balanced scorecard quarterly report · 2019-04-10 · balanced scorecard quarterly report june 2018...
TRANSCRIPT
Balanced Scorecard Quarterly Report June 2018
Page 0 of 21
Balanced Scorecard Quarterly Report
October 11
2018 Data updated to June 30, 2018
Balanced Scorecard Quarterly Report June 2018
Page 1 of 21
Table of Contents
Page Strategy Map 2 Balanced Scorecard 3
Strategic Theme: Patient and Family Centred Care • Respond to Community Health Needs
➢ % of recommendations for Horizon from Community Health Needs Assessments that have been implemented 4
• Improve Patient and Community Engagement
➢ Number of primary health care satellite sites 5
➢ Repeat hospital stays for mental health and addictions patients 6
Strategic Theme: Best Care Experience
• Best Care Experience
➢ Patient Experience Survey Results (overall rating) 7 ➢ Patient Satisfaction Survey Score – receiving service in the language of choice 8
➢ Emergency Department wait time for triage level 3 9 ➢ % of patients who received elective hip or knee replacement surgery within targeted time 10
➢ Average length of stay for inpatients with COPD 11
• Improve Patient/Client Engagement
➢ % of Key Committees with Patient Experience Advisor involvement 12 • Strengthen Clinical Networks
➢ Research income received 13
➢ Clinical network maturity index 14
Strategic Theme: Focused Investments
• Manage within Available Resources
➢ Year to date Operating Surplus(Deficit) 15
➢ Average number of paid sick leave days 16
Strategic Theme: Smarter Healthcare • Standardize and Harmonize Practices
➢ Ratio of policies that are Horizon-wide versus local area specific 17
• Collaborate with Healthcare Partners
➢ Percentage of beds occupied by ALC patients in 5 regional hospitals 18
Enablers (Human Resources,Information Technology, Culture) • Employee and Physician Engagement
➢ Bravos! Sent by Leaders 19
➢ Rate of workplace violence incidents reported 20
• Information and Technology to Improve Delivery ➢ % of planned technology initiative milestones completed to improve patient services, and communication between
care giver and patient 21
Legend for Indicator Symbols:
Meets / exceeds stretch Exceeds target /
below stretch Meets target performance
Improved performance
(between base and target)
Below base performance
Not applicable
✓✓ ✓
Legend for Initiative Status Symbols:
Complete On Track Somewhat Off
Track Off Track On Hold Cancelled
Information
Required
Balanced Scorecard Quarterly Report June 2018
Page 2 of 21
Strategy Map 2018–2019
Values: We show empathy, compassion and respect We strive for excellence We are all leaders, yet work as a team We act with integrity and are accountable
Balanced Scorecard Quarterly Report June 2018
Page 3 of 21
OwnerReporting
Frequency
(Q,SA,A)
Baseline
MeasureFull Year Target
Q1
Target
Reporting
Period
Actual
Indicator
Q1
Respond to Community Health Needs% of recommendations for Horizon from Community Health Needs
Assessments that have been implementedJean D Q N/A 80% N/A
Number of primary health care satellite sites Jean D Q 40 4340
(FY18/19, Q1)
Repeat hospital stays for mental health and addictions patients Jean D Q 4.1% 9%4.1%
(FY17/18)
Patient Experience Survey Results (overall rating) Margaret M A 85.7% 85% N/A Patient Reported Satisfaction – Receiving Service in the Language of
ChoiceMargaret M A 47.2% 90% N/A
Emergency Department wait time for triage level 3 Geri G Q 90.3 78.397.1
(FY18/19, Q1) % of patients who received elective hip or knee replacement surgery within
targeted time Geri G Q 46.3% 65%
40.6%(FY18/19, Q1)
Average length of stay for inpatients with COPD Geri G Q 6.9 5.76.9
(FY17/18)
Improve Patient/ Client Engagement % of Key Committees with Patient Experience Advisor involvement Margaret M Q 86.7% 90%86.7%
(FY18/19, Q1)
Research income received Edouard H Q $5,058,097 $4,800,000 $1,200,000$1,536,604(FY18/19, Q1)
Clinical network maturity index Geri G A N/A TBD N/A
Year-to-date Operating Surplus/ (Deficit) Dan K Q 99.97% 99.25%99.71%
(FY18/19.Q1) ✓✓
Average number of paid sick leave days Maura M Q 11.30 11.0011.24
(FY18/19, Q1)
Standardize and Harmonize Practices Ratio of policies that are Horizon-wide versus local area specific Geri G Q 30% 34%31.9%
(FY18/19,Q1)
Collaborate with Healthcare Partners Percentage of beds occupied by ALC patients in 5 regional hospitals Geri G M 25.4% 24%25.9%
(FY18/19,Q1)
