Board ReportFrom CMH President & CEO

February 2018

This report provides a brief update on some key activities within CMH as an FYI. While it is organized by our wildly important goals (WIGs) and our 2017-19 strategic themes, it may include other appropriate projects. As always, I’m happy to answer questions and discuss issues within this report or other matters.

Goal: To safely and successfully transition from Wing B to the new Wing A and Wing C.

Wing A handover update

ProjectCo has moved the hand over date to April 16.

While this date is closer to our estimates, we continue to seek counsel from Infrastructure Ontario and our capital redevelopment staff as to when we might get access to the new Wing A.

At this time we are organizing for a handover date of June 1. Once we are certain we can safely take possession of the new patient care wing, we will make a formal announcement to you and the community.

Other updates

Super-user training schedules are set for mid-March.

New ID badges are being issued at the end of February. These new badges will provide physicians and staff with access to new security systems and card readers. There will be a short period of time where everyone will need both ID badges as card readers are replaced in Wing B.

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Move plans are being finalized to vacate Wing B during the eight-week transition period when we get occupancy of the new build. All care programs will be moving to Wing A, except for the Cardio-respiratory Unit, which will remain in their current location. Rehabilitation and Inpatient Surgery are moving to Wing C for the duration of Wing B’s refurbishment.

Diagnostic Imaging and Laboratory will remain in their current locations. Both departments will work alongside their area’s refurbishment over this period.

Improved patient & staff engagement

A unique career development opportunity Cambridge Memorial Hospital is now a member of The Beryl Institute – the

largest group of healthcare providers across the globe committed to further enhancing the patient-experience.

This means all staff and physicians have free access to a wealth of information, including white papers, research, and learning forums from an industry leader.

‘Count Us In’ Council recommends initiatives

The ‘Count Us In Council’ met again in February to continue work on two themes – senior managers act on feedback and I have opportunities to develop my career.

The council was formed September 2017 to provide feedback and action items for senior management to improve overall corporate results from last year’s Count Us In staff engagement survey.

Corporately, these indicators scored the lowest in the 2017 staff engagement survey. After brainstorming root causes for both, a long list of ideas was generated. The group discussed each one and assessed them by noting how great the impact would be if the initiative was in place and how much effort it would take to implement.

This month the focus was on working on how staff will participate in the 360 review of our leaders. Each year, we do reviews of the leaders and some years we have included selected staff feedback. The hospital-wide group is developing a process for staff input for the 2018 reviews.

The second area of focus for this month was on how to implement staff

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rounding within CMH. Staff rounding is a formal program introduced at other hospitals that has leaders connect regularly with staff to explore the things that are working well, opportunities for improvement and other issues.

The group also reviewed the current leadership training strategy They meet again in May.

Barry's Boards to improve staff access to management Thanks to feedback from staff who make up the “Count Us In Council,”

management with direct staff reports now have a “Barry’s Board” outside of their offices.

These simple, yet elegant boards let everyone know where your manager or director is during the day. Managers are to write their schedules for the day on a white board.

Barry's Board came about when Barry Vermeesch, Laboratory, CRU and IPAC director first joined us. It made its way to the corporate-wide "Count Us In" council, who endorsed it as a means to improve staff access to their managers.

Program growth & redesign

Accountable CCAIR begins on B4 Medicine

On January 8, the B4 Medicine team started a structured approach to patient care, communication and discharge planning. This approach – called the ‘Accountable Care’ – is in practice at hospitals across the United States and in Saskatchewan.

In a reflection of the hospital’s core values, the B4 Medicine team adopted the moniker “Accountable CCAIR” for their version of the approach.

A major difference to past practice is the daily Structured Interdisciplinary Bedside Rounding or SIBR. After a training period in December, the B4 team applied their learning on the floor.

SIBR requires all those involved in the care of the patient – physician, occupational therapist, nurse, etc - to discuss treatment progress to date and develop or confirm a plan for discharge. Patients have the benefit of hearing from all clinical disciplines at once, lessening the chances of conflicting or missing information and having a better opportunity to ask questions.

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The feedback has been overwhelmingly positive. Families often make a point to attend and will even delay leaving their loved one’s room if they know the team is about to visit.

On the care team’s side, the already collegial working relationship of B4 staff and physicians has been strengthened by these rounds and they acknowledge that providing information by the bedside in this manner benefits everyone, including the care team.

Of note, three physicians and 13 staff are now SIBR certified (congratulations!), which involves both an on-line component and real time assessment of skills. More will be certified in the weeks ahead, including members of the Nursing Resource Team

To ensure success, scheduled Hospitalists are now dedicated to work on one Medicine Unit, which is a major change from past practice. This is to accommodate predictable rounding times for patients and families and to strengthen communication among the team.

Mary Leversidge, Vera Heldmann and Dr. Jasmine Mathew are leading the team in this new process, to strengthen the proven concepts and to sustain achievements.

Define our role

No update this month

Improve Quality

No update this month

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Strengthen our People

Whistleblower policy overview It is our accountability to inform staff of policies that promote safety, quality of

care and ethical behaviour in our organization. CMH's Whistleblower Policy (2-340) describes the process by which staff and physicians can report safety breaches, unethical behaviour, illegal business conduct, and violations to our code of conduct.

Most often, staff, physicians and volunteers are the first to know when something is going seriously wrong.

A culture of turning a "blind eye" to such problems can lead to serious damage and loss of credibility when action is not taken. Whistleblowing is the action of exposing wrongdoing and practices that are potentially illegal.

When such a perceived violation is observed, a system is in place to encourage and enable the reporting of such concerns. It protects against retaliation, including safeguarding a person's confidentiality when they come forward and it allows for anonymous reporting. One can find our whistleblower submission form on our public website at www.cmh.org/whistle-blower.

Off to market!

At the end of January, CMH participated in the McMaster Resident Marketplace. Marketplace is a forum to help support the recruitment of psychiatry residents for teaching facilities like CMH.

A team from the Mental Health (MH) program, including Mary Dempsey and Dr. Shahmalak was in attendance to provide residents with an opportunity to gain a better understanding of our hospital's MH program and what is has to offer.

Promoting a viable educational experience to residents is important to our growing Mental Health Program. It offers residents with relevant medical training in an acute MH care setting while enhancing our capacity to provide evidence-based outcomes to our patients.

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Drive Value and Affordability

Public input to CMH’s draft executive compensation framework begins

On February 23, CMH began a 30-day consultation process into its executive compensation framework. The community is invited to read the proposed framework and provide feedback via a survey that is posted to its public website at www.cmh.org.

Once the consultation phase is finished, CMH will collate and review the feedback.

In the fall of 2017, hospitals from across Ontario submitted a proposed executive compensation framework to government.

This framework had to meet the requirements of the Broader Public Sector Executive Compensation Act and its Executive Compensation Framework Regulation. It applies to the hospital’s executive management.

Broader public sector executive compensation has been frozen since March 31, 2012. The hospital sector worked with government to receive input into the executive compensation framework so that the specific needs of the sector was taken into account and can allow for important recruitment and retention of hospital leadership roles.  The freeze remains until final executive compensation programs are posted on the organizations’ website. More will be shared with you when CMH’s framework is ready to be posted on our public website. 

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