englehart and district hospital · englehart and district hospital (edh). thank you and...

Englehart and District Hospital

Annual report 2015—2016

Table of contents Board of Governors Page 3 Mission, Vision and Values Page 4 Patient Declaration of Values Page 5 Leadership Philosophy Page 6 Report of the Chief Executive Officer Page 7 Report of the Board Chair Page 8 Report of Chief of Staff Page 9 Report of Quality Committee Page 11 Report of the Treasurer Page 13 Englehart and District Hospital Financial Statements - March 31, 2016 App. A

Annual Report 2015—2016

BOARD OF GOVERNORS 2015—2016

Guy Boileau………...…………………………………………………...………Chair

Chester Jobson …...….…………………………………………..…Vice-Chair

Gary Sims …….…………...………………………...….………………Secretary

Dr. Marie Lynn Lacasse……………………..…………..…Chief of Staff

Dr. Marie Lynn Lacasse..……..…………..Medical Staff President

Michelle Schaffner….………….……………….………Elected Trustee

Norm Koch……….……………….…………………………...Elected Trustee

Marlene Howard ……………………………..……...…....Elected Trustee

Wendy Middaugh..……………………….……….…………Elected Trustee

Lois Dekker ……..………………………..……….………...Elected Trustee

Paula Mangotich…...………………….……………..…….Elected Trustee

Bonnie Lafrance…………………………..…………….....Elected Trustee

Lasha Gorecki………………………………….………….….Elected Trustee

Vacant……………………………………………………………..Elected Trustee

Vacant…..…...………………………………….……....chief nursing officer


Mission

It is our mission to serve the residents of central Temiskaming by: Providing the best Quality health care, Ensuring seamless transitions to other health service, Collaborating with other community partners to create a safe

and healthy community, and Creating an environment where the entire health care team can do

their very best work

Vision It is our vision to be: A leader in quality health care services, A collaborative workplace for the entire health care team, An innovative and valued partner in our community, respected by our peers

Values The following values reflect what is important to us: Patient centered care integrity Innovative leadership Commitment to integration Community focus accountability


Patient declaration of values


Patient Rights Patient Responsibilities You have the right to be treated in a

respectful manner, consideration given to you as a whole person, and valuing the uniqueness of you as an individual.

You have the right to obtain from your

physician complete current information concerning your diagnosis, treatment and prognosis in terms you or your substitute decision-maker can be reasonably expected to understand.

You have the right to have your personal

health information protected from unauthorized collection, use, or distribution.

You have a right to make decisions about the plan of care prior to and at any time during the course of treatment.

You have the right to a clean, comfortable,

safe, and secure environment. You have the right to be informed of any

expenses that will be incurred as a result of medical treatment.

You have the right to expect that members

of your health care team will communicate with one another in order to ensure coordination of care.

You have the right to express your

concerns and to receive a response to your questions.

You have the right to know who your care

providers are, and who the doctor is in charge of your treatment.

You have the right to refuse treatment in

accordance with the law, and to be informed of the health risks and benefits of this decision.

Provide accurate and complete information about your health to your hospital team members in order to help them care for you.

Participate cooperatively in the mutually

agreed upon plan of care, to the best of your ability.

Assist in the provision of your care by identifying one spokesperson, with whom the team can communicate in the event you become incapable.

Tell the hospital team if there is a change in your condition, or if concerns arise during treatment.

Accept responsibility for the consequences

of refusing treatment or medical advice.

Be courteous and respectful of other patients, visitors, and all members of your hospital team.

Recognize that the needs of other patients may sometimes be more urgent than your own.

Recognize that providers need not provide any treatment that they consider medically or ethically inappropriate.

Respect hospital property and comply with regulations and policies.

Make arrangements for discharge, when the physician determines that discharge is appropriate, or accept alternate level of care as appropriate.

Be responsible for all expenses not covered by OHIP or private insurance, during your hospitalization.

Leadership philosophy

The management of the Englehart and District Hospital demonstrates a commitment to the Mission and vision of the Hospital by supporting the provision of high quality integrated service and care, with equitable and cost efficient access, designed to meet the clients needs. Management provides leadership, which fosters teamwork, in an environment that is respectful of staff and encourages staffing excellence.


