concentrated Electrolytes (Medication Management Standards)

1 of 3 0 of 0

Heparin Safety (Medication Management Standards)

3 of 4 0 of 0

All ROP tests of compliance (including all of above)

297 of 307 60 of 60

All ROP tests of compliance (excluding Medication reconciliation at care transitions – ambulatory systemic cancer therapy)*

297 of 300 60 of 60

*2015 requirement for medication reconciliation at care transitions was to demonstrated this in one clinical area – we

demonstrated/met these tests of compliance in 7 of 8 areas despite only being required to do so in one clinical area.

Of the applicable ROP tests of compliance we achieved 357/360 major and minor tests of compliance or 99.2%. To summarize, at the time of the onsite survey, our performance can be expressed as follows:

Based on being cited for three (3) major ROP tests of compliance our decision level was accredited. While disappointing and deflating to the organization given the energy, passion and drive towards Exemplary Standing leading up to our onsite visit, we persevere and moved immediately into working on implementing the evidence for the three (3) cited tests of compliance.

Page 3 of 4

Follow Up Evidence Our decision letter issued December 2015 indicated that we were required to provide follow-up evidence for the three (3) ROP major tests of compliance by April 19, 2016. A phenomenal amount of work has been undertaken in the 5 months following our onsite visit across the organization and involved substantial work by pharmacy, medical leaders and physicians, educators and front line nursing staff. We provided the required evidence to Accreditation Canada and recently were informed that the ROP tests of compliance had been fulfilled; however our accreditation award remained as Accredited. As of now, our accreditation performance can be expressed as follows:

The Accreditation Canada Qmentum Four-Year Cycle Info Graph below indicates that at 5 months post onsite visit the ‘opportunity to improve decision’ exists.

(Current status)

Page 4 of 4

In a follow up conversation between Accreditation Canada and myself we were informed that given that we had three (3) major tests of compliance that were cited at our onsite, moving our status was apparently never an option for our organization. A letter was drafted in short order from Patrick to Accreditation Canada requesting the following information:

The rationale for our decision remaining as accredited

Confirmation that the “opportunity to improve” our award did not exist for Cambridge

Memorial Hospital given our onsite survey results

The rationale for why we were not informed that the “opportunity to improve” did not exist

The details as to the ramifications for the organization if we had not submitted the

evidence for the three (3) major ROP tests of compliance by April 2016

The details as to the ramifications for the organization if we do not submit the evidence

requested by April 2017

The details of any further appeal process concerning our award that may exist for us

Next Steps A teleconference with Accreditation Canada, Patrick Gaskin, Kim Pittway and myself occurred on May 31, 2016. During this call we were informed that moving the decision from accredited to commendation was not an option for CMH given that we were cited for greater than two (2) ROPs at our onsite visit. The requirement to submit evidence for the three (3) tests of compliance in April 2016 was to maintain our accreditation status; not having submitted sufficient evidence could have put our accreditation in jeopardy. Similarly, we will be required to submit additional evidence by next April 2017 in order to maintain our accreditation status. No further options exist for us to appeal our decision at this time. Cambridge Memorial Hospital has been invited to participate in a focus group with Accreditation Canada on re-developing their decision guidelines (a process that was underway prior to us sending in our letter).

Progress Report

Cambridge Memorial Hospital

On-site survey dates: November 15, 2015 - November 19, 2015

Accredited by ISQua

Cambridge, ON

Progress Report issued: May 20, 2016

Confidentiality and Dissemination

This report is confidential. Accreditation Canada provides it to the organization and does not release it to anyother parties.

In the interest of transparency and accountability, Accreditation Canada encourages the organization todisseminate its Progress Report to staff, board members, clients, the public, and other stakeholders.

About the Progress Report

Cambridge Memorial Hospital (referred to in this report as “the organization”) had an on-site survey in November2015. To maintain or improve its accreditation decision, the organization needed to complete required follow-upsafter the survey and submit evidence of action taken for Accreditation Canada’s review.

This Progress Report reflects the organization’s progress since the on-site survey. The report shows theorganization’s compliance with the quality dimensions, the standards, and the Required Organizational Practices(ROP) at the time of the on-site survey and following Accreditation Canada’s progress review.

Any alteration of this Progress Report compromises the integrity of the accreditation process and is strictlyprohibited.

QMENTUM PROGRAM

© Accreditation Canada, 2016

Accreditation Canada is a not-for-profit, independent organization that provides health services organizationswith a rigorous and comprehensive accreditation process. We foster ongoing quality improvement based onevidence-based standards and external peer review. Accredited by the International Society for Quality in HealthCare, Accreditation Canada has helped organizations strive for excellence for more than 50 years.

Table of Contents

Accreditation Decision 1

Overview by Quality Dimensions 2

Overview by Standards Set 3

Overview by Required Organizational Practices 5

Summary 12

QMENTUM PROGRAM

iTable of ContentsProgress Report

After the on-site survey, the organization’s accreditation decision was:

Accredited

After the progress review in May 2016, the organization’s accreditation decision is:

Accredited

QMENTUM PROGRAM

Accreditation Decision

Accreditation Decision 1Progress Report

QMENTUM PROGRAM

Overview by Quality Dimensions

Accreditation Canada defines quality in health care by focusing on eight dimensions that represent key serviceelements. Every criterion in the standards is associated with a quality dimension.

This table shows the organization’s standards compliance for each quality dimension at the time of the on-sitesurvey and following the progress review.

Quality Dimension Compliance (%)

On-site surveyNovember 2015

Progress reviewMay 2016

Population Focus (Work with my community toanticipate and meet our needs)

100.00% 100.00%

Accessibility (Give me timely and equitable services) 100.00% 100.00%

Safety (Keep me safe) 98.89% 99.21%

Worklife (Take care of those who take care of me) 100.00% 100.00%

Client-centred Services (Partner with me and myfamily in our care)

100.00% 100.00%

Continuity of Services (Coordinate my care across thecontinuum)

100.00% 100.00%

Appropriateness (Do the right thing to achieve thebest results)

99.26% 99.26%

Efficiency (Make the best use of resources) 100.00% 100.00%

Overview by Quality Dimensions 2Progress Report

QMENTUM PROGRAM

Overview by Standards Set

Qmentum standards sets identify policies and practices that contribute to high-quality, safe, and effectivelymanaged care. Each standard has associated criteria that contribute to achieving that standard.

System-wide sets of standards address quality and safety at the organizational level in areas such as governanceand leadership, while population-specific and service excellence sets of standards address specific populations,sectors, and services. The sets of standards used to assess an organization’s programs are based on the type ofservices it provides.

This table shows the organization’s compliance with the applicable sets of standards at the time of the on-sitesurvey and following the progress review.

