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Annual Report 2012 - 2013 HAY RIVER HEALTH AND SOCIAL SERVICES AUTHORITY TABLE OF CONTENTS Strategic Direction ........................................................................................................... 2 Public Administrator’s Message ...................................................................................... 3 Chief Executive Officer’s Message .................................................................................. 3 Financial Report .............................................................................................................. 4 Highlights of the Year Acute Care and Ambulatory Care Services ..................................................................... 5 Clinic Services ................................................................................................................. 6 Community Counseling Services ..................................................................................... 8 Community Health Services ............................................................................................ 9 Diabetes Program ......................................................................................................... 11 Diagnostic Imaging ........................................................................................................ 14 Dialysis Unit................................................................................................................... 15 Engineering Services..................................................................................................... 17 Finance Services ........................................................................................................... 18 French Language Services ............................................................................................ 20 Healthy Families Program ............................................................................................. 21 Home Care .................................................................................................................... 23 Human Resources ......................................................................................................... 25 Information Services ...................................................................................................... 26 Laboratory ..................................................................................................................... 27 Long Term Care ............................................................................................................ 28 Mammography .............................................................................................................. 30 Materials Management .................................................................................................. 31 Medical Records ............................................................................................................ 33 Nurse Educator Mentor ................................................................................................. 34 Pharmacy ...................................................................................................................... 35 Quality and Risk Management ....................................................................................... 37 Rehabilitation................................................................................................................. 39 Physiotherapy Occupational Therapy Speech Language Pathology Social Services .............................................................................................................. 42 Supply, Processing and Distribution .............................................................................. 43 Support Services ........................................................................................................... 44 Dietary Laundry Housekeeping Supportive Living Services ............................................................................................ 46 Ultrasound Services ...................................................................................................... 48 HRHSSA 2012/2013 Annual Report Page 1 HAY RIVER HEALTH AND SOCIAL SERVICES AUTHORITY STRATEGIC DIRECTION Strategic Priorities Promote a culture within the organization that encourages and supports quality improvement in the delivery of health and social programs. Improved access to quality health and social services through an integrated and coordinated care model Promote healthy environments that allow the people of Hay River region to live healthy lifestyles Provide a healthy, safe workplace that is able to attract, support and retain a competent and skilled workforce. Provide health and social services that are sustainable and accountable. Establish a culture of client safety that minimizes hazards and client harm by focusing on processes of care. Vision Healthy people living in healthy communities. Mission Meeting community needs through quality care and education. Values The Hay River Health and Social Services Authority is committed to promoting and providing health and social services in a competent and caring manner that ensures client and staff safety; integrity, accountability and respect We believe in: Client and staff safety Integrity Accountability Respect Collaboration Empowerment HRHSSA 2012/2013 Annual Report Page 2 HAY RIVER HEALTH AND SOCIAL SERVICES AUTHORITY PUBLIC ADMINISTRATOR’S MESSAGE I am pleased to present the 2012/13 annual report for the Hay River Health and Social Services Authority. The Annual Report summarizes the successes and challenges that we face in delivering safe and high quality health care services to our communities. I want to thank and congratulate our entire staff for achieving Accreditation with Exemplary Standing, this is a testament to the commitment of our staff. As this report comes out the foundation work on the new Hospital is well under way and the design is near completion. The staff involved with the design process has worked very hard to ensure Hay River has a Hospital that will serve residents of the South Slave for years to come. This past year has seen many changes at the Authority; we say good bye and thank you to Sue Cullen for her leadership over the past four years. We welcome our new CEO Michael Aeberhardt. We all need to take responsibility for our health and wellness and the staff of the Authority are there to assist residents have the information they need to lead healthy lives. Michael Maher Public Administrator CHIEF EXECUTIVE OFFICER’S MESSAGE There are a number of distinct challenges that HRHSSA faces as it works towards achieving its vision of healthy people living in healthy communities. Despite these challenges, the HRHSSA has made large strides in the past year such as achieving Accreditation with Exemplary status with Accreditation Canada, successfully implementing a tobacco-free grounds initiative, and improving access and care by improving physician recruitment and mental health services. The HRHSSA implemented a new strategic plan for 2013-2018. Extensive consultation with both internal and external stakeholders took place. They were engaged in the planning process by bringing their perspectives of the realities, challenges, opportunities, successes and needs. These perspectives shaped the development of this strategy. The strategic plan sets the direction and identifies how the HRHSSA will move forward to 2018, and encompasses a period of significant change for the Authority, as it prepares to commission a new Health Centre in 2015. While many challenges can be anticipated, many others cannot. We believe that continuing to create a culture of accountability, respect, integrity, collaboration, and empowerment with a strong focus on client and staff safety will continue to allow us to make progress in those key areas for the benefit of the community and surrounding areas. Corina Guy and Joletta Larocque Acting Chief Executive Officer HRHSSA 2012/2013 Annual Report Page 3 HAY RIVER HEALTH AND SOCIAL SERVICES AUTHORITY FINANCIAL REPORT We have just completed our annual financial audit for the fiscal year 2012/13, and after including prior year funding of $650,000, we have identified an operating deficit of $1.15 million. This deficit was driven mainly by shortfalls in the pension plan, the mammography program and the inability to hire Nurse Practitioners using the restricted Physician funding. Significant strategic work was conducted during 2012-13 with the HRHSSA Pension Plan to control funding volatility through plan design, investments and funding requirements. Changes to the pension plan include increasing the waiting period to join the plan, increasing member contributions, and in 2018 eliminating the portability option after age 50. These changes have had an immediate positive impact for the plans Going Concern funding target from $6,215,000 in January 2012 to $1,865,000 in the January 2013 valuation results. The Going Concern valuation takes a long term view of the pension plan and expects it to continue to operating for the foreseeable future. Special payments can be made over a period of 15 years to eliminate the Going Concern shortfall. The volatility of contribution requirements to the pension plan is partially driven by solvency funding requirements. The Hypothetical Wind-up and Solvency valuations continue to be a concern. The Hypothetical Wind-up and Solvency valuations assume the plan will be