HEALTH PEI Business Plan - Prince Edward Island HEALTH PEI Business Plan 2017-2018 Message from the Acting Chief Executive Officer As Acting CEO of Health PEI, I am pleased to present

HEALTH PEI

Business Plan

2017-2018

Telephone: (902) 368-6130

Fax:

(902) 368-6136

Mail: Health PEI

16 Garfield Street PO Box 2000

Charlottetown, PE CANADA C1A 7N8

Email:

[email protected]

Web: www.healthpei.ca

Twitter: @Health_PEI

Prepared by: Planning, Evaluation and Audit Published by: Health PEI PO Box 2000 Charlottetown, PE Canada C1A 7N8 October 2017

Printing: Document Publishing Centre Available online at: www.healthpei.ca

Printed in Prince Edward Island

HEALTH PEI

Business Plan

2017-2018

Contents

1 Message from the Acting Chief Executive Officer

2 Vision, Mission and Values

3 Strategic Direction

4 Introduction

5 Accountability Framework and Performance Monitoring

7 2017-18 Focus Areas

8 Goals and Strategic Priorities

19 Budget and Resource Summary

20 Appendices

26 Reference List

H E A L T H P E I B u s i n e s s P l a n 2 0 1 7 - 2 0 1 81

Message from the Acting Chief Executive Officer

As Acting CEO of Health PEI, I am pleased to present the Health PEI 2017-18 Business Plan. This is the first business plan of Health PEI’s new three-year strategic plan which provides direction for 2017-2020. This business plan outlines key actions to move forward with Health PEI’s new strategic direction and the key areas supporting the goals of: Quality and Safety, Access and Coordination, and Innovation and Efficiency. Development of the business plan builds on extensive stakeholder engagement for our strategic plan and was completed under the direction of Health PEI executive leaders and the Board of Directors in accordance with the Health Services Act.

Over the coming year, we will continue to focus on improving the care provided to Islanders by expanding engagement opportunities throughout Health PEI; improving access to services across the province; enhancing safety and security at our facilities; and increasing the use of innovative technologies to provide care.

I look forward to continuing to work with the dedicated staff, physicians and volunteers at Health PEI, as well as our health care and community partners, throughout the coming year to move forward with our new strategic direction.

Respectfully submitted,

Denise Lewis FlemingActing Chief Executive Officer Chief Operating Officer

Denise Lewis FlemingActing Chief Executive Officer

H E A L T H P E I B u s i n e s s P l a n 2 0 1 7 - 2 0 1 8 2

Vision

Our vision statement guides current and future actions and practices of the organization. The vision statement remains unchanged from the Health PEI Strategic Plan 2013-2016.1 Health PEI recognizes its vision as a future state that the organization will continue to strive toward. The vision statement was validated through the engagement process surrounding the development of the Health PEI Strategic Plan 2017-2020.2

One Island health system supporting improved health for Islanders.

Mission

Our mission statement describes the purpose of Health PEI and reflects the broad functions of the organization as defined in the Health Services Act. Our mission statement remains unchanged from the previous plan. The statement was reaffirmed during the engagement process for the development of the 2017-2020 Strategic Plan.

Working in partnership with Islanders to support and promote health through the delivery of safe and quality health care.

Values

Core values are integral to our activities and relationships as health care professionals and providers at Health PEI. Our current values are consistent with those found in our previous plan, as well as Health PEI’s Code of Conduct document entitled How We Live Our Values.3 Participants in the engagement process surrounding the development of the 2017-2020 Strategic Plan agreed that Health PEI’s current values are critical and reinforced that all staff and physicians within the organization should possess these values in the workplace.

Caring: We treat everyone with compassion, respect, fairness and dignity.

Integrity: We collaborate in an environment of trust, communicate with openness and honesty, and are accountable through responsible decision making.

Excellence: We pursue continuous quality improvement through innovation, integration and the adoption of evidence-based practices.