Standards Set Compliance (%)



High prioritycriteria

All Criteria High prioritycriteria

All Criteria

Governance 100.00% 100.00% 100.00%100.00%

Leadership 100.00% 100.00% 100.00%100.00%

Infection Prevention andControl Standards

100.00% 100.00% 100.00%100.00%

Medication ManagementStandards

94.52% 94.03% 94.03%94.52%

Ambulatory Systemic CancerTherapy Services

100.00% 100.00% 100.00%100.00%

Biomedical Laboratory Services 100.00% 100.00% 100.00%100.00%

Critical Care 100.00% 100.00% 100.00%100.00%

Diagnostic Imaging Services 100.00% 100.00% 100.00%100.00%

Emergency Department 100.00% 100.00% 100.00%100.00%

Medicine Services 93.33% 98.02% 98.02%93.33%

Mental Health Services 100.00% 100.00% 100.00%100.00%

Obstetrics Services 100.00% 99.29% 99.29%100.00%

Perioperative Services andInvasive Procedures Standards

100.00% 100.00% 100.00%100.00%

Overview by Standards Set 3Progress Report

QMENTUM PROGRAM

Standards Set Compliance (%)



High prioritycriteria

All Criteria High prioritycriteria

All Criteria

Point-of-Care Testing 100.00% 100.00% 100.00%100.00%

Rehabilitation Services 100.00% 100.00% 100.00%100.00%

Reprocessing and Sterilizationof Reusable Medical Devices

100.00% 100.00% 100.00%100.00%

Transfusion Services 100.00% 100.00% 100.00%100.00%

Overview by Standards Set 4Progress Report

QMENTUM PROGRAM

Overview by Required Organizational Practices

In the Qmentum program, a Required Organizational Practice (ROP) is defined as an essential practice that anorganization must have in place to enhance client safety and minimize risk. Each ROP has associated tests forcompliance, categorized as major and minor. All tests for compliance must be met for the ROP to be rated asmet.

This table shows the organization’s compliance with the applicable ROPs at the time of the on-site survey andfollowing the progress review.

Required Organizational Practice Compliance



Patient Safety Goal Area: Safety Culture

MetMetAccountability for Quality(Governance)

MetMetAdverse Events Disclosure(Leadership)

MetMetAdverse Events Reporting(Leadership)

MetMetClient Safety Quarterly Reports(Leadership)

MetMetClient Safety Related-Prospective Analysis(Leadership)

Patient Safety Goal Area: Communication

MetMetClient and Family Role in Safety(Ambulatory Systemic Cancer Therapy Services)

MetMetClient and Family Role in Safety(Critical Care)

MetMetClient and Family Role in Safety(Diagnostic Imaging Services)

MetMetClient and Family Role in Safety(Medicine Services)

MetMetClient and Family Role in Safety(Mental Health Services)

MetMetClient and Family Role in Safety(Obstetrics Services)

Overview by Required Organizational Practices 5Progress Report

QMENTUM PROGRAM





MetMetClient and Family Role in Safety(Perioperative Services and Invasive ProceduresStandards)

MetMetClient and Family Role in Safety(Rehabilitation Services)

MetMetInformation Transfer(Ambulatory Systemic Cancer Therapy Services)

MetMetInformation Transfer(Critical Care)

MetMetInformation Transfer(Emergency Department)

MetMetInformation Transfer(Medicine Services)

MetMetInformation Transfer(Mental Health Services)

MetMetInformation Transfer(Obstetrics Services)

MetMetInformation Transfer(Perioperative Services and Invasive ProceduresStandards)

MetMetInformation Transfer(Rehabilitation Services)

MetMetMedication reconciliation as a strategic priority(Leadership)

UnmetUnmetMedication reconciliation at care transitions(Ambulatory Systemic Cancer Therapy Services)

MetMetMedication reconciliation at care transitions(Critical Care)


QMENTUM PROGRAM





MetMetMedication reconciliation at care transitions(Emergency Department)

MetMetMedication reconciliation at care transitions(Medicine Services)

MetMetMedication reconciliation at care transitions(Mental Health Services)

MetMetMedication reconciliation at care transitions(Obstetrics Services)

MetMetMedication reconciliation at care transitions(Perioperative Services and Invasive ProceduresStandards)

MetMetMedication reconciliation at care transitions(Rehabilitation Services)

MetMetSafe Surgery Checklist(Obstetrics Services)

MetMetSafe Surgery Checklist(Perioperative Services and Invasive ProceduresStandards)

MetMetThe “Do Not Use” list of abbreviations(Medication Management Standards)

MetMetTwo Client Identifiers(Ambulatory Systemic Cancer Therapy Services)

MetMetTwo Client Identifiers(Biomedical Laboratory Services)

MetMetTwo Client Identifiers(Critical Care)

MetMetTwo Client Identifiers(Diagnostic Imaging Services)


QMENTUM PROGRAM





MetMetTwo Client Identifiers(Emergency Department)

MetMetTwo Client Identifiers(Medicine Services)

MetMetTwo Client Identifiers(Mental Health Services)

MetMetTwo Client Identifiers(Obstetrics Services)

MetMetTwo Client Identifiers(Perioperative Services and Invasive ProceduresStandards)

MetMetTwo Client Identifiers(Point-of-Care Testing)

MetMetTwo Client Identifiers(Rehabilitation Services)

MetMetTwo Client Identifiers(Transfusion Services)

Patient Safety Goal Area: Medication Use

MetMetAntimicrobial Stewardship(Medication Management Standards)

MetUnmetConcentrated Electrolytes(Medication Management Standards)

MetUnmetHeparin Safety(Medication Management Standards)

MetMetHigh-Alert Medications(Medication Management Standards)

MetMetInfusion Pumps Training(Ambulatory Systemic Cancer Therapy Services)


QMENTUM PROGRAM




Patient Safety Goal Area: Medication Use

MetMetInfusion Pumps Training(Critical Care)

MetMetInfusion Pumps Training(Emergency Department)

MetMetInfusion Pumps Training(Medicine Services)

MetMetInfusion Pumps Training(Obstetrics Services)

MetMetInfusion Pumps Training(Perioperative Services and Invasive ProceduresStandards)

MetMetInfusion Pumps Training(Rehabilitation Services)

MetMetNarcotics Safety(Medication Management Standards)

Patient Safety Goal Area: Worklife/Workforce

MetMetClient Flow(Leadership)

MetMetClient Safety Plan(Leadership)

MetMetClient Safety: Education and Training(Leadership)

MetMetPreventive Maintenance Program(Leadership)

MetMetWorkplace Violence Prevention(Leadership)


