First Nations and Inuit Home and Community Care Policies Template Manual

Part 6: Operations

First Nations and Inuit Home and Community Care Program
Policies Template Manual
Community Logo

Part 6: Operations
Community Name

Policy: Program Management
Policy Number: 6.1

Approval:
Date:

Policy

The First Nations and Inuit Home and Community Care Program has a management system for the Program that ensures that the services delivered to the community:

• Are approved of and supported by the community leadership
• Are responsive to changing needs and demographics
• Support the mission, vision and goals identified by the community and First Nations and Inuit Home and Community Care Program staff
• Are equal to those received by other Canadians
• Are fiscally responsible and financially sustainable
• Meet the standards for service delivery and quality programming
• Do not duplicate services that were available in the community prior to the establishment of the First Nations and Inuit Home and Community Care Program
• Achieve a continuum of care with other services offered in the local area, with other First Nations and Inuit communities, and with non-Aboriginal communities, as appropriate

Policy Rationale

To ensure that the Program and its services are regularly evaluated in order to provide quality care that meets the health needs of the community.

Policy Details

Management of the First Nations and Inuit Home and Community Care Program involves:

• Internal management processes/systems
• Financial management
• Fiscal efficiency analysis
• Financial reporting
• Funding/resource allocation applications and analysis
• Annual reports
• Human resource management
• Staffing needs analysis
• Recruitment and retention strategies
• Compensation and benefit decisions
• Ongoing training and development planning
• Quality management
• Risk management
• Occurrence/Incident reporting and analysis
• Quality improvement activities/planning for ongoing Program and services changes and improvements
• Resource/capacity management
• Management of funding allotments
• Capacity building analysis
• Service delivery management
• Management of the essential service elements of the Program:
• Case Management
• Client Assessment
• Home Care Nursing
• Home Support Services
• In-Home Respite
• Medical Supplies and Equipment
• Data/Information Systems and Records Management
• Physical space/equipment/materials management
• Examination of the physical location of the Program offices
• Regular maintenance of equipment and materials
• Tracking and analysis of safety audits
• Information management
• Management of external relationships, partnerships and contracts, including:
• Linkages with health and social services outside of the First Nations and Inuit Home and Community Care Program
• Contract management, as required, for communities that choose to purchase services and for the purchase of equipment, supplies, etc.
• Management of partnerships with other First Nations and Inuit communities
• Management of relationships with funding agencies

Process Guidelines

The First Nations and Inuit Home and Community Care Program has a well-defined process in place for the management of internal and external relationships that will ensure the responsiveness and success of the Program. This process includes but is not limited to:

• Clear and specific job descriptions for managers within the First Nations and Inuit Home and Community Care Program. These job descriptions outline responsibilities, authority and accountabilities associated with each position.
• The development of an organizational chart that is specific to the community and its First Nations and Inuit Home and Community Care Program. This chart defines the individuals who are accountable for the Management function within the Program and has the approval of the community leadership. • A planning process, which prepares the community for the implementation and ongoing management of the First Nations and Inuit Home and Community Care Program that includes:
• Identification of community leadership responsibility
• Development, with community input, of the mission, vision, values and goals of the First Nations and Inuit Home and Community Care Program
• Community needs assessment
• Evaluation of the Program's delivery of services to examine:
• Appropriateness
• Effectiveness
• Efficiency
• Timeliness
• Ability to address identified community needs
• Financial planning
• Development of evaluation criteria
• Regular reporting process
• Identification of potential partners and referral sources
• Identification and listing of existing services, including other community resources and programs, and programs and services provided outside of the community
• A formal review process of all contract agreements and partnerships
• A process for annual evaluation of the First Nations and Inuit Home and Community Care Program

Performance Measurement Suggestions

Indicator: This information is to be developed by communities as they work with their Programs. For an example of the kind of measures that should be identified, refer to the Hiring Policy template.