Vision, Mission and Values


Strategic Direction


Health PEI’s Strategic Plan outlines the organization’s direction and guides decision making and activities over the next three years (2017-2020). As a foundational document outlined in the Health Services Act, the strategic plan provides a basis for public reporting and Health PEI’s performance and accountability framework which includes the release of an annual business plan.4 The business plan, developed at the beginning of each fiscal year, serves as the annual operational work plan for the organization. The plan will guide Health PEI toward achieving its goals and key actions approved by the Health PEI Board in the 2017-2020 Strategic Plan directly complementing the Government of PEI’s priorities for health care, including: access to care, focus on specific populations and addressing the changing health needs of Islanders.5

The business plan is supported by the quality and patient safety plans for 2017-18, in addition to existing plans, strategies and initiatives in place within Health PEI’s units/teams, service areas and divisions. Health PEI must support current service requirements (daily operations) and respond with new strategies or key actions to address unmet health care needs of Islanders and service area pressures. To accomplish this work, Health PEI must build on what is currently working well and maximize benefits from investments identified each fiscal year while managing existing resources. Investments approved for the 2017-18 fiscal year include:

Quality and Safety

• Hillsborough Hospital Security

Access and Coordination• Women’s Wellness Centre

• Provincial Renal Program Expansion

• PEI Cancer Strategy

• New Geriatrician and Neurologist

Innovation and Efficiency • QEH Emergency Department (ED) Physician Hours

Introduction


Indicators In order to monitor progress on each goal and priority area identified in the 2017-2020 Strategic Plan, Health PEI monitors strategic performance indicators (SPIs) and business plan indicators on an ongoing basis. A SPI is a measure that is reported quarterly or annually and provides relevant and actionable information about health system performance and characteristics including effectiveness of an organization’s strategies and operational efficiency.6,7

The SPIs selected reflect the wide scope of health care services provided and reflect health system performance. The indicators also enable Health PEI to compare its performance with national and regional practices. Due to the changing nature of health care, it should be noted that key actions may have to be adjusted to achieve goals outlined. At the business plan level, indicators are in place to monitor progress on implementation of key activities that support the achievement of strategic goals. Indicators collected for the 2017-18 Business Plan will primarily focus on process indicators that will track progress on the creation or implementation of new processes, programs and services. These indicators will be tracked by different Health PEI areas. The business plan indicators are summarized under each goal area and are provided in detail in Appendix A. These indicators have been reviewed and agreed upon by leaders within the organization and are a key component in determining where progress is being made within Health PEI, as well as where adjustments or additional focus is required. Subsequent business plans will include an increased number of outcome indicators building on the processes established this fiscal year.

Leadership Accountability

Each Health PEI executive leader has been issued a mandate letter outlining their responsibilities toward leading the successful implementation of the strategic plan. The 2017-18 Business Plan is a reflection of the areas that Health PEI and its leaders will focus on to assist the organization in moving forward to better serve Islanders. Current processes for monitoring the progress of the strategic plan include: the development of the Health PEI Annual Report at the end of each fiscal year, a review of the organization’s Audited Financial Statements and regular compliance reports to the Health PEI Board of Directors.

Accountability Framework and Performance Monitoring


Source: Accreditation Canada

Integrated Quality and Safety Framework

Health PEI’s Integrated Quality and Patient Safety Framework includes the eight dimensions of quality as defined by Accreditation Canada.8,9 The quality dimensions align with the goals and strategic priorities outlined in Health PEI’s Strategic Plan. Throughout the business plan, the quality dimensions and symbols below are connected to strategic priorities and key actions to demonstrate the alignment and integration of the quality dimensions with the strategic plan and business plan. To further support the business plan and the achievement of Health PEI’s goals, quality and patient safety plans for 2017-18 have been developed. Quality and patient safety plans will be updated on an annual basis with the business planning cycle.

DIMENSION TAGLINE

Safety Keep me safe

Client-Centered Services Partner with me and my family in our care

Worklife Take care of those who take care of me

Efficiency Make the best use of resources

Appropriateness Do the right thing to achieve the best results

Accessibility Give me timely and equitable services

Population Focus Work with my community to anticipate and meet our needs

Continuity Coordinate my care across the continuum


Financial Sustainability Financial sustainability will be built upon Health PEI’s fundamental goal of working within its approved budget. In recognition of the growth of health care services provided, changing population needs and the current fiscal climate on Prince Edward Island, Health PEI will strive toward becoming more efficient and integrated across the province. Health PEI leadership will address challenges through fiscal management, developing its workforce and the implementation of best practices. As an organization, Health PEI will identify opportunities for efficiency and to work effectively to provide high quality health care to Islanders. In collaboration with the Department of Health and Wellness, Health PEI will work to achieve the goal of sustainability.

Health System AccreditationHealth care accreditation through Accreditation Canada’s Qmentum program is an ongoing process of assessing health care organizations against national standards of excellence to identify what is being done well and what needs to be improved. Accreditation helps health care organizations improve quality and safety, create stronger teams and demonstrates a commitment to quality, safety and accountability. In September of 2017, surveyors from Accreditation Canada visited PEI to assess Health PEI’s services and programs. Health PEI is striving toward maintaining accreditation status to demonstrate its commitment to quality and safety in the delivery of services and programs.