QMENTUM PROGRAM




Patient Safety Goal Area: Infection Control

MetMetHand-Hygiene Compliance(Infection Prevention and Control Standards)

MetMetHand-Hygiene Education and Training(Infection Prevention and Control Standards)

MetMetInfection Rates(Infection Prevention and Control Standards)

Patient Safety Goal Area: Risk Assessment

MetMetFalls Prevention Strategy(Ambulatory Systemic Cancer Therapy Services)

MetMetFalls Prevention Strategy(Diagnostic Imaging Services)

MetMetFalls Prevention Strategy(Emergency Department)

MetMetFalls Prevention Strategy(Medicine Services)

MetMetFalls Prevention Strategy(Mental Health Services)

MetMetFalls Prevention Strategy(Obstetrics Services)

MetMetFalls Prevention Strategy(Perioperative Services and Invasive ProceduresStandards)

MetMetFalls Prevention Strategy(Rehabilitation Services)

MetMetPressure Ulcer Prevention(Critical Care)

MetMetPressure Ulcer Prevention(Medicine Services)


QMENTUM PROGRAM




Patient Safety Goal Area: Risk Assessment

MetMetPressure Ulcer Prevention(Perioperative Services and Invasive ProceduresStandards)

MetMetPressure Ulcer Prevention(Rehabilitation Services)

MetMetSuicide Prevention(Mental Health Services)

MetMetVenous Thromboembolism Prophylaxis(Critical Care)

MetMetVenous Thromboembolism Prophylaxis(Medicine Services)

MetMetVenous Thromboembolism Prophylaxis(Perioperative Services and Invasive ProceduresStandards)


QMENTUM PROGRAM

Summary

Cambridge Memorial Hospital is using Accreditation Canada’s Qmentum program to guide its quality improvementinitiatives by assessing its services against Accreditation Canada’s standards and using the results to makeimprovements.

Accreditation Canada has reviewed the evidence of action taken and reports that, as of May 2016, theorganization’s accreditation decision remains Accredited.

In the spirit of ongoing quality improvement, the organization is encouraged to continue to use the standards toimprove the quality and safety of the services it offers.

Summary 12Progress Report

700 Coronation Blvd. Cambridge, ON N1R 3G2 www.cmh.org

Exceptional Healthcare – Exceptional People

Patrick Gaskin President & CEO 519.621.2333 ext 2301 [email protected] May 30, 2016 Julie Langlois RN, PhD Accreditation Specialist Accreditation Canada Sent via email Dear Dr. Langlois, Cambridge Memorial Hospital underwent our Accreditation Canada onsite visit in November 2015. At that time we received the following assessment of the quality dimension criteria:

Quality Dimension Met Unmet N/A Total Population Focus 64 0 0 64 Accessibility 87 0 0 87 Safety 623 7 20 650 Worklife 142 0 1 143 Client-centred Services 187 0 3 190 Continuity of Services 62 0 2 64 Appropriateness 938 7 14 959 Efficiency 66 0 0 66 Totals 2169 14 40 2223

In summary we met 99.4% of the applicable criteria (2169/2183 = 99.4%). In addition to the above criteria we achieved the following at our onsite visit on the Required Organizational Practices (ROPs) major and minor tests of compliance: ROP Test for Compliance Rating

Major Met Minor Met Medication reconciliation at care transitions (Ambulatory Systemic Cancer Therapy)*

0 of 7 0 of 0

2


ROP Test for Compliance Rating Major Met Minor Met

Concentrated Electrolytes (Medication Management Standards)

1 of 3 0 of 0

Heparin Safety (Medication Management Standards)

3 of 4 0 of 0

All ROP tests of compliance (including all of above)

297 of 307 60 of 60

All ROP tests of compliance (excluding Medication reconciliation at care transitions – ambulatory systemic cancer therapy)*

297 of 300 60 of 60

*requirement for medication reconciliation at care transitions was to demonstrated this in one clinical area – we demonstrated/met these in 7/8 areas despite only being required to do so in one clinical area.

Of the applicable ROP tests of compliance we achieved 357/360 major and minor tests of compliance or 99.2%. To summarize, at the time of the onsite survey, our performance can be expressed as follows:

Our decision letter issued December 2015 indicated that we were required to provide follow-up evidence for the three (3) ROP major tests of compliance by April 19, 2016. We provided the required evidence and recently we were informed that the ROP tests of compliance had been fulfilled; however our accreditation award remained as accredited. As of now, our accreditation performance can be expressed as follows

3


The Accreditation Canada Qmentum Four-Year Cycle Info Graph below indicates that at 5 months post onsite visit the ‘opportunity to improve decision’ exists.

In a follow up conversation between you and Liane Barefoot on May 26, 2016 you indicated that organizations rarely move from accredited to the commendation status and given that we had three (3) major tests of compliance that were cited, moving our status was apparently not an option for our organization.

(Current status)

4


I draw your attention to page 69 of your Accreditation Report to us (Appendix A) in which Accreditation Canada states:

Five months after the on-site survey, Accreditation Canada evaluates the evidence submitted by the organization. If the evidence shows that a significant percentage of previously unmet criteria are now met, a new accreditation decision that reflects the organization’s progress may be issued.

Over the last few months, our organization undertook a huge effort to achieve 100% of the required follow up actions stipulated by Accreditation Canada. We would like to understand the following in writing:

• The rationale for our decision remaining as accredited • Confirmation that the “opportunity to improve” our award did not exist for Cambridge

Memorial Hospital given our onsite survey results • The rationale for why we were not informed that the “opportunity to improve” did not

exist • The details as to the ramifications for the organization if we had not submitted the

evidence for the three (3) major ROP tests of compliance by April 2016 • The details as to the ramifications for the organization if we do not submit the

evidence requested by April 2017 • The details of any further appeal process concerning our award that may exist for

us I would appreciate this information in writing before mid-June if possible in advance of the hospital’s next board meeting. Liane, Kim Pittaway and I look forward to discussing this issue in more detail during our teleconference. Sincerely,

Patrick M. Gaskin, MHA, CHE President and CEO Cambridge Memorial Hospital cc: Liane Barefoot, Director Patient Experience, Risk and Quality