Bravos! Sent by Leaders Maura M Q 32.9% 35%30.3%
(FY18/19,Q1)
Rate of workplace violence incidents reported Maura M Q 0.77 0.680.68
(FY18/19, Q1) ✓ Information and Technology to Improve
Delivery
% of planned technology initiative milestones completed to improve patient
services, and communication between care giver and patientJennifer S Q 78% 80.0% 70%
(FY18/19, Q1)
Last Updated: October 17, 2018
Manage Within Available Resources
Strategic Theme: Focused Investments
Enablers (Human Resources, Information Technology, Culture)
Employee and Physician Engagement
Strategic Theme: Smarter Healthcare
Reporting Frequency: M = Monthly, Q = Quarterly, SA = Semi-Annual, A = Annual
Horizon Health Network - Balanced Scorecard 2018-19 (Updated to June 30, 2018)
Strategic Theme: Best Care Experience
Strengthen Clinical Networks
Enhance Primary Healthcare
Best care experience
Strategic Theme: Healthy Populations
Balanced Scorecard Quarterly Report June 2018
Page 4 of 21
Table of Contents
Percent of Recommendations for Horizon from Community Health Needs Assessments that have been Implemented
Strategic Objective: Respond to Community Health Needs
Owner: Jean Daigle
Reporting Frequency: Quarterly
Definition: Priorities are identified through Community Health Needs Assessments for each of the 17 communities in Horizon. This indicator measures the percentage of initiatives from Community Health Needs Assessments priorities that are Horizon’s responsibility that have been completed this fiscal year.
Baseline Target Actual Indicator
N/A 80% N/A
Analysis Summary: This is a new measure for FY 2018/19. We are currently developing the measurement tracking and reporting process. Data will be available for reporting in Q3.
Priority Initiatives:
Priority Initiatives/Actions Status Comments
Action Community Health Needs Assessment Recommendations
✓ First report will be in October 2018.
Balanced Scorecard Quarterly Report June 2018
Page 5 of 21
Table of Contents
Number of Primary Health Care Satellite Sites
Analysis Summary: In response to priorities identified within the Community Health Needs Assessment, Horizon plans to expand primary healthcare services using the ‘hub and spoke’ model in Charlotte County, Moncton and Miramichi in fiscal 2018/19. The goal is to add three new satellite sites this year. The Charlotte County Collaborative Wellness Centre in St. Stephen is to act as the ‘hub’ for primary health care service delivery for the communities served within Western Charlotte County (includes Campobello Island, St. Andrews and St. Stephen). The new St. Andrews satellite site will have expanded Primary Health Care services. The Moncton Primary Health Care Clinic (previously known as Refugee Health Centre) continues to provide services to families who are newcomers to Canada living in the Moncton area. We are positioning this clinic to become a ‘hub’ for the Moncton Area in the coming years. We are in the process of expanding services offered at the current Sexual Health clinic (in Chatham) to include a full scope of primary care. This will be a satellite site of the Miramichi Health Centre (in Newcastle) which is intended to evolve into the ‘hub’ site for all health centres in the Miramichi Area.
Priority Initiatives:
Priority Initiatives/Actions Status Comments
Charlotte County Collaborative Wellness Centre - St. Stephen
✓ A Nurse Practitioner has been hired and interviews are in progress for a Primary Health Care Manager.
Moncton Primary Health Care Clinic - Moncton ✓
Nurse Practitioner Sexual Health services for six Moncton Area English based High School have been absorbed from Vitalité and will be served by all Nurse Practitioners working in this clinic starting September 2018. One full-time and one part-time Nurse Practitioner are being hired for this clinic.
Miramichi Health Centre - Newcastle ✓ A full-time and a part-time Nurse Practitioner have been hired to support the ongoing implementation of the hub and spoke model.
Strategic Objective: Enhance Primary Healthcare
Owner: Jean Daigle
Reporting Frequency: Quarterly
Definition: Horizon is establishing primary health care sites in response to health care needs identified in various communities. This indicator tracks the number of Primary Health Care sites, including Community Health Centres, Health Service Centres and Community Clinics and their satellite sites.