2017-18 Focus Areas


Health PEI has developed three-year strategic goals and priorities based on significant input provided by stakeholders throughout an extensive engagement process and analysis of national and provincial literature and data. These goals and priorities build on Health PEI’s mission, vision and values. Strategic priorities outline areas requiring focus to achieve the goals with the key actions providing details on how the goals will be accomplished each year. Key actions supporting this business plan are presented in the following pages that focus on the development and establishment of many new initiatives. Subsequent business plans in the 2017-2020 strategic planning cycle will highlight or include system outcomes as opposed to establishing processes and initiatives. The following pages include a brief description of each goal, identified strategic priorities, key actions and related business plan indicators for the 2017-18 fiscal year.

Goals and Strategic Priorities


Support a culture of quality, safety and security in Health PEIHealth PEI is committed to a culture of quality, safety and security for patients, their families and those providing their care. Safety awareness and practices in the workplace can significantly reduce the risk of injury to employees. Building on this, a key driver for creating a culture that embodies quality, safety and security is one where engage-ment takes place with patients, families, staff and the general public on a daily basis. Perspectives and input provided by these groups are essential in guiding change and making improvements to the health care system.

Strategic Priorities

1. Improve patient and workplace safety and security

2017-18 Focus: Key Actions

Patient Safety

• Implement the patient safety culture action plan to enhance and support a just culture of patient safety by developing implementation plans for Health PEI facilities

• Continue medication reconciliation, including an auditing process to ensure that accurate and complete medication information is communicated to patients with a focus on acute care, community mental health and addictions (MHA)

Workplace Safety and Security

• Build on preliminary work completed as a result of the Hillsborough Hospital Safety and Security Review through planning for camera placements, fire safety and electrical work, and continue meetings with staff and unions to provide updates on progress

• Continue the peer-led Leadership Development Safety Series to provide managers and staff with education on employee safety

• Workplace wellness: continue supporting the Smoking Cessation Program at Queen Elizabeth Hospital (QEH), promoting workplace wellness during Healthy Workplace Month, including Mental Illness Week and Influenza Immunization Awareness Month

Goal 1 | Quality and Safety

Linkage to Quality and Safety Framework

Safety Worklife


2. Embed patient and family-centered care at all levels of the organization including, direct care, program and service planning and leadership to enhance patient experience


• Implement and monitor the Health PEI Family Presence Policy which improves patient and family- centered care by removing formal visiting hours

• Implement Health PEI’s Patient and Family-Centered Care (PFCC) Steering Committee’s annual work plan focusing on communication, education and training resources that can be used across Health PEI to support patient and family-centered care

• Build on current patient and family participation on groups, including the Provincial Cancer Steering Committee; Patient Flow Advisory Committee; Provincial Ambulatory Care Steering Committee; Patient and Family Advisory Councils for the Provincial Renal Program and Prince County Hospital (PCH); West Prince working groups for in-patients; Diabetes; Stroke Steering Committee and Cardiac/Respiratory Programs

• Develop and implement key actions for quality practices from the Health PEI Nursing Strategy 2017-202010

• Adopt quality nursing practices which optimize the patient/family experience (e.g. bedside hand-off reporting, 4P Rounding and senior friendly initiatives in hospitals) through the year one implementation of the Health PEI Nursing Strategy 2017-2020

• Continue to have patient and family-centered care as a focused discussion topic at staff and management forum meetings to ensure responsive action to client feedback from frontline patient discussions – discussion points for meetings will be developed as a component of education and training resources


Client-Centered Services

• Join as a signatory to the national declaration of the commitment to Psychologically Healthy and Safe Workplaces (PHSW) for the health care sector and support the work of the Health PEI advisory committee responsible for PHSW

• Develop a Health PEI policy on PHSW

• Integrate PHSW competencies into the leadership LEADS framework, providing tools and resources for Health PEI leaders to support staff members


3. Increase engagement with patients, staff, members of the public and communities


• Increase communication and engagement through staff meetings and management forums

• Work with patients, families, community partners and staff to identify new and innovative opportunities for engagement

• Provide opportunities for education on engagement for staff, physicians and volunteers

• Collaborate with the Chief Nursing Office to develop a systematic approach for engaging with patients and families

• Leverage work undertaken through PHSW to engage with staff


Client-Centered Services

Performance Measures

Business Plan Indicators Baseline 2016‐17

Target 2017‐18

1stQuarter 2017‐18

Percentage of medication reconciliation completed on admission:

For acute care 57% 61% 75%

For community mental health N/A N/A 75%

For addictions N/A N/A 75%

Percentage of quality teams with two patient/family reps 25% 100% 40%

* For detailed Health PEI Scorecard, refer to Appendix A (Page 21-22).


