Health PEI Board Meeting

February 14, 2019

M2/M3 Garfield Street

PUBLIC AGENDA 1:00-3:30

4.1 1:00 Review of Agenda J. Revell, Chair

5.0 CONSENT Agenda

5.1 Health PEI Board Minutes: December 6, 2018 J. Revell, Chair

5.2 Community Health Engagement Committee

Minutes, January 17, 2019 Helen Flynn & Colleen Parker, Chairs CHEC

5.3 Board Correspondence J. Revell, Chair

6.0 BUSINESS ITEMS

6.1 1:10 Board Chair Report J. Revell, Chair

6.2 1:20 CEO Report to Islanders D. Lewis Fleming, CEO

6.3 1:30 Divisional Update: Medical Affairs and Legal Services

Dr. A. Celliers, Executive Director

6.4 2:00 Divisional Update: Quality & Patient Safety R. Adams, Executive Director, Quality & Safety

6.5 2:30 PMAC Reappointments and Privileging J. Revell, Chair

2:40 Education\Orientation Sessions feedback Board Members

2:50 Ministerial Directives (since December 6/18) J. Revell, Chair

7.0 COMMITTEE UPDATES

7.1 3:00 Community Health Engagement Committee

update H. Flynn & C. Parker, Chairs CHEC

8.0 RESOLUTIONS/MOTIONS

8.1 3:10 Resolutions/motions from In-camera session J. Revell, Chair

9.0 QUESTION PERIOD 3:15-3:30

10.0 ADJOURNMENT AND NEXT MEETING:

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Community Health Engagement Committees - Eastern and Western Regions January 17, 2019, 6:00 pm to 8:30 pm

Central Queens United Church, Hunter River

Attendance: Helen Flynn, Chair (Eastern) Colleen Parker, Chair (Western) Tracey Gallant Eileen Brown Sandra MacFayden Noella Richard Louis Callaghan Krystyna Pottier

Merrill Scott Donna Gallant Pat Charlton Blake Adams Lynn Ann Hogan

Michelle Gaudet Whitney Harris

Brenda McAlduff Don MacEachern

Regrets: Les Chipperfield, Gertie Campbell Absent Kent Nicholson, Cliff Campbell, Krystine Richards, Stephanie Francis HPEI Staff: Claire Matheson, Executive Assistant,

Janet Hodder, Board & Organizational Development Lead Guests: Robert Mitchell, Honorable Minister of Health & Wellness Dr. Kim Critchley, Deputy Minister of Health & Wellness (regrets)

Denise Lewis Fleming, CEO, Health PEI Jaycee Sabapathy, Planning & Evaluation Jennifer LaRosa, Manager Planning & Evlauation

Welcome & Introductions Helen Flynn and Colleen Parker welcomed the Eastern and Western Region Community Health Engagement Committee members with a special welcome to the Minister of Health & Wellness and the CEO of Health PEI. Review of the Agenda and Objectives: Agenda was approved as circulated. Helen provided the background as to the purpose of the meeting and laid out the objectives for the evening. Minister Remarks Honorable Robert Mitchell opened the meeting by welcoming the group and thanking them for inviting him to be part of the evening’s meeting. He expressed his gratitude for the work of the committees and expressed the importance of community involvement and engagement in the various strategies, and policies of both the Ministry and Health PEI. He indicated he was looking forward to dialoguing with the group about their purpose and mandate. Setting the stage: Janet passed along Dr. Critchley’s (Deputy Minister of Health & Wellness) regrets for the evening as she was unable to attend due to illness. She then presented the history of the Community Health Engagement Committees to the group on behalf of Dr. Kim Critchley. This provided context for the group to aid in the evening’s discussion.

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Pre-survey results Jaycee Sabapathy provided the group with the pre-survey results. Report attached. Facilitated discussion Jaycee and Jennifer (Manager of planning & Evaluation, HPEI) broke the larger group into smaller groups and provided various questions for discussion and feedback. Wrap up The group was very engaged and much information was gathered. The group was assured that the information obtained will be compiled and brought back to group for further work and deliberation. Meeting adjourned at 8:50 p.m.