Baseline Target Actual Indicator
40 sites 43 sites 40 sites
(FY18/19, Q1)
Balanced Scorecard Quarterly Report June 2018
Page 6 of 21
Table of Contents
Repeat Hospital Stays for Mental Health and Addictions Patients
3.6% 4.1% 4.0% 3.9% 3.6% 3.4% 3.4% 4.2% 4.1%
0%
10%
20%
30%
40%
50%
FY15/16Q4
FY 16/17Q1
FY 16/17Q2
FY 16/17Q3
FY 16/17Q4
FY 17/18Q1
FY 17/18Q2
FY 17/18Q3
FY 17/18Q4
Repeat Hospital Stays for Mental Health and Addictions Patients
Horizon
Target
Analysis Summary: This indicator will be reported a quarter behind due to data availability. We continue to trend well below our target of 9% and the national average. This is expected to continue. One of the reasons that could be contributing to this positive trend is our operational guideline that stipulates that any patient transitioning from inpatient psychiatry within the last 30 days will be seen for follow-up by a clinician within two weeks. Priority Initiatives: None at this time
Priority Initiatives/Actions Status Comments
✓
Strategic Objective: Enhance Primary Healthcare
Owner: Jean Daigle
Reporting Frequency: Quarterly
Definition: The percentage of individuals who had at least three episodes of care at the same facility for mental illness in a one-year period.
Baseline Target Actual Indicator
4.1% 9% 4.1% (FY17/18, Q4)
Balanced Scorecard Quarterly Report June 2018
Page 7 of 21
Table of Contents
Patient Experience Survey Results (overall rating)
Analysis Summary: There will be no new survey results in fiscal year 2018-19. The New Brunswick Health Council will be conducting their Acute Care Patient Experience Survey during late 2018-2019 provincially. The results will hopefully be available in late 2019 for our review and action planning. The Strategic Plan for Patient Experience which was established for 2016 – 2020, has been recently refreshed with the following action plans:
1. The ONTRACC program implementation was recently started. This program was launched in Saint John and Fredericton Areas with further implementation planned in other areas.
2. The food quality steering committee has introduced a number of sub projects relating to food presentation, diet type revisions, for example. The work of this committee will be further profiled in future reports.
3. The Horizon Quality Consultants continue to work with specific networks and department teams toward initiatives to specifically address issues identified from the Horizon Experience Survey conducted in their facility.
4. In coordination with the strategy, a great deal of effort has been invested in recruiting and orienting Patient Experience Advisors (PEAs) to assist on Horizon committees and program teams to provide direct advise and involvement with program planning.
Priority Initiatives:
Priority Initiatives/Actions Status Comments
Food Service Quality ✓ This program includes 9 related projects within it.
Recruitment and Orientation of PEAS
✓ Ongoing
Strategic Objective: Best Care Experience
Owner: Margaret Melanson
Reporting Frequency: Annually
Definition: Patients who rated their hospital stay favourably (8, 9, or 10 out of 10) to the following question: • Using any number from 0 to 10, where 0 is the worst hospital possible and 10 is the best hospital possible, what number would you use to rate this hospital during your stay?
Baseline Target Actual Indicator
85.7% (Mar 2018)
85% N/A
Balanced Scorecard Quarterly Report June 2018
Page 8 of 21
Table of Contents
Patient Reported Satisfaction – Receiving Service in the Language of Choice
Analysis Summary: There will be no new survey results in fiscal year 2018/19. Statistics on patients always served in the language of their choice has seen some improvement since the NBHC Survey results of 42% that was conducted in 2016. After several months of the Active Offer Everyday Project (Dialogue Sessions) and approximately 2500 participants, we have analyzed the feedback data gathered through these sessions to identify actionable items. A full-time facilitator is continuing to offer sessions to staff. Feedback data is consistent. No new feedback is being provided. For this reason, our next step is to evaluate if the sessions continue to have a positive impact on staff engagement relating to the active offer and the provision of services in the patients’ language of choice.
Priority Initiatives:
Priority Initiatives/Actions Status Comments
Active Offer Everyday Project ✓ Ongoing
Strategic Objective: Best Care Experience
Owner: Margaret Melanson
Reporting Frequency: Annually
Definition: This data reflects the patient experience as it is gathered through patient experience surveys completed by the New Brunswick Health Council (Acute Care Survey) every three years as well as the Horizon Patient Experience Survey conducted by the Horizon’s Quality team annually. The survey starts by identifying the patient’s language of choice. It then proceeds to ask how often the service was offered in their preferred language. The measure reported is the percentage of patients who responded that they always received services in their language of choice when French is indicated as the preferred language.