wound-up on the next valuation date which is very unlikely. The shortfall grew from $10,126,000 to $13,637,000. Special payments must be made over a period of no less than 5 years. The HRHSSA worked with Mercer Global to change the asset mix at the beginning of the year with a goal of matching the investment assets to the plans liabilities in order to avoid significant fluctuations that could cause increasing shortfalls over time. In the meantime, the HRHSSA continues work on achieving a solvency exemption, which would eliminate the solvency funding requirements. Solvency exemptions are typically given to Crown Corporations or via letter of credit. It does not appear that the HRHSSA meets the requirements to be determined a Crown Corporation. The GNWT is currently investigating ways to help the Authority achieve the possibility of obtaining a letter of credit. Good news going into 2013-14 is that the mammography program secured core funding through the annual GNWT forced growth process. Also, a portion of the restricted Physician funding will be released to allow the flexibility to hire Nurse Practitioners when physician levels are low, on a two-year trial basis. HRHSSA 2012/2013 Annual Report Page 4 HAY RIVER HEALTH AND SOCIAL SERVICES AUTHORITY HIGHLIGHTS OF THE YEAR Acute and Ambulatory Care Services Acute Care Services provides inpatient acute care, palliative care, respite care and alternate levels of care. Ambulatory Care Service provides 24/7 Emergency care services, a dental surgical program, endoscopy services, stress testing, pulmonary function testing, phlebotomy services and chronic intravenous therapy infusions. Highlights Implementation of additional Emergency Intravenous Infusion Kits Implementation of supplementary Sexual Assault Kits Implementation of Falls Prevention/ Injury Reduction Program on Acute Care 212 Day Surgery procedures: Dental & Endoscopy procedures 62 Pulmonary function tests 5671 Emergency Department visits Goals Achieved Goal: Cross training of RN’s to work in the Recovery Room, Endoscopy Suite, Operating Room, Stress Testing and Charge Nursing. Performance Indicators Nosocomial monthly Infection tracking Work loading stats Infection Control Environmental Audits CTAS Audit Endoscopy satisfaction surveys Discharge Status HRHSSA 2012/2013 Annual Report Page 5 HAY RIVER HEALTH AND SOCIAL SERVICES AUTHORITY Clinic Services Clinic Services provides primary care to Hay River and catchment areas that include Ft. Resolution, Katlo’deeche, Enterprise, Kakisa and Fort Providence. Highlights Better utilization of the Treatment Room – Since September 2012 the treatment room has been utilized on a scheduled basis once a week for lumps and bumps removal. Practitioners and clients are quite happy and we look forward to expanding our services for the room Hired additional Clinical Assistant casual support – enables staff to be on leave and to have proper coverage Through the dedicated recruitment efforts by our Physician Recruiter, we have been successful not only to retain a full complement of locum physicians and nurse practitioners, but sign a permanent general practitioner for a three year term which began April 2, 2013 Dr. Doug McTaggart in the Clinical Advisor role - excellent resource Electronic Medical Records support – More involvement with in Territorial meetings has benefited us with a greater understanding of Wolf and its successes and limitations Increased number of clients getting appointments due to the increase in practitioners – this seems to have decreased the amount of complaints the Clinic was receiving Wolf generated waitlists for the Specialty Clinic – The clinic is working on establishing waitlists for the Specialty Clinic on Wolf so practitioners can access. Interest of some Nurse Practitioners/Physicians for longer term locums Hiring of a full time practitioner April 2013 Goals Achieved Goal: To follow through with the plan to develop a safe, accessible and efficient specialty clinic program. This is ongoing, but successes have been made. Clinics being placed on EMR for easy access to practitioners is enabling for better follow up. Paper flow has been examined and key changes have been made. Goal: To develop a safe, accessible and efficient treatment room program. The room is being used now for lumps and bumps removal once a week when needed. The procedure is scheduled and a practitioner is assigned with a nurse. Depending on the need more procedure days are added. The room is also used to assess walk-ins before they are seen by the practitioner. HRHSSA 2012/2013 Annual Report Page 6 HAY RIVER HEALTH AND SOCIAL SERVICES AUTHORITY Appointments for Hay River Specialty Clinics 2012 350 329 300 250 200 200 205 200 150 100 50 165 146 117 95 0 Internal Medicine General Gynecology Surgery Adult Psych. Ortho Peds Audio ENT Specialty Clinics- Number of Actual Travel Clinics in Hay River Internal Medicine General Surgery Gynecology Adult Psychology Orthopedics Pediatrics Audiology Ear, Nose & Throat (ENT) 4 5 12 4 7 12 4 4 Clients Traveling outside Hay River for Appoinments 200 150 100 50 0 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Clients Traveling outside Hay River for Appoinments HRHSSA 2012/2013 Annual Report Page 7 HAY RIVER HEALTH AND SOCIAL SERVICES AUTHORITY Community Counseling Services Community Counselling Services (CCS) provides outpatient counselling for individuals, families, groups, couples, and children from the age of six, inpatient counseling at the hospital, addictions counseling, awareness and prevention, community outreach and collaboration with other agencies. CCS facilitates the improved wellness and mental health of community members. Other services are treatment referrals, crisis prevention, case management, and psycho-educational programs and workshops. Highlights New staff hired between January and April 2013 : one Clinical Supervisor/Counsellor, three Mental Health & Addictions Counsellors, two Community Wellness Workers Brought wait list of 100 in January 2013 to zero in April 2013 Participation in Rounds, Diabetes Team, school planning meetings, Employee Wellness Committee and FASD Territorial Networking Group. Successful completion of first Matrix Program New staff met with other HRHSSA departments and several schools and agencies for collaborative planning Goals Achieved Orientation of new staff to the Hay River Health & Social Services Authority Wellness Workers orientation to Fort Smith Matrix Program, a drug and alcohol day program Eliminated wait list and transfer files Held several outreach meetings with community agencies, schools, and other HRHSSA departments to plan collaborative programming for the Fall Performance indicators CCS gathers statistics on completed sessions, no shows, cancellations, wait list, and referrals. CCS has focused on reduction and elimination of the wait list and transfer files. CCS is also monitoring the continued trend in addiction counseling no shows and cancellations. HRHSSA 2012/2013 Annual Report Page 8 HAY RIVER HEALTH AND SOCIAL SERVICES AUTHORITY Community Health Services The Public Health department operates core public health programs, including immunizations for 0-18 months, school age and adult; school health programs, health promotion and prevention education, TB surveillance, prenatal education, postnatal services, Well Child and Adult Clinics, infectious disease surveillance, Employee Health Risk Assessments (EHRA). Highlights Had services of a Nurse Practitioner in Community Health Services for 2 days per week Obtained funding from the Hay River Elks service club to purchase an: ‘Audix Pro,’ infant hearing screening device Received new audio equipment for our unit in Hay River this year Administrative Assistant has completed a user friendly school database program which will enable public health nurses to print off work sheets to use when preparing for mass immunization days at the schools Completed a set of posters to promote prevention of FASD. Was done in partnership with the Hay River Interagency group and many community members HRHSSA Foundation approved funding for 2 new breast pumps for our breast pump loan program Literacy Committee continued to provide post-natal book bags to hand out to new parents New Territorial Immunization Registry was implemented territorial wide changing the way information is collected Goals Achieved Goal: Continue to find ways to enhance electronic, paperless systems of recording client health information. Public Health continues to use the EMR to enhance our client care. Templates have been developed for the system that captures the information needed from our territorial forms. Different data bases have also been created to assist collecting proper information. Goal: To maintain core programming as mandated in the NWT Community Health Nursing Program Standards and Guidelines. Nurses continue to provide GNWT mandated community health services to the community. Priorities are identified and maintained even with low staffing levels. Goal: To provide consistent STI education and follow-up in a timely manner. Teaching is done as asked for in the schools, monthly at the treatment centre, and on a one to one basis. Numbers of clients seen by Public Health for STI testing and treatment is going down slightly which hopefully reflects our education efforts. Performance Indicators STI Rates 106 Clients seen in 2010/11 for STI testing and treatment 111 Clients seen in 2011/12 for STI testing and treatment 82 Clients seen in 2012/13 for STI testing and treatment HRHSSA 2012/2013 Annual Report Page 9 HAY RIVER HEALTH