Mission Assessment. A Leader s Guide for Measuring Mission Performance and Setting Annual Mission Targets

Transcription

1 Mission Assessment A Leader s Guide for Measuring Mission Performance and Setting Annual Mission Targets

2 Contents 4 Introduction 13 Mission Standards, Indicators, and Examples of Required Evidence 13 Standard 1: We can achieve the mission, now and into the future, with committed individuals who share our calling and embody the values of Covenant Health. 17 Standard 2: We can better serve those most in need by collaborating with others and supporting the conditions that will help people to flourish. 20 Standard 3: We are stewards of trust, serving the whole person in a safe environment with the highest quality care. 24 Standard 4: We align what we say is important with what we do, demonstrating our mission and values with every decision, behaviour, attitude and service we provide. 28 Appendix 1

3 Our Mission We are called to continue the healing ministry of Jesus by serving with compassion, upholding the sacredness of life in all stages, and caring for the whole person body, mind and soul. Our Vision Covenant Health will positively influence the health of Albertans and be of service to those in need by working together with compassion, quality and innovation. Our Values As a Catholic organization, we are committed to serving people of all faiths, cultures and circumstances, according to our values: Compassion Social Justice Respect Integrity Collaboration Stewardship Living our mission and values in all we do There are three non-negotiable commitments to which we are accountable in Catholic health care: ensuring the highest standards of quality care, wise stewardship of resources, and making sure the mission is in the forefront of all we do. These commitments are critical in preserving our identity and reputation as the largest Catholic health care provider in Canada. Ensuring mission fidelity is a must-do priority and leaders can use the Mission Assessment Tool to provide quantifiable evidence of how we demonstrate mission in our work and to consult with their teams to set annual mission targets. No matter how well our founders may have lived the mission, our challenge is what we are going to do to deepen the mission. The Mission Assessment tool, and this Leader s Guide, will help us realize our strategic direction to live the mission and values in all we do. Patrick Dumelie President and CEO 2 3

4 Introduction We are pleased to present the Mission Assessment Leader s Guide to support your work in completing the annual Mission Assessment, and in setting and monitoring mission targets throughout the year. This guide provides: Accountabilities, timelines, a reporting framework and facilitation steps for Mission Assessment A description of the four Mission Standards A suggested list of evidence and behaviours that demonstrate compliance to each of the 20 Mission Indicators While the assessment process will yield a quantifiable measure of how well your team lives the mission and values of Covenant Health, it can also serve as an educational experience and renewal opportunity. Through team discussion and honest inquiry, Mission Assessment can ignite your team s imagination of what yet is possible and what is necessary to continue the healing ministry of Jesus today. What is Mission Assessment? Mission Assessment is a facilitated process to evaluate how we are achieving, advancing and aligning current operations and decision-making with our mission. Through the use of a tailored scorecard developed by, and for Covenant Health leaders, Mission Assessment provides quantifiable benchmark data on how we live the mission as facilities, corporate services and as an organization. The Mission Assessment Tool will help you identify annual mission targets, including stretch and improvement goals to strengthen mission fidelity. The data collected will allow each Covenant Health site to measure their performance against four Mission Standards and 20 Indicators from year to year, and across sites and portfolios. We may also be able to compare our annual mission scores with other Catholic health care providers in Canada who employ similar sets of mission selfassessment questions. As the primary measure for determining our commitment to mission fidelity, an annual dashboard of indicators and performance based on the results of the Mission Assessment is reported to the Covenant Health Board of Directors and shared with each Community Board. The compiled data will help us understand areas of strength and opportunity, including trends in mission fidelity, and enable us to tell the story of Covenant Health s unique value-add to the health care system. Mission is more than what is written on corporate documents or neatly framed pictures hung on the wall. It is something we live and so we must look to everyday behaviours and practices to see our mission at work. 4 5

