Central East LHIN Organizational Health Self Assessment Tool

Transcription

1 Organizational Self Assessment Tool Purpose: This self assessment tool is designed for use by community support services and community mental health and addictions agencies to quickly assess their organizational health status. The results of this selfassessment are for internal use by agencies and are not required to be reported to the Central East LHIN the results will not be used for evaluation purposes by the Central East LHIN. The statements in this tool are those considered important by the Central East LHIN for a health service provider to effectively and efficiently provide client/patient services and be accountable for the public funds received to provide services. An individual agencies organizational health status will be determined by scoring the statements and totalling the scores and like personal health, organizational health may vary from optimal to poor. It is recommended the tool be completed by an agency Board and the senior executive leader to assess the health status of their organization the result will provide an organizational health rating and will suggest action, including integration opportunities, to mitigate the issues identified. Instructions: 1. Allow approximately 30 minutes for the self assessment. 2. Score each of the following statements using the following grading scale. 4 = Strongly Agree 2 = Agree 0 = Neutral 2 = Disagree 4 = Strongly Disagree 3. Sum the Sub Total Scores and overall Total Score. 4. Check the overall health status using the scoring tables provided. 5. Consider the action recommended. 6. Review the resources section and take action. For assistance contact: Barry Hyde, Lead CE LHIN Project Management Office, (289) or bhyde@tsh.to Service Provider Name: Completed by: 1. Agency Governance There is a full complement of Directors on the Board. 2. You are easily able to find individuals to serve as Directors. 3. The Board of Directors role is strategic and does not provide day to day operational oversight. 4. There is a good relationship between the Board and the administration. 1

2 Organizational Self Assessment Tool 5. The Board follows the corporate by laws and has formal processes in place for conducting meetings and decision making. 6. The Board has a Board Policy and Procedure Manual. 7. The Board has a Recruitment Policy and Procedure that targets specific skill sets. 8. The Board has a documented Succession Plan for Board Members and senior administrative staff. 9. The Board annually assesses it performance using a specific tool. 10. The Board engages with the community to discuss its stewardship of the organization, perception of organization, and whether the organization is still relevant and valuable. 11. The Board regularly monitors and assesses its trust/reputation level and impact of the organization on the wider community. 12. The Board has adopted quality services and patient safety as a priority and has developed and articulated strategies to ensure improvement in these areas. 13. Executive and Strategic Leadership You have a documented strategic plan that outlines your agency s strategic objectives and is updated on a regular basis. 14. Your strategic plan is aligned to the strategic aims and directions of the Central East LHIN. 15. There is someone currently in a position responsible for executive leadership for the organization (Executive Director, Chief Executive Officer, etc.). 16. There is a Performance Agreement with the Chief Executive that includes the objectives of the Strategic Plan and the Strategic Aims of the CE LHIN. 17. You typically have no difficulty recruiting a qualified executive to lead the agency. 18. Your executive leader has a good grasp of the health care system and is able to systemsthink about your organization s relationship to your healthcare sector and overall community. 19. Your executive leader is able to operate with a comprehensive understanding of the organization s business components and inter relationships. 20. Your executive leader is able to build strategic relationships and/or partnerships on behalf of the organization/board. 21. You have a documented operational plan that demonstrates how you will achieve your strategic objectives and you are actively following the plan. 22. Sustainability Given your understanding of the current fiscal climate and your best fiscal and operational service projections, you are confident your agencies services are sustainable for the next 10 years. Sub Total (# s 1 to 22) Maximum = 88 Minimum = 88 Agency Staffing 23. You typically have no difficulty recruiting qualified staff for key operational or program positions. 24. Your staff turnover is low. 25. Your staff salaries are competitive with similar service providers. 26. You have contingency plans to provide services in the event of staff absences. 27. The organizational culture and staff morale is positive. 2