AND SOCIAL SERVICES AUTHORITY Community Health Services cont’d 60 50 40 2010-11 30 2011-12 20 2012-13 10 0 Immunizations given on a monthly basis Immunizations Received Monthly 2012 700 600 658 500 400 300 200 100 349 181 207 176 139 187 228 Immunizations Received Monthly 2012 116 143 133 117 0 HRHSSA 2012/2013 Annual Report Page 10 HAY RIVER HEALTH AND SOCIAL SERVICES AUTHORITY Diabetes Program The focus of the Diabetes Program under the Home Care & Community Enhancement (HC&CE) initiative has been to provide a comprehensive Diabetes Education and Support Program which improves care and treatment for clients, encourages self management and provides culturally appropriate prevention programs. Within the community of Hay River, there are approximately 490 individuals with type 1, type 2 and gestational diabetes that have been identified. Within an overall population of ~3,600, these individuals represent a significant proportion of the individuals in which we serve. The program currently has 175 active clients that are seen on a regular basis. Highlights Group Diabetes Appointments were initiated June 2011, 48 group appointments were completed and at present 90 clients are receiving follow-up in a group appointment Working with one Practitioner on a weekly basis has allowed for better continuity of care for diabetes clients Continued addition of a term Dietician accessed through the ADI funding (Aboriginal Diabetes Initiative) in 2012/2013, allowed for an increase of community teaching on healthy choices and diabetes Renal Program added through Yellowknife Specialty program - 25 referred to program. This has increased workload, but has given better client care Received Certificate of Recognition from the Canadian Diabetes Association Standards and Recognition Program Increased health promotion/diabetes awareness programming and established stronger working relationship with Hay River Reserve as a result of ADI funding: Kids in the Kitchen, Health Fair, Treatment Center, Lunch & Learn, focus Groups, Elders in Motion, Weight Loss program, Grocery store tours, Adult Cooking Circle, Women’s Walking Club, STI Awareness Workshop, Nutrition month activities, etc. Developed stronger partnerships in the community: Hay River Committee for Persons with Disabilities, Aurora College, Schools, Hay River Interagency, Hay River Reserve Goals Achieved 1. To provide a comprehensive Diabetes Education and support program which improves care and treatment for clients, encourages self management and provides culturally appropriate prevention programs. Increase in group programming allowed for more clients to receive consistent care. 2. To increase community knowledge about diabetes and risk factors, by increasing screening among the general population with a goal of increasing early detection of diabetes. Screening is done on a regular basis in the community through such events as the Adult Health Fair, World Diabetes Day and Health and Wellness programs with different businesses. HRHSSA 2012/2013 Annual Report Page 11 HAY RIVER HEALTH AND SOCIAL SERVICES AUTHORITY Diabetes Program cont’d 3. To provide education for clients diagnosed with pre-diabetes and clients at high risk for developing diabetes. Education is done through many different programs offered by the diabetes team. Cooking circles, weight loss programs, community presentations, grocery store tours, education booths as well as individual appointments and diabetes workshops. 4. To have Standards and Recognitions recertified in 2012. This was achieved. Diabetes Program was recertified as an accredited program by the Canadian Diabetes Association. Performance Indicators Clients seen or chart reviewed by the Nurse Practitioner. Since having a dedicated practitioner for the Diabetes Program more clients have been able to be medically reviewed. Issues such as medication refills, insulin starts, medication management, timely adjustment to dosages, and referrals to specialists are dealt with during these sessions. Continuity allows from better patient care and proper follow up. By having the practitioner as part of the program it decrease the amount of medical clinic visits. 400 350 300 250 200 150 100 50 0 2010-11 HRHSSA 2012/2013 Annual Report 2011-12 2012-13 Page 12 HAY RIVER HEALTH AND SOCIAL SERVICES AUTHORITY Diabetes Program cont’d Number of Clients seen in Group Sessions Group sessions started in June 2011 and are held off site. The goal is to help facilitate diabetes self management. 90 clients are now managed in groups and are seen every three months. The intent for 2013/14 is to continue to increase the amount of group sessions and clients seen this way. 30 25 20 15 10 5 0 HRHSSA 2012/2013 Annual Report Page 13 HAY RIVER HEALTH AND SOCIAL SERVICES AUTHORITY Diagnostic Imaging The 24 hr Diagnostic Imaging Services include the provision of quality general radiology views performed in both a fixed radiology room, and portably when required. Images are reviewed and reported by offsite Radiologists at the RCA (Radiogy Consultant Associated) radiology group in Calgary. The Diagnostic Imaging staff liaises with the physicians to provide the best client care possible. Highlights Sang Andrews, with RCA , was tasked with forwarding urgent report requests to RCA radiologists to speed up STAT or Urgent results reporting Upgrade installed for PACS (Picture Archiving and Communication System) In house patient satisfaction survey completed Goals Achieved The Radiation Safety Manual was reviewed by the Radiologists at RCA and signed off prior to Accreditation Dr. Donald Beach made an onsite visit in January of this year fulfilling an accreditation requirement Diane Blaquiere was hired in August of last year, filling a vacant position Performance Indicators Wait time for X-Ray Appointments excluding emergency referrals March 1 to March 31, 2013 60 # of appointments 50 40 30 20 10 0 0 1 2 3 4 5 # of days waiting Due to unscheduled staffing change, data was not collected from March 18th to March 25th. HRHSSA 2012/2013 Annual Report Page 14 HAY RIVER HEALTH AND SOCIAL SERVICES AUTHORITY Dialysis Unit The dialysis unit provides Hemodialysis, Renal Insufficiency Clinic and Venous Access Study program with a transonic device. Highlights Ever greening program with the Territorial government resulted in the purchase of six Bellco 2000 plus dialysis units in June of 2012 Two staff were hired for causal relief and trained in the NARP (Northern Alberta Renal Program) renal program at the University of Alberta Hospital Stanton Territorial Hospital hired a new clinical coordinator and no longer requires the services of the clinical coordinator of HRHSSA Dr. Glick, nephrologist, relocated to British Columbia and as a result Dr. Kelly Craig is the nephrologist that replaced her The current hemodialysis population is 4 patients Goals Achieved Goal: job shadowing at the Grey Nuns Hospital Access program Goal: recertification in CNeph (Certified Nephrology) HRHSSA 2012/2013 Annual Report Page 15 HAY RIVER HEALTH AND SOCIAL SERVICES AUTHORITY Dialysis Unit (con’t) Performance indicators KT/V Water Purification Renal clearance during dialysis 2.4 2.2 2 Pt 1 KT/V 1.8 Pt 2 KT/V 1.6 Pt 3 KT/V 1.4 Pt 4 KT/V Pt 5 KT/V 1.2 Normal Value 1 MONTH PRU KT/V: A measurement to identify the adequacy of clearing urea in a hemodialysis treatment. Adequate is considered to be achieved when KT/V is 1.4 K: The effective (delivered) dialyzer urea clearance in millilitres per minute integrated over the entire dialysis. T: The time in minutes measured from beginning to end of dialysis V: The patient’s volume of urea distribution in millilitres 90 85 80 Pt 1 PRU 75 Pt 2 PRU 70 Pt 3 PRU 65 Pt 4 PRU 60 Pt 5 PRU 55 Normal Value 50 MONTH HRHSSA 2012/2013 Annual Report Page 16 HAY RIVER HEALTH AND SOCIAL SERVICES AUTHORITY Engineering Services Provide a functionally appropriate, safe and comfortable environment for clients and staff of the HRHSSA. Responsibilities Provide maintenance services to all HRHSSA facilities Perform scheduled & preventive maintenance Perform regular inspections Execute direct request maintenance Provide summer grounds work & snow removal Develop, review, and implement functional plans for various emergencies Provide project management services Highlights Endoscopy, Project (Scope Processing & Sterilization) $126K Supported Living Accessibility Improvement (Washrooms) $79K Departmental grew by 1 FTE Goals Achieved Goal 1 – Refine Department’s Scope of Work. Data collected demonstrated significant growth in maintenance activities due to the increase in buildings (SLS Complex), and programs over time, and the new workload required by the “New Health Center” project Goal 2 – Improve service model. The addition of 1 FTE within the maintenance department improved customer service by providing additional skills, reducing response time, and re-establishing abandoned preventive maintenance procedures. Performance Indicators In order to manage a fleet of 20 vehicles, Engineering Services record the maintenance costs of each vehicle as preventive or immediate maintenance service is performed. This provides a historic evaluation of each vehicle in the fleet, ensuring a safe fleet by identifying concerning maintenance patterns and/or excessive costs. This indicator provides sound data for annual fleet budgeting and life cycle recommendations. $2,500.00 Annual Maintenance Cost for 2001 Ford Focus $2,000.00 $1,500.00 $1,000.00 $500.00 $- HRHSSA 2012/2013 Annual Report Page 17 HAY RIVER HEALTH AND SOCIAL SERVICES AUTHORITY Finance Services The Finance Department provides