5 How does Mission Assessment fit with other reporting measures? The Mission Assessment Tool is designed to support and complement the Employee Engagement and Accreditation processes. Facility mission assessment scores provide useful comparative data with individual engagement scores on the importance of the mission to the employee, as well as how our values impact work-life culture, quality process improvements, and decision-making integrity. The tool is also aligned with our Strategic Plan to provide lineof-site between the mission, vision and organizational priorities. This will be further reinforced as you integrate your mission targets into your overall facility s strategic plan. How does Mission Assessment serve as an educational and engagement tool? The Health Ethics Guide recommends organizations complete a regular audit to ensure compliance with mission. Regular review and monitoring of performance signals the importance of mission, much as financial reporting and quality measures help drive excellence. But it is more than a mere compliance exercise. Mission Assessment creates a deeper sense of ownership with the mission when used to promote awareness, support, and goal setting. Some leaders may not automatically think their work contributes to the mission, especially if not directly involved in clinical activities. The robust list of indicators helps dispel that myth, reflecting just how pervasive the reach of mission is in the life and fabric of the organization. All department leaders should evaluate their team s work as indispensable to the mission of Covenant Health. We cannot fulfill our mission without the efforts of our entire team. Who leads the process? Executive Directors and Senior Operating Officers are accountable for completing the annual Mission Assessment at their Covenant Health site(s), and for setting and monitoring annual mission targets. Determining the self-assessment scores on each indicator requires the input of the leadership team for the entire facility/facilities since they are likely in the best position to accurately score facility performance against each of the 20 Indicators, and to present the supporting evidence. It is intended that the Mission Assessment process be completed through facilitated discussion, in order to reach consensus on the score that accurately reflects the current reality of the site(s). How do I facilitate Mission Assessment scoring and target setting? As a facility leader, you are asked to meet and discuss each Mission Standard and Indicator with your team. You should precirculate the scorecard to your leadership team, and invite reflection, even individual scoring, before gathering as a team to confirm a single facility score. The Mission Standards and Indicators remain consistent from year to year, creating familiarity around the specific area of focus to help teams build on past discussions and learning. Scoring should be based on candid conversations with your team, leading to consensus. While this is a facility score (or multi-site score in some cases) it is expected that leaders rank their performance based on continuous feedback learning from front-line staff, physicians and other stakeholders to ensure accurate reporting. It is assumed that the evidence provided to support each score can be validated and owned by the entire site personnel. 6 7

6 It is also important that the scoring is realistic, recognizing that unique circumstances from year to year at each site may cause some fluctuation in scores. This is expected. Finally, sites should use the process to celebrate mission accomplishment and reflect this in their scoring. This is important since it gives other Covenant Health sites the opportunity to consult and emulate practices of those who have achieved consistent, positive results in a specific area. Once completed, the assessment process will provide sites with: A quantifiable measure to highlight areas of opportunity and/or excellence A robust picture of how every department and service contributes to the mission A set of improvement and stretch goals to strengthen mission fidelity What are improvement and stretch goals? Review of mission performance will inevitably identify areas of improvement. While continuous improvement is always needed, so is the opportunity to build on success by stretching sites to take practices to the next level of performance. This is what is meant by a stretch goal, whereby a site also commits their energy to focus on its strengths, that can serve to inspire and support other sites that wish to advance in that particular area. The Mission Assessment process therefore requires each site to set two mission targets each year. One target is known as the Improvement Goal and the other as the Stretch Goal. They are defined as: Improvement Goal: An improvement goal reflects an area where mission performance is satisfactory, inconsistent or waning, requiring an investment of time and energy to achieve consistently positive results. This goal represents the classic quality improvement opportunity, knowing that at any one time, sites will be challenged in at least some areas to provide more consistent mission leadership. We never fully arrive in achieving the mission. The healing ministry of Jesus calls us to grow deeper and responsive to the needs of those we serve. Stretch Goal: A stretch goal builds on the success of an area where we are already demonstrating consistent leadership and that, with additional effort, can take our performance to the next level of excellence. This goal may be likened to the efforts of an Olympic athlete, who commits that additional effort to go from Bronze or Silver performance, already remarkable in itself, to reach Gold. In some cases, you may elect to continue to work on targets you set the year before if they remain a focus of performance improvement or advancement. In other cases, you will indicate new targets given the emerging needs and circumstances of your site and to keep in alignment with shifts in your facility s strategic plan. What do we do once we have completed the assessment? Once you complete the Mission Assessment, a member of the Mission, Ethics and Spirituality (MES) portfolio will visit your facility to review your scores, confirm meaningful and relevant mission targets, and discuss next steps. Some sites prefer to go through the scoring process themselves in advance of the MES site visit, only to confirm the scores at that later time, whereas other sites elect to have a member of MES team facilitate the conversation at the outset to help the team complete their scoring. Either process is acceptable. What is important is that the exercise is meaningful, yielding candid conversation and realistic scoring that will be owned by the entire team. 8 9