Efficient

Cambridge Memorial Hospital HSAA Scorecard

Fiscal Year 201 - 201Indicator Status & Trends

Integrated & Equitable

IndicatorNumber

1

3

6

7

8

9

10

12

11

13

16

18

17

19

20

22

2

Status

PreviousStatus

Year EndProjection

QIP/HSAA 90th Percentile ED Length of Stay

HSAA 90th Percentile ED Wait-Time for Non-Admit Minor Patients

HSAA Emergency Department Weighted Cases

HSAA Day Surgery Weighted Visits

HSAA Mental Health Weighted Patient Days

HSAA Acute Inpatient Weighted Cases

HSAA Rehab Inpatient Weighted Cases

HSAA

HSAA

HSAA

HSAA

HSAA

HSAA

HSAA

90th Percentile Wait-Times for Cancer Surgery

90th Percentile Wait-Times for Cataract Surgery

90th Percentile Wait-Times for Computed Tomography

90th Percentile Wait-Times for Magnetic Resonance Imaging

Percentage Alternate Level of Care Days - Closed Cases

agnetic Resonance Imaging Operating Hours

HSAA

HSAA

HSAA Ambulatory Care Visits

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Detailed Monthly Data Points

Target:

MRP:

Action Plan Updated:

Analysis:

Action Plan:

Indicator: 1

Year EndProjection:

Cambridge Memorial Hospital Corporate Scorecard FY2015/2016

90th Percentile Emergency Department Length Of Stay for Admitted Patients

Status:Year End

Projection:

Indicator Details/Components

Definition:

Formula:

01 Apr 02 May 03 Jun 04 Jul 05 Aug 06 Sep 07 Oct 08 Nov 09 Dec 10 Jan 11 Feb 12 Mar

2014/2015 18.10 22.90 20.70 12.30 16.10 14.80 19.50 22.50 20.00 27.40 25.10 21.20

2015/2016 25.70 24.90 20.90 18.70 22.00 15.40 21.00 16.40 18.60 16.10 21.10 21.70

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

Month

Hours

6

10

14

18

22

26

30

2014/2015 2015/2016

The total emergency room length of stay (in hours) where 9 out of 10 admitted patients completed their visits. ED LOS is defined as the time

from triage to the time when the patient leaves the ED. The 90th percentile length of stay is from triage to left ED (in hours) for admitted

patients. Excludes Left Without Being Seen, and cases with incomplete date and time stamps

The ED LOS are ranked from lowest to highest, and the number of occurences are multipled by 0.9 to find the 90th percentile rank. The value

at this rank is represented. If there is a decimal this is rounded up.

Current Year Target is 12 hours. Corridor is 13.2 Hours. HSAA Target is 8 Hours

EDLOS continues to challenge us well above the 13.2 hour corridor. The reasons for this are multi-factorial, including ability to staff any

surging of beds; and complex discharge planning needs for patients.

A new Flow Team was established in early August comprising of physicians, management, and nursing leaders. A new dashboard was developed

to monitor discharges, CDU usage, PIA times, ALC and patient discharge times. Some Flow work actions include - working towards goal of 10

medicine discharges per day, ALC bi-weekly meetings, hospitalists attending bullet rounds identifying EDD, Home First discharge planning

processes refresh occurred in November. Concurrent work with ALC and discharge planning processes refocus flow meeting was done early

April. Work plan in process to return to pulling patients to inpatient units within 60 minutes of decision to admit. Planning around # of and

staffing of medicine beds ongoing.

SHARRATT,RITA

2016/05/09 09:18

Target:


MRP:


Analysis:

Action Plan:

Indicator: 3

Year EndProjection:


90th Percentile Wait-Times for Emergency Department Non-Admit Minor Patients

Status:Year End

Projection:


Definition:

Formula:


2014/2015 4.50 4.80 4.70 3.90 4.00 4.30 4.60 4.90 4.80 4.80 4.40 4.30

2015/2016 4.40 5.10 4.70 4.30 4.10 4.80 4.90 4.40 4.40 4.40 5.00 5.00


Month

Wait

Tim

e in H

ours

3

3.4

3.8

4.2

4.6

5

5.4

2014/2015 2015/2016

The total emergency room length of stay (in hours) where 9 out of 10 non-admitted minor patients completed their

visits. ED LOS is defined as the time from triage to the time when the patient leaves the ED. The 90th percentile

length of stay is from triage to left ED (in hours) for admitted patients. Excludes Left Without Being Seen, and cases

with incomplete date and time stamps.

Using Disposition Code 01 or 15, CTAS 4 or 5 and inclusion and exclusion criteria, The ED LOS are ranked from lowest

to highest, and the number of occurences are multipled by 0.9 to find the 90th percentile rank. The value at this rank

is represented. If there is a decimal this is rounded up.

Performance target is 4 hours. Corridor is 4.4 hours.

All year projected result in yellow, however February and March pushed CMH to red category.

The challenge of physical space in the ED is the main reason for February and March to be so challenging. Inability to

transfer admitted patients to the inpatient units quickly compromises this metric as there are only limited spaces to

see patients. The admitted patients must stay in ED until another bed available. Work continues on flow in general

that will assist this metric.

SHARRATT,RITA

2016/05/09 09:36


Target:

MRP:


Analysis:

Action Plan:

Indicator: 6

Year EndProjection:


Day Surgery Weighted Visits - Year To Date

Status:Year End

Projection:


Definition:

Formula:


2014/2015 187 395 586 705 837 1,027 1,230 1,410 1,555 1,759 1,944 2,149

2015/2016 182 372 572 701 839 1,021 1,217 1,404 1,545 1,721


Month

Weig

hte

d V

isit

s Year

To D

ate

0

400

800

1.2K

1.6K

2K

2.4K

Weighted Visits: 2014/2015 Target: 2014/2015 Weighted Visits: 2015/2016 Target: 2015/2016

Total day surgery visits adjusted for resource intensity

Sum of Day Surgery visits multiplied by the associate weight

Performance year end target is 2000 weighted visits. Year end corridor is 1800-2200 weighted visits.

We expect to achieve the target volume by year end.

Our volumes are trending similar to last year, where we finished the year 7% over target. We expect this to continue

and should finish the year 5% to 7% over target. Our total case volume is up about 1.5% over last year, but the average

weight per case is down resulting in the weighted cases being about the same as last year.

No additional action is needed to achieve the target.

MEYETTE,MICHAEL

2016/05/06 11:51


Target:

MRP:

Action Plan updated:

Analysis:

Action Plan:

Indicator: 7

Year EndProjection:


Emergency Department Weighted Cases Year To Date

Status:Year End

Projection:


Definition:

Formula:


2014/2015 264 534 799 1,058 1,320 1,581 1,852 2,108 2,377 2,659 2,889 3,145

2015/2016 235 480 712 955 1,187 1,420 1,660 1,888 2,138 2,392


Month

Weig

hte

d C

ase

s Year

To D

ate

0K

.4K

.8K

1.2K

1.6K

2K

2.4K

2.8K

3.2K

3.6K

Weighted Cases: 2014/2015 Target: 2014/2015 Weighted Cases: 2015/2016 Target: 2015/2016

Total Emergency Department visits adjusted for resource intensity

Sum of all scheduled and non-scheduled ED visits multiplied by the associated weights

Performance year end target is 2747 weighted cases. Year end corridor is 2472-3022 weighted cases.

