BOARD CLIENT SERVICES, QUALITY & SAFETY COMMITTEE...

2015 12 07_Board CSQS Committee _DRAFT Agenda_v1

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BOARD CLIENT SERVICES, QUALITY & SAFETY COMMITTEE MEETING

DATE: December 7, 2015

TIME: 9:00 – 11:00am

PLACE: Labelle Boardroom

AGENDA

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9:00-9:05 1.0 Welcome; Declaration of Conflict Melody Isinger √

Core Business

2.0 Approval of Agenda for December 7, 2015 Melody Isinger √

9:05-9:10 3.0 Minutes from November 9, 2015 Meeting Melody Isinger √

4.0 Business Arising Melody Isinger √

Consent Agenda – assumed approved unless any member of CSQS wishes to discuss

nil

Standing Items

9:10–9:25

5.0 Quality Reports 5.1 Adverse Events (verbal) 5.2 QIP Quarterly Status Update 5.3 Events Reporting Quarterly Status Update 5.4 Complaints Reporting Quarterly Status Update 5.5 CCEE Semi-Annual Update

Ellen Alie √ √ √ √ √

Strategic Discussion

9:25 – 9:45 6.0 Committee Member Remarks, Insights from Board

Strategic Retreat All

9:45–10:05 7.0 Bi-Annual People Services and Organizational

Development Update Patrice Connolly √

10:05-10:30 8.0 Patient and Caregiver Council Update Patrice Connolly √

10:30-11:00 9.0 Scorecard Review; Discussion – Performance

Improvement Plan for Key Quality Indicators Deryl Rasquinha / Catherine Butler

√

CONFIDENTIAL

DRAFT

Minutes – Champlain CCAC Client Services, Quality and Safety Committee – November 9, 2015

Champlain Community Care Access Centre Centre d’accès aux soins communautaires de Champlain

Head Office

4200 Labelle Street Suite 100 Ottawa ON K1J 1J8 Siège social 4200, rue Labelle Bureau 100 Ottawa ON K1J 1J8

Tel/Tél : 613 745 5525 866-994-8124 Fax/Téléc : 613 745 1422

www.champlain.ccac-ont.ca

MINUTES

Client Services, Quality & Safety Committee (CSQS)

Held November 9, 2015

Champlain CCAC Head Office

BOARD COMMITTEE

MEMBERS (CSQS):

Melody Isinger

Denise Alcock

Andrée Durieux-Smith

Abebe Engdasaw

Sherryl Smith

Chair

Ex-officio member

REGRETS (CSQS):

OTHER BOARD

MEMBERS

Bill Skinner

BOARD COMMITTEE

MEMBERS

(FINANCE):

Maria Barrados

Robert D’Aoust

Michel Parent

Chair

FINANCE REGRETS

STAFF PRESENT

(CSQS):

Marc Sougavinski

Catherine Butler

Paula Greco

Ashley Haugh

Claire Ludwig

Ellen Odai

Deryl Rasquinha

Chief Executive Officer

Vice-President, Clinical Care

Senior Lead, Program Evaluation

Executive Assistant

Director, Program Development & Clinical Care (item 9.0)

Manager, Client Relations

Vice-President, Performance and Strategy

FINANCE STAFF

PRESENT FOR JOINT

PORTION OF

MEETING:

RECORDER: Ashley Haugh Executive Assistant

GUEST(S):

2

Minutes–Champlain CCAC Client Services, Quality & Safety Committee, November 9, 2015

AGENDA ITEM ACTION TO BE TAKEN

1.0 Declaration of Conflict of Interest

There were no declarations of conflict

2.0 Approval of Agenda for November 9, 2015

The amended agenda was approved by consent.

3.0 Approval of Minutes

It was moved by Abebe Engdasaw, seconded by Sherryl Smith and agreed to

approve the minutes of the October 5, 2015 meeting.

CARRIED

4.0 Business Arising

Sherryl Smith attended the Canadian Hospice Palliative Care Conference in Ottawa

and provided suggestions for generative discussion topics/speakers.

ACTION: Ashley Haugh

to provide information to

the Governance committee.

5.0 Quality Reports It was moved by Sherryl Smith, seconded by Abebe Engdasaw and agreed to move in-camera.

CARRIED 5.1 Adverse Events There are no adverse events to report.

6.0 Care Model, Program Evaluation Discussion The Committee received an update and discussed the new Care Model (CM)

Program Evaluation:

Following a rigorous evaluation of the Client Care Model (CCM)

introduced in 2011, the Champlain CCAC evolved clinical care in early

2015 with a new Care Model. o The evolution to the new Care Model took place after a rigorous

evaluation of CCM focused on the care experience. CCM had population-based caseloads in three areas: complex, chronic and community independence.

o The evaluation included the analysis of five years of data and chart audits. It also included feedback and engagement of patients/caregivers, staff, service providers, partners, etc.

The CCM had some positive impact on care experience

(particularly re: high needs clients).

The CCM had a negative impact on continuity of care and

efficiency, i.e. caseload turnover, multiple providers

assigned to a geographic area and residential homes, multiple

transitions, assessments, etc.

.

3



Care Coordinators continued to prioritize their efforts on

higher needs clients.

A “true” population based model for long stay patients had

not been achieved.

There are opportunities for improvement to enhance care

experience along the care pathway.

After reviewing the results of the CCM evaluation, a Proof of Concept

(PoC) of a new CM was undertaken in congregate settings and provided

further feedback and information in the refinement of the new CM across

the organization. The PoC included approximately 1,400 patients in urban

and rural settings as well as French and English patients.

The new CM creates a stronger foundation for the introduction of Person Driven Care objectives.

The need for ongoing evaluation was identified from the beginning of the

new CM. Two Masters of Nursing students assisted with evaluations of the

PoC; still too early for evaluation of the new CM in the district/rest of the

organization. The initial evaluation focused on the new CM

implementation:

o There was improved communications within the professional care

team under the new CM.

o There is still work to do to further decrease CC’s administrative

tasks and increase time spent with patients, conducting counseling,

navigating health system for patient, etc.

o More training on facilitating team huddles, etc. will be provided to

CCs.

o Overall, majority felt that the new CM has had a positive impact on

the patient experience as CCs are more visible.

o Transitions, across care settings, still needs further improvement.

o Majority of CCAC patients in retirement homes/congregate care are

of high acuity with 30% waiting for Long-Term Care placement.

o There was an increase in patient assessments.

o With the CC embedded in retirement homes and able to see/gather

real time information, e.g., visits to emergency rooms, etc.

Based on information collected and analyzed during the evaluation, it is

believed the new CM has ongoing sustainability. Work is being done to

tweak the model and enhance sustainability.

Discussion included:

The CCM evaluation included a review of data such as age, geography

(urban/rural), level of patient acuity, caregiver status, functional ability,

length of stay, etc. It did not include a review of data based on cultural

diversity or the social determinants of access to care; these could be

potential research topics in the future.

Team huddles take place in congregate care settings (e.g. retirement homes)

and provide an opportunity for the CC, Service Providers and Director of

Care to proactively identify and mitigate emerging issues across all patients.

4



Where issues are identified with individual patients, the patient and/or

caregiver are involved in developing and implementing next steps.

Staff are working with hospital partners to have hospital CCs further

integrated into hospital team huddles.

Long-Term Care residents are also of higher acuity than in the past.

The Masters of Nursing students have not asked if their work can be

published, but this will be suggest to them. There have been discussions on

who the information can be presented to.

The job description for CCs includes both professional requirements as well

as soft skills – e.g., working as part of team, etc.

7.0 Interactive Voice Response (IVR) Quality Calls The Committee received an update on the IVR (automated) quality calls:

IVR calls allow for more immediate feedback from patients on their CCAC services.