financial services to management and staff of the Authority and provides financial reporting to outside stakeholders as required. Services include cash handling, accounts receivable, payroll, accounts payable, general ledger maintenance, contribution agreement reporting, variance reporting as well as many other financial and reporting services. Highlights During the 2012-13 fiscal year, the Finance and Materiel Management departments successfully completed an Environmental Scan of their operations, both separately and together. From the Strengths, Weaknesses, Opportunities and Treats (SWOT) analysis, three priorities were identified to improve the delivery of services to other departments. The three priorities identified were 1. Improve the lines of communication between staff and departments 2. Enhance services to departments 3. Create and maintain policies and procedures while expanding appropriate educational opportunities. The HRHSSA financial chart of accounts has been updated to be Canadian Institute for Health Information (CIHI) compliant. The Financial Services and Materiel Management staffs have been trained in the updated CIHI Management Information Systems (MIS). Staff working in Accounts Receivable (AR) completed ICORE training which allowed them to learn and master many key functions including how to submit shadow billing, reading, and understand medical terminology, mastering billing codes, and how to properly correct errors. The training also allowed for a more formal schedule to be introduced for shadow billing and as such is now completed on a weekly basis. In addition to AR staff learning new skills, cross training has been ongoing and will continue in order to ensure that in the event of a staff shortage there is always one staff member with appropriate training on the AR desk. Goals Achieved Implementation of priorities from the Environmental Scan. Baseline mapping of all processes in Finance and Materiel Management. Updating Policies and Procedures (ie: establish a policy for the timing of AP Payments and cut off deadlines) Follow through with: o Training initiatives both within the Finance and Materiel Management department and to other HRHSSA departments (ie: training other departments on Finance and MM procedures and policies and how they affect those departments). o Creating up to date procedures manuals that are user friendly and provide complete instructions and other necessary information that will allow staff with limited experience and knowledge to perform all tasks properly (ex: casual staff). Introduction of Lean and Quality Management Initiatives to improve services and to reduce nonvalue activities. Initiation of processes to retain and maintain corporate knowledge Work to ensure that GNWT and Year End Audit reporting is completed on a more regular basis in order to lessen stress and time crunch at year end. Including reconciliations, physician reporting, forced growth reporting. Update the asset inventory and develop processes to systematically maintain and control inventory. Create an updated specimen signature record and in collaboration with the GNWT, HRHSSA Human Resources Department and Information Technology Department develop processes for HRHSSA 2012/2013 Annual Report Page 18 HAY RIVER HEALTH AND SOCIAL SERVICES AUTHORITY signing authority records and delegation, its implementation in Ormed and application in daily operations. Continue cross training within the Finance and Materiel Management departments to ensure that all staff is knowledgeable in all positions if extra coverage is needed. Extra training in Accounts Receivable’s Trust Accounting and collections of outstanding invoices should be a priority. Performance Indicators Year End 2012/13 Year End 2011/12 Year End 2010/11 Year End 2009/10 AP Invoices Processed 5973 5781 6545 9369 AP Cheques Issued 3251 3357 3965 2767 AR Receipts Issued 1964 1655 1681 1734 AR Invoices Issued 2455 1987 1808 1732 T4’s Issued (incl. Casuals) 277 278 278 224 HRHSSA 2012/2013 Annual Report Page 19 HAY RIVER HEALTH AND SOCIAL SERVICES AUTHORITY French Language Services French Language Services ensures that clients have access to the services and programs offered by the Authority in French enabling our francophone clients to give true informed consent to services provided to them. The French Language Services Coordinator plans, supports and advises directors, managers and staff on all issues related to the delivery of services and programs in French. The Coordinator ensures that the Authority meets its legal obligations under the Official Languages Legislation. French Language Services also provides language facilitation services to the Authority’s aboriginal clients. Highlights Began work with Conseil de développement économique des Territories du Nord-Ouest (CDETNO) to help with recruitment of bilingual health professionals Increased number of positions advertised on the HRHSSA website are translated A Bilingual (English/French) Doctor has sign a 3 year contract with the HRHSSA The HRHSSA has 9 French Bilinguals person on Staff Visit with Lisa Berthier the DHSS Manager of Official Language in Hay River Trip to Montreal’s Job Fair to promote Health and Social Services in the NWT Developing a project with teleconference coordinator Lynne McBryan to offer the service and information in French Goals Achieved Supported HR with recruitment of bilingual health professionals by working with CDETNO and promoting the Hay River Hospital at The Palais des congres Job Fair in Montreal, Quebec Worked with Translation Services to prioritize the translation process Worked on the process of developing a program to address the training needs of bilingual staff to offer interpretation and facilitation services Performance Indicators Percentage of French language newspaper and HRHSSA website postings compared with total English language postings (compliance with requirements and regulations) % of French language newspaper postings L'Aquilon % of French language HRHSSA website postings 2011-2012 2012-2013 10% 0% 5% 35% There has been no external posting in the paper this year and the Website is still under construction HRHSSA 2012/2013 Annual Report Page 20 HAY RIVER HEALTH AND SOCIAL SERVICES AUTHORITY Healthy Families Program The Hay River Health & Social Services Authority recognizes the importance of investing in the children and families in our community and has delivered the Healthy Families Program since September of 2004. Healthy Families provides in home visitation services to parents with children ages 0-6 as well as prenatal mothers and parents reuniting with their children (ages 0-6). Healthy families offer parents who are especially experiencing extraordinary and stressful personal circumstances with support, advocacy and linkages to resources along with curriculum activities (Growing Great Families is the main curriculum we use). Transportation to medical appointments, special ‘in home’ or community workshops are also available (as funding is found) on home safety, healthy cooking/baby food making, low cost/educational homemade play ideas and toy making. The best part about Healthy Families is that is customized to meet the needs of the family where they are at, collect information on where they would like to be (in 5 years) and help assist them in meeting those goals along with putting their priority on their child(ren) and not on their stress. Providing families with these services also blends well with the mission, vision and goals set out by the Hay River Health & Social Services Authority. Prevention, intervention and education that is free, accessible and ongoing will build stronger and healthier children for the next generation to come. Highlights Participated in a round table (January 2013 in YK) to discuss the future ten year direction the GNWT will take on the Early Childhood Development Framework for Action. Directed by Education Culture and Employment, Health & Social Services and Government of the North West Territories Continuing to provide free home based visits to currently 23 families within the community. Continuing to provide weekly Tuesday visits (as required) to fathers who are in the South Mackenzie Correctional Centre and who will be reuniting with their children upon release. (We do the Growing Great Families curriculum with them) Piloted a Healthy Baby Feeding Basics program with funding from Health Canada and the Public Health Agency of Canada community-based funding in the territories. Goals Achieved Enhanced programming by introducing the baby food making program. This program will help keep children and future children healthy decreasing the risks of preventable diseases like diabetes. Provided free family education through monthly binder themes that we create (on sensory play, fine motor skills, etc.) that promote simple and educational ways to help baby’s brain development and preparation for school. Increased number of families participating in the Healthy Family Program (mostly all new families were self-referred) Participated in the Early Childhood Framework for Action Roundtable Updated our daily & monthly forms for recording our data and reviewed this with our departments that monitor policies and information gathering to ensure information sharing and data recording is safe and accounted for Developed new metaphoric tools and resources (brochures, literacy friendly reference sheets, booklets and visual tools) that our families could use to better understand our programming topics. Expansion of program will be prominent in the next few years and we are