Projecting green performance for year.

CMH is on target to attain target volumes. Patient volumes down about 6% overall compared to the large volume

increases in 2014/15.

No further action at this time.

SHARRATT,RITA

2016/05/09 09:21

Target:


MRP:


Analysis:

Action Plan:

Indicator: 8

Year EndProjection:


Inpatient Weighted Cases Year To Date

Status:Year End

Projection:


Definition:

Formula:


2014/2015 867 1,688 2,535 3,287 3,961 4,668 5,517 6,365 7,235 8,145 8,960 9,840

2015/2016 813 1,681 2,663 3,430 4,122 4,876 5,702 6,511 7,280 8,074 8,790


Month

Weig

hte

d C

ase

s Year

To D

ate

0

2K

4K

6K

8K

10K

12K


Total acute inpatient cases adjusted for resource intensity

Sum of inpatient discharges multiplied by the resource intensity weight for their associated Case Mix Group


We Expect to Achieve the Target Volume

Our inpatient discharges are about 2% lower than last year to the end of February. However, we still expect to

achieve the target weighted cases. Our average weight per case is higher this year, which partially offsets the lower

case volume. Our HIG Weighted cases, which drive funding, are about 1% higher year to date.

We will continue to pay particular attention to data quality and most responsible diagnoses, and reinforce the

importance of documentation with all clinicians.

MEYETTE,MICHAEL

2016/05/09 08:47

Target:


MRP:


Analysis:

Action Plan:

Indicator: 9

Year EndProjection:


Mental Health Weighted Patient Days

Status:Year End

Projection:


Definition:

Formula:

Quarter 1 Quarter 2 Quarter 3 Quarter 4

2014/2015 1,883.76 3,841.21 5,449.92 7,304.36

2015/2016 1,715.57 3,047.82 4,869.99

Apr Jul Oct Jan

Month

Weig

hte

d C

ase

s Year

To D

ate

0

2K

4K

6K

8K

10K


Total mental health patient days adjusted for resource intensity

A weighted total of days based on the SCIPP weighted patient days

Performance year end target is 7446 weighted patient days. Year end corridor is 6329 weighted patient days.

The year end projection will be Yellow.

Our new target has been reduced to 7,446 weighted cases and the performance corridor is 6,329 to 8,563. At the end

of Q2 our volumes are lower than expected, and the patient days being reported by CIHI are significantly lower than

our internal data. We have reconciled the CIHI data to our internal data and identified a number of cases where

assessments are missing in the CIHI data.

Processes have been put in place to identify any assessment errors, that would prevent them from being accepted by

CIHI, as well as any missing assessments. this should improve data quality and completeness going forward. We are

also following up on assessments that are missing in the CIHI data for Q1 and Q2 so those can be corrected and

submitted so that the Q3 and year end reports will reflect the true volume of activity.

SHARRATT,RITA

2016/03/04 13:53

Target:

MRP:



Analysis:

Action Plan:

Indicator: 10

Year EndProjection:


Rehab Inpatient Weighted Cases - Year To Date

Status:Year End

Projection:


Definition:

Formula:

Quarter 1 Quarter 2 Quarter 3 Quarter 4

2014/2015 75 143 214 276

2015/2016 58 116 192

Apr Jul Oct Jan

Month

Weig

hte

d C

ase

s Year

To D

ate

40

80

120

160

200

240

280

320


Total rehab cases adjusted for resource intensity

The total Number of inpatient rehabilitation cases, adjusted for resource intensity using Rehabilitation Patient Group

(RPG) weights


We are on track to achieve the target volume, but at risk of being a little under March 2016 - volumes lower than

expected

Our volumes at the end of quarter 2 just met the Target. They were significantly lower than the previous year. These

numbers are based on CIHI reports. The volumes on the CIHI reports are lower than our internal volumes suggesting

there may be some data quality/assessment completion issues. The patient records with discrepancies are being

identified so that any missing information can be submitted.

With a new Rehab Manager in place, we are analyzing the volume discrepancy between our internal data and what has

been submitted to CIHI. We will also review the data submission process to ensure the data being submitted is

complete and comprehensive, and will put in place mechanisms to reconcile our CIHI submissions to our internal

data March 2016 - data under review to understand lower RIW and volumes

SHARRATT,RITA

2016/05/06 11:49


Target:

MRP:


Analysis:

Action Plan:

Indicator: 11

Year EndProjection:


90th Percentile Wait-Times for Cancer Surgery

Status:Year End

Projection:


Definition:

Formula:


2014/2015 57 51 55 47 103 80 83 57 46 64 65 63

2015/2016 42 46 69 38 57 71 57 57 99 69 66 53


Month

Wait

Tim

e in D

ays

30

40

50

60

70

80

90

100

110

2014/2015 2015/2016

The wait time in days that 9 out of 10 patients receive service.

The 90th percentile wait time of cancer surgery procedures performed.

Performance target is 84 days. Corridor is 76-92 days. Provincial target is 84 days.

We are reviewing the procedure mapping in the new O.R. Software that was implemented this year to ensure these

cases are being accurately mapped in the provincial wait time system. Surgeons have OR time allocated and manage

the patient list by priority of patient condition. Review of specific outlier cases has occurred (ENT, general surgery)

Monitor by WTIS co ordinator, decision support and OR Manager. Surgeons request additional OR time if as required to

ensure provincial wait targets are achieved. Feedback to surgeons regarding performance is pending based on new

provincial strategy. Investigation underway by WTIS clinical system co ordinator with outliers in this data to

determine if data entry error. Working with surgeon and office and WTIS liaison to determine exact issue and address

same. May 2016 Working with offices to improve cancer surgery wait times

HAUCK,ROBINNE

2016/05/06 11:48


Target:

MRP:


Analysis:

Action Plan:

Indicator: 12

Year EndProjection:


90th Percentile Wait-Times for Cataract Surgery

Status:Year End

Projection:


Definition:

Formula:


2014/2015 103 219 165 190 200 190 196 198 199 220 231 210

2015/2016 192 212 213 241 260 247 240 206 227 250 265 247


Month

Wait

Tim

e in D

ays

80

120

160

200

240

280

2014/2015 2015/2016

The wait time in days that 9 out of 10 patients receive service.

The 90th percentile wait time of cataract procedures performed.

Performance target is 166 days. Corridor is 166-182 days. Provincial target is 182 days.