IVR calls have already been successful used by the Champlain CCAC to gather feedback from discharged clients.

All IVR calls have an opportunity for respondent to request a call back from the CCAC.

The first project overseen by the IMPACT Centre, IVR quality calls will be piloted with current patients receiving Personal Support Services (PSS).

The IVR questions were taken from the Client and Caregiver Experience Evaluation (CCEE) so have been validated.

The pilot will start with 2,000 long stay patients. Once 30 requests for a call back from the CCAC have been received, the pilot will be paused to ensure staff are addressing questions in a timely manner. The pilot will then resume and will pause again once reach another 30 call back requests.

Results will be shared with the CSQS committee.

The other CCACs are very interested in our pilot and results will be shared of the pilot outcome.

8.0 Scorecard Review

The scorecard review was deferred to the Board meeting.

ACTION: The scorecard

will be reviewed at the

Board meeting.

9.0 Innovation eMpowering Patients And Caregivers

through Technology (IMPACT) Centre Update

The IMPACT Centre presentation was deferred to the Board meeting.

The meeting was adjourned by consent.

ACTION: The IMPACT

Centre presentation will be

reviewed at the Board

meeting.

CONFIRMED: ________________________________________________

MELODY ISINGER, CHAIR

CASC de Champlain CCAC

FY 15-16 QualityImprovement Plan (QIP)

Q2 Update

Presented to: CSQS Committee of the BoardDecember 7, 2015


Reduce % of adult long-stay home care clients who record a fall on their follow-up Resident Assessment Instrument-Home Care (RAI-HC) assessment

TARGET ≤36.0% Q2 FY 14-15= 41.2%*

SAFETY

Improvement Activity Target Status

Collaboration with Ottawa Public Health, primary care and community partners to address falls prevention and support exercise programs withpersonal support workers (PSWs) in the community

All Service Provider Organizations

(SPOs) implement by March 31 2016

In Progress

Implement training and education with clinical teams and SPOs re: falls awareness with clients

Improvement on CCEE Safety key

performance indicator (KPI)

In Progress

* Acuity levels would drive higher prevalence of falls


ACCESS

Increase the % of complex patients who received their first personal support service within 5 days of the service authorization dateTARGET ≥95% JUL= 53.0% AUG= 64.8% SEPT=73.1%

Increase the % of clients who received their first nursing visit within 5 days of the service authorization TARGET ≥95% JUL= 95.6% AUG= 92.7% SEPT=93.2%


Collaboration to develop processes for 24 hours discharge notification

% of new referrals with 24 hour notice of

hospital discharge

Will not be completed;

replaced with eNotification pilot

Implement Neighborhood Care 100% of SPOs Paused

Review process of time to SPO/internalprovider offer to first service date

Identify improvement opportunities

Planned



**Additional Action:Reinforce first visit date field in CHRIS

Improvement in access metrics for PSW and Nursing

In Progress

**Additional Action:Use “Client on Hold” feature in CHRIS more effectively

Improvement in access metrics for PSW and Nursing

In Progress

Increase the % of complex patients who received their first personal support service within 5 days of the service authorization dateTARGET ≥95% JUL= 53.0% AUG= 64.8% SEPT=73.1%

Increase the % of clients who received their first nursing visit within 5 days of the service authorization TARGET ≥95% JUL= 95.6% AUG= 92.7% SEPT=93.2%

ACCESS


Reduce % of home care clients with an unplanned, less-urgent emergency department (ED) visit within the first 30 days of discharge from hospital.TARGET ≤7.0% Q1 FY 14-15 = 7.2%

Reduce % of home care clients who experienced an unplanned readmission to hospital within 30 days of discharge from hospital.TARGET ≤ 18.2% Q1 FY 14-15 = 19.9%


Collaboration with The Ottawa Hospital (TOH)

Identify improvementopportunities

Late

Implement Community Health Evaluation completed using Paramedicine Services (CHECUPS) with Renfrew County Paramedics

Establish baselineperformance

In progress

EFFECTIVENESS



**Continuation: Rapid Response Nurse Program

Continuation from14-15 QIP

In Progress

** New Project:Integrated Discharge Planning Model

10% decrease in readmissions and (ED)

visits at TOHIn Progress

EFFECTIVENESS

Reduce % of home care clients with an unplanned, less-urgent emergency department (ED) visit within the first 30 days of discharge from hospital.TARGET ≤7.0% Q1 FY 14-15 = 7.2%

Reduce % of home care clients who experienced an unplanned readmission to hospital within 30 days of discharge from hospital.TARGET ≤ 18.2% Q1 FY 14-15 = 19.9%


Percentage of clients who have reassessment on time, per population standards of care.

TARGET≤80% JUL = 71.9% AUG = 87% SEPT = 91%


Increase the percentage of completed in-home assessments as per guidelines of care

80% In Progress

EFFECTIVENESS


Increase the % Positive Response to KPI 1 “Overall Experience” on the client experience survey.

TARGET ≥94% JUL = 91.4% AUG = 92.8% SEPT = 92.8%


Implement AIDET (Acknowledge, Introduce,

Duration, Explanation, Thank You)All CCAC and SPO Staff Late

Define Care Plan FlexibilityDefine; Educate Staff

and SPOsIn Progress

Implement Client Check-in across all Congregate Care Teams

100% of CongregateCare Teams engaged in

client check-insLate

Patient and Caregiver Council engagement in specific workplan activities

Council activelyconsulted on 2 key

organizational initiativesIn progress

CLIENT-CENTRED



Trial Interactive Voice Response (IVR) Technology as a means of obtaining real-time client satisfaction data

Develop and trial survey In Progress

Reduce average number of calendar days to resolve client complaints

20 days In Progress

Reduce the occurrence of missed careDetermine baseline missed care rate

Planned review beginning Q3

FY 15-16

**New Initiative:Automated Provider Reports

Improve communication between CCAC and

SPOsIn Progress

Patient-Centred Appointments 85% In Progress

Increase the % Positive Response to KPI 1 “Overall Experience” on the client experience survey.

TARGET ≥94% JUL = 91.4% AUG = 92.8% SEPT = 92.8%

CLIENT-CENTRED

Champlain CCAC Board CSQS Committee – December 7, 2015

Item 5.3 – Quarterly Events Report PAGE 1

Submission to the CSQS Committee of the Board

Quarterly Events Report: July 2015 – September 2015(Q2)

December 7, 2015

EVENT REPORTING

Adverse Events: The last Adverse Event occurred on September 21, 2013. There have been no confirmed Adverse Events for the last 687 days. Q2 Risk Events Reporting and Improvement Activities Update: Client Falls: There has been continued work to address client falls, including the addition of a new CELS category: category Client Fall – Unwitnessed: Fall resulting in injury, recommendation to call 911 and/or additional healthcare resources. Please see page 4 for full details on the initiatives. Non-Reportable Events: Non-Reportables have been tracked since June 2014 to capture events not currently categorized within the CELS system. Please see page 5 for full details of the review of non-reportable events. Top 5 Reported Events in CELS Within CELS, the event categories and definitions include those required internally and by the OACCAC reporting requirements and data collection needs. In Q2, the top five reported events were:

1. Quality of Services Provided by Champlain CCAC, SPO and HealthCare Team (Subcategories: professionalism; responsiveness; time management; cleanliness)

2. Client Fall (Subcategories: Witnessed – without injury; Witnessed - with injury; Client Fall- Unwitnessed; Client Fall - Unwitnessed fall - resulting in injury; recommendation to call 911; and/or additional healthcare resources )

3. Improper procedure or intervention as per College standards or established practice (Subcategories: clinical; organizational (CCAC and SPO); organizational (SPO); organizational (CCAC))