February 14, 2019

INFORMATION ITEM: HEALTH PEI CHAIR PUBLIC REPORT SUBMITTED BY: Jim Revell This report is presented for information purposes only This report reviews the operations of the Health PEI Board since the last Public Meeting on December 6, 2018. During that time the Board has made continued efforts to orientate new Board members and move towards setting the Annual Business Plan as well as commencing first steps towards the organization’s three year Strategic Plan. Since the Board last met there have been no written Ministerial Directions to the CEO. When legislative changes were implemented in 2018 the intention was to confirm the role of the department and the Minister in the operation of Health PEI. The Minister has confirmed that the best route in which to proceed in day to day operational direction to the CEO will be in writing. The Board is of the view that should a written Ministerial Directive be received from the Minister it should be reported publicly in a timely manner if possible without breaching privacy legislation. The Board during its orientation meetings received updates from all Senior Management team members both on their functions and the current and future challenges they face. The intent for the Board is to ensure that the CEO and the Leadership team she has assembled is focused on the goal of a sustainable One Island Health Care system. The focus should be on quality but also take into consideration the dual necessity of having the human resources to carry out all functions and providing them in a fiscal manner which meets the province’s current and future financial capabilities. As we proceeded through our orientation sessions it became apparent that the continuing need for resources from all divisions is significant. It is imperative that the CEO provide options to the Board, and ultimately the public which balances the many needs of the system. We all play a role in this exercise as choices will have to be made after information and evidence is gathered. The Board received its fiscal update and current year operations are proceeding as forecasted in November 2018. We have also received an outline on the budget submission for 2019-20 which incorporates the expected collective bargaining agreements, expected system utilization and announced government initiatives. We are guarded in our expectations for 2019-2020 year, however we believe most of the priorities identified by the CEO and the Executive Leadership team has been addressed. The Board received updates on challenges with the primary care physician waitlist as well as access in our facilities including unplanned closures. We have and will continue to impress the importance of these issues and ensure our planning both short term and long term has those concerns being addressed. We have appointed two Board committees being Audit and Risk to be chaired by Phil Jost and Quality and Safety to be chaired by Andrea Slysz. We are also pleased with the appointment of the Executive Director of Corporate Services to the Executive Leadership team made by the CEO and recognize their role in ensuring our future success. Jim Revell Board Chair

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Health PEI CEO Report to Islanders February 2019 Topics for Public Report & Key Messages: Health System Planning

Work is underway to develop a budget and operational plan for the upcoming fiscal year. In preparing our budget submissions, management considered Health PEI’s strategic plan, other program or disease specific strategies (such as Cancer, Mental Health & Addictions) as well as current critical operational pressures.

Work continues on a number of health human resource planning initiatives to address significant current pressures in a variety of professions, including the nursing, physiotherapy and primary care clinicians (physicians and nurse practitioners). Health PEI is leading the Nursing Recruitment & Retention Working Group, which is evaluating and updating recruitment incentives, as well as meeting with stakeholders and facilitating conversations to identify potential solutions to current challenges in staffing nursing positions in West Prince and physiotherapist positions at the QEH and Community Hospitals West.

Strategic Goal: Quality & Safety

Patient and Family Advisory Council – Evolving out of the Patient & Family Centered Care Steering

Committee, this council was launched in January. Similar to councils established by other health

authorities, this group will provide advice and guidance across Health PEI in order to improve

patient and family centered care and experiences. The council serves in an advisory capacity,

making recommendations on matters that impact the experience of patients and families.

The Bariatric Patient Management Policy was released in December 2018 across Health PEI. The

policy and accompanying guides have been prepared through the collaborative work of the

Provincial Bariatric Planning Committee with significant stakeholder engagement in the past number

of years. It is in response to the increase in bariatric patients in our hospitals, manors and

community programs. The policy and associated guides will support caring for these patients in a

respectful and responsive manner while also managing the risk of injury to both the patient and

staff.

Strategic Goal: Access & Coordination

Work continues to improve access to French-language healthcare services. Four initiatives relating to home care and long-term care services were recently approved for funding under the Canada-PEI Agreement on French-language Services.

On January 1, 2019, the new Ostomy Supplies program was rolled out. There are approximately 585 individuals living with ostomies in our province. Under the new program, all Islanders who require a permanent ostomy will be eligible for financial assistance, coverage will vary based on income ranging from 60 to 90 percent coverage, up to $2,400 per year. Program reimbursement will also be coordinated with individual’s private health insurance coverage.