CEO Annual Report 2015/16 Gary Sims, President and CEO

As President and CEO of Blanche River Health Partners I am pleased to provide an annual report for 2015/16. This has been a year of growth, change, challenge, celebration and loss. We have grown to become one integrated organization partnering Kirkland and District Hospital (KDH) and Englehart and District Hospital (EDH). Thank you and congratulations goes out to both Boards of Directors for their vision and courage during this exciting time. This partnership has seen alignment of the organizations in policies and procedures and quality based practices. As a result we are seeing improved access for patients, sharing of expertise across sites, and cost savings. We have seen a complete change in the executive leadership team. Thank you to Lois Kozak for stepping up as the integrated interim CEO during the transition period and to the management team for their hard work. Congratulations to all, as the management team are now fully integrated across both sites. We have faced increased challenges from funding shortages for both sites. Congratulations to all staff and managers for getting both sites to a slight surplus financially for the year end. This would not have been possible without $800,000 in one time funding for EDH from the North East LHIN. We cannot celebrate the year’s achievements without thanking all those who make what we do each day possible. To all staff who come to work every day and give of themselves to better the lives of each patient and family, we thank you! To our dedicated physician group and community health care partners without whom coordination and continuity of care in the hospital and community would not be possible, we thank you! To our volunteers and auxiliary staff whose ongoing support ensures we can continue to provide quality equipment and services, we thank you! To our Board of Directors without your guidance and leadership we would not be where we are today, we thank you! To our physician leaders who give of themselves to ensure the best possible patient outcomes across the continuum of care, we thank you! Our greatest loss this year was our beloved Annie. Annie represented our organizations in heart and soul. As the guiding spirit Annie always put the patient first. Annie is now and will always be our guardian. We will miss you Annie but we will not forget you. We celebrate this year as a year of transition and growth. A year that embraces the future while recognizing the strength of our past. We are fortunate to have a foundation of committed staff and partners across both sites from which to build our future. With all the financial and industry pressures we remain committed to delivering efficient patient focused quality healthcare that addresses our population health needs. Respectfully Submitted, Gary Sims, President and Chief Executive Officer Blanche River Health Partners Englehart and District Hospital / Kirkland and District Hospital

Report from the Chief Executive Officer

As I reflect on this past year, it certainly seems like it’s been more than a year when you factor the work and many positive milestones we have achieved so far. The road towards integration with our two neighbouring hospitals has been a long one with much time, effort, dedication, vision and perseverance by our past and present Board members. This year was the culmination of much of that work with our agreement to work towards integration with Kirkland and District Hospital. The signing of the Blanche River Health Partnership agreement was the stepping stone we needed to start implementing our vision for health care in Timiskaming. A hiring committee was struck to find our first joint CEO to lead our organizations. That process involved some long hours and we were very fortunate to find Gary Sims to lead our management team. In fact, the existing management team was small, very small, which provided an opportunity to build it as required for both entities. During this period of transition, we are very fortunate to have a dedicated group of managers and staff in both Englehart and Kirkland Lake. When called upon, they quickly accepted the challenge and provided us with the leadership we needed at all levels to give Gary some time to get settled and to start building his own team. One of our challenges has been on the financial side with a considerable annual funding shortage over the last number of years. As a Board, we have taken this issue seriously and will continue to take a proactive stance to balance our budget. Thank you to Gary and Sean who worked with the North East LHIN to secure one time funding of $800,000 which covered our shortfall for this fiscal year. We are also proud of the glowing report received from our external auditors, KPMG. They again made it clear that our staff is to be commended on the work they do to track, record, maintain and make available the required information for our annual reports. Already, we are seeing many positive steps towards integrating our two organizations, as noted in the CEO report. A plan is under way for a joint Board session in the fall to align our vision for health care and possibly moving to a joint Board for both hospitals which should provide improve communication and efficiencies in providing good governance. There will be many challenges and opportunities going forward as we work with the LHIN and the numerous health provides in Timiskaming. The white paper, the hub model, ever increasing fixed costs, changes to home care delivery to name a few, will mean that we will have to change how we service the communities we serve. I feel that we can turn these into advantages as we can be true leaders of change. As change can bring additional stress and anxiety to all involved in the process, as a Board, we are committed to clear communication with our staff, our patients and our communities and an arduous review of all aspects of our organization. All of the decisions made at the governance level are made with the goal of maintaining or improving timely access to appropriate health care for all our residents. As a Board, we recognize that our staff is our greatest asset and we ac-knowledge their dedication, professionalism and caring for our patients and our communities. We truly thank you for all you do and we support you in all you do! Finally, I want to personally thank our Board members for their time, participation, commitment and devotion to our hospital. It does mean considerable time away from family, friends, hobbies, etc. and your efforts are to be commended. As we have a number of directors who are stepping down this year, a big thank you and I know you will continue to support our hospital in the years to come. Respectfully Submitted, Guy Boileau, Board Chair

Report from the Chair of the Board of Directors

Last year, we parted on an optimistic note and I am pleased to report that as a group, your medical team has grown beyond my greatest expectations. The most striking, pervading element for 2016 has been the strength of senior physician and nursing mentorship to the juniors. This has been catalyzed under the expert guidance, vision, and tutelage of our energetic CEO. As a united medical front, we have embraced virtual care medicine which continues to be a source of advanced medical education for everyone; hence translating into enhanced medical care locally for our patients.