currently looking into our options HRHSSA 2012/2013 Annual Report Page 21 HAY RIVER HEALTH AND SOCIAL SERVICES AUTHORITY Healthy Families Program (con’t) Our upcoming goals for 2013/14 will include successfully implementing a new and updated referral process (self-referral and agency referral) and screening tool Performance Indicators Family Contact Breakdown 2012/13 Home Vist by HFP Drop Into Office SMCC Sessions Called In/Other Contact made HRHSSA 2012/2013 Annual Report Page 22 HAY RIVER HEALTH AND SOCIAL SERVICES AUTHORITY Home Care The Home Care nursing staff’s focus is on keeping clients in their own homes by assisting them with maintaining their health and independence. Home Support workers assist in a variety of activities to help clients maintain their health and enhance feelings of independence, self-worth and dignity. The Foot Care nurse provides a wide range of services to clients with advanced foot care disorders and advanced circulation checks. A large part of her practice is focused on helping clients/staff with education on foot care health. Highlights Foot care nurse has completed her instructor certificate. She is now able to teach Advanced Foot Care to staff within our authority as well as to other authorities. This education was funded by the Dept. of Health as well as the HRHSSA. This is the first certified Foot Care Instructor in the NWT. Supportive Pathways has been implemented and education sessions are under way. This is a program that focuses on quality of care for persons living with dementia. Home Care RN has applied to become a certified Enterostomal therapist (Ostomy/wound care specialist). Waiting to see if she is accepted into the program. Home support worker 0.5 PTE hired August 2012 to fill vacancy Palliative Care Intensive training taken by two Home Care nurses in Victoria Goals Achieved Goal: Meals on Wheels process improved. Goal: Basic foot care sessions implemented to staff Goal: Medication reconciliation being done regularly between client’s meds, home care records and electronic record Performance Indicators Meals on wheels surveys completed Attendance in basic foot care sessions and requests for future sessions Regular chart audits HRHSSA 2012/2013 Annual Report Page 23 HAY RIVER HEALTH AND SOCIAL SERVICES AUTHORITY Home Care (con’t) Service Reports from 2012-2013 2011-2012 2012-2013 New Referrals 114 123 Discharges 46 36 Admissions Acute Post Hospital Total number of Home Care clients Total amount of Client Service time 77 21 86 21 273 288 5540.08 5321.63 Post procedure/operative clients are returning back to their home communities earlier and in a more acute condition. They are often being discharged directly to their own homes and home care is receiving a lot more short term higher acuity referrals. Home care currently has reached its client service capacity to staffing ratio and will be considering a wait list or referring clients back to Out Patient depart or Active Care. HRHSSA 2012/2013 Annual Report Page 24 HAY RIVER HEALTH AND SOCIAL SERVICES AUTHORITY Human Resources The Human Resources (HR) department’s key areas of responsibility include recruitment, selection, position administration/job evaluation, HR planning, corporate training, orientation, labour relations, collective bargaining, pay, benefits, staff service recognition (longs service awards, staff appreciation), return to work/stay at work program, performance management, HR policies administration, employee wellness & attendance management. Highlights Collective Bargaining Enhanced SharePoint services via Employee Wellness & Manager Toolkit tabs Learning Management System (LMS) test server introduced using “Moodle” “Getting to Know Employees of the HRHSSA” project enhanced Succession Planning program introduced Enhanced “on-boarding” for out of town hires Restructure of Community Counselling department Goals Achieved Goal: Successful negotiation of a 4 year Collective Agreement Goal: HR Policy maintenance schedule developed and up to date Goal: Employee Health Audit Survey completed as part of the Employee Wellness Program initiative Goal: Attendance Management Toolkit presentation developed Performance Indicators Human Resources Performance Indicators 90.00% 80.00% 70.00% 60.00% 50.00% 40.00% 30.00% 20.00% 10.00% 0.00% 2009/10 2010/11 2011/12 2012/13 HRHSSA 2012/2013 Annual Report Page 25 HAY RIVER HEALTH AND SOCIAL SERVICES AUTHORITY Information Services The Department provides information technology services (computers, printers and some software support), telephone support and administration, French language services, and Telehealth coordination and administration. Highlights Major Wolf EMR software upgrade completed. Major Financial/HR software upgrade and virtualization of system complete. Major upgrade to Hospital software system (Medipatient). 50% of PC’s migrated to Windows 7. Virtualization project at 75% complete. Participation with EMR Territorial working groups Replaced Network Security servers and upgraded to latest standards. Implemented Employee Self Service for Payroll. Completed a 5 yr Authority specific IT Strategic plan. Increased Telehealth usage by 15% Goals Achieved Maximize network IT systems availability - Average of 99.6% uptime for major systems Maximize the telephone system availability – no major issues affected system availability. Performance Indicators. Server Thefileserver admin-server lab-server System Availablity 99.9935% 99.6491% 0% Medisolutionserver 99.9539% Ormedmisserver 99.1147% VMSVLab1 100% winrecserver 99.0739% SVWolfTS 99.9995% HRHSSA 2012/2013 Annual Report Systems Stats since July 1, 2012 to May 14, 2013 Mean Time Total Total between Downtime Reboots Reboots Notes Primary file and Sharepoint 0d 0h:30m:0s 5 63.68 days server Risk Pro, Antivirus, IT Helpdesk 1d 15 21.23 days (Preparing to decommission in 6 2h:48m:47s months) Hosts the GE Lab Information 0d 0h:0m:0s 0 0 days system Database (Decommissioned) Hosts the 0d 10 31.84 days Medipatient/Medipharm 3h:31m:11s systems Hosts the Finance file shares. 2d 15 21.29 days (Server decommissioning within 19h:51m:45s 6 months) Hosts the Glucometer 0d 0h:0m:0s 0 NA days software/DB (new virtual server started in April 2013) Hosts the Medical Records 2d 2 159.20 days reporting software (converted 22h:45m:55s to a Virtual system) Wolf EMR Server. Auto na na 1 day rebooted every day at 5:15 am. Page 26 HAY RIVER HEALTH AND SOCIAL SERVICES AUTHORITY Laboratory The 24 hour Laboratory Services include: specimen collections, referral and analysis of specimens collected as well as receipt and analysis of offsite collections. The Laboratory ensures the quality of results that are delivered efficiently to the practitioners. The Laboratory staff liaises with practitioners to ensure the best client care. Highlights Ruby analyzer validation completed – analyzer now in use New occult blood slides (FIT) ordered and will be put in use Work begins on “beefing up” the Quality Management System. In house Client Satisfaction Survey completed Goals Achieved Accreditation achieved Performance Indicators Source Referred in for testing in lab: YMCE 392 Woodland Manor 28 Fort Providence 13 Specialist Clinic 31 Fort Smith Clinic 3 Hay River Clinic 21203 Hospital - Inpatient 10539 Public Health 140 Hay River 533 Renal Dialysis 1388 Fort Resolution 2993 Frame Lake 1 YMCL 518 YMHC 35 YPCC 3 37820 HRHSSA 2012/2013 Annual Report YMCE Woodland Manor Fort Providence Specialist Clinic Fort Smith Clinic Hay River Clinic Hospital - Inpatient Public Health Hay River Renal Dialysis Page 27 HAY RIVER HEALTH AND SOCIAL SERVICES AUTHORITY Long Term Care Services We provide Long Term Care (LTC) services to 15 residents at Woodland Manor (WLM) and 10 residents on the Long Term Care Unit at the HH Williams Memorial Hospital. 24 hour professional nursing care is provided, as well as medical, rehabilitation, dietary, recreation, pharmacy, pastoral care, housekeeping and laundry services. The residents in our care range in age from 46 to 94 years of age. The age criteria for LTC admission is 60 in the NWT but where other suitable services are not available the age criteria may be accommodated. We also offer day programming for four hours a day for up to three clients. Highlights The Resident Care Coordinator (RCC) position that was responsible for Long Term Care (LTC) and Supportive Living Services was restructured. A RCC position for LTC was created to provide services exclusively for LTC. Polypharmacy review project was completed for all LTC residents. Full occupancy was maintained throughout the year, as beds became vacant those were filled immediately with clients on the Territorial Admissions Committee wait list. 10 LPNs successfully completed an Intravenous Therapy Course through Norquest College. The Tub Room in the Long Term Care Hospital Unit was redecorated to create a home like atmosphere. The Recreation services were expanded with the addition of 0.5 FTE, Activity Coordinator position. Smoke free initiative implemented, closure of WLM smoke room and designated smoke area for WLM was created. Electronic Care Plans were developed for the residents. Brad Mapes continues to work in collaboration with the “Friends of WLM” on the gardens and grounds at WLM. Three staff attended the Supportive Pathways Train the Trainer program and have started providing training to staff throughout the organization. Bi-weekly Chaplain visits on site commenced October 2012 Goals Achieved Wound Management training started to create a LTC wound champion Two LPN completed a Palliative Care certificate program and they have started