Provide access and coordination to community health and mental health and addictions to meet the needs of IslandersHealth PEI is committed to working closely with Islanders to support creating and maintaining healthy people in Island communities. In order to achieve this, Health PEI must ensure that Islanders are able to access programs, services and providers when they are needed. Therefore, Health PEI will continue to focus on increasing access to primary care providers, MHA and community-based services. Having all professionals in the system trained and working to full scope of practice will be vital for ensuring that the most appropriate provider has sufficient time to spend with patients and families that need their services the most.


1. Improve access to primary care services


• Develop a business case for implementing changes to the Patient Registry with regular reporting on the status of patients on the registry and those removed from the registry

• Continue implementation of services and programs for the Women’s Wellness Centre: sexual health, reproductive health programs, provision of pre-natal care for unaffiliated patients and provision of pregnancy terminations

• Consider the addition of nurse practitioners (NP) to primary care health centres

• Through key actions in the Health PEI Nursing Strategy 2017-2020, enable nurses to practice to the level to which they are educated and licensed by determining barriers for nurses, partnering with professional associations, reviewing policies, practices, and current legislation.

• Conduct research on evidence-based opportunities for NPs, registered nurses (RNs) and licensed practical nurses (LPNs) that can strengthen nursing across different areas such as primary care, MHA and long-term care (LTC)

Goal 2 | Access and Coordination


Accessibility Appropriateness


2. Improve access to mental health and addictions services


• Transfer additional psychiatry hours to outpatient mental health services and treatment, pending recruitment of clinicians

• Hire a resource to coordinate and launch the Collaborative Mental Health Care in Primary Care Program across the province

• Continue work with Aboriginal and refugee populations through dedicated psychiatry support

• Provide MHA staff with evidence-based best practices through focused training on: suicide prevention therapy, workbook use, group therapy, Community Reinforcement Approach and Family Training (CRAFT), crisis intervention, cognitive behaviour therapy (CBT), dialectical behaviour therapy (DBT) and trauma- informed therapy


Accessibility Continuity


3. Improve access to community-based specialized care programs for chronic and complex clients


• Increase the number of patients enrolled in the Remote Patient Monitoring (RPM) Program


Accessibility Continuity Population Focus

• Implement a communication campaign to increase the number of eligible/at risk Islanders participating in PEI’s cancer screening programs

• Conduct a feasibility study to determine if a lung cancer screening program will be launched

• Identify patients that are currently being screened outside of the Colorectal Cancer Screening Program

• Chronic Kidney Disease (CKD) Clinics – RNs to lead CKD clinics and provide ongoing monitoring of stable CKD clients

• Build on additional allied health (e.g. social worker, dietitian, pharmacist) supports in the Provincial Renal Clinic to improve support and access to services

• Continue to conduct RN-led education sessions and presentations to medical staff across the province

• Include chronic obstructive pulmonary disease (COPD) patients to the program


2. Enhance home care services


• Enhance home care services in the community through collaboration between home care and the newly hired internist geriatrician

• Develop and update provincial standards for the delivery of geriatric care as directed by best practices and following Accreditation Canada standards

• Continue to promote enhanced palliative care in the home program to physicians

• Focus on three priority populations: frail seniors, post acute and palliative populations through the implementation of the 2017-2020 Home Care Development Plan

• Implement the Caring for Older Adults and Caregivers in Community and at Home (COACH) Program in Prince County to connect frail seniors to the right services to help them remain at home


Accessibility Continuity Population Focus




Target 2017‐18


Number of Women’s Wellness procedures performed in ambulatory care at the PCH 101 ‐ 226

Number of residents with COPD/heart failure participating in the RPM Program 53 100

30

Number of clients enrolled in the COACH Program 60 15‐20% increase 47

Number of palliative care clients in home care 962 10% increase 316


Develop new and innovative approaches to improve the efficiency and utilization of acute care services and ambulatory care resourcesHealth PEI is committed to effectively managing the use of its resources to benefit the health outcomes of Islanders and their access to services while also reducing cost and creating sustainability. It is important to enhance how patients flow within acute care and community services, and to optimize transitions between sites, sectors and programs. Health PEI must also continue to streamline and improve existing processes and resource allocations to increase efficiency where possible. The increased use of telemedicine and other innovative technologies will improve access to care and support for staff.