Formula:

Related Standards

1.1 Community Needs Assessment
1.3 Capacity Building
1.4 Resource Management
3.1 Services Delivery
3.2 Continuity of Services
3.7 Confidentiality
4.2 Equipment and Materials
4.3 Building/Physical Space
4.4 Partnerships/Community Linkages
5.2 Recruitment and Retention
5.3 Evaluating Performance
6.1 Information Needs
6.2 Data Collection and Reporting
6.3 Analysis and Evaluation
6.5 Program Changes and Improvements

Some Suggested References

The First Nations and Inuit Home and Community Care Planning Resource Kit: All sections
Draft Liability Documents: May, sections 2 to 2.9; June, pgs 6-12

CCHSA AIM Standards, 1999 -- Leadership and Partnerships, Home Care Services
Professional Practice Standards
Provincial/Territorial and Federal Legislation
DIAND/FNIHB Home and Community Care Directives

Review Process:
Dates:

Each community is responsible for developing and putting in place their own procedures. These procedures need to outline the practical steps to be taken to carry out the process guidelines for this policy.

Suggested Procedures

1. Procedure for reporting, recording and handling incidents and complaints, with a specific procedure for high-risk complaints.
   Suggested tools:
• Incident report form
2. Procedure for conducting a Program evaluation each year.
   Suggested tools:
• Information guide, to ensure the necessary information is collected
• Report guide, to ensure the most important aspects of the Program, its strengths and its weaknesses, are considered
3. Procedure for identifying, monitoring, and recording key indicators and reporting on the changes that have occurred from one year to another, and, as appropriate, from one quarter to another.
   Suggested tools:
• List of key indicators in clinical, financial, human resources, and quality areas
• Tool to measure indicators on a regular basis for comparison purposes
4. Procedure for completing a community needs assessment and annually reviewing this assessment to identify any changes that suggest a need to adjust the Program to be more responsive.
5. Procedure for managing contracts for services, equipment and materials.
   Suggested tools:
• Sample contracts for service provision and for equipment and materials purchases
6. Procedures for interviewing and discussing client, family, community and staff satisfaction with the Program.
   Suggested tools:
• Objective questions regarding the program, service delivery, staff competency and attitude, and other key aspects of the Program

First Nations and Inuit Home and Community Care Program
Policies Template Manual
Community Logo

Part 6: Operations
Community Name

Policy: Record Management
Policy Number: 6.2

Approval:
Date:

Policy

The First Nations and Inuit Home and Community Care Program has a record management system that:

• Protects client and staff information
• Assists quality monitoring activities
• Provides data for planning activities
• Conforms to relevant Federal/Provincial/Territorial legislation

Policy Rationale

To ensure that all records, including client information, staff information and financial information, are confidentially maintained and stored.

Policy Details

The First Nations and Inuit Home and Community Care Program management of records ensures the security, efficient use and appropriateness of:

• Client care records, including:
• Client assessments
• Case management files
• Ongoing client information and notes written by staff providing direct services, which may be kept in the home and/or in the Program office
• Financial records, including:
• Income and expense records
• Program funding applications/approvals/allotments
• Data pertaining to annual reporting
• Inventory records for medical supplies, equipment and medications
• Human resource records, including:
• Income and expense records
• Payroll records
• Staff files
• Active
• Terminated
• Contracts/partnership agreements/cooperative service delivery agreements
• Quality management records
• Client satisfaction data
• Community needs assessment data
• Occurrence reporting and tracking

Process Guidelines

All First Nations and Inuit Home and Community Care Program services have a process that ensures the security, efficient use and appropriateness of all records relating to the Program through:

• Recruiting appropriately trained and experienced staff to Program management positions
• Educating all staff in the responsibilities of their positions as they pertain to record management
• Educating all staff to procedures regarding the release of information, storage of files, destruction of files, use of quality monitoring data, and data gathered through the community needs assessment process
• Monitoring legislative requirements for records management to determine the need for changes in policy or direction
• Documenting any incidents of inappropriate use/release/destruction/loss of records for quality monitoring purpose
• Storing all records listed above in secure locations with access available only to approved staff

Performance Measurement Suggestions

Indicator: This information is to be developed by communities as they work with their Programs. For an example of the kind of measures that should be identified, refer to the Hiring Policy template.