Baseline Target Actual Indicator
47.2% (March 2018)
90% N/A
Balanced Scorecard Quarterly Report June 2018
Page 9 of 21
Table of Contents
Emergency Department Wait Time for Triage Level 3
93.0 91.481.7 85.4 86.5 84.2 86.9
104.097.1
0
20
40
60
80
100
120
FY 16/17Q1
FY 16/17Q2
FY 16/17Q3
FY 16/17Q4
FY 17/18Q1
FY 17/18Q2
FY 17/18Q3
FY 17/18Q4
FY 18/19Q1
ED wait time for triage level 3
Horizon
Target
Strategic Objective: Best Care Experience
Owner: Geri Geldart
Reporting Frequency: Quarterly
Definition: The average time (in min) a triage 3 patient waits in ED from the time they are triaged/ registered to the time they are seen by a physician. Excludes those patients where no seen time was documented. The 5 regional hospitals (TMH, SJRH, DECRH, URVH, MRH) are included in this indicator. NOTE: Treatment may have been initiated by nursing staff prior to being seen by a physician.
Baseline Target Actual Indicator
90.3 min 78.3 min 97.1 min (FY18/19, Q1)
Analysis Summary: There has been a slight reduction from Quarter 4 of FY17/18 in the wait time noted for the first quarter of 2018/19, however the time waiting continues to exceed the Horizon target and the national benchmark set by the Canadian Triage and Acuity Scale of 30 minutes or less. The lowest average wait is at URVH with 44.9 minutes and the highest average wait is at TMH with 131.1 minutes for triage level 3 patients. Wait times in the emergency department are affected by multiple factors including the number of patients who are being seen in the department, the number of spaces to see patients, acuity of patients and the ability to transfer admitted patients to inpatient units. Each of the emergency departments continue to work on local initiatives in conjunction with the patient flow committees to reduce wait times. Priority Initiatives:
Priority Initiatives/Actions Status Comments
ER redirect Looking at options to make this easier for staff.
Why Wait ✓ Ongoing.
Balanced Scorecard Quarterly Report June 2018
Page 10 of 21
Table of Contents
Percent of Patients Who Received Elective Hip or Knee Replacement Surgery within Targeted Time
44.7% 49.8% 45.7% 45.5% 40.6%
0%
20%
40%
60%
80%
100%
FY 17/18Q1
FY 17/18Q2
FY 17/18Q3
FY 17/18Q4
FY 18/19Q1
% of patients receiving elective hip or knee replacement surgery within targeted time
Horizon
Target
Analysis Summary: We continue to struggle with long wait times for both hip and knee replacement surgeries. All areas with the exception of Fredericton are experiencing a decrease in the percentage of cases that are completed within the target timeframe. Variables that can impact the wait times include: • Limited OR time (scheduling, number of available OR’s) • Limited human resources (surgeons, anesthesia, nursing) • High volume of cases referred.
The orthopedic wait list in Moncton increased from 1253 in Q1 of 2017/18 to 1479 in Q1 of 18/19. Ongoing concerns regarding anaesthesia availability has resulted in a reduction in OR time. Although Anaesthesia coverage was somewhat improved in Q1, Moncton continues to run below their target of 8 OR theatres per day.
A Joint Initiative project started July 1, 2018 in Moncton; long waiting total hip and total knee cases are being prioritized for completion. Initial focus is on completing the longest waiting cases. This will not help improve this indicator as these cases are well past the target timeframe of 182 days, however it will lead to an overall improvement of the wait time. OR time and available beds will affect the number of cases completed.
Priority Initiatives:
Priority Initiatives/Actions Status Comments
Reduction of Hip & Knee wait times in Moncton
✓ Joint Initiative project started.
Strategic Objective: Best Care Experience
Owner: Geri Geldart
Reporting Frequency: Quarterly
Definition: Percentage of Hip and Knee replacement cases that were completed within the target timeframe (182 days). Wait times are calculated from the date that the patient and physician agree to the surgery and the patient is ready to receive it to the date of the completion of surgery. These statistics do not include emergency surgeries. Timeframes during which the patient was not available to have surgery are excluded from the wait time calculations.
Baseline Target Actual Indicator
46.3% 65% 40.6% (FY18/19, Q1)
Balanced Scorecard Quarterly Report June 2018
Page 11 of 21
Table of Contents
Average Length of Stay for Inpatients with COPD
6.7 7.26.6 6.7 6.9 6.6 7.0 6.6
7.4
0
2
4
6
8
10
FY 15/16Q4
FY 16/17Q1
FY 16/17Q2
FY 16/17Q3
FY 16/17Q4
FY 17/18Q1
FY 17/18Q2
FY 17/18Q3
FY 17/18Q4
Average length of stay for inpatients with COPD
Horizon
Target
Analysis Summary: This indicator will be reported a quarter behind due to data availability. Horizon continues to report higher lengths of stay for the COPD cases than CIHI’s expected length of stay (ELOS). The ELOS for FY17/18 was 5.74 and the ELOS for Q4 was 5.83. With the implementation of Inspired, there has been a drop in the amount of admissions for COPD, however the average length of stay has increased; this may be due to sicker patients being admitted. Patient Flow is working on an in-depth analysis of COPD discharges to seek opportunities for improvement. Work is underway to revamp the current clinical order set (COS) for COPD. Priority Initiatives: None at this time.
