Surgical Safety Checklist (SSCL)
CMH Board Report From CMH President & CEO
May 2015
This report provides a brief update on some key activities within CMH as an FYI to the Board. While it is organized against our four 2014-17 strategic themes, it may include strategic, corporate and other projects as necessary. As always, happy to answer questions and discuss issues within this report or other matters.
WIG UPDATES
Exceptional Experience for All: New advisors recruited ? In April, we recruited three new members to the Patient and Family Advisory Council (PFAC): Jen Hazell, Tom Barker and Cathy Shangas. ? Jen Hazell's journey through the healthcare system began in May 2011 with an unexpected diagnosis that eventually weaved itself and led to CMH's PFAC. In Jen's words: "Being a part of the PFAC allows me to do something that I am very passionate about, which is using my experiences to help make a difference in the lives of other patients and their families." ? Tom Barker is joining because he wants to advocate for the patient and champion the great things that are done at this hospital. He also wants to be part of discussions to help grow and improve our hospital as our community and region changes. His interests include patient/staff relations, community health needs, mental health issues and patient involvement in their own treatment. Tom is an elementary school teacher, a social media enthusiast and volunteers with a number of organizations. ? Cathy Shangas' motivation for becoming a Patient and Family Advisor stems from her strong interest in how we support our aging population. Specifically, she is interested in how elderly people can stay healthy and would like to support families to become more involved in the care of their loved ones. Cathy cares about patient safety and would like the opportunity to help make positive changes within our organization. She works in the construction industry, responsible for day-to-day operations and sits on a number of committees at her work.
Exception Experience for All ? Free Wi-Fi in the Emergency Department
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? As a way to enhance the overall patient experience, free Wi-Fi was made available for patients and family member waiting in the Emergency Department.
? The Wi-Fi service is available in both the new Emergency Triage & Registration and Emergency Department areas.
? The suggestion to provide free Wi-Fi was made by many as part of our 1780 Ideas campaign in 2014-15. It was also a recommendation made by our newly formed Patient and Family Advisory Council.
Defining Our Role
Clinical Services Plan ? A workshop with the MAC and senior leadership is planned for June 10 to discuss the work done by the consultants related to the draft clinical services plan.
Improving Quality
HELP celebrates three successful years ? Over three short years, the Hospital Elder Life Program (HELP) has taken leaps and bounds, expanding from a modest program of 15 dedicated volunteers covering one unit to 33 and three units! ? Developed by the Yale School of Medicine, HELP is a unique program that helps prevent delirium and loss of function in our elderly patients. ? Under supervision of CMH staff, specially trained volunteers provide non-clinical interventions to help our elderly patients maintain orientation and prevent cognitive decline. ? Below are some of the statistics of the HELP program since implementation.
# of
# of Patients # of Patients # of Volunteer # of Volunteers &
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Year
Launch January 2012 to March 2012 Year 1 April 1, 2012 to March 31, 2013
Volunteer Hours
371 hours
2,672 hours
Screened 52 341
Year 2
April 1, 2013 to
March 31, 2014 4,019 hours
494
Year 3
April 1, 2014 to
March 31, 2015 3,625 hours
630
Enrolled 23 156
235
269
HELP Interventions
Areas Served
15 volunteers
904
? 5B Medicine
5,618 12,311 12,860
Average # of volunteers: 28 ? 5B Medicine ? 3BN-Roll Out
March 2013
Average # of volunteers: 34 ? 5B ? 3B ? 4B-Roll Out
Nov. 2013
Average # of volunteers: 33 ? 5B-Medicine ? 3B-Medicine ? 4B-Surgery
CMH celebrates World Hand Hygiene Day; posts Hand Hygiene rates ? CMH celebrated World Hand Hygiene Day with some fun, coffee and cookies. ? On Tuesday May 5, friendly members of the Infection Prevention and Control team and management dropped by different departments to play Hand Hygiene Jeopardy and raise awareness of this important safety practice. ? Hand hygiene is a priority for the hospital. On April 30, we posted our inpatient 2014-15 hand hygiene rates which dipped slightly when compared to the year prior. For Moment #1 (2013-14 rates) we had 88.96% compliance (90.10%) and we recorded a 92.96% compliance for Moment #4 (93.21%). ? For the 2015-16 Quality Improvement Plan, improving hand hygiene compliance is part of an overall strategy to reduce C. difficile healthcare acquired infections. Some initiatives include hiring a full time Hand Hygiene auditor and to increase access to education to both volunteers and staff working in patient care areas.