CMH completes funded volumes annually. Despite additional volumes (126) added in 14/15, the wait list was not

reduced for cataract surgery. One of the ophthalmologists has a longer wait list and reviewing this physician specific

data to determine if accurate processes in this office that are contributing to this variance.

Continue to achieve funded volumes. Meeting occurred with WWLHIN liaison in September 2015 to further discuss

funded volumes and CMH growing wait list. A plan was created that included meeting with ophthalmologists to review

their individual wait time and performance. (Working on an outreach newsletter similar to orthopaedics to send to

the referring optometrists to determine ability to influence referral patterns). CMH Has received some additional

volumes this year, but not enough to bring the wait times within target. March 2016 Continue to monitor and work

with offices on wait time challenges. May 2016 Works continues with offices. Newsletter going out for June 1.

HAUCK,ROBINNE

2016/05/06 11:45


Target:

MRP:

P3

P4

Analysis:

Action Plan:

Indicator: 13


Year EndProjection:


90th Percentile Wait-Times for Computed Tomography (CT)

Status:Year End

Projection:


Definition:

Formula:


2014/2015 10 10 10 10 10 10 10 10 10 10 11 9

2015/2016 10 13 9 9 9 9 10 13 10 14 10 9


Month

Wait

Tim

e in D

ays

5

10

15

20

25

30

35

40

P3: 2014/2015 P4: 2014/2015 P3: 2015/2016 P4: 2015/2016

The wait time in days that 9 out of 10 patients receive service. P3 are Priority Level 3 patients and have a 90th

percentile target of 10 days. P4 are Priority Level 4 Patients and have a target of 28 days.

The 90th percentile of CT scans performed. Wait days are the number of days between the date the CT scan order was

received and the date the CT scan was performed.

Performance Target is 28 days for Priority Level 4, Corridor is 28-31 days. Priority level 3 Target is 10 days.

N/A.

Demand for CT services continues to grow and in absence of increased resources, there is risk of increased P4 wait

time. Managing P3 wait time will remain CMH's main priority.

CMH will continue with the current service offering and do its best to prioritize P3 access.

PROCIW,MICHAEL


2014/2015 28 28 28 29 28 28 28 28 30 30 29 28

2015/2016 28 28 28 28 28 28 35 28 38 30 28 28

2016/04/15 15:21


Target:

MRP:

P3

P4

Analysis:

Action Plan:


Year EndProjection:

Cambridge Memorial Hospital Corporate Scorecard FY2015/2016 Indicator: 16

90th Percentile Wait-Times for Magnetic Resonance Imaging (MRI)

Status:Year End

Projection:


Definition:

Formula:


2014/2015 9 12 11 13 10 12 11 13 10 10 10 10

2015/2016 8 7 7 7 9 9 10 10 12 8 9 9


Month

Wait

Tim

e in D

ays

0

10

20

30

40

50

60

70

80

P3: 2014/2015 P4: 2014/2015 P3: 2015/2016 P4: 2015/2016

P3 are Priority Level 3 patients and have a 90th percentile target of 10 days. P4 are Priority Level 4 Patients and have

a target of 28 days.

The 90th percentile of MRI procedures performed. Wait days are the number of days between the date the MRI order

was received and the date the MRI was performed.

Performance target is 28 days for Priority Level 4. Corridor is 28-31 days. Priority Level 3 target is 10 days.

N/A.

Strategies have been implemented by the management team to maximize MRI throughput. Provincial throughput

targets are at 1.6 patients per operating hour. Currently, CMH is operating at 2.37 patients per operating hour.

Operating hour utilization is 97.5% (versus provincial average of 70%)and the no-show rate is 2.15% (versus a provincial

average of 5.5%). This effort is reflective of the strong leadership of management and the Radiologist Lead. Despite

these efforts, demand and the associated wait time continues to grow.

Management has begun the process of upgrading its automated requisitioning process to include referral guidelines

with the intent of creating appropriateness criteria for MRI referrals. The regional Surgical Council will also be

engaged regarding appropriateness criteria for select orthopedic procedures. In addition, a regional initiative will

result in a MRI protcol review across the LHIN which may add to further efficiencies. MRI requisitions continue to be

reviewed with the intent of juggling available capacity to ensure those in greatest need (P3) have the best possible

access. Thus far, this has been successful.

PROCIW,MICHAEL


2014/2015 22 32 42 53 62 66 57 57 54 55 47 41

2015/2016 41 42 48 56 60 63 64 65 59 67 70 71

2016/04/15 15:31


Target:

MRP:


Analysis:

Action Plan:

Indicator: 17

Year EndProjection:


Percentage Alternate Level of Care - Closed Cases

Status:Year End

Projection:


Definition:

Formula:


2014/2015 14.00 11.11 14.66 19.45 17.63 12.91 13.57 14.29 16.82 21.24 16.97 28.89

2015/2016 15.16 15.17 18.86 15.41 15.13 18.02 16.48 15.21 15.15 20.32 20.51


Month

Perc

enta

ge A

LC D

ays

(Clo

sed)

9

13

17

21

25

29

33

2014/2015 2015/2016

The Closed ALC rate is the rate of ALC patient days for discharged patients over the total patient days for patients

discharged in the period. An ALC day is a day accrued by a patient who originally was admitted for acute care, and has

now completed the acute care phase of their care plan and is waiting for a more appropriate level of care placement

while continuing to occupy an acute care bed

Closed ALC Cases = (Total Acute ALC Patient Days / Total Patient Days) x 100. The sum of acute patient days excludes

newborn/obstetrics) and patient days for SSR, CCC, and rehab *Calculated using Coded data as data source

Performance target is 15% ALC Days. Corridor is 16.5%. H-SAA target 9.46%.

Projecting yellow performance based on 2014/15 year and opportunities available to improve from red status.

October, November and December have seen declines after high points in June and September.

Commencement of new CMH/CCAC Integrated Discharge Planning Manager late October 2015 has given our teams

focus to ALC patients. Home First strategies along with CCAC intensive home services part 1 of complex discharge

planning with patients and families. Home First refresh for all team members including physicians occurred. ALC

rounds continue with managers and discharge team. ALC refresh of terms and usage scheduled for Flow Team in early

April - improvements for physician, nursing and allied health groups.