Priority Initiatives/Actions Status Comments
Implementation of a Clinical Order Set for COPD
✓Use of the COS for COPD is being monitored by Patient Flow. Changes to the COS is expected to help improve compliance.
Strategic Objective: Best Care Experience
Owner: Geri Geldart
Reporting Frequency: Quarterly
Definition: Average length of stay in days for inpatients with Case Mix Group of Chronic Obstructive Pulmonary Disease (COPD). This indicator excludes those patients who expired and those who were transferred to an acute care facility.
Baseline Target Actual Indicator
6.9 days 5.7 days 6.9 days (FY17/18)
Balanced Scorecard Quarterly Report June 2018
Page 12 of 21
Table of Contents
Percentage of Key Committees with Patient Experience Advisor Involvement
Strategic Objective: Improve Patient and Community Engagement
Owner: Margaret Melanson
Reporting Frequency: Quarterly
Definition: The percent of 30 Horizon key committees with Patient Experience Advisor (PEA) involvement. Key committees include clinical networks and committees with focus on quality & safety. Involvement means inclusion in focused groups or as a standing committee member.
Baseline Target Actual Indicator
86.7% 90% 86.7% (FY18/19, Q1)
Analysis Summary: Last year a focused effort was made to identify committees where PEA involvement is appropriate and matching volunteers with the committees. A few of the committees without PEAs have submitted requests and work is ongoing to find the appropriate match for the committee. We have successfully assigned PEAs to most clinical networks and the PEAs have become more involved with Quality and Patient Safety initiatives. We continue to strategically address patient engagement and work toward fully supporting our PEAs and our Horizon committees who interact with them. Our PEAs are very engaged with working with our accreditation preparation teams. The PEA program has been integrated as a core program of the Volunteer Resources Department. Processes, tools and resources are currently being revised to reflect the current evolution of patient engagement within Horizon. This includes the application process, recruitment of PEAs and matching them to the most appropriate committee or special project, and orientation and training of both the PEA and the team that will be working with the PEA.
Priority Initiatives:
Priority Initiatives/Actions Status Comments
Matching volunteers with committees requesting PEA
✓ On track to have PEA involvement on all identified committees.
Balanced Scorecard Quarterly Report June 2018
Page 13 of 21
Table of Contents
Research Income Received
$969,555
$1,701,289
$2,874,492
$3,955,515
$1,691,913
$2,772,119
$4,203,946
$5,058,097
$1,536,604
$0
$1,000,000
$2,000,000
$3,000,000
$4,000,000
$5,000,000
$6,000,000
FY 16/17Q1
FY 16/17Q2
FY 16/17Q3
FY 16/17Q4
FY 17/18Q1
FY 17/18Q2
FY 17/18Q3
FY 17/18Q4
FY 18/19Q1
FYTD Research income received
Horizon
Target
Strategic Objective: Create Centres of Expertise
Owner: Edouard Hendriks
Reporting Frequency: Quarterly
Definition: This metric captures all income research funds received from external sources (i.e. outside of our departmental budget) and represents income received from pharmaceutical companies, granting agencies, and other sponsors of research.
Baseline Target Q1 Target Actual Indicator
$5,058,097 $4,800,000 $1,200,000 $1,536,604 (FY18/19, Q1)
Analysis Summary: The total income received for end of Q1 for 2018/19 ($1,536,604) fell approximately 9% below 2017/18 Q1 total income ($1,691,913). This reduction is partly due to a number of clinical trials that have recently been initiated but have not yet enrolled patients, which is one mechanism through which clinical trial income is derived. In addition, several large projects administered through Research Services received significant funding during 2017/18 which may have resulted in larger than anticipated levels of income during that fiscal year. In addition to the research income reported, other institutions within New Brunswick (e.g. UNB) have received significant income related to health research through their strategic partnerships with Horizon.