3 Organizational Self Assessment Tool 28. You have documented job descriptions for all paid staff and volunteers. 29. For regulated staff employed in your organization (social workers, nurses, therapists, etc.) there are policies and procedures that address compliance with regulated acts and staff qualifications. 30. For all staff members there is a staff education/professional development plan in place. 31. Operations Direct Client Services Your organization is motivated by a continuous focus on how to best meet client needs. 32. You have a mechanism in place to capture client feedback. 33. Client feedback indicates they are satisfied with the services they receive. 34. Your services meet best practices and standards for your service sector. 35. You have comprehensive program policies in place (including a policy on how to assess client s needs and prioritize services) and consistently follow them. 36. For those clients deemed to be a priority for services there is no wait list. 37. Your organization can offer a range of different services to support the continuum of service needs of clients (not a single service provider). 38. You have formal partnerships and/or service coordination relationships with other service providers (evidenced by MOUs, other agreements, etc.). 39. Volunteers You have adequate numbers of volunteers to meet your service expectations. 40. You are consistently able to recruit volunteers. 41. Volunteers have adequate staff to provide them support and coordinate their efforts. 42. There are specific Volunteer Policies and Procedures in place. Sub Total (# s 23 to 42) Maximum = 80 Minimum = Back Office Services You have comprehensive human resource policies and processes in place and consistently follow them. 44. You have financial policies and processes in place and consistently follow them. 45. You have administrative policies and processes in place (i.e. privacy, records retention, procurement) and consistently follow them. 46. You have in house or contracted IT support that meets your needs. 47. You have appropriate systems and processes in place to support your operations and reporting obligations. 48. You always comply with all financial and operational performance reporting deadlines and quality standards for reports. 49. You have appropriate safeguards in place to protect client personal health information. 50. Financial You manage your operations within your financial means you have a balanced budget. 51. You have audited financial statements for your last fiscal year and regularly submit reports to MoHLTC and CE LHIN as required under MSAA. 52. You have little trouble meeting your fundraising/donations targets. 53. Fundraising activities and receipt of donations is conducted ethically and according to Canada Revenue Agency guidelines. 54. There are no out of the ordinary contingent financial liabilities (lawsuits, etc.). 3

4 Organizational Self Assessment Tool 55. Accounting practices in your organization conform to Generally Accepted Accounting Principles. An organization wide fiscal policy is followed. 56. An operating budget is developed annually. This is inclusive of all program costs, management and fundraising and all funding sources. 57. Costs of programs are monitored. Cash flow projections are prepared and there is a monthly reconciliation of all cash accounts. 58. A Balance Sheet and Statement of Revenue and Expenses are prepared timely and accurately. 59. Payroll is prepared following appropriate Provincial and Federal regulations and organizational policy. 60. The issues of cash and deposits, over spending and disbursement are documented in the internal control process. 61. A contingency plan is in place for actions to be taken in the event of a reduction or loss in funding. Established or an active development of reserve of funds to cover at least three months of operating expenses is underway. 62. You have a plan to replace capital assets, if required. Sub Total (# s 43 to 62) Maximum = 80 Minimum = 80 Total Score (# s 1 to 62) Maximum = 248 Minimum = 248 4