4. Compliment to Service Provider 5. Not Reportable Events



Improvement Activities: Quality of Service Quality of Service, for both CCAC and SPO staff, is captured through the subcategories: professionalism, responsiveness, time management and cleanliness. The quality team has improved the accuracy of capturing these events with the goal of increasing awareness and facilitating improvement activities. Client Falls Client Falls is captured through the subcategories of: Witnessed – without injury; Witnessed – with injury; Not witnessed. Upon review of the CELS categories, a new category Client Fall - Unwitnessed fall resulting in injury, recommendation to call 911 and/or additional healthcare resources was added to better capture unwitnessed events that have an impact on client safety. Continued work in relation to falls includes the development of consistent guidelines for CCAC and for SPO staff regarding safe client transfers and use of mechanical lifts. Other key initiatives include: Collaboration with Ottawa Public Health on the implementation of a Falls Prevention program with PSS workers. Improper Procedure or Intervention as per College Standards or Established Practice Improper Procedure or Intervention as per College Standards or Established Practice is captured through the subcategories of: clinical; organizational (CCAC and SPO); organizational (SPO); organizational (CCAC).The improved categorization of these



events by The Quality Team allows for greater consistency and accuracy and has led to an increased focus on joint event reviews between staff and SPOs to gain learnings from reported events and work together to improve client care. Compliment to Service Provider Through continued efforts, the Quality team is able to more accurately capture and categorize events, including events related to positive aspects of care for clients. Not Reportable Events The category of Not Reportable Events was initiated with the launch of CELS 2.0. This category was added to ensure that incidents noted in CELS which did not fit into previously identified categories could be accurately captured. After a review in July-August 2015, three categories previously categorized as non-reportable were added to the list of reportable CELS events: Quality of Service – Vendor; Quality of Services by the CCAC – Organizational Policy; and Incomplete Referral. Education to CCAC and SPO staff about appropriate items to be reported in CELS will continue. Ellen Alie Manager, Quality, Risk and Client Experience Sponsoring Executive: Deryl Rasquinha, VP, Performance & Strategy


Item 5.4 – Quarterly Complaints Report PAGE 1


Quarterly Complaints and Compliments Report:

July 2015- September 2015(Q2)

December 7, 2015

COMPLAINT AND COMPLIMENT REPORTING

Complaint categories: There are six complaint categories captured in Champlain Event Learning System (CELS) 2.0. Compliments provided to both CCAC and service provider organization (SPO) staff are also reported:

Amount of services: Complaint regarding the CCAC’s decision about the amount of any particular service included in the plan of service

Eligibility for services: Complaint regarding the CCAC’s decision regarding eligibility for service

Exclusion of services: Complaint regarding the CCAC’s decision to exclude a particular service from the plan of service

Quality of services: Complaint regarding the quality of service provided or arranged

Termination of services: Complaint regarding the decision to terminate service

Violation of rights: Complaint about violation of client rights: Client Bill of Rights (Long-Term Care (LTC) Act) or the Human Rights Act

Compliments about CCAC: Expression of appreciation, praise, or commendation of a CCAC staff member

Compliments about SPO: Expression of appreciation, praise, or commendation of a Service Provider staff member

Compliments about Health Care Team: Champlain CCAC category; expression of appreciation, praise, or commendation of both CCAC and SPO staff

Each of the complaint categories are continuously reviewed and broken down into subcategories to better capture the actual area of concern.

Complaints and Compliments Reported in CELS

Total Number Reported

(FY 2014/15)

Number Reported Q2 (FY 2015/16)

Number Reported

YTD (FY 2015/16)

Average Days to

Resolution (FY 2014/15)

Average Days to Resolution

Q2 (FY 2015/16)

Average Days to Resolution

YTD (FY 2015/2016)

Complaints

584 192 351 36.83 30.33 27.83

Compliments

205 48 70 N/A N/A N/A



Chart 1 – Total Number of Complaints Reported In CELS (By Month):

Chart 2 – Total Number of Complaints and Compliments Reported in CELS (By Theme)



Chart 3 – Days to Resolution for Complaints Reported in CELS

Ellen Alie Manager, Quality, Risk and Client Experience Sponsoring Executive: Deryl Rasquinha, VP, Performance & Strategy


Client and Caregiver Experience Evaluation (CCEE)

Results forFY 2014-15 and

CCEE Action Plan Focus Areas

Presented to: CSQS Committee of the Board

December 7, 2015


• Provincial tool used by all 14 CCACs

• Available in English and French

• Conducted over the phone with clients or their designated caregivers

• 47 Questions and 9 Key Performance Indicators

• Statistically relevant data across:

• Regions• Service Providers• Service Type (nursing, social work (SW), occupational therapy (OT),

physiotherapy (PT))• Clinical Care Teams

• Approximately 2200 completed surveys per year

Background

2

CASC de Champlain CCAC 3

Scope


KPI Comparison

KPI 1 -Overall

Experience

KPI 2 - ClientCentred

Care

KPI 3 - ClientCentred

CareAppointmen

ts

KPI 4 -Quality of

Care

KPI 5 -Building

Relationships and Trust

KPI 6 -Linking to

otherservices

KPI 7 -Willingness

toRecommend

KPI 8 -Expectations of Quality

KPI 9 -Safety

Champlain CCAC 92.8 88.3 91.7 92.5 92.8 76.4 96.7 60.6 73.5

Provincial CCAC 92.2 88.8 91.5 92.9 91.6 77.1 96.7 59.9 76.5

50.0

55.0

60.0

65.0

70.0

75.0

80.0

85.0

90.0

95.0

100.0

% P

osi

tive

Champlain vs the Province FY 2014-15

Champlain CCAC

Provincial CCAC

4


Overall Satisfaction By Service

48.6%39.1% 43.7% 39.8% 40.3% 41.3% 42.9%

34.1%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

Overall Satisfaction by Service - By ResponseFY 2014-15

Poor

Fair

Good

Very Good

Excellent

5


Key Performance Indicators YOY

Year of Survey FY 2012FY 2013FY 2014FY 2015

KPI 1 - Overall Experience 93.2 92.8 92.5 92.4

KPI 2 – Client-Centred Care 89.5 88.6 88.4 87.7

KPI 3 – Client-Centred Care Appointments 92.4 92.4 91.7 92.0

KPI 4 - Quality of Care 93.9 93.1 92.2 93.9

KPI 5 - Building Relationships and Trust 92.1 91.6 92.5 91.6

KPI 6 - Linking to Other Services 49.7 74.1 77.6 77.4

KPI 7 - Willingness to Recommend 96.5 97.0 96.8 96.5

KPI 8 - Expectations of Quality 61.6 61.8 60.1 63.1

KPI 9 - Safety 74.4 73.5 75.3 73.6

6


Overall Services YOY

Year of Survey FY 2012 FY 2013 FY 2014 FY 2015

Nursing 96.5 96.2 93.6 94.2

PSS 92.8 91.6 92.2 94.0

PT 94.2 93.4 93.9 92.3

OT 91.5 92.2 91.7 87.1

Nutrition 95.3 95.2 95.8 94.4

SLP 92.3 95.4 97.0 94.1

SW 87.1 94.1 89.0 92.9

Placement -- 91.3 87.8 91.1

7


Champlain CCAC Priority Matrix


Based on the FY14-15 CCEE results, areas of focus for 15-16 are:

• KPI 1: Overall experience

• KPI 2: Client-centred care

• KPI 6: Integrated care and support of transitions

• KPI 9: Safety

• And additionally, question of “ease of contact of care coordinator” (given strong correlation to Client Experience)