Broad participation by Health PEI staff in Bell ‘Let’s Talk’ Day on January 30

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Goal: Innovation & Efficiency

Health PEI has entered into an agreement with the Canadian Partnership against Cancer for funding

of a Tobacco Cessation Project for PEI Cancer Treatment Centre patients for a 24-month period

ending December 31, 2020. This project is to continue work to align patient supports with the

Ottawa Model of Smoking Cessation, currently used across Health PEI acute care and primary care

settings. The aim of the project is to support optimal outcomes for cancer patients as scientific

evidence clearly shows that tobacco use in patients with cancer leads to poorer outcomes

Distinction in Stroke Services awarded by Accreditation Canada

Patient Flow and Hospital Bed Management: the new Out-of-Province Bed Board went live near the

end of January. This is a tool to better coordinate the return of patients from hospitals in Nova

Scotia and New Brunswick and is available to Health PEI staff, NS staff and NB staff

Engagement & Communication

CEO meetings with various external stakeholders and partners since the last report include: Workers

Compensation Board, Medical Society of PEI, Canada Health Infoway, and Canadian Institute for

Health Information.

In the last quarter of 2018 (Oct to Dec) there were 88 patient & family engagement interactions

across by various divisions; There was also a call out to Islanders to apply to be a patient& family

advisor to sit on various provincial steering committees and working groups to help inform programs

and services, ensuring that they are more patient and family centered

Work continues to improve the information available on the Health PEI website – PEI patient

registry numbers now posted & updated weekly;

Developing our Leaders

Congratulations to the Health PEI staff who were part of the graduating class of the “Leaders in

Action” program that was sponsored & organized by the Public Service Commission

Cultural Diversity and Inclusion Training was provided to our leaders’ community by Lisa Dollar from

the Newcomers Association. This presentation highlighted the importance of building intercultural

skills so that we, as leaders, can work effectively across cultures as more immigrants join the

workforce.

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Annual Divisional Update/Briefing to the

Health PEI Board of Directors

Division: Medical Affairs and Legal Services

Date: January 31, 2019

Introduction:

Medical Affairs and Legal Services Division is responsible for the administration of health

services under the Health Services Payment Act. For more information on the responsibilities of

the division and divisional staffing, please see Appendices A and B.

Long-Term Outcomes of Divisional Work

Continuing to foster stronger relationships built on trust, transparency and collaboration with physicians and key partners, such as the Medical Society of PEI and the College of Physicians and Surgeons.

Enhancing opportunities to strengthen existing partnerships for clinical and administrative expertise in health service delivery in serving both individual and collective patient needs by standardizing processes to further increase efficiency and reduce risk while enhancing responsiveness of health services

Achievements and Improvements in service delivery (in relation to Strategic Goals and

Priorities) over the Past Year:

New Physicians: Seventeen physicians were recruited for 2018 and twelve have been recruited for 2019. Medical Affairs and Legal services (MA & LS) is involved in every aspect of physician recruitment and retention from identifying physician positions, advertising vacancies, identifying funding, and negotiating contracts. Once a new physician begins working in PEI, MA& LS develops the supporting structure to ensure they succeed in their position. (Quality and Safety; Access and Coordination)

New Medical Directors: We have hired one new Medical Director and are currently working to fill two more positions. Medical Directors play an important role in supporting quality of care, physician health and the efficient management of the provision of services. (Quality and Safety; Access and Coordination)

Medical Staff Bylaws Review: Planning of the Bylaws review process via a transparent and collaborative review process, led by a working group made up of stakeholders from across the system, has occurred. A process mapping of the current state of the privileging process has occurred this year, and some changes have already been implemented to provide better efficiency. (Quality and Safety; Access and Coordination; Innovation and Efficiency)

Obstetrics and Gynecology clinic: This clinic reports to Medical Affairs and is moving into a new space in the spring of 2019. It has received further staffing resources to

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support improved safety and security of space and quality OBGYN care. (Quality and Safety; Access and Coordination)

Implementation of The Fee Code Advisory Committee (FCAC): Through Master Agreement investment, FCAC is mandated to review proposed changes to the Tariff of Fees through a fair and transparent review process. This allows for flexibility for the health system when creating, modifying or removing fee codes. Committee meetings commenced in the fall of 2018. (Innovation and Efficiency)

Out of Province Policies Review: A review of the out of province health services program policies has occurred to streamline processes. (Access and Coordination)

Medical Assistance in Dying (MAID):

- Reviewed and updated policy and process for physicians, nurse practitioners and

pharmacists that assist patients in fulfilling their requests;’

- Educated new practitioners and provided guidance and assistance for practitioners in

relation to complying with federal legislation;

- Act as a referral service for those patients requesting an assessment for MAID;