rolling out inservices related to palliative care to front line staff 33% of LTC staff trained in Non Violent Crisis Intervention, decrease in incidents and no incidents with injury over the past fiscal year Continuing Care Standards still in draft form with the DHSS, policy review for HRHSSA LTC Department Performance Indicators Resident and Family Survey completed in 2012 with overall positive results. Quality improvement initiatives started on those areas identified as needing improvement. Polypharmacy and inappropriate mediation use is a problem in the elderly population. The elderly are more likely to experience adverse effects from multiple treatments and less likely to obtain the same therapeutic benefit as the younger population. A polypharmacy review of 24 residents was completed and the results are indicated in the chart below. Any new admission to LTC will have a polypharmacy review completed and quarterly orders reviews will continue for all residents. HRHSSA 2012/2013 Annual Report Page 28 HAY RIVER HEALTH AND SOCIAL SERVICES AUTHORITY Long Term Care Services (con’t) PolyPharmacy Review Results Number of Medications 60 50 40 30 20 10 0 Medications discontinued Medications changes Medications restarted Polypharmacy Outcomes HRHSSA 2012/2013 Annual Report Page 29 HAY RIVER HEALTH AND SOCIAL SERVICES AUTHORITY Mammography The Mammography department provides Breast Screening Services to the women, 40 and over. The program was expanded in June 2010 to include the women outside the Hay River catchment area, but within the South Great Slave Lake area. The digital mammography images are reported by offsite radiologists either at the RCA radiology group in Calgary or at Stanton Territorial Hospital. Highlights The procurement of several locums to facilitate the growing needs of the program Implementation of General mail outs with program information and Breast Health information in English and French Release of Teen Breast Health pamphlet that Public Health has been using Goals Achieved Obtained Territorial funding for 2013-14 fiscal year through effectiveness Obtained Mammography Accreditation through Canadian Association of Radiologists Completion of Client Satisfaction Survey Performance Indicators FIVE YEAR STATISTICAL DATA Exam Units Completed 08/09 09/10 10/11 11/12 12/13 Examinations Completed 47 382 644 569 522 Patient Education 1305 5370 8730 7170 7830 Exam Units 7100 25950 45019 44705 46640 The numbers calculated above are based on the Workload Measurement System Manual for Diagnostic Imaging Services and confirmed with the Breast Screening Program in Yellowknife prior to use. HRHSSA 2012/2013 Annual Report Page 30 HAY RIVER HEALTH AND SOCIAL SERVICES AUTHORITY Materials Management The Materiel Management Department provides supply chain management services to management and staff of the Authority. Services include: sourcing, purchasing, shipping and receiving, travel and accommodation arrangements, inventory management, contract management, assets management and many other related services. Highlights During the 2012-13 fiscal year, the Finance and Materiel Management departments successfully completed an Environmental Scan of their operations, both separately and together. From the Strengths, Weaknesses, Opportunities and Treats (SWOT) analysis, three priorities were identified to improve the delivery of services to other departments. The three priorities identified were 1. Improve the lines of communication between staff and departments 2. Enhance services to departments 3. Create and maintain policies and procedures while expanding appropriate educational opportunities. The HRHSSA financial chart of accounts has been updated to be Canadian Institute for Health Information (CIHI) compliant. The Financial Services and Materiel Management staffs have been trained in the updated CIHI Management Information Systems (MIS). Staff working in Accounts Receivable (AR) completed ICORE training which allowed them to learn and master many key functions including how to submit shadow billing, reading, and understand medical terminology, mastering billing codes, and how to properly correct errors. The training also allowed for a more formal schedule to be introduced for shadow billing and as such is now completed on a weekly basis. In addition to AR staff learning new skills, cross training has been ongoing and will continue in order to ensure that in the event of a staff shortage there is always one staff member with appropriate training on the AR desk. Goals Implementation of priorities from the Environmental Scan. Baseline mapping of all processes in Finance and Materiel Management. Updating Policies and Procedures (Ex: Establish a policy for the timing of AP Payments and cut off deadlines) Follow through with: o Training initiatives both within the Finance and Materiel Management department and to other HRHSSA departments (ie: training other departments on Finance and MM procedures and policies and how they affect those departments). o Creating up to date procedures manuals that are user friendly and provide complete instructions and other necessary information that will allow staff with limited experience and knowledge to perform all tasks properly (ex: casual staff). Introduction of Lean and Quality Management Initiatives to improve services and to reduce nonvalue activities. Initiation of processes to retain and maintain corporate knowledge Work to ensure that GNWT and Year End Audit reporting is completed on a more regular basis in order to lessen stress and time crunch at year end. Including reconciliations, physician reporting, forced growth reporting. Update the asset inventory and develop processes to systematically maintain and control inventory. Create an updated specimen signature record and in collaboration with the GNWT, HRHSSA Human Resources Department and Information Technology Department develop processes for HRHSSA 2012/2013 Annual Report Page 31 HAY RIVER HEALTH AND SOCIAL SERVICES AUTHORITY signing authority records and delegation, its implementation in Ormed and application in daily operations. Continue cross training within the Finance and Materiel Management departments to ensure that all staff is knowledgeable in all positions if extra coverage is needed. Extra training in Accounts Receivable’s Trust Accounting and collections of outstanding invoices should be a priority. HRHSSA 2012/2013 Annual Report Page 32 HAY RIVER HEALTH AND SOCIAL SERVICES AUTHORITY Medical Records Processing, Coding & Abstracting of inpatient \outpatient records Transcribing dictations for in house physicians and visiting Specialist Processing the release of information to Lawyers, RCMP, Insurance Claims and other Institution where the patient is receiving care. Deals with the compilation of all reports and information generated in the health care of the client Highlights Department was moved from IT to Quality Improvement and Risk Management portfolio in September 2012 Practicum Student finish 2nd year Goals Achieved! All deadlines were met, CIHI, ROI and Training etc. Performance Indicators Release of Information Performance Indicator Total # of Releases Processed Total # of Releases Processed ≤ 14 days First Second Third Fourth Quarter Quarter Quarter Quarter 94 109 99 116 75 69 76 61 Total 418 281 1000 100 75 94 109 69 76 116 99 61 14 days Release 10 1 1st Quarter 2nd Quarter 3rd Quarter 4th Quarter Medical Records strives to ensure all clients receive quality care in a timely manner. Even though Medical Records Release of Information are allowed 45 days to process all information requests, staff attempt to complete the request sooner. The measures above indicate how many requests are completed equal to and under 14 days after the completed request has been received in the Medical Records Department. HRHSSA 2012/2013 Annual Report Page 33 HAY RIVER HEALTH AND SOCIAL SERVICES AUTHORITY Nurse Educator Mentor The position of Nurse Educator Mentor is responsible for the Grad Placement Mentorship Program, CPR & ACLS education for staff, student placement preceptorship, nursing staff in-servicing, nursing staff orientation and professional development initiatives application assistance/mentoring for the nursing staff. Highlights ACLS November 2012: 9 Registered Nurses and 1 Locum Nurse Practitioner completed certification. Goals Achieved Goal: Maintained current BLS certification for all staff Goal: One Grad Placement Nurse accepted permanent position on Acute Care Unit Performance Indicators Number of grad placements/Aurora graduates per year Number of applicants that accept full time positions at HRHSSA Number of staff certified in BLS Number of RN’s certified in ACLS RNs & LPNs Trained in ACLS & BLS 60 40 20 0 RNs on ACU RNs RNs LPNs on LPNs Total Trained in Trained in ECU Trained in Trained in ACLS BLS BLS BLS Number of Grad Placements Hired 5 4 3 2 1 0 Grad Placements in Last 5 Yrs HRHSSA 2012/2013 Annual Report Grad Placements Still Employed at HRHSSA Page 34 HAY RIVER HEALTH AND SOCIAL SERVICES AUTHORITY Pharmacy The Pharmacy Department is responsible to implement and maintain policies and procedures that meet the national standards for medication management within HRHSSA as set out by Accreditation Canada; to ensure that there is an adequate supply of all medications available within HRHSSA and to monitor these medications for safety, expiry date and proper use; and to provide pharmaceutical clinical support to all areas of HRHSSA that will help insure enhanced client care and safety as an integral part of our health care team. Highlights Successfully