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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
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HAY RIVER HEALTH AND SOCIAL SERVICES AUTHORITY
STRATEGIC DIRECTION
Strategic Priorities
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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
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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
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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
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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
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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
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Nosocomial monthly Infection tracking
Work loading stats
Infection Control Environmental Audits
CTAS Audit
Endoscopy satisfaction surveys
Discharge Status
HRHSSA 2012/2013 Annual Report
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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