- Worked with physicians, nurse practitioners and pharmacists to streamline and

improve our MAID processes. (Quality and Safety; Access and Coordination)

Creation of Gender Confirming Surgery Policy:

- Worked with community partners, internal stakeholders, and Government to develop

a policy and process for patients seeking gender confirming surgery in keeping with

WPATH guidelines

- Built relationships with community partners and helped to identify service gaps for

trans patients, which resulted in a new steering committee to develop Transgender

pathways. (Quality and Safety; Access and Coordination)

Adoption of a Closed ICU to reduce risk for our most vulnerable patients: A business case was developed in collaboration with physicians to present for adoption to Health PEI’s executive leadership team. (Quality and Safety; Innovation and Efficiency)

Kings Country emergency room: In partnership with KCMH, Primary Care, Physicians, and the community, we developed a new model for the KCMH Emergency department to create sustainability for emergency room coverage. This model was implemented as a mechanism to prevent emergency room closures, physician and clinical staff burnout. (Quality and Safety; Innovation and Efficiency; Innovation and Efficiency)

Physician Training and Education: The Dalhousie Family Medicine Residency Program was accredited. Our PEI site participated in the survey and site visit in November 2018. Medical residents that complete their education on PEI achieve education outcomes that are highly valued within the medical community. (Quality and Safety; Innovation and Efficiency)

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Physician Leadership Education:

- Collaboration with the Canadian Medical Protective Association (CMPA) and The

College of Physicians and Surgeons to provide education for increased opportunities

for physician peers to participate in dialogue supporting clinical excellence. This

systematic approach will strengthen the health system’s responsiveness to individual

and collective physician needs and performance goals within a just culture.

- Master Certificate program funded through Master Agreement investment and

developed and coordinated through MSPEI funded by HPEI enabled 25 physician

leaders (10% of total complement) to gain added competency in leadership that will

ultimately benefit the system and the population of PEI. A second cohort is planned

for 2019.

Legal and Risk Management Services: Developing processes to promote further efficiencies in relation to internal contract management and support for the broader system. (Innovation and Efficiency)

Resource planning and investment: Proposals have been submitted and approved, in partnership with Western Hospital’s Maple program for telehealth services. (Quality and Safety; Access and Coordination; Innovation and Efficiency)

Physician Resource Planning: The MA & LS EDMA acts as Chair to PRPC and, along with other staff of MA& LS, provides support, guidance and advice to the PRPC in relation to physician complement matters, such as appropriate number, equitable distribution of physicians participating in the plan. The Department of Health and Wellness has initiated a steering committee, which will include MA & LS staff, to plan and deliver a strategy for primary care enhancement as phase one of an overall Health Human resource plan for PEI.

Prior Year Planned Activities Not Achieved:

Medical Leadership Payment and Structure: Some work has been completed, but overall, it is in the early stages. Expansion of the Medical Staff Bylaws review process will provide a robust input to later refinements in leadership structure due to the collaborative and broad based discussion planned regarding leadership structure within the Bylaws.

Locum Policy Update: We have approximately 80 locums and visiting specialists providing services in PEI each year. The Policy is in need of updating and will be a project that we will plan to tackle in 2019.

Priorities and Plans for the Upcoming Year:

Master Agreement negotiations (the current agreement expires in 2019). A consultation process has been completed and the planning process, research and priorities determination is in progress for upcoming negotiations. An updated Master Agreement

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supports physician engagement and retention by ensuring our physicians continue to be fairly compensated, and that our health system is proactively monitoring cost and value for health service delivery.

Medical Staff Bylaws review process is currently underway, designed to enable a broad based discussion to seek opportunities to improve on how current Bylaws are supporting the administrative structure of the medical staff, and high-level decision-making in the health system. Stakeholders in many areas have been engaged and early feedback seems to favour our approach. Board support and feedback will be sought throughout this process. Areas that will be reviewed include the privileging and credentialing process, medical administrative structures, and the medical staff complaint process.

• Medical Leadership structure will be reviewed, in part, through the Medical Staff Bylaws review process. MA & LS will seek opportunities to improve communication channels and enhance operational support through improved meeting management processes and increased collaboration (informal and formalized) between providers and health system administration. Investment will be needed to attract and retain competent physician leaders needed to drive the quest for system improvement.

Physician Health (Caring for the Care-Takers): Efforts have begun to increase awareness and to formalize proactive measures within physician services to ensure our valued physicians get the care they personally need. There was, in the last Master Agreement, investment to Medical Society of Prince Edward Island to support the development and operation of a program to provide assistance to physicians who are experiencing difficulty in their personal or professional lives.