met the Medication Management Standards for the April 2012 Accreditation Survey including meeting the appropriate Required Operational Practices. Planning the process and purchasing the necessary equipment to implement a unit dose medication delivery system for acute care in order to comply with accreditation standards and to enhance the safe and up to date dispensing of medications. Working with acute care, homecare and retail pharmacy for patient medication discharge planning which involves providing medication counseling and insuring that the patient receives the correct prescriptions in a timely manner upon discharge from acute care. This has led to improved safe medication use and compliance from our clients. Pharmacist continues to provide locum coverage to Stanton Hospital Pharmacy which benefits a positive and useful relationship between our two authorities. Goals Achieved Goal: Medication Management Standards met for Accreditation Survey April 2012 Goal: VTE prophylaxis implemented on acute care and pharmacist audits for compliance Goal: Pharmacist actively involved in med reconciliation and patient discharge process Goal: Successfully completed the fiscal year approximately $33,000.00under budget Performance Indicators Dangerous Abbreviation ROP audits Medication Reconciliation ROP audits HRHSSA 2012/2013 Annual Report Page 35 HAY RIVER HEALTH AND SOCIAL SERVICES AUTHORITY # of Dangerous Abbreviations Used January 2012 18 April 2013 16 14 12 20 Charts are audited, comprised of both inpatients and recently discharged 10 8 6 4 2 0 Dangerous Abbreviations ------------------------------------------------------------------------------------------------------------------------------------------ January 2012 April 2013 # of Charts Completed 20 15 10 5 0 Areas of the Medication Reconcilliation Form Audited HRHSSA 2012/2013 Annual Report Page 36 HAY RIVER HEALTH AND SOCIAL SERVICES AUTHORITY Quality Improvement and Risk Management This department is responsible for the overall planning, development and facilitating of an integrated quality management program for HRHSSA including integrating risk management, accreditation, complaint management, interdisciplinary program standards, organization wide quality improvement initiatives, and the measurement evaluation and assessment of quality initiatives. The Manager of Quality Improvement and Risk Management and Quality Improvement Coordinator is responsible for ensuring the goals of the Risk Management Programs and Quality Improvement Framework are coordinated to support the mission, vision, values, and strategic priorities of the organization. Highlights Met with departments to discuss: role of Quality & Risk Management in the organization, Risk Management Plan, Quality Improvement Framework, Quality & Risk Management Committee, Ethics Committee, and importance of Emergency Preparedness; Collected information to understand how departments are monitoring their goals and what information they are responsible to report Territorially; with the goal to assist each department in developing meaning indicators for information based thinking; Worked through the paper process at the Medical Clinic, performed a GAP analysis and will be prioritizing initiatives for ongoing quality improvement of this process. Champion of accreditation process for HRHSSA: Coordinated on-site accreditation survey team; Coordinated efforts to obtain highest award from Accreditation Canada – Accreditation with Exemplary Standing; Member of the Electronic Medical Records (EMR) Project: Information Management (IM) and Privacy Working Group; Department grew from 1 to 2 employees and now manages Medical Records; Coordinated on-site Ethics Training with Dr. Robert Butcher, Ethicist; Department participated in LEAN Workshop in Yellowknife; Manager is member of the NWT Patient Safety Project; Manager became a surveyor with Accreditation Canada; Goals Achieved Ongoing promotion of HRHSSA having a culture of continuous quality improvement; Continue to develop meaningful indicators for every department; Continue to develop an encompassing risk management document for the organization. HRHSSA 2012/2013 Annual Report Page 37 HAY RIVER HEALTH AND SOCIAL SERVICES AUTHORITY Quality Improvement and Risk Management (con’t) Falls by Fiscal Year 2009-10 2010-11 50 45 40 35 30 25 20 15 10 5 0 2011-12 2012-13 When falls are reported, staff are asked to indicate how the client fell or indicate what they were doing at the time just prior to the fall. Majority of clients are either: 1. Unwitnessed - are found on the floor and the actual fall is not seen by anyone 2. While ambulating - this includes ambulating with / without assistance regardless of what direction the client has been given 3. From a Wheel Chair / Chair The Falls Prevention Injury Reduction Program aims to reduce the number of falls and severity of injury of a fall. The numbers indicate that our number of falls have increased over the past four years. Variances to this include: better reporting by staff via online incident reporting system, increase in programming (addition of Supportive Living Services), increase in number of ambulatory clients into care (respite or long term care) who are requiring nursing care, clients maintaining ambulatory status longer with activity and rehabilitation programming. HRHSSA continues to work towards keeping clients safe while receiving services for care. with ongoing programming evaluation and quality improvement strategies. HRHSSA 2012/2013 Annual Report Page 38 HAY RIVER HEALTH AND SOCIAL SERVICES AUTHORITY Rehabilitation Services The HRHSSA Rehabilitation Department provides Occupational Therapy, Physiotherapy and Speech Language Pathology to all ages in the Hay River area. In addition, PT and OT services are provided to the community of Fort Resolution. Occupational Therapy: Two full time Occupational Therapists work in the Authority. Occupational Therapists work with people of any age to promote health, prevent disability, and develop or maintain abilities. Occupation refers to the activities and tasks of daily life that have value and meaning to a person. Occupations can include self-care (i.e. personal care, mobility), leisure (i.e. social activities, sports) and productivity (play, school, employment, home making). Physiotherapy: There are currently two full time physiotherapists employed with the HRHSSA. Physiotherapists help to manage and prevent a number of physical problems that may have been caused by illness, disease, sport or work related injury, aging and long periods of inactivity. Physiotherapists are skilled in the assessment and management of conditions that affect musculoskeletal, circulatory, respiratory and nervous systems. Speech and Language Pathology: A Speech Language Pathologist is a communication specialist who is trained to prevent, diagnose, and treat speech, language, voice, fluency, and swallowing disorders. An SLP provides assessment, treatment, and consultation for children and adults, for the following areas of communication: receptive and expressive language, articulation, apraxia (motor programming), dysarthria (motor speech), stuttering, voice, and swallowing, augmentative and alternative communication. The SLP position has been vacant since July 2011. Attempts to recruit a new SLP have been unsuccessful to date and contract SLP services are currently being provided. Highlights 1. OT’s and dietitians now certified practitioners in swallowing and feeding assessments of adults. 2. Aquatic Rehabilitation Program commenced; A partnership with the Town of Hay River 3. Memorandum of Understanding pending with the SSDEC/DEA to create a dedicat4d space for paediatric rehabilitation services at Harry Camsell School. 4. Self-referral pilot project for Physiotherapy being researched to provide smoother access to services. Performance Indicators A total of 730 individuals were referred for service in 2012-13. All referrals to Rehabilitation are prioritized according to specific criteria as determined by a priory tool. Priority level 1 is acute care inpatients, palliative clients and those with urgent safety concerns. Priority 2 clients represent urgent orthopaedic conditions and children under the age of five. Priority 3 clients are those with recent injuries, who are off of work or require pre-operative intervention. Priority 4 and 5 are those individuals with chronic conditions. HRHSSA 2012/2013 Annual Report Page 39 HAY RIVER HEALTH AND SOCIAL SERVICES AUTHORITY Occupational Therapy 160 140 120 100 80 60 40 20 0 Priority 1 Priority 2 Pirority 3 Pirority 4 & 5 A total of 304 individuals were referred to Occupational Therapy in 2012-13. The large percentage of priority 1 and 2 clients reflects the large number of urgent safety assessments, discharge planning, swallowing and feeding assessments and the large paediatric caseload. Physiotherapy 140 120 100 80 60 40 20 0 Priority 1 Priority 2 Priority 3 Priority 4 & 5 A total of 409 individuals were referred to physiotherapy. Priority 1 clients reflect referrals from Acute Care of HH Williams Memorial Hospital. Priority 3 and 4 clients largely recommend musculoskeletal conditions of acute and chronic nature. HRHSSA 2012/2013 Annual Report Page 40 HAY RIVER HEALTH AND SOCIAL SERVICES AUTHORITY Speech Language Pathology 9 8 7 6 5 4 3 2 1 0 Priority 1 Priority 2 Priority 3 Priority 4 There were seventeen new referrals to Speech and Language Pathology in 2012-13. SLP services were delivered by a private practitioner and a part-time paediatric rehab aide. There were four site SLP visits in 2012-13. There