7 How can we compare our scores with other Covenant Health sites? Once facility scoring and targets have been confirmed, a Mission Assessment dashboard will be created using the data from each site. The dashboard will compare site performance against each of the 20 Indicators, and across programs and sites, providing leaders with values that outline the distribution of the scores. It will also include the site improvement and stretch targets. With each completed year, we will be able to see how well the organization is performing over time with mission fidelity. A copy of the dashboard will be provided to Executive Directors and Senior Operating Officers shortly after the site visits are completed. You are encouraged to share the dashboard with your team, and use it as an educational opportunity to showcase mission performance. The dashboard will be presented each Fall to the Covenant Health Board of Directors. Facility leaders are also encouraged to discuss the dashboard with their own Community Boards, and use the data to help build facility work plans. The dashboard will also be available on the Covenant Health intranet. Together, the facility self-assessment exercise, target setting, and the reporting and monitoring framework helps fulfill Covenant Health s strategic objective to strengthen the commitment to our mission, values and ethical framework (Strategic Objective 1.1). How often are we to use the tool? Leaders are expected to conduct the Mission Assessment between May and June each year. The MES site visit to confirm the scores must also be completed during this time. Facility leaders are strongly encouraged to schedule the selfassessment and MES site visit early to ensure compliance with our mission fidelity obligations to the Covenant Health Board. Site visits can be scheduled by calling How can I find out how other facilities ranked themselves? Information from all Covenant Health facilities will be compiled and presented via the Mission Assessment dashboard. This electronic report provides sites with a comprehensive set of data that also carries forward previous year s reporting to illustrate trends. The dashboard will: Reflect each site s response to the four Standards and 20 Indicators Provide summary information including overall scores summarized by site and program Detail the average, median and variance score against each indicator List each site s stretch and improvement goals in keeping with our value of Collaboration, sites can consult one another in support of meeting target goals. For example, an improvement goal for one site may be a stretch goal for another which can lead to leveraging of ideas between teams Include an overall Mission Assessment Score for the organization How do we validate scores and present the evidence? As with any self-assessment process there will be some degree of subjectivity in the scoring. But perceptions are ultimately based on lived experiences, and you and your team are expected to present the evidence that validates your perceptions, and to ensure it accurately reflects front-line opinion. The bi-annual Employee Engagement process and continuous review of Accreditation Standards will provide a useful comparative with facility Mission Assessment scoring

8 The facilitated site visit discussion by MES will serve to confirm scores by reviewing the evidence you and your team provide. Bringing in an external facilitator is an important step as experience has shown most sites tend to be overly critical of their performance and may underreport their scores. Or, key areas of mission excellence may be simply overlooked, especially if they are not clinically focused. Some sites tend to be harder on themselves in self-reporting than how their own staff would rank their fidelity to mission. Reviewing the mission assessment scoring from year to year may help leadership teams to better gauge staff perceptions as well. The quantifiable measures are important and support the facilitated discussion, which is invaluable in creating shared ownership and commitment to mission. Setting mission targets strengthens ownership, especially when the targets are aligned with the facility s strategic plan and monitored regularly. How do we need to monitor and report on our Mission Targets? Site leadership teams are expected to continuously monitor their Mission Assessment measures and targets, ideally in conjunction with continuous review of their facility strategic plan. Quarterly updates must be completed and integrated into the facility strategic plan update template. This achieves two things: it reduces the number of reports to be filled out and it helps reinforce that living the mission and values in all we do should be evident in the strategic priorities of the site. Who can I talk to about the Mission Assessment tool? If you have questions, comments or feedback on the Mission Assessment process, tool, dashboard, site visits or reporting requirements, please call Mission, Ethics and Spirituality at Mission Standards, Indicators, and Examples of Required Evidence Linked to Strategic Direction: Build and engage our team The following section provides a definition for each Mission Standard, the associated Indicators of mission performance, and examples of behaviours and practices that demonstrate compliance to each Indicator. This is not an exhaustive list of the required evidence, but a sampling to orient you when completing the self-assessment. Standard 1 We can achieve the mission, now and into the future, with committed individuals who share our calling and embody the values of Covenant Health. Definition: Having the right people is critical to achieving the mission. It begins with recruiting leaders, physicians, board members, students and volunteers who truly understand what it means to represent a faith-based organization. This does not mean everyone is or should be Catholic. Covenant Health serves residents and patients from all cultural, religious and ethnic backgrounds. So too does our team of people represent the rich diversity of the broader community. What distinguishes our team from other organizations is our commitment to the mission. We get the mission. This starts at the selection, recruitment and orientation process with upfront conversation about the values and legacy of Catholic health care