Interdependencies

Health system/administration support to enable physician leadership and engagement; Health system policy and procedures to enable standardization; Patient-centered frameworks to guide how care is delivered, evaluated and continuously improved.

Risks/Challenges/Issues – and Mitigations (to the plan for the upcoming year)

Managing budget with respect to competing priorities for funding (responsiveness to needs involves complex analysis and decision-making between needed services).

Physician recruitment, retention and complement (multifaceted and demanding processes, compounding factors can make this process difficult and complex at times due to budget constraints, legislative and policy requirements). Increasing complexity in physician practices and changes in the standards of care. Competition across Canada for certain specialties and the increasing demand for family practitioners.

Management of programs that vary greatly in design and implementation requires a budget that reflects the scope of oversight required (physician contracts, locum coverage, and legal/ risk management services for all Health PEI each require distinct and complex oversight measures)

Physician Leadership roles need to be fully supported by health system budget to allow physicians to accommodate administrative commitments within already full schedules and be appropriately compensated for non-clinical time.

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Appendix A – Divisional Responsibilities Medical Affairs includes all activities related to:

Management and oversight of physician services, which encompasses working with physicians and physician groups to develop and support new programs and initiatives;

Management and oversight of physician compensation, for the provision of audit of physician compensation, as well as providing guidance and monitoring to physicians in relation to physician claims;

Delivery of medical services related to both in-province and out-of-province services;

Development of effective partnerships with physicians, as well other collaborating professionals in the health care delivery system;

Interpretation and management of processes and issues that arise under the Medical Staff Bylaws;

Management of the physician contracts, including the Master Agreement;

Ongoing support and collaboration for critical health services committees created through legislation, the Master Agreement and the Medical Staff Bylaws:

- Physician Resource Planning Committee (PRPC) (Legislative) - Joint Consultation Committee (JCC) (Master Agreement) - Fee Code Advisory Committee (FCAC) (Master Agreement) - Provincial Medical Advisory Committee (PMAC)

Legal Services includes:

Internal Legal Counsel, who provides advice on all ranges of internal matters, including contracts, the provision of legal opinions regarding interpretations of the health legislation, the Master Agreement and the Medical Staff Bylaws, and;

Risk Advisor, who provides advice on matters relating to risk management services, including liability, litigation matters, complaint management, conflict resolution and who is the primary liaison with government’s self-insurer.

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Appendix B – Divisional Staffing

Divisional Staffing and Budget: $180,905,200

FTEs: 144.71

Salaried Physicians: 116.60

Administration (including Medical Directors): 28.11 FTEs

Note: FTE count includes only salaried positions, and does not account for contract for service,

sessional or fee for services physicians. There are approximately 260 complement physicians

in PEI. Additionally, approximately 80 locums and visiting specialists provide service in PEI each

year.

Medical Affairs

Executive Director, Medical Affairs and Legal Services

Director, Medical Affairs and Legal Services *

Manager, Alternate Pay Specialists

Manager, Physician Services

Program Development Lead

Senior Claims Auditor

Physician Claims Monitoring and Educational Specialist

Medical Consultant

Administrative Assistant, Executive Director of Medical Affairs and Legal Services

Administrative Assistant, Medical Directors/Primary Care/Public Health

Administrative Assistant, Manager Alternate Pay Specialists and Manager Physician

Services

* Temporary position, not included in FTE count

Legal Services and Risk

Internal Legal Counsel

Risk Advisor

Medical Education and Residency Program

Site Administrator, Family Residency Program

Medical Education Coordinator

Administrative Assistant, Medical Education/Residency Program (0.2 FTE)

Obstetrics and Gynecology Clinic

Manager, OBGYN Clinic

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Medical Directors and Program Medical Directors:

Medical Director, PEI West (1.0 FTE)

Medical Director, Queen Elizabeth Hospital (1.0 FTE)

Medical Director, Queens

Medical Director, Kings

Program Medical Director/Chief, Mental Health and Addictions

Program Medical Director, Long Term Care

Program Medical Director, Medical Education

Program Medical Director, Laboratory Services

Program Medical Director, Emergency Medicine

Program Medical Director, Diagnostic Imaging

Program Medical Director, Chief Medical Information Officer

Program Medical Director, Physical Medicine

Program Medical Director, Diabetes

Program Medical Director, Ambulatory Care QEH

Palliative Care Medical Consultant

Health PEI

Divisional Update

Division: Medical Affairs & Legal Services

Date: February 7, 2019

Divisional Profile - Programs and Services -

Medical Affairs and Legal Services Division is responsible for the administration

of health services under the Health Services Payment Act.