were 134 attendances in total for the site visits and 229 Telehealth sessions. HRHSSA 2012/2013 Annual Report Page 41 HAY RIVER HEALTH AND SOCIAL SERVICES AUTHORITY Social Services Child and Family Services operate in accordance with its Northwest Territories policy and procedures, the Child and Family Services and Adoption Acts. The child, youth, and adult services provided by Social Services include child protection, adoption, foster care, family enhancement, indigent income assistance, notarizing and commissioning of documents and adoption services. Highlights Ongoing work to maintain, support and increase the capacity of foster care in Hay River and area. The four social workers currently have their Adoption Appointments. A local 4th year BSW student from the University of Manitoba began her final practicum (420 hrs) on January 7, 2013. She is expected to complete her hours in June 2013. The HRHSSA continues to have representation on the Out of Territory Treatment Committee. The committee meets monthly to review all southern treatment applicants for children, youth, adults and families who reside in the Northwest Territories. The clinical Supervisor position was filled on March 28, 2013. Goals Achieved Goal: Goal: Foster Home reviews were completed in September 2012 HRHSSA continues to promote the approval of provisional/extended family foster homes that provide a familiar, safe, caring, and supportive environment to foster children. It is significant in that children who are place in care remain closely connected with family. These homes may share common cultural values and traditions. Summary of Foster Home Placements Aboriginal placements Non-aboriginal placements Need Ethnicity Total active placements Extended Family Regular Foster Home Provisional Care Room & Board 33 12 1 46 72% 26% 2% Aboriginal % Aboriginal NonAboriginal % NonAboriginal Require Ethnicity % Require Ethnicity 6 6 100% 0 0% 0 0% 23 12 52% 10 43% 1 4% 13 13 100% 0 0% 0 0% 4 2 50% 2 50% 0 0% Summary of Adult Intakes Adult Intake HRHSSA 2012/2013 Annual Report 144 Page 42 HAY RIVER HEALTH AND SOCIAL SERVICES AUTHORITY Supply, Processing and Distribution Highlights Completion of new Endoscopy Processing Clean & Dirty Rooms, as per Accreditation Canada Standards Installation of 1 additional Endoscopy Sterilizer Goals Achieved Goal: More efficient sterilization of the scope equipment, allowing for an increase in client capacity for the endoscopy program Performance Indicators Cleaning equipment in sufficient amount of time for the physicians Having adequate stock and supplies Zero complaints from the staff and physicians on duty WASHER LOADS STERILIZER LOADS COLONOSCOPY EQUIPMENT GASTROSCOPY EQUIPMENT DENTAL EQUIPMENT HRHSSA 2012/2013 Annual Report 2012/13 2011/12 2010/11 2009/10 982 708 773 695 742 452 576 495 53 89 98 58 23 28 19 14 170 232 142 134 Page 43 HAY RIVER HEALTH AND SOCIAL SERVICES AUTHORITY Support Services Our purpose is to support and enhance the quality of care by providing healthy nutritious food in a safe, clean and comfortable environment. Highlights Food Services again catered to the Long Service and Staff Appreciation Tea held in the Cafeteria on December 7, 2012 The Laundry Department contract with Fort Smith ended February 8th, 2013 Housekeeping has continued to maintain our facilities at a high standard Goals Achieved Food Services completed two Satisfaction Surveys for each of the following areas – staff, resident ECU and Resident WLM Food Service – menu and production schedule revised and in place Laundry – laundered 156,555 lbs of linen Housekeeping – All areas of Hospital maintained to a high degree 1.2 extra FTE hired for Woodland Manor Performance Indicators Statistics are kept for all departments including cost per meal for Food Services, pounds of laundry per day and per month and extra workload stats for Housekeeping Food Services Cost Per Meal Patient Meals Non Patient Total Meals Total Expen ses Total Cost Per Meal April May June July Aug Sept Oct Nov Dec Jan Feb March 2713 3170 2840 2644 2763 2440 2543 2557 2392 2413 2297 2314 1173 1533 1306 1247 1201 1100 1409 1494 1199 1750 1346 1382 3886 4703 4146 3891 3964 3540 3951 4051 3591 4163 3643 3696 78448 93902 93590 88326 91987 92842 68022 97108 97108 95618 88917 109898 20.19 19.96 22.57 22.69 23.20 26.22 17.21 27.03 27.03 22.96 24.40 29.72 The average cost per meal for the fiscal year is $22.79 HRHSSA 2012/2013 Annual Report Page 44 HAY RIVER HEALTH AND SOCIAL SERVICES AUTHORITY Support Services (con’t) Laundry Workload Statistics Regular Client WLM Rinsing Fort Smith Total Work days Lbs/day Apr May Jun July Aug Sept Oct Nov Dec Jan Feb Mar 7950 450 810 1250 3940 1440 0 20 720 8655 535 940 1035 4330 1549 5 22 705 7220 495 835 1270 4180 1400 0 20 700 7005 460 840 925 4165 1339 5 21 638 6735 520 1005 955 4910 1412 5 22 642 6410 395 770 990 3935 1250 0 19 658 8065 550 1080 935 4760 1539 0 22 700 6930 485 860 950 4495 1372 0 21 653 7050 370 1080 1050 3975 1352 5 19 712 6850 500 950 1205 4715 1422 0 22 647 5625 410 720 575 1090 6010 380 770 205 0 8420 7365 20 421 20 369 Total Regular Client WLM Rinsing Fort Smith Total Work days Lbs/day 84505 5550 10660 11345 44495 156555 248 632 The average amount of laundry done each workday in FY 12/13 was 632 pounds. HRHSSA 2012/2013 Annual Report Page 45 HAY RIVER HEALTH AND SOCIAL SERVICES AUTHORITY Supportive Living Services Residential care services are provided to improve the quality of life for people with intellectual disabilities through dignity, support, community inclusion, participation and choice. There are 10 permanent residents and two respite beds at the Supportive Living Campus. Minimum age for admission is 19 years. Highlights The Campus remained at full capacity during the year with bed vacancies filled immediately by the Territorial Admissions Committee. Respite for the 2012/13 fiscal year was the most the respite beds have been utilized since the Campus opened at 377 bed days. A policy committee was formed to conduct a policy review. To date, 30 policies have been developed. Resident Care Coordinator (RCC) position that was responsible for Long Term Care and Supportive Living Services (SLS) was restructured. A RCC position for SLS was created to provide services focusing solely on Supportive Living Services. A Resident Care Aide position was created to support both the SLS and LTC programs. The RCC, Day Program Facilitator and Behavior Management Counselor commenced on-call rotations in October to provide 24-hour case management support to Personal Outcome Support Workers. Electronic Care Plans were developed for the residents. All the common areas in each of the houses were painted by the SLS staff with the resident’s assistance. The staff collaborated with residents to pick colours. Bathroom renovations to House 1 and 2 were completed to create a barrier free environment. The Smoke-free initiative was implemented in November. A designated smoking area was created on site for residents. A Christmas bake sale was held in December which raised $1100.00 for residents’ activities. Multidisciplinary team approach was established for resident conferences and care planning. SLS trainers provide CPR training to all non Registered Nurse HRHSSA staff. Two resident day trips to High Level in the summer months which were thoroughly enjoyed by residents and staff. Linkages with Council for Disabilities were established with positive results noted. Goals Achieved Barrier free bathroom House 1 and 2 Multidisciplinary service delivery Policy review, development and implementation Staff confidence in addressing unusual situations and behaviours resulting in decrease call to staff on call Performance Indicator Resident and family satisfaction survey were completed in 2012 with overall positive results. Areas identified as needing improvement from residents were discussed at Resident Council meetings and individually with residents to initiate quality improvement initiatives. HRHSSA 2012/2013 Annual Report Page 46 HAY RIVER HEALTH AND SOCIAL SERVICES AUTHORITY Supportive Living Services (con’t) Staff training 30 25 20 15 Total SLS staff requiring training Total with current certifications 10 5 0 CPR NVCI First Aide ASIST Food Handling Key: NVCI-Non Violent Crisis Intervention ASIST- Applied Suicide Intervention Skills Training CPR- Cardiopulmonary resuscitation HRHSSA 2012/2013 Annual Report Page 47 HAY RIVER HEALTH AND SOCIAL SERVICES AUTHORITY Ultrasound Services Ultrasound services include the provision of quality sonographic images provided from 0800 to 1600 hours Monday to Friday. Images are reviewed and reported by offsite Radiologists at the RCA radiology group in Calgary. The Ultrasound staff liaises with the physicians to provide the best client care possible. Highlights Akram Bishara was hired to fill the technologist position that had been absent due to injury for almost 2 years GUS sterilization containment unit installed in ultrasound as per accreditation requirements Goals Achieved Ultrasound staff continuing education updated to required national standards Dr. Donald Beach made onsite visit New probe cleaning procedure implemented with installation of GUS Performance Indicators Wait time for Ultrasound Appointments excluding emergency referrals March 1 to March 31, 2013 # of appointments 35 30 Fast Facts: 25 64 total appointments 1.23 days - Avg. wait time 45.3% of appointments - no wait 20 15 10 5 0 0 1 2 3 4 5+ # of days waiting Due to unscheduled staffing change, data was not collected from March 18th to March 25th. HRHSSA 2012/2013 Annual Report Page 48