Priority Initiatives:
Priority Initiatives/Actions Status Comments
Implement actions from the Research Services Strategic Plan
✓
Research Services is implementing a new service delivery model that will increase the support we can provide to clinician researchers engaged in both clinical trials and Investigator Initiated Research initiatives. We expect this to increase the level of external funding we receive. We have also partnered with University New Brunswick, Dalhousie Medical School NB, and New Brunswick Community College to develop a proposal for a Health Research Institute. This has been reviewed by government and is under consideration.
Balanced Scorecard Quarterly Report June 2018
Page 14 of 21
Table of Contents
Clinical Network Maturity Index
Strategic Objective: Strengthen Clinical Networks
Owner: Geri Geldart
Reporting Frequency: Annually
Definition: To be determined
Baseline Target Actual Indicator
N/A TBD N/A
Analysis Summary: This is a new measure for FY 2018/19.
Horizon needs to strengthen all its clinical networks before they can move successfully to centres of expertise. The
networks are in various stages of development. A Clinical Network Maturity Index will help the clinical networks
assess their strengths and identify opportunities for development to systematically move the program areas
forward. A framework and measurement process is being developed to gauge progress for each network.
Priority Initiatives:
Priority Initiatives/Actions Status Comments
Develop Clinical Network Maturity Framework
✓ Ongoing
Balanced Scorecard Quarterly Report June 2018
Page 15 of 21
Table of Contents
Year to date Operating Surplus(Deficit)
99.62% 99.88% 99.90% 99.94% 99.77% 99.83% 99.83% 99.97% 99.71%
0%
20%
40%
60%
80%
100%
120%
FY 16/17Q1
FY 16/17Q2
FY 16/17Q3
FY 16/17Q4
FY 17/18Q1
FY 17/18Q2
FY 17/18Q3
FY 17/18Q4
FY 18/19Q1
Ratio of Actual to Budget Funded Expenditures
Horizon
Target
Analysis Summary: Over the period, Horizon has been able to maintain spending within our available resources. Year to date expenses of $287,336,793 were offset by revenues of $288,182,347 resulting in a YTD surplus of $845,554. The first quarter resulted in a larger surplus of revenues to expenses. This is typical for the first quarter where new initiatives are not fully operational or projects have been delayed but will be incurred later. Spending can fluctuate due to extraordinary events but are normally offset by increased revenues as in the case of contract settlements. During the first quarter there were no significant events. We are operating on budget in most areas. We have a few areas showing cost overruns at this point but efforts are underway to control and reduce these costs.
Priority Initiatives: None at this time.
Priority Initiatives/Actions Status Comments
✓
Strategic Objective: Manage within Available Resources
Owner: Dan Keenan
Reporting Frequency: Quarterly
Definition: Ratio of Hospital Operations Actual Expenses (Including Medicare and excluding amortization and sick pay obligation) to actual revenues (Excluding Capital Grant Funding).
Baseline Target Actual Indicator
99.97% 99.25% 99.71%
(FY18/19, Q1) ✓✓
Balanced Scorecard Quarterly Report June 2018
Page 16 of 21
Table of Contents
Average Number of Paid Sick Leave Days
11.36 10.98 11.23 11.6310.68 10.42 10.89 11.30 11.24
0
2
4
6
8
10
12
14
FY 16/17Q1
FY 16/17Q2
FY 16/17Q3
FY 16/17Q4
FY 17/18Q1
FY 17/18Q2
FY 17/18Q3
FY 17/18Q4
FY 18/19Q1
Average number of paid sick days
Horizon
Target
Analysis Summary: Historically Q1 paid sick trends better than Q3 and Q4. Q1 2018/19 resulted in a 5% increase from Q1 2017/18. This could be attributed to the flu season being much longer than the previous year; declared on January 8th and finished May 7th. Managers are encouraged to act proactively with employees who are trending toward attendance issues and to address employees who have exceeded the Horizon attendance trigger. We will continue to use the Attendance Management tools to manage and monitor attendance. The HR team will continue to educate and support its use by managers. Human Resources Strategic plans include initiatives to identify opportunities for improvement.
Priority Initiatives:
Priority Initiatives/Actions Status Comments
Human Resource Strategic Plan Attendance Management Pilot
✓ The goal of the pilot is to reduce the rate of absenteeism by one day per eligible employee in the pilot site. Planning to start in Q3.
Strategic Objective: Manage within Available Resources
Owner: Maura Mackinnon
Reporting Frequency: Quarterly
Definition: This measure is an annualized average number of paid sick days per employee eligible to receive the benefit.