Medical Affairs includes management and oversight

of: physician services to support for new programs and

initiatives

physician compensation services for guidance and

monitoring of physician claims

medical services for in-province and out-of-province

partnerships and collaboration with physicians and

other professionals in the health care delivery system

processes and issues that arise under the Medical Staff

Bylaws

contracts including the Master Agreement

committees created through legislation, the Master

Agreement and the Medical Staff Bylaws (i.e. PRPC, JCC,

FCAC, PMAC)

Legal Services includes advice

on: internal matters (contracts, legal

opinions regarding interpretations of

the health legislation, the Master

Agreement and the Medical Staff

Bylaws)

matters relating to risk

management services (liability,

litigation matters, complaint

management, conflict resolution,

liaison with government’s self-

insurer)

Divisional Profile - Resources: Staff and Budget -

Department Staffing and Budget: $180,905,200

• FTEs: 144.71

• Salaried Physicians: 116.60

• Administration (including Medical Directors): 28.11 FTEs

Note: FTE count includes only salaried positions, and does not account for

contract for service, sessional or fee for services physicians.

• There are approximately 260 complement physicians in PEI, which Medical

Affairs and Legal Services manages.

• Additionally, approximately 80 locums and visiting specialists provide

service in PEI each year.

Achievements (Past Year)

Quality and Safety New Hires: Medical Directors

New Policy: Medical Assistance in Dying (MAID)

New Policy: Adoption of Closed ICU

Access and Coordination

New Hires: 17 physicians (2018); 12 physicians (2019)

New Clinic: OBGYN clinic (opening 2019)

New Policy: Gender Confirming Surgery

Updated Policy: Out of Province Health Services

New Proposals: Resource Planning and Investment

Achievements (Past Year)

Innovation and Efficiency Project Planning: broad-based review and update of Medical Staff

Bylaws

Implementation of: Fee Code Advisory Committee (FCAC)

Education Support: Physician Training and Education; Physician

Leadership Education

Process Improvement: Legal and Risk Management services

Enablers: Highly engaged physicians who deliver administrative leadership

beyond direct patient care

Strong partnerships between stakeholders across the health system

Innovative and committed personnel to improve existing processes

Patient-centered and process-driven communication channels

Priorities (Coming Year)

• Master Agreement negotiations: the planning process, research and priorities

determination is in progress for upcoming negotiations.

• Medical Staff Bylaws review process: to enable a broad based discussion to

improve on how current Bylaws are supporting the administrative structure of the

medical staff, and high-level decision-making in the health system.

• Medical Leadership structure: will be reviewed to improve communication

channels and improved meeting management processes between providers and

health system administration.

• Physician Health (Caring for the Care-Takers): to increase awareness and to

formalize proactive measures within physician services to ensure our valued

physicians get the care they personally need (an investment has been made to

MSPEI for a program to provide assistance to physicians)

Discussion

Health PEI

Divisional Update

Division: Quality & Patient Safety

Date: February 7, 2019

Divisional Profile - Programs and Services -

• Quality and Risk Management (including

Accreditation)

• Patient Safety

• Clinical and Organizational Ethics

• Research Ethics

Divisional Profile - Resources: Staff and Budget -

Functional Area Staff

Complement

(FTE):

2018-19

Operating

Budget:

Executive Director’s

office

2.7

Quality/Risk/Patient

Safety

12.0

Total 14.7 $1,498,100

Achievements - Past Year • Quality and Safety*

Progress on Patient Safety Culture Action Plan:

Education sessions delivered in Leadership Development

Series

“Just Culture in Action” education sessions created and

implemented

Two staff became TeamSTEPPS Master Trainers, 12 staff

educated as trainers

Continued adding patient and family advisors to

quality improvement teams

Implemented Pan-Canadian List of Never Events for

Hospital Care * Several of these initiatives also support the following enablers: People,

Collaboration & Engagement, and Communication & Information Sharing

Achievements - Past Year

• Quality & Safety

Accreditation Canada accepted evidence for 27/30

unmet recommendations

Developed Quality Improvement Activity work plan

Delivered several documentation sessions

Developed automated falls reports in acute care

Implemented New Care Management form in PSMS

• Enabler – Collaboration & Engagement:

Implemented Quality Risk Coordinator Survey

Contractual agreement with NS Health Ethics Network

Priorities - Coming Year

• Quality and Safety

Spread implementation of TeamSTEPPS

Implement Quality Improvement Activity work plan

Continue strengthening physician engagement in

quality improvement and patient safety

Revisit the quality structure

Continue working towards 2 patient and family

advisors on each quality improvement team

* Several of these initiatives also support the following enablers: People,

Collaboration & Engagement, and Communication & Information Sharing

Priorities - Coming Year

• Quality and Safety

Approve and implement new operational standards

for the Health PEI Clinical & Organizational Ethics

Committee

• Enabler – People

Develop an Education Toolbox of course offerings

related to quality, patient safety, risk and ethics

Discussion

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Annual Divisional Update/Briefing to the Health PEI Board of Directors

NOTE: This is a public document (maximum 3-5 pages) which will be posted online for

viewing.

Division: Quality & Patient Safety

Date: February 7, 2019

Introduction:

The Quality and Patient Safety Division is responsible for providing leadership, assistance and

support for all divisions within Health PEI in the areas of quality and risk management, patient

safety, clinical and organizational ethics, and research ethics.

Strategic Plan goals and enablers that guide divisional operations

Goal – Quality & Safety:

o Improving patient safety through the implementation of the patient safety culture

action plan to enhance and support a just culture of patient safety

o Embedding patient and family-centered care through the recruitment and addition

of patient and family advisors on quality improvement teams

Enabler – People: developing and delivering education to support staff in improving

quality and patient safety; providing recognition for actions that support quality, safety

and patient-centered care

Enabler – Collaboration & Engagement: building and supporting effective relationships

throughout Health PEI and with external quality and patient safety organizations to

improve quality and patient safety

Enabler – Communication & Information Sharing: engaging with patient and family

advisors on the quality improvement teams; sharing alerts and quality and patient safety

updates throughout Health PEI

Long-Term Outcomes of Divisional Work

Quality and patient safety will be improved for all Islanders through:

o Embedding a just culture of patient safety

o Implementing national standards and evidence-based practices related to quality

and safety

o Ongoing patient safety and risk identification, assessment, monitoring and

mitigation

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o Continuous quality improvement

o Partnering with patients and families

Clinical and organizational decisions in the health system will be made using an ethical

lens

Islanders will be appropriately protected if they participate in clinical trials or other forms

of research

Achievements over the Past Year

Goal – Quality & Safety (several of these initiatives also support the following enablers: People,

Collaboration & Engagement, and Communication & Information Sharing):

Progress continued on the implementation of the Patient Safety Culture Survey Action

Plan to enhance and support a just culture of patient safety:

o 2 education sessions were presented in the Health PEI Leadership Development

Series on “Building a Culture of Patient Safety, Teamwork, and Quality

Improvement”. 95% of participants identified the skills and concepts as relevant

to their role and 100% of participants rated their overall impression of the session

as ‘very good’ or ‘excellent’.

o “Just Culture in Action” education sessions were created and implemented in 3

service areas (QEH Nutrition Services, PCH Ambulatory Care and Riverview

Manor) to increase knowledge and awareness of a just safety culture through the

Leaders in Action Program. 23% improvement in participants understanding

what a just culture of safety means, and the majority of participants felt the

information presented was meaningful, appropriate to their job and tasks, and

were satisfied with the information presented.

o Two Health PEI staff received education to be TeamSTEPPS Master Trainers in

Halifax in April 2018. 12 additional staff has been educated as trainers. One

education session has been delivered to rehab staff at PCH. The outcome of

implementing TeamSTEPPS is improved teamwork and communication skills

among staff to prevent and mitigate harm for patients within Health PEI.

o Safer Practices Notices continue to be circulated to alert the system about

patient safety issues when appropriate.

o Quarterly newsletter continues to be distributed on schedule to educate the

system on quality and safety, and provide recognition to staff and physicians.

Patient and family advisors continue to be added to the quality improvement teams to

ensure the patient perspective is incorporated in our work – 90% of quality improvement

teams have at least one patient and family advisor. One of the co-chairs of the Health

PEI Clinical and Organizational Ethics Committee is a patient and family advisor.

The Pan-Canadian List of Never Events for Hospital Care was implemented in Health

PEI. The Provincial Safety Management System (PSMS) was adapted to include the

never events, alerts were created from PSMS, and education was provided across the

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system to leaders and staff. The number of never events are tracked and reported

through the quarterly risk report.