SHARRATT,RITA

2016/04/04 09:49


Target:

MRP:


Analysis:

Action Plan:

Indicator: 18

Year EndProjection:


Percentage Alternate Level of Care - Open Cases

Status:Year End

Projection:


Definition:

Formula:


2014/2015 18.61 18.15 13.89 12.40 12.55 16.00 14.01 12.53 14.42 13.54 14.28 13.42

2015/2016 11.14 21.09 17.28 13.27 11.59 16.82 10.76 9.43 9.82 12.19 9.28 12.26


Month

Perc

enta

ge o

f ALC d

ays

8

10

12

14

16

18

20

22

24

2014/2015 2015/2016

The Open ALC rate is the rate of ALC patient days, including patients still in hospital, over the total patient days in

the period. An ALC day is a day accrued by a patient who originally was admitted for acute care, and has now

completed the acute care phase of their care plan and is waiting for a more appropriate level of care placement while

continuing to occupy an acute care bed

Open ALC Cases = (Total Acute ALC Patient Days / Total Patient Days) x 100. The sum of acute patient days excludes

newborn/obstetrics) and patient days for SSR, CCC, and rehab *Calculated using Meditech as data source

Performance target is 15% ALC Days. Corridor is 16.5%.

N/A.

ALC open cases in green. An Integrated Discharge Planning Manager shared between CMH and CCAC began late

October 2015 after a 12 week vacancy. After declines in Oct, Nov and Dec - we see an increase in open cases in

January. This is due to overall increased volume of patients in our hospital.

Laser focus on ALC rounds continue bi-weekly planning. Policies for escalation of long term care and discharge

planning efforts reviewed and revised. Escalation of any barriers to patient discharge done daily.

SHARRATT,RITA

2016/04/04 09:53


Target:

MRP:


Analysis:

Action Plan:

Indicator: 19

Year EndProjection:


Computed Tomography (CT) Operating Hours

Status:Year End

Projection:


Definition:

Formula:


2014/2015 238.36 484.66 723.01 969.31 1,215.62 1,453.97 1,700.27 1,938.64 2,184.93 2,431.23 2,685.70 2,964.00

2015/2016 238.36 484.66 723.01 969.31 1,215.62 1,454.00 1,700.27 1,938.64 2,184.93 2,431.23 2,741.70 3,020.00


Month

Opera

ting H

ours

0

400

800

1.2K

1.6K

2K

2.4K

2.8K3K

Operating Hours: 2014/2015 Target: 2014/2015 Operating Hours: 2015/2016 Target: 2015/2016

CT Total Operating Hours

CT Total Operating Hours for month

Performance year end target is 2964 hours.

N/A.

CMH is providing its service offering at the approved wait time allocation level.

No action is required at this time

PROCIW,MICHAEL

2016/04/15 15:34

Target:


MRP:


Analysis:

Action Plan:

Indicator: 20

Year EndProjection:


Magnetic Resonance Imaging (MRI) Operating Hours

Status:Year End

Projection:


Definition:

Formula:


2014/2015 330 661 1,006 1,371 1,714 2,095 2,511 2,940 3,318 3,727 4,095 4,511

2015/2016 383 741 1,139 2,084 2,428 2,796 3,164 3,524 3,886 4,254 4,696 5,168


Month

Opera

ting H

ours

0K

.5K

1K

1.5K

2K

2.5K

3K

3.5K

4K

4.5K4.6K

Operating Hours: 2014/2015 Target: 2014/2015 Operating Hours: 2015/2016 Target: 2015/2016

MRI Total Operating Hours

MRI Total Operating Hours for month

Performance year end target is 4514 hours.

N/A.

CMH is operating at its approved funding level and has adjusted to incorporate the additional hours allocated in

February.

No action is required at this time.

PROCIW,MICHAEL

2016/04/15 15:35


Target:

MRP:


Analysis:

Action Plan:

Indicator: 22

Year EndProjection:


QBP Hip Volumes - Year To Date

Status:Year End

Projection:


Definition:

Forumla:


2014/2015 15 33 54 66 76 83 103 120 133 147 175 203

2015/2016 12 29 40 52 66 89 107 126 146 168 192


Month

Volu

mes

Year

To D

ate

0

40

80

120

160

200

240

Volume: 2014/2015 Target: 2014/2015 Volume: 2015/2016 Target: 2015/2016

Number of hip replacement surgeries done

Number of hip replacement surgeries done

Performance year end target is 215 surgeries. Year end corridor is 194 surgeries.

Anticipate achieving annual hip replacement surgery targets.

Achieving monthly targets as per plan. There is month to month variation with knee replacement surgery based on

specific patient referrals (between hip and knee) and urgency. Planning the OR schedule with the orthopaedic

surgeons and known volume targets, allows confidence in achieving the plan.

Monthly monitoring and feedback of volumes achieved compared to targets is circulated to orthopaedic surgeons.

Monitoring of the OR list by the OR Manager occurs.

HAUCK,ROBINNE

2016/05/06 11:50


Target:

MRP:


Analysis:

Action Plan:

Indicator:

Year EndProjection:


Ambulatory Care Visits - Year To Date

Status:Year End

Projection:


Definition:

Forumla:


2014/2015 6,891 13,902 20,838 26,939 32,624 39,210 46,614 53,075 60,157 65,857 71,896 78,945

2015/2016 7,107 13,766 21,160 27,486 32,550 40,824 47,830 54,111 60,688 67,379 74,057 81,153


Month

Vis

its

0K

10K

20K

30K

40K

50K

60K

70K

80K

90K

Visits: 2014/2015 Target: 2014/2015 Visits: 2015/2016 Target: 2015/2016

Number of ambulatory care visits.

Number of ambulatory care visits (clinic, community, and surgery), excludes emergency and telephone visits

Performance year end target is 73050 visits. Year end Corridor is 58440 vsits.

N/A.

Volumes are about 3% higher than last year, and 11% over target. Increased volumes have been experienced in

Psychiatric clinics, pain clinic, and obstetric clinics.

No additional action required as we are on target.

MEYETTE,MICHAEL

2016/05/03 13:49

Page 1 of 3

BRIEFING NOTE – Quality Committee

Date: June 7, 2016 Issue: Patient Family Advisory Council (PFAC) Update Purpose: Information Prepared by: Liane Barefoot, Director Patient Experience, Quality & Risk Approved: Patrick Gaskin, President & CEO

Council Membership The last update on the PFAC was presented to Quality Committee in September 2015. At that time the total membership was reported at six (6) members. Interviews have continued over the past 9 months and the council has finally reached nine (9) members. In April 2016 we transitioned from Patrick chairing the PFAC meetings to a PFAC member. Two PFAC members agreed to co-chair the Council. They have adopted a rotating co-chair model as this was ideal for personal schedules. In addition, at our request we have begun to structure the agendas to include an ‘in-camera/without management’ portion each month. PFAC members had requested waiting until the Council reached eight (8) to ten (10) members before deciding which roles from the organization will fulfill the staff positions as defined in the Terms of Reference. Following the June meeting, PFAC indicated they are ready to proceed with the inclusion of two (2) staff members so internal recruitment will take place over the summer. The hospital will do the initial screening of applications/expressions of interest and PFAC members alone will interview a short list of staff members with the intention they would be present for the September 2016 meeting. In addition to staff members, at the request of the CEO, PFAC members were asked to select which one (1) of the three (3) Senior Executives they wanted to continue to attend meetings on a regular basis – the other two would be invited on an ad hoc basis as determined by the agenda. Following the June meeting, discussion ensued that included a reference to the legitimacy and corporate importance of having the CEO and