1. Improve patient flow


Patient Flow

• Implement year one of the Patient Flow and System Utilization Strategy 2017-202011 with a focus on provincial bed management

• Launch patient flow and system utilization projects, including an application process and the promotion of opportunities

• Activate and support activities to meet the requirements of the Accreditation Canada Client Flow standards

Hospital (Acute Care) Utilization

• Develop a provincial bed map that includes the designation of all acute care beds according to the care provided to determine profile of bed (level, suitable patient)

• Develop and roll-out provincial over capacity policy and protocol

Goal 3 | Innovation and Efficiency


Efficiency Appropriateness


2. Reduce wait times in emergency departments


• Pilot a short stay unit (Clinical Decision Unit) at the QEH ED, with the aim of reducing inpatient admissions and providing an alternate pathway for patients

• Pilot a collaborative project with the QEH ED and home care liaison to ensure the frail elderly population being seen in the ED are assessed for the need of increased services or change in services

• Strengthen and continue collaboration between MHA and EDs through mental health representation on the ED Quality Team and ED representation on the Mental Health Quality Team

• Continuing “Drip and Ship” protocol for myocardial infarction (MI). Patients are transferred to St. John, New Brunswick post thrombolytic. This initiative reduces wait times for patients requiring cardiac catheterization and reduces/eliminates hospital admission to the QEH


Efficiency Accessibility Continuity

3. Ensure appropriate use of ambulatory care resources


• Focus on developing ambulatory care processes for data standardization and service delivery


Appropriateness

• Work to create standard orders across ambulatory care

• Develop process to review new requests for services

• Review current services


4. Increase use of innovative practices 2017-18 Focus: Key Actions

• Use of telemedicine and other innovative technologies across the province

• Establish telemedicine linkages between different sites and specialty areas including nephrology at PCH and Western Hospital; neurology; telepsychiatry at PCH ED; LTC; Telestroke; and Pediatric Psychiatry

• Install connections to different boardrooms

• Install online e-scheduling and application database for volunteers at Community Hospital O’Leary (CHO)

• Continue Strongest Families, an online and telehealth program for children and youth and their families, to improve mental health service access

• Distribute utilization reports and Choosing Wisely best practice information on lab and diagnostic imaging (DI) tests to clinicians

• Partnering with provincial stroke and hyperacute stroke committees to reduce door to thrombolytics for stroke patients and develop a “Drip and Ship” model for clot retrieval. This will help to improve outcomes for patients and reduce length of stay (LOS) in hospital in the acute and rehab phases and long term


Efficiency Appropriateness




Target 2017‐18


Median wait time in the ED for admitted patients 16.7 hrs 8.0 hrs

16.7 hrs

Median wait time for physician initial assessment for triage level 3 in the ED 1.4 hrs 1.0 hr

1.4 hrs

Volume of telemedicine services 338 ‐

91


Budget and Resource SummaryHEALTH PEI

2017-2018 2016-2017 2016-2017Budget Forecast Budget

$ $ $EXPENDITURE*

CORPORATE SERVICES AND PHARMACARE…….………..…………… 54,493,400 50,164,800 49,769,100 MEDICAL AFFAIRS…………………………………………………………. 164,476,100 169,907,000 156,335,900 EHS, LTC AND HOSPITAL SERVICES EAST……………………………….. 284,676,700 275,725,100 275,029,500 FAMILY, COMMUNITY MEDICINE AND HOSPITAL SERVICES WEST 109,671,000 102,563,900 102,023,000 MENTAL HEALTH AND ADDICTIONS………………………………….. 45,043,900 41,483,500 42,139,300 NURSING, ALLIED HEALTH AND PATIENT EXPERIENCE…………… 381,900 359,500 377,600 HUMAN RESOURCES……………………………………………………….. 4,817,800 4,770,100 4,433,400 QUALITY AND SAFETY……………………………………………………. 1,323,100 1,319,100 1,206,400 GROSS EXPENDITURE…...…...…..…………..……………………………. 664,883,900 646,293,000 631,314,200