Evidence to demonstrate compliance with follow-up requirements from Accreditation

Canada was submitted in 2018, and Accreditation Canada accepted the evidence for 27

of the 30 unmet criteria, including all the required organizational practices (ROPs). The

three responses that require further evidence are from the Medication Management

Standards. One response is required by February 2019, and the remaining two at our

next onsite survey in 2021. The accreditation process helps to ensure we are meeting

national standards of care.

Work plan to assist in meeting Quality Improvement Activity (QIA) targets was

developed. Including an administrative support role on a QIA was tested and felt to be

valuable in scheduling meetings and taking minutes to assist with report development.

Several documentation sessions were held across Health PEI to support managers and

staff in improving chart documentation. Improving documentation has been included in

Long-Term Care’s strategic plan as a priority.

All acute care quality improvement teams met to collaborate on developing standardized

audit tools for falls prevention, and automated reports were developed that capture the

completion rate of the Falls Conely Assessment Tool by facility and unit. Trending

reports for falls on frequency, type and severity are also available through PSMS.

New Care Management form was developed in PSMS to more accurately and

comprehensively capture incidents related to care management, including transfer of

care issues.

Resource entitled “PSMS List of Specific Event Types” was developed to assist staff in

accurately reporting incidents in PSMS.

Education specific to physicians on incident reporting and PSMS was developed to

further educate and engage physician in reporting incidents.

Enabler – Collaboration & Engagement:

A survey was implemented across Health PEI to assess the knowledge of and

engagement with Quality Risk Coordinators across the system. The results of this

survey will help to continue building effective relationships throughout Health PEI.

Contractual agreement was created with Nova Scotia Health Ethics Network (NSHEN) to

provide ethicist support to the Health PEI Clinical and Organizational Ethics Committee.

Prior Year Planned Activities Not Achieved

Implement Enterprise Risk Management – this item was deferred until a later year in the

management plan based on priority setting.

4

Priorities and Plans for the Upcoming Year

Goal – Quality & Safety (several of these initiatives also support the following enablers: People,

Collaboration & Engagement, and Communication & Information Sharing):

Spread implementation of TeamSTEPPS as part of the patient safety culture action plan

to improve teamwork and communication skills among staff to prevent and mitigate harm

for patients within Health PEI [long-term outcome measure – Patient Safety Culture

Survey results; implementation measures – pre/post attitude and perception

questionnaires]

Implement Quality Improvement Activity (QIA) work plan to ensure the timely completion

of QIA processes [measure: # of days to complete QIAs)

Continue strengthening physician engagement in quality improvement and patient safety

through engaging with Medical Advisory Committees and physician leaders [measure: #

of presentations, # of physician led activities]

Revisit the quality structure to improve alignment with operations/patient flow and

connectivity between quality teams [measure: TBD]

Continue working towards goal of having 2 patient and family advisors on each quality

improvement team to ensure the patient perspective is incorporated into our quality work

[measure: % of quality improvement teams with 2 patient and family advisors]

Approve and implement new operational standards for the Health PEI Clinical &

Organizational Ethics Committee to outline standardized processes and guide the work

of the committee [measure: standards approved by Executive Leadership Team]

Enabler – People:

Develop an Education Toolbox that will include a list of course offerings to support staff

and physicians with education on quality, patient safety, risk and ethics [measures: # of

requests for courses, # of participants, satisfaction with courses]

Interdependencies

Operational divisions, service areas and physicians will need to actively participate in

education (e.g. TeamSTEPPS) and improvement initiatives (e.g. QIA workplan)

Risks/Challenges/Issues – and Mitigations (to the plan for the upcoming year)

Risk #1: Retirement of Executive Director of Quality & Patient Safety in mid-spring 2019

Issue: Retirement will leave a gap in the leadership of the division and new leadership

and/or organizational changes may result in a change in divisional priorities.

5

Mitigation: Manager in Division has been working closely with the Executive Director and

has participated in ELT meetings and Board presentations to build leadership capacity to

ensure continuity of priorities and support for staff through the transition. The Executive

Director will also work with the Chief Executive Officer to develop mitigation plans.

Risk #2: Competing priorities

Challenge: It can be a challenge to implement and sustain initiatives that will improve

quality and safety when operations have so many priorities.

Mitigation: Share divisional priorities with ELT to ensure their support. Ensure quality and

safety is included in all strategic and management plans.