9 Our founding Sisters have given us the responsibility and privilege to carry the mission forward. Our mission compels us to continuously engage one another in shaping our preferred culture, actively participating in decision-making, and providing the necessary mentoring and leadership development opportunities to ensure the mission resonates with tomorrow s leaders. Indicator 1a: We recruit board members, staff, physicians and volunteers to our facilities who share the mission and values of our organization. We clearly communicate the mission and values in all promotional and recruitment materials We hire for fit as evident in short-listing practices, interview questions, and reference checks We are able to clearly articulate to potential candidates what expected behaviours demonstrate our mission and values in action We explore how candidates own values may align with the values of the organization We assess for fit in the physician privileging process and support physician site leadership development Indicator 1b: We promote a culturally appropriate work and care environment, respectful of all we serve. We celebrate the diversity of our team and are sensitive of different ethnic and religious observances We promote cultural diversity through meaningful images and text in the Reflection of the Week We respect the cultural differences that define departments, teams and Covenant Health sites, and work to promote collaboration and inclusion We acknowledge the contributions of staff in providing interpretive services to residents and patients in emergent situations We support the provision of intercultural awareness and enculturation programming to staff Indicator 1c: We facilitate board member, physician, staff, volunteer and student understanding of the organization s mission, values, history and ethical traditions. We orient new team members to the identity, legacy, mission and values of Covenant Health We review Our Commitment to Ethical Integrity (code of conduct) with new team members and the expected behaviours of conduct We provide copies of the Health Ethics Guide to board members and leaders to better understand the ethical traditions of Catholic health care We provide regular education sessions on the mission, values, and ethical tradition of Catholic health care We ground key policies and strategic documents in the mission and values of the organization 14 15

10 Indicator 1d: We encourage people to participate in decisions that affect their work. We model open door policies and collaborative decisionmaking practices, and actively seek team feedback We ensure there are opportunities to meaningfully engage staff and address their questions and concerns when leading projects and managing change We hold regular team forums, gatherings, and roundtables to promote exchange of information and dialogue We hold people accountable for the decisions they have made We promote decision-making at the most appropriate level (principle of subsidiarity) Indicator 1e: We are committed to developing our current and future leaders. We encourage and support leadership development We provide mentorship and shadowing opportunities We complete annual performance evaluations with team members We encourage and support leadership coaching We promote education grants and leaves with return service agreements Linked to Strategic Directions: Respond to those in need, and, Engage and work with community Standard 2 We can better serve those most in need by collaborating with others and supporting the conditions that will help people to flourish. Definition: We cannot achieve the mission by ourselves. While clinicians are indispensable in embodying our mission and values through compassionate bedside care; in reality, all Covenant Health team members create the healing culture of our organization. The complex and interdependent functions of a large organization necessarily require collaboration in order to leverage the skills and gifts across teams and sites. By doing so we can all succeed, and flourish. We also need to be attentive to the needs of the community. We cannot claim we are living our mission if we remain out of touch and unresponsive to the needs of the vulnerable people we serve. We also demonstrate our commitment to mission by cooperating with the promptings of the Spirit through prayerful reflection, and informing our decisionmaking by the teachings of the Gospel. We also inform our work through the example of the founding congregations or through consultation with broader ethics and discernment frameworks. By working together with the community, the funder, the founding congregations, and the church, and being willing risk-takers to carry the healing ministry of Jesus, we ensure the mission is sustained into the future