Action plan to be completed in December 2015, and actioned starting January 2016

CCEE Action Plan Development: Areas of Focus


Appendix


86.0

88.0

90.0

92.0

94.0

96.0

98.0

100.0

% P

osi

tive

KPI 1 - Overall Experience

11


80.0

82.0

84.0

86.0

88.0

90.0

92.0

94.0

96.0

98.0

100.0

% P

osi

tive

KPI 1 - Overall Experience, By Question

Rate management/handling of case by case manager Rate services Rate services provided by agency

12


KPI 1 - Overall Experience

Date Long Stay Short Stay

2012-13

Q1 91.1 93.6

Q2 94.3 93.5

Q3 93.2 94.7

Q4 92.7 93.8

2013-14

Q1 92.5 94.1

Q2 94.2 94.2

Q3 91.1 94.7

Q4 93.5 94.8

2014-15

Q1 92.1 94.3

Q2 91.9 92.9

Q3 91.6 92.8

Q4 92.7 94.5

2015-16 Q1 93.5 92.0

13


80.0

82.0

84.0

86.0

88.0

90.0

92.0

94.0

96.0

98.0

100.0

% P

osi

tive

KPI 2 – Client-Centred Care

14


70

75

80

85

90

95

100

% P

osi

tive

KPI 2 – Client-Centred Care, By Question

Felt involved in developing care plan Given needed information about CCAC services

15


KP1 2 – Patient-Centred Care


2012-13

Q1 95.7 88.7Q2 93.1 91.2Q3 92.3 84.6Q4 88.2 85.3

2013-14

Q1 90.1 86.9Q2 91.5 84.5Q3 92.3 90.6Q4 89.4 91.9

2014-15

Q1 90.4 86.4Q2 91.0 84.7Q3 89.3 86.3Q4 90.1 87.6

2015-16 Q1 88.9 86.7

16


* Note: As of April 2013, a second question was added to KPI 6.

40.0

50.0

60.0

70.0

80.0

90.0

100.0

% P

osi

tive

KPI 6 – Linking to Other Services

17


40.0

50.0

60.0

70.0

80.0

90.0

100.0

% P

osi

tive

KPI 6 - Linking to Other Services, by Question

CCAC link to other community services after discharge

CCAC linked to other community services

18


KPI 6 - Linking to Other Services


2012-13

Q1 35.0 52.4Q2 38.9 57.1Q3 71.4 45.1Q4 66.7 54.6

2013-14

Q1 79.8 67.7Q2 80.5 61.6Q3 76.2 72.2Q4 79.0 72.0

2014-15

Q1 80.4 68.6Q2 81.2 72.3Q3 78.4 75.7Q4 76.4 65.0

2015-16 Q1 85.1 73.9

19


60.0

65.0

70.0

75.0

80.0

85.0

90.0

95.0

100.0

% P

osi

tive

KPI 9 – Safety

20


60.0

65.0

70.0

75.0

80.0

85.0

90.0

95.0

100.0

% P

osi

tive

KPI 9 – Safety, by Question

Case manager discusses safety issues Told how to set up home to move around safely

21


KPI 9 - Safety


2012-13

Q1 77.9 66.5Q2 78.5 61.9Q3 81.4 63.1Q4 77.8 62.3

2013-14

Q1 80.4 60.6Q2 78.7 61.4Q3 79.8 63.5Q4 76.0 67.8

2014-15

Q1 81.0 67.9Q2 78.5 66.0Q3 78.8 66.0Q4 78.6 58.9

2015-16 Q1 81.4 67.8

22


70.0

75.0

80.0

85.0

90.0

95.0

100.0

% P

osi

tive

Ease of Contacting Case Manager

All Long Stay Short Stay

23


Discussion

25


People Services & Organizational Development

Update

Client Services, Quality and Safety CommitteeDecember 7, 2015

Martin Hajek – Director, People ServicesDan Merritt – Director, Organizational Development


Table of Contents

Integrated HR-OD Talent Management Framework

Indicators• Employee Headcount

• Full Time Equivalents

• Age of Employees

• Length of Service

• Employee Turnover

• Absenteeism

• Occupational Health and Safety

• Labour and Employee Relations

• Exit Interviews

• Performance Development

• Education Hours

• Employee Engagement Survey

Highlights


Integrated HR-OD Talent Management Framework

Rewards & Recognition

Workforce Planning &

Management

Talent Acquisition

Onboarding

Performance Management

Learning & Development

Organizational Effectiveness

& DesignLabour

Relations

Health, Safety & Wellness

Compensation & Benefits

Employee Engagement


0

100

200

300

400

500

600

700

800

Employee Headcount

Full Time Part Time Job Share

Sum of Casual Sum of Temp

• Headcount has been reduced from 756 to 719 over the past 12 months.

• Full time employees continue to be the key component of our work force.

• Casual and temporary employees continue to be used only for absence replacement and short term projects.

4

Employee Headcount


0

100

200

300

400

500

600

700

800

Number of Full Time Equivalent Positions • Reduction of 30 FTE in the past 12

months, driven by deliberate efforts to reduce in February 2015.

• FTE has remained relatively stable since the February 2015 staff reductions.

5

Full Time Equivalents


0

50

100

150

200

250

0-25 26-35 36-45 46-55 56-65 65+

Regular Employees by AgeSeptember 30, 2015

• Champlain CCAC average age is 46.1.

• Age distribution does not indicate any immediate issue.

6

Age of Employees


0

20

40

60

80

100

120

140

160

180

0-2 2-5 5-10 10-15 15-20 20-25 25+

Regular Employees Length of Service September 30, 2015

• Significant number of highly experienced employees.

• Pros – excellent knowledge of CCAC, well developed skills.

• Cons – could increase resistance to significant change initiatives.

7

Length of Service


0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

20%

2013/14Q3

2013/14Q4

2014/15Q1

2014/15Q2

2014/15Q3

2014/15Q4

2015/16Q1

2015/16Q2

Annual Turnover Rate

• Spike in turnover is due to early retirement offers and layoffs in Q4 2014-15.

• With early retirements and layoffs removed, turnover rate is within target of 10%.

• 7 permanent employees were hired between May 2014 and April 2015. None of these terminated within 6 months of being hired.

8

Employee Turnover


0

2

4

6

8

10

12

14

Average Number of Days of Absence per Year

Rate Target

• Target rate for number of days of absence per year was reduced from 12 days to 9 days (or 3.46%), to reflect performance in the previous year.

• Seeing a significant increase in absenteeism among both team assistants and care coordinators.

• Detailed analysis of absenteeism is in progress.

• Continued focus on early and safe return to work.

9

Absenteeism


• NEER surcharge of $210K expected in 2015.

• NEER surcharge is driven by 2 lost time claims – one in 2014 and one in 2011.

10

Occupational Health and Safety

0

1

2

3

WSIB Claims By MonthApproved and Pending

Lost Time No Lost time


0

2

4

6

8

10

12

14

16

18

20

Incidents by TypeFiscal YTD Sept. 2015

• Harmful substances – 18 incidents reported during Pembroke flood and remediation. Only 1 was approved by WSIB, and is currently under appeal.

11

Occupational Health and Safety


• CUPE grievances related to February 2015 layoffs have been settled.

• Only one CUPE grievance remains outstanding. It is related to 2014 layoffs – no financial implications. Settlement discussions are ongoing.

• No outstanding OPSEU grievances.

• No other legal, human rights or other claims outstanding.

12

Labour and Employee Relations


Exit Interviews: SummaryQ1 & Q2 2015 – 2016


Exit Interviews Q1 & Q2 2015 – 2016 at a glance…

Totals for Q1 & Q2 2015 - 2016

Number of

Departures

Not Eligible

for Interviews

Eligible for

Interviews

Exit Interviews

Conducted

27 3 24 12

Offer rate:

100%

Participation rate:

50%

1-5 years continues to be the highest group of

departures


Primary Reason for Leaving

RetirementsBetter Job

OpportunityPersonal / Relocation

17% 42% 25%

Interesting fact:

80% of employees leaving

for a “better job

opportunity” had tenure of

less than 5 years.