We continue to forge forward with our Kirkland Lake partners in adopting common hospital bylaws, medical credentialing, inpatient medical documentation, and patient order sets. Most recently, we have joined efforts in recruitment, showcasing the wealth of medical expertise and collaboration which set the foundation for sustained quality medical manpower. The driving force behind all this remains continuous, quality patient care...for the District.

I am happy to report, in stark contrast to the past four years, this year we have gained physician manpower without loss. To everyone's credit, this remains the best index of success in this day and age where seeking and retaining physicians who are willing to work under the classic model of delivery of medical care is increasingly challenging.

Despite the austerity of rural medicine in Englehart, a place where one's knowledge and skill is put to the test with spartan resources, we continue to forge strong relationships with our partners at the University of Toronto and a good complement of returning locums. Trained under Sir William Osler ideology, I am relieved to see there still exists in the world of medicine, students, residents and physicians who covet the breadth and richness of rural critical care. This fellowship appeals to seemingly few souls these days; in an age where sub specialization and 9 to 5 medicine is all too popular and sought after...

Why do physicians come to Englehart, Kirkland Lake and Temiskaming? Because great work gets done here. As an example, I recently was fortunate to participate in a resuscitation executed by junior and senior staff which resulted in a return of spontaneous circulation. I was equally delighted by the rescue of a 2 year old child in severe respiratory distress by the collaborative efforts of staff from EDH, Ornge, and Temiskaming. This is rural medicine at its best; enhanced by the expertise of virtual critical care!

By these measures, it is my sense that everyday, among our peers along Highway 11, we hover on the cusp of something great. On making a life altering change for that patient in need of immediate critical care. Herein lies the true greatness and reward of the painstaking calling of medicine. That spirit lives here at EDH...in the District of Timiskaming.

On this even more optimistic note in 2016, with your sound judgment and under the vision and executive savvy of our administration, I look forward as your Chief of Staff to forging yet stronger and far reaching alliances among our medical teams.

Respectfully Submitted,

Dr Marie Lynn Lacasse, Chief of Staff

Report From the Chief of Staff

QUALITY COMMITTEE BOARD REPORT JUNE 2016

The Quality Committee continued to be a fairly well attended, robust, informative Committee, though it remained challenged with recruiting a physician to attend the meetings on a consistent basis. On a very positive note: the EDH and KDH Quality Committee Leads began meeting regularly in order to move to a single integrated Quality Committee with one Quality Lead. In complying with the Excellent Care for All Act the 2016/17 Quality Improvement Plan was developed with pertinent indicators and submitted to Health Quality Ontario and made public on our hospital website by the target date. However, as part of the integration movement the Quality Leads of both EDH and KDH along with their Committees were able to develop one common narrative component and an almost identical work plan component of the QIP for submission. The QIP was submitted individually but had both logos on the Plan. The 2015/16 QIP plan and indictors were monitored over the year. ER patient satisfaction return rates continue to be well below desired and thus an accurate result can not be determined. The Tuck Shop gift card draw continues and is being utilized by the draw winners 80% of the time. New incentives for completing the one sentence survey were considered by the Committee and some changes will be taking place to hopefully increase the response rate. In-patient satisfaction exceeded our target as well as hand hygiene compliance. The ER LOS (length of stay) result shows that we have met or exceeded our target. Medication reconciliation was above 95% in 3 of the 4 quarters, with one of those 3 at 100%, however, one quarter was slightly below the 95% target at 94%. The results that were available on March 31 for the 2015/16 QIP indicators were submitted to Health Quality Ontario and were posted on the hospital website. Both the QIP and indicator results were also posted on the quality bulletin board near the main entrance of the hospital. The new Accreditation Canada inpatient survey tool that began April 1, 2013, had a good response rate and the results for the fiscal year 2014/15 were summarized with those areas that were an opportunity for improvement and presented to the Quality Committee. The hospital underwent the Accreditation Canada survey in June 2015. Accreditation status was achieved with 1 of 2 reports due in November 2015. There were 8 unmet ROP’s (Required Organizational Practices) out of 40 at the time of the survey and after our first report 5 are outstanding and will be reported on in November 2016. Of all the standards surveyed we achieved a 95% compliance rate which is an improvement from 94% in 2012 and 81% in 2009. Standing items on the Quality Committee Agenda: Ad hoc presentations, QIP, Accreditation, Patient Safety, Risk Management and Ethics were presented and reviewed with ample opportunity for questions, clarifications and suggestions for improvement. Included are reports on goals and objectives from departments, programs, services and committees. The year 2015/16 saw an 89% rate of completion of goals and objectives with a report to the Quality Committee following the presentation schedule. This is an increase from 86% in the previous year.