HEALTH PEI TOTAL REVENUE 24,731,100 25,399,300 26,619,600

NET HEALTH PEI EXPENDITURE………..……………………………………. 640,152,800 620,893,700 604,694,600

CAPITAL PROJECT CONTRIBUTIONS - External Organizations 3,000,000 3,686,500 3,424,900

Capital Plan"Capital Improvements and Repairs 22,866,800 6,973,700 16,185,300 Capital Equipment 3,839,000 7,225,600 5,229,900 Total Capital Expenditures 26,705,800 14,199,300 21,415,200

Full-Time Permanent Equivalents 2017-18 2016-17 2015-16(Direct FTEs)Corporate Services and Pharmacare 150.05 154.55 152.55 Medical Affairs 138.16 129.12 115.12 EHS, LTC and Hospital Services East 2,253.04 2,224.82 2,216.48 Family, Community Medicine and Hospital Services West 964.22 940.83 931.08 Mental Health and Addictions 423.83 415.81 396.30 Nursing, Allied Health and Patient Experience 3.85 3.80 2.00 Human Resources 36.00 36.00 36.00 Quality and Safety 13.70 24.80 25.55 Total FTEs 3,982.85 3,929.73 3,875.08

* PEI Estimates of Revenue and Expenditures 2017/18

"2017-18 Capital Budget and Five Year Capital Plan. Capital Investments ensure the province's health infrastructure is maintained and modified or expanded to meet health service needs of changing demographics. The health sector invests in health facilities, such as hospitals (e.g., Expansion of PCH ambulatory care), manors and clinics. Capital investment is also made in medical equipment including hemodialysis machines, a new linear accelerator and surgical equipment. Five year capital plans are prepared annually to ensure that the significant costs associated with capital investments are strategic, cost-effective, and align with other health sector planning.

Full time equivalency information for 2017-18 was derived from Health PEI salary budget documents. Permanent FTEs, including permanent vacancies are included. Please note that due to 2016-17 organizational changes, positions moved from Corporate Services and Pharmacare and Quality and Safety to other divisions within Health PEI.

FTEs for Medical Affairs include all staff, including salaried physicians. Fee-for-service, contract and sessional physicians are not included.


Appendix A: Health PEI Scorecard

Appendix B: Business Plan Indicator Definitions

Appendix C: Organizational Structure

Appendices


Appendix A – Health PEI Scorecard

PERFORMANCE LEGEND Meeting target – 100% Almost meeting target – 75% Not meeting target – 50%

TREND LEGEND √ Meeting target or on track to meet target X Not meeting or will not meet

target ∆ Caution – needs work to meet target → Trending towards target ◊ No established target,

standard, or benchmark

BUSINESS PLAN INDICATORS FY 2017‐18 ‐ QUARTERLY REPORTING

Goal Indicator 1st

Quarter 2017‐18

2nd

Quarter 2017‐18

3rd

Quarter 2017‐18

4th

Quarter 2017‐18

Baseline 2016‐17

Target Trend Executive Director/ CAO/Chiefs Comments

Quality and Safety


For acute care 61%

57%

75% ∆ Rick Adams

For community mental health N/A N/A 75% ‐ Tracked twice a year. First audit Aug 2017

For addictions N/A N/A 75% ‐ Tracked twice a year. First audit Aug 2017

Percentage of quality teams with two patient/family reps 40% 25% 100% ∆ Rick Adams

Access and Coordination

Number of Women’s Wellness procedures performed in ambulatory care at the PCH 226 101 ‐ ◊ Arlene Gallant‐Bernard, Dr. Andre Celliers

FY 2016‐17 is a partial year. Started Jan 17


100

√ Arlene Gallant‐Bernard, Dr. Andre Celliers

Quarterly target minimum 25

Number of clients enrolled in the COACH Program 47 60 15‐20% increase √ Arlene Gallant‐Bernard,

Dr. Andre Celliers Quarterly target minimum 18

Number of palliative care clients in home care 316 962 10% increase √ Arlene Gallant‐Bernard,


Innovation and Efficiency

Median wait time in the ED for admitted patients 16.7 hrs 16.7 hrs 8.0 hrs X Arlene Gallant‐Bernard, Dr. Andre Celliers , Jamie MacDonald, Dr. Tom Dorran

Median wait time for physician initial assessment for triage level 3 in the ED 1.4 hrs 1.4 hrs 1.0 hr → Arlene Gallant‐Bernard, Dr. Andre Celliers , Jamie MacDonald, Dr. Tom Dorran

Volume of telemedicine services 91 338 ‐ ◊

Arlene Gallant‐Bernard, Dr. Andre Celliers , Jamie MacDonald, Dr. Tom Dorran, Verna Ryan, Dr. Heather Keizer

QEH and PCH


What is accreditation?