15

Exit Interviews Q1 & Q2 2015 – 2016 at a glance…


Exit Interview Q1 & Q2 2015 -2016 Trending

• 92% of employees would recommend Champlain CCAC to others as a good place to work.

• Q2 on average falls below Q1 in all categories with the exception of communication & senior leadership.

• On average the lowest rated response from Q1 and Q2 was, “I had career advancement opportunities within CCAC”. This correlates with the 42% of employees who left CCAC for a better job opportunity.

• Employees in Q2 agree that the amount of work they are expected to do is reasonable, an increase from Q1.

• Employees on average feel strongly that they receive support and meaningful feedback from their direct managers.

• Other positive themes were with regards to respect for one another, satisfaction with their benefits package, and flexible work arrangements.


Comments:

The frequency of change of managers

made the expectations change frequently.

The CCAC offers flexible work arrangements, great benefits.

But need to focus on programs that do offers professional

development/succession planning. Stretch

opportunities/rounding is not provided on an on-going basis, but

often as a reaction to a gap/void due to an unexpected departure or leave of

absence.

I do think it is a good work environment for a

work life balance profession. For most

health care professionals, shift work is required, not

to have to work night shifts is a positive point.

Good relationship with Manager with the open

door policy.

Program managers are too busy managing portfolios and not their staff. Program managers (in general) don't have time to assist staff to identify learning needs and provide mentorship that could lead to

promotion with the organization.

We have robust policies and procedures

but application varies from department

to department.


Performance development activities include appraisal, goal setting, learning and development planning, ongoing feedback and coaching.

MPE staff

Completed in spring. 100% completion.

Unionized staff

27% completion to date. Intentional delays of performance appraisal activities due to new Care Model in February.

18

Performance Development

100%27%

100%

%

MPE Unionized

100%

27%


Learning and Development

• Patient safety

• Workplace violence and harassment

• Self-defense and situational awareness

• Person-driven care techniques: AIDET

• Self-care and mindfulness

• Professional practice

• Health and safety

• Orientation programs

• CHRIS & RAI training

• Leadership development: conflict / self-care / mentoring

• Individual development opportunities


Education Hours


Employee Engagement Survey

The 2015 survey is currently open, and will close December 9th.

Final survey data will be provided to CCAC in January.

Analysis, reporting and action planning will occur January-February.


Champlain Summit

Internal development opportunities

- Clinical care managers

- Accreditation positions

- People and Stakeholder Engagement

Accreditation preparation

Enhanced position control processes

Annual influenza campaign launched

22

Highlights


Champlain CCAC won the Platinum Level Quality Healthcare Workplace Award from the Ontario Hospital Association (OHA) and the Ministry of Health and Long-Term Care (MOHLTC) for the 2nd year in a row.

This is the highest level of achievement for this prestigious competition, and follows Platinum in 2014, Gold in 2013, and Silver in 2012.

23

Highlights


Item 8.0a – Patient & Caregiver Council Update PAGE 1


Patient and Caregiver Council Update

December 7, 2015

June to November 2015 Review

Key Deliverables

The Patient and Caregiver Council is part of the committee governance structure of the

Champlain CCAC. In accordance to the Terms of Reference, the Council is obliged to

report annually to the Champlain CCAC Board of Directors (June) and annually to the

CSQS Committee of the Board (December).

The following table provides an overview of the levels of engagement from a patient and

organizational perspective, mapping accomplishments to date and those planned for the

future using the Balik and Carmen Engagement Framework. These initiatives span

from introducing new criteria for board of director recruitment to identifying key

Accreditation committees that require patient input, and have moved to the stage where

various organizational initiatives are asking for a patient representative to provide

perspective and experience.

Table: Champlain CCAC Engagement Journey – DRAFT

Levels of engagement Consultation Involvement Partnership & Shared

Leadership

Direct Care

Welcome Package

Review (2015)

Input to CCAC

Care Model (2015)

Input into new web design

related to Wait Times (2015)

Self-Directed Care Pilot

(2016)

Neighborhood Care

Organization-wide training in

Person Driven Care approach

(2015)

Person Driven Care

Steering Committee (2015)

Define Flexible Care

Approach (2016)

Organization Design

and Governance

Quarterly Client

Surveys

Patient and Caregiver Council

launched May 2014

First In-House Patient Advisor

(2015)

Expansion of Patient Advisor

Program – Target 2016

Patient Rights &

Responsibilities (2016)

Representation to Key

Accreditation Committees

(2016)



Levels of engagement Consultation Involvement Partnership & Shared

Leadership

Board of Directors Criteria

includes Patient and

Caregiver experience (2015)

Patient Rep to Quality &

Safety Committee of Board

(2016)

Patients on Hiring

Committees (2016)

Policy Making

CCAC Caregiver

Strategy (2014)

Supplies &

Equipment Strategy

(2014)

Complaints/Feedback

Policy & Procedure

(2014)

CIHR Review Committee

(eHIPP) (2015)

What Does Patient Safety

Mean to Me? (2015)

Patient Declaration of

Values (2015)

MOHLTC Home &

Community Care, Patient &

Caregiver Advisory

Organization Committee

(2015)

Define Respite Services to

meet needs (2016)

Highlights

Revised Terms of Reference

Collaboration with Council members to create rich online content on respite

Feedback on wait times reporting

Patient and caregiver stories for use in media articles and for the website

The Champlain CCAC Patient and Caregiver Declaration of Values were officially

launched at the 2015 Champlain CCAC AGM. Council were actively involved in

media outreach related to the Declaration of Values – radio and print stories.

Council members were invited to the 2015 Staff Summit and some played active

roles at this event.

In Q2, Council reviewed and proposed changes to its Terms of Reference and set

priorities for Year 2 of the 2015-2016 work plan.

What does Patient Safety mean to me? July 2015 Council feedback.

CCAC Patient Advisor Kelsey Lett was recently awarded the prestigious James

Conway Patient and Family Advisor scholarship from The Institute for Healthcare

Improvement. Dec 2015.

Source: Adapted from Barbara Bolik, Institute for Healthcare Improvement and Corman, K.L. et al (2013)

Patient and Family Engagement: A Framework for understanding the elements and developing interventions

and policies, Health Affairs.



Kelsey brings the patient voice as member of the Champlain CCAC Cares

Donations Fund.

Council Members are on steering committees related to person-driven care and

innovation such as IMPACT (Innovation eMpowering Patients and Caregivers

through Technology) – the new innovation centre to support patients and

caregivers in the home

Council members have added the patient and caregiver voice locally, and have also

contributed to provincial and international initiatives.