Report from the Quality Committee

Monthly patient safety information was presented including adverse events, medication errors, and nosocomial infections. As well, disaster plan and code reviews including mock and actual were reported to the committee from the Joint Occupational Health and Safety Committee. Risk Management indicators were reviewed bi-annually. Our Ethics process review was approved and passed the Accreditation Canada survey. As part of the integration the ethics component of the Quality Committee is in the process of being changed. The services of Dr. Butcher, the Ethicist for KDH will be utilized to develop a more robust, community partner involved committee. Dr. Butcher presented a session at EDH in December that was well attended and very favorably received. Utilization reviews for Acute Care and Emergency Room were completed for the fiscal year 2014/15 and presented to the Committee with availability to all staff. The Quality Leader met with the full Board in May and November 2015 and presented the Board quality indicators. The indicators include the Quality Improvement Plan indicators, risk management indicators and two financial indicators. This indicator “dashboard” was posted on the Quality bulletin board. The Quality Leader is a member of the Medical Quality Advisory Committee and although the committee has not met due to physician shortages the auditing of death charts continues following the audit process. The venous thromboembolism prophylaxis audits and “do not use” abbreviation audit results are forwarded to Nursing via the Nurse Manager and the individual physicians. With the new Pharmacy module in place the “Do Not Use Abbreviations” audit results have improved considerably. The results of both audits as well as the falls rate and the QIP results of hand hygiene and medication reconciliation are posted on the Patient Safety bulletin board near the Nursing Station. A new Governance structure has been introduced and approved by the Boards of both hospitals. As part of this new structure the Quality Committee will become one integrated committee effective September 2016 with one Quality Lead. We have been fortunate to have members committed to our Quality Program which began in February 2006 and thus I am certain that the new format will be just as successful. Respectfully Submitted, Christine Brownlee, Patient Quality Coordinator for Lois Dekker, Quality Committee Chair

Report from the Quality Committee Continued

As the Chief Financial Officer of the Englehart and District Hospital I am pleased to report on the 2015/16 fiscal year. This year has presented significant financial challenges, as well as opportunities for change within the Hospital as we continue to focus on enhancing quality, efficiency and the overall patient experience. Operationally, the Hospital was facing a significant deficit of almost $800,000 for 2015/16 which was among the largest in its history. Through negotiations with our key funding partner – the North East LHIN – we were successful in obtaining one-time operating pressure funding to offset our expected deficit for 2015/16. Receiving this funding was a significant milestone for our Hospital, but there is no guarantee of future funding as we move forward into the 2016/17 fiscal year faced with an estimated $900,000 deficit position. Further change, such as the integration with Kirkland and District Hospital as well as ongoing internal operational reviews will be necessary as we work in partnership with the North East LHIN and Ministry of Health to address our financial and operational challenges. In terms of our financial results for the fiscal year ended March 31, 2016, we ended the year with a small operating surplus of $51,152 due to the one-time funding of $800,000 received from the North East LHIN. Operational and financial pressures were primarily the result of shortages in nursing resources as well as general cost increases in routine operating costs (ie: supplies, utilities, etc.) which tend to far exceed our 1% annual base funding increase. Additionally, we have seen further erosion in our cash position in 2015/16 due primarily to necessary capital asset expenditures to maintain our building infrastructure and the replacement of aging equipment. As disclosed in our Statement of Operations, we ended the fiscal year with an operating surplus of $51,152 (compared to a deficit of $622,044 in 2014/15) and an overall deficit of $41,315 (compared to an overall deficit of $714,743 in 2014/15). Addressing our financial and operating pressures as we move forward will encompass: i) advancing our integration strategy (sharing staff, services and other resources) among other Hospitals in the District; ii) assessing opportunities to maintain and/or enhance services through a cost recovery model; and iii) internal departmental reviews aimed at assessing efficiency, quality / enhancements in patient service, and cost savings. As disclosed in our Statement of Financial Position, we ended the fiscal year with a weaker cash and working capital position. Our current ratio (a measure of our liquidity) has reduced to 0.82 (compared to 0.93 in 2014/15). Capital expenditures of $197,534 ($217,197 in 2014/15) have declined slightly as we focus on maintaining core assets and infrastructure while judiciously managing our cash position. Future capital investments will require support through various funding programs and fundraising initiatives.