Accreditation is a voluntary method of quality assurance.

Accreditation Canada provides hospitals with an external peer review process that is used to improve services provided to patients based on standards of excellence.

Accreditation Canada uses a process called Qmentum which is a combination of the words “Quality and Momentum” and focuses more on staff, physician, and volunteer involvement.

Accreditation for Health PEI took place from September 25 – 29, 2017.

PERFORMANCE LEGEND Meeting target – 100% Almost meeting target – 75% Not meeting target – 50%

TREND LEGEND √ Meeting target or on track to meet target X Not meeting or will not meet

target ∆ Caution – needs work to meet target → Trending towards target ◊ No established target,

standard, or benchmark

BUSINESS PLAN INDICATORS FY 2017‐18 ‐ QUARTERLY REPORTING

Goal Indicator 1st

Quarter 2017‐18

2nd

Quarter 2017‐18

3rd

Quarter 2017‐18

4th

Quarter 2017‐18

Baseline 2016‐17

Target Trend Executive Director/ CAO/Chiefs Comments

Quality and Safety


For acute care 61%

57%

75% ∆ Rick Adams

For community mental health N/A N/A 75% ‐ Tracked twice a year. First audit Aug 2017

For addictions N/A N/A 75% ‐ Tracked twice a year. First audit Aug 2017

Percentage of quality teams with two patient/family reps 40% 25% 100% ∆ Rick Adams

Access and Coordination

Number of Women’s Wellness procedures performed in ambulatory care at the PCH 226 101 ‐ ◊ Arlene Gallant‐Bernard, Dr. Andre Celliers

FY 2016‐17 is a partial year. Started Jan 17


100

√ Arlene Gallant‐Bernard, Dr. Andre Celliers

Quarterly target minimum 25

Number of clients enrolled in the COACH Program 47 60 15‐20% increase √ Arlene Gallant‐Bernard,


Number of palliative care clients in home care 316 962 10% increase √ Arlene Gallant‐Bernard,


Innovation and Efficiency

Median wait time in the ED for admitted patients 16.7 hrs 16.7 hrs 8.0 hrs X Arlene Gallant‐Bernard, Dr. Andre Celliers , Jamie MacDonald, Dr. Tom Dorran

Median wait time for physician initial assessment for triage level 3 in the ED 1.4 hrs 1.4 hrs 1.0 hr → Arlene Gallant‐Bernard, Dr. Andre Celliers , Jamie MacDonald, Dr. Tom Dorran

Volume of telemedicine services 91 338 ‐ ◊

Arlene Gallant‐Bernard, Dr. Andre Celliers , Jamie MacDonald, Dr. Tom Dorran, Verna Ryan, Dr. Heather Keizer

QEH and PCH


Appendix B – Business Plan Indicator DefinitionsQuality and SafetyPercentage of medication reconciliation completed on admission for acute care, community mental health, addictions

Acute care medication reconciliation reflects the ratio of admission medication reconciliation completed within 24 hours to the number of patients admitted within the specified time period. Community mental health and addictions medication reconciliation reflects the ratio of admission medication reconciliation to the service (for those where medication is part of their treatment) to the number of patients admitted to the service within the specified time period.

Percentage of quality teams with two patient/family representatives

This indicator displays the number of quality teams with two patient/family representatives divided by the total number of quality teams, displayed as a percentage.

Access and CoordinationNumber of Women’s Wellness procedures performed in ambulatory care at the PCH

This indicator displays the number of procedures performed through ambulatory care at the PCH related to Women’s Wellness. The types of procedures include options/birth control counseling, surgical abortions, IUD (post-op), post-abortion counseling, post-abortion follow-up, miscarriage counseling, crisis counseling, postpartum depression counseling, IUD insertions, IUD removal, IUD removal & insertion, IUD recheck, endometrial biopsy, loop electrosurgical excision procedure (LEEP), cryotherapy cervix, vulvar biopsy, urodynamic study, pap, STI swab, gynecological - not otherwise specified (NOS) and contraception counseling.

Number of residents with COPD/heart failure participating in the RPM Program

This indicator displays the number of people participating in the RPM Program who have COPD and heart failure. There are 30 kits available for use. Clients can be referred through:

• Primary care (family physician)

• Acute care

• Self-referral

• Heart failure report (created from the ED)


Volume of clients enrolled in the COACH Program

The COACH Program is Caring for Older Adults in Community and at Home. This indicator represents a unique count of Personal Health Numbers (PHNs) for the fiscal year.