Local

Bruyere Continuing Care – IMPACT Project (April 2015 ongoing)

Algonquin College – development of caregiver course (October 2015)

Provincial

Council members Kelsey Lett and Russ Morton presented at the 2015 OACCAC

Conference. Kelsey provided opening remarks at the Awards Dinner and later

received the OACCAC Citizenship Award (May 27-29, 2015)

Health Quality Ontario’s Patient, Family and Public Advisors Program

(September 2015)

MOHLTC Home and Community Care /Patient and Caregiver Advisory Table

(September 2015)

National

Canadian Institutes of Health Research - eHealth Innovation Partnership

Program (eHIPP) (September 2015)

Council members Kelsey Lett, Scott Johnston and Sharon Haig presented at the

2015 Canadian Home Care Conference held in Ottawa. (November 2015)

Council in the Media

CCAC articles

Putting Patients and Caregivers First: Champlain CCAC Introduces Declaration

of Patient and Caregiver Values (June 2015)

Introducing our First Patient Engagement Advisor (June 2015)

Nursing Clinics Increasing Access to Care (June 2015)

Kelsey Lett wins prestigious James Conway Patient and Family Advisor

scholarship (September 2015)

https://www.researchnet-recherchenet.ca/rnr16/vwOpprtntyDtls.do?prog=2171&view=currentOpps&type=EXACT&resultCount=25&sort=program&all=1&masterList=true#objective

https://www.researchnet-recherchenet.ca/rnr16/vwOpprtntyDtls.do?prog=2171&view=currentOpps&type=EXACT&resultCount=25&sort=program&all=1&masterList=true#objective



A Caregiver’s Journey: Preparing for Respite Care (September 2015)

Media Mentions

Russ Morton – interview on the Valley Heritage Radio - Renfrew (August 2015)

Scott Johnston - Patient to Adviser - Cornwall Standard Freeholder (August

2015)

Scott Johnston - Every cloud has a silver lining – Glengarry News (August 2015)

Russ Morton - Patient and caregiver voice added to home care support - Arnprior

EMC (August 2015)

Adding patient, caregiver voice to home care; Champlain CCAC unveils Patient

and Caregiver Declaration of Values - Renfrew Mercury (July 2015)

Orléans girl receives health care advisor scholarship - Orléans Online

(November 2015)

New Initiative

Expanded Patient Advisor Program

We are currently conducting an environmental scan of other CCACs and service

provider organizations to review the approaches and lessons learned related to patient

engagement programming as well as opportunities for collaboration or streamlining. We

are also conducting an extensive review of the literature to determine best-practices and

emerging issues. Champlain CCAC’s established processes and tools for patient

engagement are also undergoing a review and revision to reflect the updated short and

long-term goals of the Patient Advisor Program. The work underway will enable efficient

and active recruitment and onboarding of approximately a dozen Patient Advisors. The

objective is to begin recruitment early in the new year.

Sponsoring Executive:

Patrice Connolly, Vice-President, People and Stakeholder Engagement

Terms of Reference

Champlain CCAC Patient and Caregiver Council Approved July 17 2014 – REVISED Nov 20 2015

Page 1

CHAMPLAIN CCAC PATIENT AND CAREGIVER COUNCIL

Leadership Sponsor:

Patrice Connolly Vice-President

People and Stakeholder Engagement

1. Purpose

The Champlain Community Care Access Centre (CCAC) recognizes patients, caregivers and

families as essential partners in care. The Patient and Caregiver Council is a forum to improve

the home care experience in the Champlain region for former, current and future patients

and caregivers.

The Patient and Caregiver Council is part of the Committee Governance Structure of the

Champlain CCAC. The objectives of this Council are:

• To provide input regarding their personal experiences to inform in CCAC planning,

implementation and evaluation of services

To reflect the needs of Patients and Caregivers in order to improve the quality of care and

services

• To provide input on matters concerning the health and well-being of patients and their

caregivers

To identify gaps in information, services and education for patients and caregivers

To provide an opportunity to identify and monitor emerging issues concerning patients

and their caregivers

2. Responsibilities

The responsibilities of the Champlain CCAC Patient and Caregiver Council are:

• To declare conflict of interest at meetings where indicated

To give advice from the perspective of the patient and caregiver to the CCAC on its

directions, initiatives and services

• To go beyond their experiences to improve care for others

To be willing to share their story or contribute to public awareness

• To provide input to improve services for patients and their caregivers

Represent on other local, provincial or internal committees as required

Terms of Reference


Page 2

The responsibilities of the Champlain CCAC are:

To include the patient and family voice in board meetings

To support the efforts of the Council and its members

To maintain transparent and open communications

To ensure responsiveness and awareness of caregiver needs, where possible thru unique

programs for caregivers

To have regular dialogues between the organization’s leaders and clients and families to

solicit and incorporate client and family perspectives as opportunities for improvement

Members

The Council will be between 10 and 12 members who represent a cross-section of patients

and caregivers from the territory served by the Champlain CCAC.

Members will be current, former and future home care patients and caregivers.

Membership is at the invitation of the CCAC and selected by an internal working group

composed of staff and members.

Members will represent operational departments including, but not limited to:

VP People and Stakeholder Engagement

VP of Clinical Care or designate

Other staff on invitation

Invited guests on an ad-hoc basis

Trial Period

There will be an initial trial period of 6-month for all new members to ensure “fit”.

The purpose of the trial period is to provide orientation, guidance, and coaching to a new council member. This period is also the final phase of the selection process that will provide co-chairs

and the new member an opportunity to mutually evaluate their position on council to ensure a suitable and acceptable fit and goals.

Membership Term

The term is a two-year membership with the possibility of a one-term renewal (max. 4

consecutive years)

Members may withdraw from membership at any time and by any means (i.e. written or

verbal)

Terms of Reference


Page 3

In the management of term renewals, consideration will be made to maintain a balance of

new and experienced members

Terms of Reference and Membership to be reviewed annually

In recognition that patients may experience difficult periods due to their condition or

circumstances, a member may request a leave of absence or alternately Council may

suggest a leave of absence.

Leadership

The VP of People and Stakeholder Engagement will be the Executive sponsor. There will be

two (2) Co- Chairs of the Patient and Caregiver Council.

3. Meetings

The Patient and Caregiver Council will meet a maximum of four times per year. A draft agenda for each meeting shall be sent one week prior to the meeting.

The Council Co-Chairs will ensure that the following documents are circulated at least three (3) days in advance of each meeting:

The Agenda for the meeting; The Minutes of the previous meeting;

Any other documentation related to the business to be conducted by the Council.

4. Infrastructure Supports

For members who wish to participate in face-to-face meetings, mileage will be reimbursed at

the standard CCAC rate. Personal support services and/or respite care will be covered on advance request.

For members who wish to participate from home, teleconference services will be arranged. Videoconferencing from a CCAC branch office can also be arranged.

Staff Support

The Council will be supported by the Coordinator Stakeholder Engagement. This person will provide administrative support to the Council. The meetings shall be recorded by the

Coordinator for all meetings and a log of all meetings minutes including past agendas will be kept.

The Coordinator, Stakeholder Engagement will be the primary point of contact with the membership.

Terms of Reference


Page 4

Orientation

All new members will receive an orientation providing an overview of the Champlain CCAC

including governing provincial legislation, providing a better understanding of the who, what, when, where, and why of the organization, and how they as a new member of council fit within the larger picture.

5. Accountabilities

All members are obligated to sign a non-disclosure, confidentiality and conflict of interest

agreements.

All meetings will be recorded and Meeting Highlights will be translated and posted on the

Champlain CCAC website.

The Patient and Caregiver Council will develop an annual a work plan.

The Patient and Caregiver Council is accountable to the Champlain CCAC Executive

Committee.

The Council will report annually to the Champlain CCAC Board of Directors (June) and

annually to the CQSC of the Board (December).

Expectations of Members

Members of the Champlain CCAC Patient and Caregiver Council are expected to:

Suggest agenda items and priority areas of work for the Council. Regularly attend and be an active participant in Council meetings.

Prepare for meetings by reviewing minutes and reports. Be prepared to draw on their personal experiences. At the same time, reflect on the

broad needs of Patients and Caregivers. Represent the voice of patients and caregivers on other CCAC initiatives, as requested. Assist with recruitment of new members.

Respect the privacy and confidentiality of other members and their personal

experiences.

Respect the organization at public or specific engagement.