Baseline Target Actual Indicator
11.3 days 11.0 days 11.24 days (FY17/18, Q1)
Balanced Scorecard Quarterly Report June 2018
Page 17 of 21
Table of Contents
Ratio of Policies that are Horizon-wide versus Local Area Specific
26.5% 27.5% 28.5% 30.7% 31.9%
0%
20%
40%
60%
80%
100%
FY 17/18Q1
FY 17/18Q2
FY 17/18Q3
FY 17/18Q4
FY 18/19Q1
% of policies that are Horizon-wide
Horizon
Target
Strategic Objective: Standardize and Harmonize Practices
Owner: Margaret Melanson
Reporting Frequency: Quarterly
Definition: This indicator reports the percentage of total policies that are Horizon-wide, measuring the progress toward the Regionalization of our policies to encourage consistency in practice throughout Horizon.
Baseline Target Actual Indicator
30% 34% 31.9% (FY18/19, Q1)
Analysis Summary: To encourage regionalization Horizon requires that all policies be Regional unless they must be Area policies. The positive trend of this indicator is attributed to the number of Regional policies increasing while the number of Area policies has decreased. This is mainly due to 2 factors:
1) regionalization of policies; where a regional policy replaces existing area policies; and 2) the deletion of policies that are out of date; which are disproportionally area policies.
The Policy’s Office priority initiative to identify policy ownership provided a “reminder” of the existence of older policies which led to a significant amount of deletions in Q3 and Q4 of 2017-2018 and Q1 of 2018-2019. As the amount of out of date policies is finite, the rate of deletions is unsustainable and the rate of improvement of this indicator is expected to slow in 2018-2019 year. Priority Initiatives:
Priority Initiatives/Actions Status Comments
Identify out of date policies and ownership of all policies
All out of date policies have been identified. Ownership has been identified on 96% on the policies.
Balanced Scorecard Quarterly Report June 2018
Page 18 of 21
Table of Contents
Percent of Beds Occupied by ALC Patients in 5 Regional Hospitals
23% 24% 23% 24% 26% 25% 27% 27% 26% 27% 26% 27% 26% 26% 26%
0%
10%
20%
30%
40%
50%
Apr2017
May2017
Jun2017
Jul2017
Aug2017
Sep2017
Oct2017
Nov2017
Dec2017
Jan2018
Feb2018
Mar2018
Apr2018
May2018
Jun2018
% of beds occupied by ALC patients
Horizon
Target
Strategic Objective: Collaborate with Healthcare Partners
Owner: Geri Geldart
Reporting Frequency: Monthly
Definition: The percentage of beds occupied by Alternative Level of Care (ALC) patients. Includes ALC patients in all beds, regardless of bed classification, and is based on the MIS Nursing Unit functional centres. The measure includes only the five regional hospitals (TMH, SJRH, DECRH, URVH, MRH).
Baseline Target Actual Indicator
25.4% 24% 25.9% (FY18/19, Q1)
Analysis Summary: ALC remains a significant cause of hospital congestion. This is a complex problem with no simple solution. 27% of our ALC patients are dependent on Department of Social Development (DSD) processes, mostly waiting for assessment. 68% are waiting for outside services (ex. Nursing Home). Internal services (ex. rehab) decreased from 7% to 4% of the ALC population. In Quarter 1 of FY 18-19 we are seeing a decrease of ALC patients overall in Horizon; the only sites with a rise in ALC numbers are SJH and MRH. Horizon is collaborating with Vitalité, DSD and Department of Health to develop actions to help reduce the number of inpatients waiting for community services. We hope to see a positive impact with the various Home First initiatives. Expanded long term care capacity will be an important part of the solution. Priority Initiatives:
Priority Initiatives/Actions Status Comments
Home First ✓ Ongoing
Balanced Scorecard Quarterly Report June 2018
Page 19 of 21
Table of Contents
Bravos! Sent by Leaders
23.8%18.8%
38.0%32.9% 30.3%
0%
20%
40%
60%
80%
100%
FY 17/18Q1
FY 17/18Q2
FY 17/18Q3
FY 17/18Q4
FY 18/19Q1
Bravos! Sent by Leaders
Horizon
Target
Analysis Summary: Of the 449 Leaders that have direct reports, 136 sent at least one Bravo in the reporting period. A total of 2787 Bravos! were submitted in Q1; 721 were submitted by Leaders. Human Resources is currently implementing an initiative to provide Leaders with support and education of the impact recognition has on engagement and how to increase employee recognition. Priority Initiatives:
Priority Initiatives/Actions Status Comments
Accreditation Worklife Pulse area of opportunity – ‘I receive recognition for good work’.
✓ The project charter is drafted; pending approval.