5 Organizational Self Assessment Tool Sub Total Scoring Statements 1 to 22 Statements 23 to 42 Statements 43 to 62 Criteria Agency Governance, Executive and Strategic Leadership, Sustainability Agency Staffing, Operations Direct Client Services, Volunteers Back Office Services, Financial Sub Total Score 88 to to 0 0 to to to 0 0 to to to 0 0 to 80 Rating Description and Recommendation Your organization has the majority of the elements in place to successfully meet its obligations. Take steps to address and any statements/issues where the score is less than 2. There are several issues that need immediate attention to ensure your agency has the appropriate standards, safeguards and oversight in place. Focus immediately on those statements/issues where the score is 0 or less. If resolution of the issues cannot be achieved within 3 months consider a transfer of services or merger with another service provider. Your organization does not have the appropriate standards, safeguards and oversight in place to ensure your agency is able to deliver on its contracted services (M SAA) for the immediate and longer term. You should immediately consider a merger or transfer of services with another service provider. Your organization has the majority of the elements in place to successfully deliver services to clients. Take steps to address and any statements/issues where the score is less than 2. Consider partnerships and coordination of services with other agencies as opportunities to further enhance client services. There are several issues that need immediate attention to enable your organization to adequately deliver services to clients. Focus immediately on those statements/issues where the score is 0 or less. If resolution of the issues cannot be achieved within 3 months consider a transfer of services, partnership or coordination of services with another agency. Your organization is having trouble delivering services and meeting contracted obligations to clients. You should immediately consider a merger, transfer of services or a partnership opportunity with another agency. Your organization has the majority of the elements in place to support agency operations. Take steps to address and any statements/issues where the score is less than 2. Consider a transfer of services, partnerships and coordination of services with other agencies as opportunities to further enhance client services. There are several issues that need immediate attention to support the operation of your agency. Focus immediately on those statements/issues where the score is 0 or less. If resolution of the issues cannot be achieved within 3 months consider a transfer of services, partnership or coordination of services with another agency. Your organization does not have the required policies and procedures, services and financial processes in place to adequately support your agencies operations. At a minimum you should immediately consider an integration of these services through the transfer of services to another agency with the capability and capacity to provide the services. If your score is less than 0 on the other key criteria immediately consider a merger or transfer of services with another service provider. 5

6 Organizational Self Assessment Tool Total Scoring Total Score 248 to to 0 0 to to 248 Overall Organizational Rating High Risk of Operational Failure Description and Recommendation Your organization has all of the elements to successfully provide services and ensure they are sustainable for the longer term. Take steps to address any statements/issues where the score is less than 2. Integration opportunities can still be considered to improve service delivery to clients and overall agency performance. Your organization has some issues that need special attention. Focus immediately on those statements/issues where the score is 0 or less. You may consider the full scope of integration opportunities (coordination of services through merger) to mitigate these issues. Your organization is facing a large number of issues and is at risk of not meeting its contacted service delivery obligations. You should consider exploring a merger or transfer of services with other service providers in your community for the service to remain viable and sustainable for the longer term. Your organization has too many issues to remain a viable service provider. Immediate action to merge or transfer services with another service provider is strongly recommended for the service to remain viable and sustainable for the longer term. Resources: Refer to the following Integration Chart to identify integration activity and integration types (tools) available to the Central East LHIN and Service Providers. Refer to the integration page on the Central East LHIN website for additional tools and advice on integration: Refer to the project management page on the Central East LHIN website for additional tools and advice on managing an integration project: Refer to tools/supports that may be available through provincial or national organizations that your organization may belong to. 6

7 Organizational Self Assessment Tool Integration Chart The following chart is derived from the Local Services integration Act, 2006 (LHSIA) and identifies which types of integration applies to specific integration activities. Integration Type Integration Activity (LHSIA S.2) LHIN Funding (LHSIA S.19) LHIN Facilitated and Negotiated (LHSIA S.25) LHIN Required (LHSIA S.26) Voluntarily Initiated by HSP (LHSIA S.27) s Order (LHSIA S.28) Partial integration Coordinate services and interactions between different persons and entities Partner with another person or entity in providing services or in operating X X Full entity integration Transfer, merge or amalgamate services, operations, persons or entities Start or cease providing services Cease to operate or to dissolve or wind up the operations of a person or entity excludes amalgamation of health service providers S.26(2)(e) X X X Applicable to one or more of the HSPs involved Applicable to one or more of the HSPs involved Applicable to one or more of the HSPs involved Services must be funded at least in part by the LHIN. Per S25(1)(a) Integration by providing or changing funding to a health service provider under S.19(1) Per S.25(1)(b) Integration of persons or entities where at least one is a health service provider or integration of services between heath service providers Per S.26(1) LHIN requires one or more health service providers to which it provides funding to integrate, subject to restrictions per S.26(2) Per S.27(1) Integration between another person or entity Per S.28(1) based on advice from the LHIN and deemed to be in the public interest 7