Date Reviewed: Date Updated: November 2015 Next Review Date:

Champlain

Board Scorecard

November 2015

(Data as of October 2015)

Champlain

Operational Dashboard

2

Client

Financial

Quality

People

Financial Trends

FYTD Target

(as at Oct

2015)

Oct-15

Oct 2015

Variance

vs. Plan

FY 2015/16

Variance

vs. Plan

FY 2015/16

Projected

Deficit

Tracking to Budget Targets +$0k -$955k +$955k +$27k TBD

Client Trends Oct-14 Target / Baseline Sep-15 Oct-15 FY 2015/16

Referra l Volume 4612 4400 4849 4938 4651

Intake queue wait time 32 10* 9 9 16

989 Fully Waitlisted 48 12 360

547 Partially Waitlisted 2 1 264Total PT Cl ients Waitl i s ted 90 N/A 124 4 165

Total OT Cl ients Waitl i s ted 650 N/A 78 4 292

Total PSS Cl ients Waitl i s ted

*Note: Intake Queue Target was updated from 21 days to 10 days, beginning July 2015

Quality Trends Oct-14 Target / Baseline Sep-15 Oct-15 FY 2015/16

Service Wait-time Community (90th

Percenti le Days Waiting)**61.5 21 days 63 51.9 76.7

2014/15 Q2 Target / Baseline 2015/16 Q1 2015/16 Q2 FY 2015/16

5 day wait time – Complex PSS* 77.9% 95% 64.8% 73.1% 69.0%

5 day wait time – nurs ing* 93.1% 95% 92.7% 93.2% 92.9%

Sep-14 Aug-15 Sep-15 FY 2015/16

Cl ient Compla ints Resolution Time* 27.3 20 days 43.1 TBD 28.2


Cl ient Experience* 93.9% 94.5% 91.4% 92.8% 92.3%*QIP Metrics

** MSAA Metrics

People Trends 2014/15 Q2 Target / Baseline 2015/16 Q1 2015/16 Q2 FY 2015/16

Staff Turnover 2.8% 8.5% 7.3% 6.4% 6.4%

Staff Turnover within 6 months 17.0% 3.0% 0.0% 0.0% 0%

Oct-14 Target / Baseline Sep-15 Oct-15 FY 2015/16

Absenteeism annual ized rate 9.9 9 days 11.7 12.2 N/A

Staff WSIB Reported Incidents 1 1 0 1 1

Champlain

3

Financial People

Client Trends Definition Discussion Questions

Referral Volume

The count of new referrals to the CCAC during the time period. Only referrals that initiate Case Management intake Assessments are counted in this indicator.

Is CCAC demand increasing? Is it from hospitals, physicians, or community?

Intake queue wait time

90th percentile days waited from the client’s referral date to the date of the Intake Assessment.

How is client risk being managed for clients waiting for service? What options exist to streamline intake?

Total Personal Support Services (PSS) Clients Waitlisted

A snapshot view of the count of the number of PSS clients on the waitlist as at the end of the month, divided by those who are fully waitlisted (having no PSS service), and those that are partially waitlisted (having some PSS service, but assessed for needing more).

What is being done to manage client risk?

Total Physiotherapy (PT) Clients Waitlisted

A snapshot view of the count of the number of PT clients on the waitlist as at the end of the month

How are client risks being managed?

Total Occupational Therapy (OT) Clients Waitlisted

A snapshot view of the count of the number of OT clients on the waitlist as at the end of the month

How are client risks being managed?


Service Wait-timeCommunity (90th

Percentile Days Waiting)

Wait time from client intake / application date for referrals sourced from the community (e.g. Family, Self) to receiving the first direct care service visit, where the client is an adult client on Home Care services. The 90th percentile focuses on ensuring that 90% of clients will receive a visit in the targeted time frame, or better.

Should service eligibility or service guidelines be reviewed/reduced? What advocacy should the Board engage in?

5 day wait time –Complex PersonalSupport Services (PSS)

Measures the percent of clients whose 1st PSS visit was achieved within 5 days, from Service Authorization Date to the 1st PSS Visit Date for the episode of care. Clients with an “On-Hold” episode between the authorization and 1st visit, are excluded from the measure. (On hold is used, for example, if a clients discharge is delayed from hospital due to complications)

How have Quality Improvement Plan (QIP) action plans improved performance?

5 day wait time -Nursing

Measures the percent of clients whose 1st Nursing visit was achieved within 5 days, from Service Authorization Date to the 1st Nursing Visit Date for the episode of care. Clients with an “On-Hold” episode between the authorization and 1st visit, are excluded from the measure. (On hold is used, for example, if a clients discharge is delayed from hospital due to complications)

How have QIP action plans improved performance?

Client Complaints Resolution Time

Measures the number of days for a complaint to be resolved with the client, from the time the complaint was recorded.

How are we doing with addressing clients’ needs and/or resolving issues?

Client Experience Measures the percent positive rating for overall satisfaction with care. How have Person Driven Care action plans improved client experience?


Tracking to Budget targetsNet surplus/deficit as calculated by Revenue minus Expenses, as per plan.

Are we tracking to budget plans? Are our cost/clients to plan? Is demand for service to expectations? What additional actions if any, are required at this time?


Staff Turnover Rate at which employees leave an organization. Calculated as number of permanent employees who terminate or cease employment, divided by the average number of permanent employees on staff

If not as expected, what is the underlying cause and mitigating action plan?

Staff Turnover within 6 months

Rate at which employees leave an organization within the first 6 months of hire.


Absenteeism annualizedRate

Total number of sick hours, paid and unpaid for all permanent and temporary staff (excludes casuals), divided by number of permanent staff.


Staff Workplace Safety & Insurance Board (WSIB) Reported Incidents

The count of WSIB claims submitted per month.If not as expected, what is the underlying cause and mitigating action plan?

Client Quality

Operational Dashboard: Glossary

Champlain

Person Driven Care

Engaged & Proactive People

Sustainable Health Care

4

Strategic Dashboard

Person Driven Care Trends Oct-14 Target / Baseline Sep-15 Oct-15 FY 2015/16

Hospital Transition- % RRN cl ient

contact within 24 hours64% 90% 91% 83% 77%

Safety in Home - reassessment of

complex cl ients with PSS service

within Guidel ines of Care

92% 80% 91% 88% 89%

Avg # of RAI-HCs completed per month

per CC*15.9 30 19.8 19.5 20

# of vis i ts (external ) to the Caregiver

Exchange ResourceN/A

Actuals / Monthly

Target152 / 204 167 / 208 1058 / 1384

Cl ient check-ins per month per CC

(Retirement Home Setting)N/A 15 N/A N/A N/A


Patient Centred Appointment metric 88.3.% 85.0% 87.7% 87.5% 88.1%

Engaged & Proactive People Trends Oct-14 Target / Baseline Sep-15 Oct-15 FY 2015/16

% completion of monthly mandatory

tra ining for ful l -time staff98.8% 95%

No M andatory

Training 75.0% 81.0%

Healthl ine Vis i ts 45,758 45,000 49,603 45,837 46,907

Earned Media Coverage 20 18 / month 38 16 21

Website vis i ts 5,876 6,000 6,795 6,938 6,611

204/15 Q2 Target / Baseline 2015/16 Q1 2015/16 Q2FY 2015/16 (as

at end of Q1)

Performance Agreements completed

YTD32.6% 80% 7.3% 44.4% 44.4%

Sustainable Health Care Trends Aug-14 Target / Baseline Jul-15 Aug-15

ALC Rate*** 12.4% 12.70% 12.3% 13.0% 12.1%

2014/15 Q1 2014/16 Q4 2015/16 Q1 FY 2015/16

Very High and High MAPLe Score %

supported by Champla in CCAC,

compared to Provincia l Averages

51.8%

(2)Top Quartile

54.2%

(1)

59.9%

(1)

53.5%

(1)

Jun-14 May-15 Jun-15

LTCH LOS *Minis try Source 3.0 2.5 years 2.7 2.7 N/A

2014/15 Q1 2015/16 Q1 2015/16 Q1 FY 2015/16

2.0 Long StayTop Quarti le*

1.3 1.3 1.3

7.3 Short StayTop Quarti le**

7.0 7.0 7.0

Oct-14 Sep-15 Oct-15 FY 2015/16

# CSS Referra ls per Month 346 400 366 492 366

% Cl inic Vis i t Uti l i zation 24.3% 25% 31.2% 30.7% 29.4%

Ranking relative to other CCACs for

average cost/cl ient across a l l cl ient

groups

*Champla in i s ranked cons is tently amongst the highest MAPLe proportion provincia l ly. ; Long Stay

populations us ing provincia l reference rates .