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Page 2 of 3

COS at the table regularly. The VP Clinical Programs/CNE will review agenda/minutes and attend as appropriate. Work To Date The two (2) PFAC members that participated on the Model of CCAIR Steering Committee were invited to the evaluation meeting in the Fall 2015 where the provided feedback on their perception of the work done by the Steering Committee and on their involvement. They commented on feeling like valued and welcomed members of the team. Two (2) PFAC members have been participating with the Emergency Department Transitional Planning team; meeting monthly to look at care delivery in the new emergency space. Informal feedback from the manager of emergency has been very positive – ‘having the patients there keeps us from going off on tangents – we stay more focused having them there’. Again, feedback from the two patients participating has been that they feel valued, listened to and appreciated. In August 2015 at PFAC a lengthy discussion ensued around expanded and/or unrestricted visiting hours. Some points discussed were: how to define family or care partners vs. general visitors, does the number of persons at the bedside need to be defined and determining if the parameters for visiting should be different in certain care settings (e.g. ICU and MH). A draft policy was brought forward to the September 2015 meeting where further, extensive discussion ensued. Modifications to the policy were made and it was well socialized through many internal committees through the fall and early part of 2016. The new policy was launched on target in February 2016 to coincide with Family Day. While not without some anecdotal issues brought forward by nursing staff, the launch has been relatively uneventful. PFAC has taken a keen interest in regular updates on how the patient directed visiting hours are going. Seven (7) of the PFAC members were able to tour the mock up rooms during the public tour on June 1st. Jayne Herring, one of the PFAC co-chairs joined Patrick and Rita Westbrook at the beginning of each tour to do a formal welcome and overview of hospital key accomplishments in 2015-16. Feedback from the tours formed the basis of a great discussion at the June meeting. In addition, five (5) clinical managers attended the June meeting and each did a mini presentation to PFAC members on what is changing in Phase 2 of the CRP with their program(s) with a particular emphasis on potentially positive/negative impacts to patient experience. Presentations were provided by: Women’s and Children, Mental Health, ICU, Inpatient Surgical/Rehab, and Medicine. Many questions were posed on various issues that could potentially impact the patient experience (epidural availability, cultural sensitivity, sleep options for family members visiting, shared bathrooms in internal space). Representative from the CRP plan provided PFAC members with an overview of the project progress.

Page 3 of 3

Next Steps A PFAC member has been offered the opportunity to attend the 3rd Annual Patient Experience conference in Toronto on September 30and October 1, 2016. Recruitment for the two (2) staff positions will commence immediately with the target of having them attend the September meeting.

Agenda Item 2.4.1

Page 1 of 2

BRIEFING NOTE – Board of Directors Date: June 8, 2016 Issue: Medical Advisory Committee – June 2016 Open meeting Purpose: Update Prepared by: Dr. Kunuk Rhee, Chief of Staff Approved by: Patrick Gaskin, CEO Presentations M&T Update: MAC accepted Medication and Therapeutics’ recommendation to remove the Auto-Stop Date for opiate narcotics (except for medications such as methadone where there are strict regulatory parameters). This policy change was communicated out to clinical programs by the chiefs and pharmacy on June 15. This will align with OCP recommendations and will facilitate our ongoing c-MAR implementation. Physician Engagement in the HIS RFP Process The CIO from Grand River Hospital and St. Mary’s along with two project leads, presented on the importance of medical engagement in the RFP process. The time commitment required, the scope of work requested and the collaborative nature of the RFP evaluation process were all highlighted. The medical leadership at CMH struggled with the accelerated timelines and the deployment of scarce medical administration time over the summer. It was understood that CMH may not be able to engage in the evaluation as robustly as requested given the work already underway in CRP Transition Planning. CRP Status Update Mr. Hildebrand and Mr. Prociw presented on the current status of the CRP. Particular focus was given to potential risks for Code Blue or Code Pink first responders in the context of proposed Unit/Room numbering changes. Robust orientation and transition planning will mitigate these risks, but additional resources may need to be deployed. AEDs, added security for transition months, additional training/mock codes were all identified as viable transition strategies. The pre-construction operating plan or PCOP was reviewed with MAC. The myriad of Ministry-mandated variables, constraints and approvals were all shared. Understanding this context will assist medical leaders in refreshing health human resources master plans over the summer.


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Agenda Item 2.4.1

Page 2 of 2

On-call Room Assignments in CRP MAC endorsed having more dedicated on-call rooms. This aligns with an organizational vision of encouraging/incenting more in-hospital providers after-hours. Business Arising Clinical Services Plan Update MAC signaled a clear desire to continue the CSP work and planning within the proposed program groupings presented. Developing clearly defined services/programs (with a cogent path and rationale) will occur over the next three months. Surgical Assist Scheduling & Status Following City call’s recent cessation of services at CMH (in 2015) and a decade-old province-wide trend of the migration of family physicians out of hospital services, our local surgical assistants may be downloading on-call surgical assistance onto the hospital. The risks to surgical safety are high if a mitigation strategy is not implemented. Surgical hospitalists, nursing assists and second tier surgical specialists are options that will need to be fully explored in the upcoming months. CMH could consider downloading this responsibility onto the surgeons, but our pool of surgical assists may be too small to make this a viable option. New Business Succession Planning for Chiefs of Department The Chiefs of Pediatrics, ED, Diagnostic Imaging, Midwifery, Oncology and Hospital Medicine will all be completing their terms before April 2017. There are no identified chiefs in five of these departments at this time and the importance of succession planning was re-enforced with each of the Chiefs. Medical Assistance in Dying (MAID) MAC was informed of the Board’s decision to provide MAID services at CMH. Protocols and a policy were pre-circulated and feedback was elicited. Several challenges and ambiguities were raised. A provisional pre-printed order is in place for MAID deployment . An Oversight Committee has been created and our processes have been shared with GRH and GGH for commentary. GRH and GGH will be offering out-patient Assistance in Dying services and will have a much more robust communication/referral tool. We will endeavor to expand our scope of services over the next twelve months. Clarity regarding the legislation is key prior to final MAC approval (which will likely be electronically over the summer). Ordering of Laboratory Investigations: MEDICAL DIRECTIVE #558 The above Medical Directive was unanimously approved.

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