Strength through People
Karen Cziraki assumes role of Interim CNE
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? On May 20 we announced that Karen Cziraki would provide leadership as Chief Nursing Executive (CNE) on an interim basis as we recruit for the VP/CNE position. The CNE role is an important one, both internally and within the region. Over the next few months, her priority will be the implementation of the Interprofessional Model of Care of which she is also the executive sponsor. Working closely with Sue Robertson, the project's lead, she will provide oversight to the project and apprise both the Board of Directors and executive leadership of its progress.
? Karen continues as our Professional Practice Specialist and can be reached Tuesday through Friday in the Administration offices.
? I am also grateful and wish to thank Rita Sharratt for taking on this role this past month. Without her unreserved willingness to step in and do this important work, we would not have had the opportunity to assess and address our organizational needs.
Interprofessional Model of Care update ? Sue Robertson has rejoined CMH on a contract basis to help implement the Interprofessional Model of Care (MOC) that will roll out in August. ? You may recall Sue as our interim VP of Clinical Programs and Chief Nursing Executive when she covered the leadership gap after Susan Gregoroff's retirement last spring ? Sue is already integrated in her role and has just concluded stakeholder interviews and the planning phase of the project. ? A Project Team has been established to lead the implementation of the MOC. This team will work through the key components of the new model including recruitment and orientation of new staff members, role clarity, scope of practice and review of unit processes. ? The Project Team has made a commitment to provide frequent communication updates directly to units where the MOC is being implemented. General updates to other staff, physicians and volunteers will be done through the weekly e-cast newsletter. ? In April, we welcomed the first staff who will work in the role of Personal Support Worker (PSW) as part of the MOC. Five PSWs have been hired into part-time positions and are currently assigned to the float pool, providing support to patients requiring one-on-one and constant supervision. They have been very warmly welcomed by everyone. ? In August, the Interprofessional Model of Care will be implemented in Medicine, Inpatient Surgery and Rehab units. A phased approach to evaluating the model will take place at 3, 9 and 12 months after the MOC is implemented.
Nursing Week at CMH ? CMH celebrated its nurses during Nursing Week, May 11 ? 17. ? Planned activities included lunch and learns and education fairs. ? MPP Kathryn McGarry, a former CMH nurse, visited our hospital to shadow different nurses in different areas. She visited the new
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Emergency Triage and Registration areas, the Mental Health program and the COPD clinic. In all, MPP McGarry remarked how impressed she was with their work in these areas. ? The community also showed their gratitude and appreciation for our nurses. A Facebook campaign featuring two nurses a day during Nursing Week reached over 50 000 people, garnering many `likes' and kind posts added to CMH's page.
CMH volunteers honoured by the Province ? On Tuesday April 26, some of CMH's finest volunteers were honoured by the Province at the Ontario Volunteer Service Awards. ? Recipients included 10-year recipients Patricia Brunel, Bonnie Potentier, Grant Robertson and Henry Vanderloo; five year recipients Carol Henderson and Anne Pearson; and Youth recipients Rebecca Correia Nikhil Thomas, and Chelsea Vanoverbek. ? The guest speaker, Cathy Brothers, CEO of Capacity Canada, seemed to have tailored her remarks to our wonderful caring volunteers. It was as if she had experienced a "Grant Robertson" encounter. Grant is one of our very first Ambassador Volunteers who also helped develop the program. ? Cathy specifically referenced the impact a volunteer can make during a hospital visit with their warm welcome and reassuring approach. ? We applaud all our recipients and thank them for their continued years of service and caring at CMH!
Driving Value and Affordability
Emergency Department move goes smoothly ? April 15 ? It was a long and busy day, but the opening of the new Emergency Department (ED) Entrance on April 15 went as planned, with only a few minor hiccups along the way. ? ED staff went over and beyond to ensure the day went smoothly, even accommodating changes on the fly and helping to improve processes at hand. ? The Volunteers were fantastic and helpful in every way. The Lab put up and rolled with an unplanned process change half-way into the day. Maintenance and Information Management accommodated last-minute requests and produced results immediately. ? The Capital Redevelopment Project (CRP) team got the space ready in time, working on it until the very last minute. ? Everyone in the organization p to help support this move ? our first major step into the CRP journey!
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