Volume of palliative care clients in home care

This indicator represents the number of home care clients who are identified as palliative in Integrated Services Management (ISM).

Innovation and EfficiencyMedian wait time in the ED for admitted patients

This indicator represents the median LOS in the ED from the time of registration to the time the client is transferred to their unit. This is represented in hours.

Median wait time for physician initial assessment for triage level 3 in the ED

This indicator displays the median wait time from the time of registration in the ED to the time of physician initial assessment (PIA). This is represented in hours.

Volume of telemedicine services

This indicator displays the overall use of telemedicine in ambulatory care settings.


Appendix C – Organizational Structure

Policy

Oversight

Operations

Senior Management

Group

Audit, Compliance & Monitoring Committee

Quality & Safety Committee

Public Engagement Committee

Nursing, Allied Health and Patient Experience

Emergency Health Services, Long-Term Care and Hospital Services East

Mental Health and Addictions Services

Family and Community Medicine, and Hospital

Services West

Human ResourcesQuality and Patient Safety Corporate Services and Pharmacare

Department of Health and Wellness

Health PEI Board

Health PEICEO


1 Health PEI Strategic Plan 2013-2016

2 Health PEI Strategic Plan 2017-2020

3 Health PEI’s Code of Conduct, How We Live Our Values

4 Health Services Act, R.S.P.E.I. 1988, Cap. H-1.6.

5 Government of PEI Budget Address 2017. Retrieved from: https://www.princeedwardisland.ca/en/information/finance/budget-address-2017

6 Canadian Institute for Health Information (CIHI) Health Indicators. Retrieved from: https://www.cihi.ca/en/cihi-health-indicators

7 Alberta Health Services. Healthy system outcomes and measurement framework, 2014. Retrieved from: https://open.alberta.ca/publications/health-system-outcomes-and-measurement-framework

8 Health PEI’s Integrated Quality and Patient Safety Framework, 2017.

9 Accreditation Canada Quality Standards

10 Health PEI Nursing Strategy: 2017-2020. Retrieved from: https://www.princeedwardisland.ca/en/information/health-pei/health-pei-nursing-strategy-2017-2020

11 Health PEI Patient Flow and System Utilization Strategy: 2017-2020. Retrieved from: https://www.princeedwardisland.ca/sites/default/files/publications/patient_flow_and_system_utilization_ strategy_2017-2020.pdf

Reference List


List of Acroynms Used ACRONYM DEFINITION ACRONYM DEFINITION

CBT

CHO

CKD

COACH

COPD

CRAFT

DBT

DI

ED

ISM

LOS

LPN

LTC

Cognitive Behaviour Therapy

Community Hospital O’Leary

Chronic Kidney Disease

Caring for Older Adults in Community and at Home

Chronic Obstructive Pulmonary Disease

Community Reinforcement Approach & Family Training

Dialectical Behaviour Therapy

Diagnostic Imaging

Emergency Department

Integrated Services Management

Length of Stay

Licensed Practical Nurse

Long-Term Care

MHA

MI

NP

PCH

PFCC

PHN

PHSW

PIA

QEH

RN

RPM

SPI

Mental Health and Addictions

Myocardial Infarction

Nurse Practitioner

Prince County Hospital

Patient and Family-Centered Care

Personal Health Number

Psychologically Healthy and Safe Workplaces

Physician Initial Assessment

Queen Elizabeth Hospital

Registered Nurse

Remote Patient Monitoring

Strategic Performance Indicator

Notes

Telephone: (902) 368-6130

Fax:

(902) 368-6136

Mail: Health PEI

16 Garfield Street PO Box 2000

Charlottetown, PE CANADA C1A 7N8

Email:

[email protected]

Web: www.healthpei.ca

Twitter: @Health_PEI

Prepared by: Planning, Evaluation and Audit Published by: Health PEI PO Box 2000 Charlottetown, PE Canada C1A 7N8 October 2017

Printing: Document Publishing Centre Available online at: www.healthpei.ca

Printed in Prince Edward Island

HEALTH PEI

Business Plan

2017-2018

Documents

HEALTH PEI Business Plan - Prince Edward Island HEALTH PEI Business Plan 2017-2018 Message from the Acting Chief Executive Officer As Acting CEO of Health PEI, I am pleased to present