11 Indicator 2a: We identify and address unmet needs among the vulnerable populations we serve. We participate in community needs assessments to identify health needs and opportunities We partner with local community agencies to provide a coordinated response to vulnerable populations We have developed programs or services to better address gaps in health services We have implemented financial guidelines when caring for underinsured or noninsured patients We ensure timely and quality interpretive services to better support those whose first language is not English Indicator 2b: We are committed to ethical and socially responsible recruitment practices. We disclose areas of organizational challenge as well as opportunity to potential candidates in the recruitment process We ensure staff receive a just wage, and are duly represented by their professional association and/or union We recruit people to positions where we are confident they can succeed and support them in their new position learning period We have developed and implemented an ethics framework for recruiting internationally educated health care workers We ensure appropriate boundaries are in place and respected when recruiting a family member of a staff, based on the competency of the candidate, not their relationship to other employees Indicator 2c: We celebrate the heritage and tradition of our founding congregations. We recognize feast days and other anniversaries of the founding congregations We pay tribute to the Sisters in preserving historical documents, photos, artwork and other artifacts that recognize their unique contributions We participate in local and corporate mission award celebrations that recognize the Sisters with named award criteria or values that they embodied We maintain regular contact with the founding congregations through meetings, renewal days, and heritage meetings We ensure our tributes do not romanticize the Sisters and/ or absolve us of our responsibilities in carrying on their work Indicator 2d: We ensure clinical and operational practices are consistent with the Health Ethics Guide. We have copies of the Health Ethics Guide for every department and leader in our facility We hold periodic educational workshops on the Health Ethics Guide We integrate relevant articles from the Health Ethics Guide in key clinical and operational policies We ensure ethics consultation recommendations are consistent with the Health Ethics Guide We are familiar with key sections of the Health Ethics Guide that inform our everyday work 18 19

12 Indicator 2e: We exercise mission due diligence prior to establishing significant organizational partnerships. We evaluate fit with potential partners before concluding legal and financial due diligence We are prepared to walk away from partner relationships if our mission is compromised or co-opted We make use of Mission Discernment and commit the necessary time and energy to adequately assess partnership fit We are able to communicate the rationale for the decision if we elect not to establish a partnership We continue to evaluate partnership relationships in their ability to help advance quality, stewardship of resources and mission fidelity The commitment to quality also requires fostering an environment of learning and discovery. As a human enterprise we will make mistakes in the delivery of health care, but we must be willing to learn from our experience to prevent similar errors from occurring again. We must be willing to stay engaged with others to discover diverse perspectives. We must also be willing to look below the surface for the deeper questions of meaning and spirituality that inform a person s health care choices. Quality care, in the context of our ministry, also requires us to attend to the whole person body, mind, and spirit. Indicator 3a: We demonstrate our mission and values through regular review of clinical quality and safety standards, and making process improvements. Linked to Strategic Direction: Continuously improve quality and safety Standard 3 We are stewards of trust, serving the whole person in a safe environment with the highest quality care. Definition: Catholic health care has a proud tradition of providing safe, quality care. The Sisters who built our hospitals were known for their compassion, but also for the efficiency and impeccable standards they demanded. We can do no less today, for at the heart of these expectations is the commitment to hospitality, from which the word hospital is derived. We truly welcome the stranger, the destitute, the sick and the vulnerable into our facility where they know they can be safe. It is this assurance that promotes healing and confidence. Health care is a sacred trust. Our patients, residents and families trust us with their lives and we must be good stewards of this trust. Our claims of living the mission are meaningless if not grounded in a commitment to quality and safety. We have established functioning Quality Assurance committees that regularly review adverse events, near misses, and hazards in order to continually improve care and service We have established policies, procedures, and quality safety frameworks, and monitor compliance through safety audits and regular reporting to the Board We have implemented medication reconciliation, key quality and safety processes, and other safety measures, devices and equipment We make continuous quality process improvements through a documented action plan We provide education, consultation and mentoring support to promote a culture of quality and safety 20 21