** Champla in continues to increase specia l programs, such as NPWT and CHIPP programs, impacting avg. cost;

Champlain

Person Driven Care Engaged & Proactive People

Sustainable Health System


Hospital Transition- % RRN contact within 24 hours

Percent of clients whose 1st RRN visit occurred within 1 day from the hospital discharge date to the 1st RRN contact date, either through a telephone assessment visit, or face to face visit

How has RRN intervention helped reduce ED visits and hospital readmissions? What activities are being undertaken to increase performance?

Safety in Home - reassessment of complex clients with PSS service within Standards of Care guidelines

Percent of complex clients (per population coding), who receive their RAI reassessments within guidelines. E.g. Complex Population patients are to receive a reassessment every 3-6 months.

With the growth of complex clients, are we appropriately monitoring their safety/status? Have CELS events changed?

Avg # of RAI-HCs completed per month per CC*

The average number of RAI-HCs completed by care coordinators in the Community and Congregate Care Teams per month, normalized to a 20 workday month

Are we creating efficiencies in processes to allow for CCs to complete the Ax?

# of visits (external) to the Caregiver Exchange Resource

The count of site visits during the periodHow are we informing clients and caregivers of the resource?

Client check-ins per month per CC (Retirement Home Setting) *Developmental Metric

The average number of client check-ins completed by staff per month, for staff in retirement home settings.

Are the staff reaching out to our clients? Are client check-ins achieving desired outcomes?

Patient Centred Appointment metric

Measures the satisfaction of clients’ experience with the scheduling of the care visits

Are schedules for clients person centered?

Trends Definition Discussion Questions

% completion of monthly mandatory training for full-time staff

The count of fulltime staff who complete mandatory training as a total of all fulltime staff required to complete the training

What may be causing staff not to complete training?

Healthline Visits The count of site visits during the period, to Healthline.

Has awareness of CCAC improved to plan? Are clients able to find information they are looking for in Healthline?

Earned Media Coverage The count of stories in the media (Television, Radio, Newspapers) where the CCAC is mentioned

Has awareness of CCAC improved to plan? What is the nature of the coverage and impact on CCAC reputation?

Website visits The count of site visits to the Champlain CCAC public website.

Has awareness of CCAC improved to plan? Are clients able to find information they are looking for?

Performance Agreements completed when due

FYTD percent of staff whose performance appraisal is completed on time.

Is staff development being appropriately managed?


ALC Rate New Indicator: Counts the total ALC bed days as a percentage of Total Bed days, during the period. Includes sub-acute (rehab and complex care bed and counts patients not yet discharged).

Are our programs appropriately supporting LHIN-Wide ALC targets? What if any additional actions are required to improve performance?

Very High & High MAPLe Score % supported by Champlain CCAC

The proportion of CCAC clients assessed by a RAI-HC, with a MAPLe Score of High or Very High, out of the total number of clients with a RAI-HC assessment.

What is the financial impact of sustaining higher needs clients? What effects does this have for provincial HBAM funding/

Ranking relative to other CCACs for average cost/client across all client groups

Using the LHIN Benchmark report, average costs per patient are reported by population group. Ranking can be achieved through the comparison of average cost per patient, across peers.

Are we delivering appropriate service levels to different client populations (HBAM neutral or positive) and properly balancing cost & client risk/safety?

# of CSS Referrals per month Count of the number of referrals made to CSS Agencies within the period. (g. Adult Day Program, Assisted Living, Acquired brain injury, Respite/PSS for Seniors, Supportive Housing, Transportation)

Are we increasing CCAC-CSS collaboration to plan? Are there opportunities for greater collaboration?

% Clinic Visit Utilization Percent of Clinic Visits out of total Visit Nursing and Clinic Nursing Visits

Strategic Dashboard: Glossary

Organizational Scorecard: Review of Items Tracking Red

Overview

The following is a summary of the Champlain CCAC’s Scorecard performance metrics that are currently tracking RED. For each metric at risk, explanations and actions for improvement have been identified.

Review

Metric Target Current

Performance Current Performance Explanation

Actions Identified

Service Wait-time Community (90th Percentile Days Waiting)

21 Days 51.9 Days (Oct 2015)

This metric will continue to be affected until all clients previously waitlisted have had their first visit. Once the backlog of waitlisted therapy clients is addressed, the metric should improve significantly

All Allied Health (AH) clients have now been released from the waitlist and will continue to be released immediately. The Service Providers continue to ramp up staff to accommodate this large waitlist release and prepare for ongoing immediate releases but the first visit target will be affected until they are caught up as indicated above.

5 Day Wait-Time – Complex Personal Support Services (PSS)

95% 73.1% 2015/16-Q2

Variance showing a 50% improvement since February appears plateauing. 3 causal reason for plateau identified and addressed. Note that additional push on Home First program could put pressure on this metric

Education re process provided to staff and direct follow up with reports available. One month plateau addressed with education in October and manager follow up. Additional focus on exceptional circumstances if not changed by Dec. Additional time data entry error alerts provided directly to Authorizing CCs, three times daily.

Annual Absenteeism Rate

9 Days 12.2 12 months ending Oct 2015

Adaptation to significant organizational changes such as the implementation of the CARE (Caring, Collaboration, Accountability, Respect, Excellence) model and revised caseload sizes, coupled with the restrictions on the use of relief staff, are believed to be contributing to absenteeism.

Casual positions have been opened which will allow for greater use of relief staff. Detailed review of absenteeism is underway to further understand trending, and to develop an action plan.

Number of Visits to the Caregiver Exchange

20% increase over the year

167 Visits (Target: 208) Oct 2015

caregiverexchange.ca has a new project manager – the role has been unstaffed for the past two

*There has been a change in staffing at the provincial level – currently unclear as to replacement plan and impact on roll-out of marketing plan. In the meantime,

Metric Target Current Performance

Current Performance Explanation

Actions Identified

Resource months. We will meet with the new team to understand the vision for the site and then make a recommendation about its viability. The site is currently English only and very limited. New caregiver sites are under development and may offer better opportunities.

the Communications Department continues to build Caregiver content for our public website and social media community interested in issues and information affecting caregivers. There may be a need to revisit the viability of the caregiver exchange site and its limitations.

% Completion of Monthly Mandatory Training for Full-time Staff

95% 75% Oct 2015

With portfolio changes and new managers within Clinical Care, follow-up with individual teams fell behind.

Support will be provided for managers in reviewing mandatory training completion within teams.

Performance Agreements completed YTD

80% by end of FY

44.4% 2015/16-Q2

Managers in new Care Model teams (Community East, West, North and South, and Congregate Care East and West teams) are likely not going to start appraisals for another few months. This time is needed for them to get to know their employees, and monitor performance over a period of a few months.

Completion rates will be reviewed at the end of Q3 to determine whether a concerted effort is required for Q4.

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