Despite the operational and financial challenges our Hospital is facing, there continues to be a strong sense of commitment to our patient services and community, as well as optimism for the future. Our management team is to be commended for their ongoing commitment to financial stewardship in an environment of resource challenges and increasing operating costs.

Despite the operational and financial challstrong sense of commitment to our patientfuture. Our management team is to be costewardship in an environment of resoIntegration efforts between our Hospital creation of the Blanche River Health Pabringing departments and teams together idiscuss opportunities and standardize acrteam and Board also continue to pursue with key funding partners to assist with oura year of transition, change and growthchallenges that lie ahead while remaining focused health care in our communities.

Report from the Treasurer

Integration efforts between our Hospital and the Kirkland and District Hospital (through the creation of the Blanche River Health Partnership) are producing positive changes that are bringing departments and teams together in a more collaborative and supportive environment to discuss opportunities and standardize across the organizations. Our executive management team and Board also continue to pursue funding opportunities and advocate for our Hospital with key funding partners to assist with our ongoing capital and operating needs. This has been a year of transition, change and growth, and I believe we are positioned to embrace the challenges that lie ahead while remaining committed to providing efficient, quality and patient-focused health care in our communities.

Respectfully Submitted,

Sean Conroy Chief Financial Officer

Despite the operational and financial challstrong sense of commitment to our patientfuture. Our management team is to be costewardship in an environment of resoIntegration efforts between our Hospital creation of the Blanche River Health Pabringing departments and teams together idiscuss opportunities and standardize acrteam and Board also continue to pursue with key funding partners to assist with oura year of transition, change and growthchallenges that lie ahead while remaining focused health care in our communities.

Report from the Treasurer

ENGLEHART AND DISTRICT HOSPITAL STATISTICAL REPORT Year Ending Year Ending

March 31, 2016 March 31, 2015 Admissions 329 356 Patient Days 6,090 6,391

Diagnostic Imaging Examinations 8,278 10,331

Emergency Visits 4,755 5,421 Physiotherapy Visits 4,542 3,380 Respiratory Therapy Visits 313 231 Specialist Visits 1,740 1,330 Food Costs $90,707 $90,491 Full Time Staff 37 34 Part Time Staff 66 59 Paid Hours of Work 121,809 115,342 Natural Gas Costs $17,686 $21,273 Natural Gas Consumed 65,386 cu mt 102,090 cu mt Hydro Costs $76,766 $74,869 Hydro Usage 381,244 kwh 540,466 kwh

Annual Report App. A 2015—2016

Englehart and District Hospital Financial Statements March 31, 2016

Englehart and District HospitalAnnual report2015—2016Table of contentsBoard of Governors Page 3Mission, Vision and ValuesPage 4Patient Declaration of ValuesPage 5Leadership PhilosophyPage 6Report of the Chief Executive Officer Page 7Report of the Board ChairPage 8Report of Chief of StaffPage 9Report of Quality CommitteePage 11Report of the TreasurerPage 13Englehart and District Hospital Financial Statements - March 31, 2016 App. A Annual Report 2015—2016Guy Boileau………...…………………………………………………...………ChairAnnual Report 2015—2016MissionIt is our mission to serve the residents of central Temiskaming by:Providing the best Quality health care,Ensuring seamless transitions to other health service,Collaborating with other community partners to create a safe and healthy community, andCreating an environment where the entire health care team can do their very best workVisionIt is our vision to be:A leader in quality health care services,A collaborative workplace for the entire health care team,An innovative and valued partner in our community, respected by our peersValuesThe following values reflect what is important to us:Patient centered careintegrityInnovative leadershipCommitment to integrationCommunity focusaccountabilityAnnual Report 2015—2016Patient declaration of valuesAnnual Report 2015—2016Leadership philosophyThe management of the Englehart and District Hospital demonstrates a commitment to the Mission and vision of the Hospital by supporting the provision of high quality integrated service and care, with equitable and cost efficient access, designed to meet the clients needs.Management provides leadership, which fosters teamwork, in an environment that is respectful of staff and encourages staffing excellence.Annual Report 2015—2016Report from the Chief Executive OfficerReport from the Chair of the Board of DirectorsReport From the Chief of StaffReport from the Quality CommitteeReport from the Quality CommitteeContinuedReport from the TreasurerReport from the TreasurerAnnual Report App. A2015—2016

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