13 Indicator 3b: We respond to adverse outcomes with prompt and truthful disclosure. We have ongoing conversations with patients, residents and families We have a process in place to report adverse events and with taking immediate corrective action We have a disclosure framework and trained disclosure coaches We have a mechanism to learn from adverse events and near misses for quality process improvements We have a communications, ethics, legal and risk management structure in place to support timely disclosure practices Indicator 3d: We provide clinical ethical services to help diffuse or resolve ethical conflict. We have a mechanism for initiating timely ethics consults We have resources to support ethical reflection on the goals of care We work together with stakeholders to identify areas of differing perspectives, and strategies to mediate mutually agreeable plans of care We incorporate trend consult data in educational sessions as part of a preventative ethics strategy We provide competency education and mentoring support to ethics committees Indicator 3c: We support patients/residents and their substitute decision-makers in clarifying the goals of care. We ensure informed consent is obtained regarding proposed treatments, including the risks, benefits and alternatives of treatment We explore the need, wishes and values of patients/residents when clarifying the goals of care We respect different cultural and religious perspectives that inform a patient/resident s goals of care We have a process for assessing decision-making capacity We collaborate with substitute decision-makers and respect the clinically appropriate wishes clearly expressed in personal directives Indicator 3e: We provide quality spiritual care resources that are responsive to the diverse cultures, faiths and religions of the people we serve. We have dedicated staff chaplaincy services and an on-call system for around the clock referral We provide spiritual care interventions without discrimination, or obligation We ensure chaplains are professionally trained and informed of different cultural and religious perspectives on end-of-life care and other complex care needs We provide ecumenical and interfaith services and support materials We ensure spiritual care services are responsive to the diverse needs of staff and physicians, and able to navigate effectively in the clinical setting 22 23

14 Standard 4 We align what we say is important with what we do, demonstrating our mission and values with every decision, behaviour, attitude and service we provide. Indicator 4a: We make significant strategic, financial and policy decisions using a values based decisionmaking process. Suggested evidence and behaviours Linked to Strategic Direction: Live our mission and values in all we do Definition: The mission of Covenant Health pervades the entire organization. Every role and service must contribute to deepening of the mission, including the decisions we make. Our decisions reveal what is of fundamental importance, or of value, to the organization. Therefore, we need to ensure what we espouse is important in our mission and value statements are congruent with our decisionmaking practices. How we treat our staff, steward our financial resources, set policy and strategic priorities, communicate to internal and external audiences, adorn our facilities, care for the environment, and advance social policy efforts must demonstrate this alignment with what we claim to be of fundamental value. Inconsistent behaviour between what we say and do can undermine our reputation. Mission fidelity means just that -being faithful to the mission even when it may be expedient to do otherwise. It is a demanding standard to which we hold ourselves accountable. But such fidelity demonstrates the preferred culture to which we continuously aspire. We set site and corporate strategic plans in alignment with our mission, values and ethical traditions We integrate values and principles in project management practices and templates We balance financial and capital planning to ensure proportionate weighting of all our Covenant Health values We develop key operational and administrative policies based on our values We use ethical reflection and discernment in making significant organizational decisions Indicator 4b: We exercise responsible stewardship of all our resources, including the environment. Suggested evidence and behaviours We anticipate future resource needs (human, capital, infrastructure) and develop strategies and project management processes to realize these needs We honour our commitments to work within budget and not be irresponsible of our financial assets We consider our staff our greatest resource and model this in all human resource policies and practices We assume risks and continuously develop our business to ensure our long-term presence and viability in the community We evaluate the environmental impact of the materials we use and implement green initiatives 24 25

15 Indicator 4c: We display art and symbols that reflect the mission, founding traditions, and communities we serve. Suggested evidence and behaviours We intentionally choose art and symbols with consideration of the overall fit with the ethos of the facility We reserve the right to refuse donated art if it undermines our Catholic identity We solicit art and displays that advance our strategic priorities, including respect for the diversity of the local populations we serve We display Christian symbols and crucifixes, and reserve sacred space for prayer, and celebration of the Eucharist We honour our founding traditions with tribute space that depicts their history, charism and enduring contribution to Catholic health care Indicator 4e: We support social policy efforts that advance the common good and justice in health care. Suggested evidence and behaviours We participate in community forums, round tables, and public relations activities to help positively influence social change We reflect on the social justice implications of labour, fundraising and clinical practices that undermine the dignity of the person We lobby government and professional associations with practical recommendations and organizational commitments We advocate for compassionate care for vulnerable people through media stories, position papers, publications and other vehicles We commit proportionate resources to advocacy and social policy efforts Indicator 4d: We reflect our mission, values and Catholic identity with all internal and external communications. Suggested evidence and behaviours We incorporate our logo and tagline Compassionate care led by Catholic values on all key internal and external documents We articulate how our values inform our decision-making in significant organizational announcements We ensure the tone, language, and content of our internal and external communications reflect and promote understanding of our history, values, mission and ethical traditions We engage in respectful communications, including and phone etiquette We promote awareness of the organization and our contributions regularly with key stakeholders, including patients, residents, government, community groups, and donors 26 27