Strategic Objective: Improved Employee and Physician Engagement
Owner: Maura McKinnon
Reporting Frequency: Quarterly
Definition: Percentage of Leaders who sent at least one Bravo! In the reporting period.
Baseline Target Actual Indicator
32.9% 35% 30.3%
(FY18/19, Q1)
Balanced Scorecard Quarterly Report June 2018
Page 20 of 21
Table of Contents
Rate of Workplace Violence Incidents Reported
0.52
0.73
0.610.71
0.830.78
0.89
0.770.68
0.00
0.20
0.40
0.60
0.80
1.00
FY 16/17Q1
FY 16/17Q2
FY 16/17Q3
FY 16/17Q4
FY 17/18Q1
FY 17/18Q2
FY 17/18Q3
FY 17/18Q4
FY 18/19Q1
Rate of workplace violence incidents reported
Horizon
Target
Analysis Summary: Our overall objective is to reduce workplace injuries through reduction of incidents of workplace violence. Q1 2018-19 reflects a 11.7% decrease from Q4 2017-18 in the rate of reported workplace violence incidents.
Use of the incident tracking system is providing useful data to identify trends or most likely causes of incidents, which enables targeted responses.
Based on feedback from staff, one area of high incidents of workplace violence is the Emergency Departments (ED). A pilot project is underway to provide customized training in the Emergency Department staff which then will be assessed to determine wider rollout.
Priority Initiatives:
Priority Initiatives/Actions Status Comments
Workplace Violence Prevention Program Implementation Phase 2 Project
✓ Significant progress in various project elements Example: Education - Code White and non-violent crisis intervention Training, development of a comprehensive communication plan to relaunch and re-education staff on tools and resources available.
Strategic Objective: Improved Employee and Physician Engagement
Owner: Maura McKinnon
Reporting Frequency: Quarterly
Definition: The number of recordable Workplace Violence incidents per 100 full time employees. To accurately reflect trending, this indicator is calculated on a rolling year. Recordable: includes Parklane Incident Reporting System recorded incidents of Health Care and Lost Time (Health Care: MD seen, treatment received, no lost-time; Lost Time: MD seen, treatment received, lost time). Includes Salaried Physicians but does not include Nursing Home personnel.
Baseline Target Actual Indicator
0.77 Per 100 employees
0.68 Per 100 employees
0.68 per 100 employees (FY18/19, Q1) ✓
Balanced Scorecard Quarterly Report June 2018
Page 21 of 21
Table of Contents
Percent of Planned Technology Initiatives Completed to Improve Patient Services and Communication between Caregiver and Patient
The following table represents the planned milestones for each initiative by quarter:
Initiatives Q1 Q2 Q3 Q4 Total
Allscripts eDoc Expansion to St. Joseph's Hospital 1 5 6
Anesthesia Information Management System 5 1 2 8
Corporate Email on Physicians Personal Devices (Horizon) 2 3 5
Electronic Operating Room Documentation (Moncton) 2 2 4
Horizon IT Strategic Plan 2 3 2 2 9
Mobile Access to Kronos Workforce Management for Staff (Horizon) 5 2 2 9
Provincial Incident Management Platform 1 2 3 8 14
Secure Communication & Collaboration Platform (Horizon) 1 3 4 8
Surgical Patient Tracking Tool (Moncton) 3 5 8
Total 10 17 18 26 71
Milestones Achieved in Quarter 7
% Milestones in Expected Quarter Achieved 70%
Analysis Summary: Seven out of the 10 planned milestones for Q1 were met on target.
Anesthesia Information System deployment throughout Horizon was delayed after the initial implementation in
Fredericton as a platform upgrade was required to address some key functionality. As a result, the planned
implementation for Moncton was delayed, causing the 3 deliverables to be delayed outside of the quarter. This has
been escalated and is being managed jointly at the executive levels.
Corporate email access of physician personal devices to improve communications completed the pilot, in
preparation for a full expansion to other physicians. The provincial incident management system (tracked in FY
17/18) was selected and the project officially started. There was a change request to push out some functionality
revisions for delivery in November.
Following the current state assessment, the development of the IT Strategic Plan has started and broad consultation
is underway.
Priority Initiatives: As above
Strategic Objective: Available Information and technology to improve delivery
Owner: Jennifer Sheils
Reporting Frequency: Monthly
Definition: A list of Information and Technology projects has been identified for completion, or progress, in this fiscal year, with target milestones. This measure will track the percent of the milestones that were met.
Baseline Target Actual Indicator
78% 80% 70% (FY18/19, Q1)