16 Covenant Health Mission Assessment Scorecard Appendix The Scorecard is included here for reference, and electronic copies are available through the office of Mission, Ethics and Spirituality. Thanks to Covenant Health leaders who provided feedback in its development and trial. When completing the Mission Assessment, leaders should precirculate the scorecard to their leadership teams, and invite reflection, even individual scoring, before gathering as a team to confirm a single facility score. Over time, familiarity with the tool and the evidence required by each Indicator will greatly assist in accurately scoring facility performance. The Dashboard will provide a comprehensive quantitative picture of how each facility, portfolio and the organization is performing against the 20 Indicators. Monitoring performance from year to year will yield useful trend data, and support the establishment of mission targets. Linked to Strategic Direction: Build and engage our team Score your facility based on the assessment scale Below: 1 Strongly disagree 2 Disagree 3 Neither agree or disagree 4 Agree 5 Strongly agree DK Don t know /can t answer OUR MISSION We are called to continue the healing ministry of Jesus by serving with compassion, upholding the sacredness of life in all stages, and caring for the whole person body, mind and soul. Facility Date Standard 1 We can achieve the mission, now and into the future, with committed individuals who share our calling and embody the values of Covenant Health Self-assessment of your Covenant Health facility s performance 1a: We recruit board members, staff, physicians and volunteers to our facilities who share the mission and values of our organization. 1b: We promote a culturally appropriate work and care environment, respectful of all we serve. 1c: We facilitate board member, physician, staff, volunteer and student understanding of the organization s mission, values, history and ethical traditions. 1d: We encourage people to participate in decisions that affect their work. 1e: We are committed to developing our current and future leaders. score 28 I

17 Covenant Health Mission Assessment Scorecard Covenant Health Mission Assessment Scorecard Linked to Strategic Directions: Respond to those in need, and, Engage and work with community Standard 2 We can better serve those most in need by collaborating with others and supporting the conditions that will help people to flourish Linked to Strategic Direction: Live our mission and values in all we do Standard 4 We align what we say is important with what we do, demonstrating our mission and values with every decision, behaviour, attitude and service we provide. Self-assessment of your Covenant Health facility s performance score Self-assessment of your Covenant Health facility s performance score 2a: We identify and address unmet needs among the vulnerable populations we serve. 4a: We make significant strategic, financial and policy decisions using a values-based decision making process. 2b: We are committed to ethical and socially responsible recruitment practices. 4b: We exercise responsible stewardship of all our resources, including the environment. 2c: We celebrate the heritage and tradition of our founding congregations. 4c: We display art and symbols that reflect the mission, founding traditions, and communities we serve. 2d: We ensure clinical and operational practices are consistent with the Health Ethics Guide. 4d: We reflect our mission, values and Catholic identity with all internal and external communications. 2e: We exercise mission due diligence prior to establishing significant organizational partnerships. 4e: We support social policy efforts that advance the common good and justice in health care. Linked to Strategic Direction: Continuously improve quality and safety Standard 3 We are stewards of trust, serving the whole person in a safe environment with the highest quality care Mission Targets To be completed in a facilitated discussion with site leadership team and Vice President, Mission, Ethics and Spirituality Self-assessment of your Covenant Health facility s performance 3a: We demonstrate our mission and values through regular review of clinical quality and safety standards, and making process improvements. 3b: We respond to adverse outcomes with prompt and truthful disclosure. 3c: We support patients/residents and their substitute decision-makers in clarifying the goals of care. 3d: We provide clinical ethical services to help diffuse or resolve ethical conflict. 3e: We provide quality spiritual care resources that are responsive to the diverse cultures, faiths and religions of the people we serve. score Stretch Goal: Improvement Goal: II III