Formula:

Related Standards

1.1 Community Needs Assessment
3.7 Confidentiality
6.1 Information Needs
6.2 Data Collection and Reporting
6,4 Information Exchange
6.4 Program Changes and Improvements

Some Suggested References

The First Nations and Inuit Home and Community Care Planning Resource Kit: Program Criteria and sections 1, 2, 3A, 4, and 5
Draft Liability Documents: May, sections 6 to 6.8; June, pgs 7-10, 37- 39

CCHSA AIM Standards, 1999 -- Information Management,
Leadership and Partnerships
Professional Practice Standards
Provincial/Territorial and Federal Legislation
DIAND/FNIHB Home and Community Care Directives

Review Process:
Dates:

Each community is responsible for developing and putting in place their own procedures. These procedures need to outline the practical steps to be taken to carry out the process guidelines for this policy.

Suggested Procedures

1. Procedure for the release of information.
   Suggested tools:
• Consent form for informed consent release of information
2. Procedure for storing confidential client, staff, contract and financial information.
3. Procedure for discarding confidential information.
4. Procedure for determining access to information.
5. Procedure for gathering, recording, and reporting quality monitoring data.
6. Procedure for the use of data gathered through the community needs assessment process.
7. Procedure for development and distribution of reports about the Program.
   Suggested tools:
• Sample report outline to ensure the most useful information is collected, analyzed and shared appropriately
8. Procedure for faxing and e-mailing confidential information.

First Nations and Inuit Home and Community Care Program
Policies Template Manual
Community Logo

Part 6: Operations
Community Name

Policy: Communications
Policy Number: 6.3

Approval:
Date:

Policy

The First Nations and Inuit Home and Community Care Program ensures that all communications (verbal and written, within the Program, to other programs and services, the community, the media, government, and others) are:

• Delivered by the appropriate Program manager or community leader
• Accurate
• Consistent with the goals of the First Nations and Inuit Home and Community Care Program
• Consistent with policies regarding confidentiality of client and staff information
• Respectful of community values and traditions

Policy Rationale

To ensure that there is senior accountability for all information shared inside and outside the Program, and that all information fits with the mission, vision, values and goals of the Program.

Policy Details

The First Nations and Inuit Home and Community Care Program appoints either the Program manager or another senior person as the Program spokesperson. This individual will be responsible for:

• Ensuring that staff are informed of all Program, policy and process changes relevant to their responsibilities in the Program
• Ensuring that community members are informed about the Program and the services available
• Ensuring that all information being supplied to the media, government, community partners and other First Nations and Inuit communities is accurate and current
• Ensuring that only appropriate information is released
• Ensuring that information shared or released does not violate confidentiality policies for client and/or staff information
• Receiving all incoming requests for information
• Responding to all media requests for information or, when appropriate, referring the media to the others, either within the Program or to other programs, services or the community leadership
• Preparing for and assisting in the delivery of the Program's annual report, by:
• Ensuring that the community is involved
• Ensuring that information included in the annual report is accurate
• Ensuring that appropriate government, media, community partners, and others are included in the distribution of the report and any other related activities
• Monitoring information prepared and delivered by other communities delivering First Nation and Inuit Home and Community Care Program services and partnering with them, when appropriate, to explore shared trends in data analysis and quality improvement

Process Guidelines

The First Nations and Inuit Home and Community Care Program has a well-defined process for handling information that may include but is not limited to:

• All internal information that is being prepared for delivery to staff or/and clients is checked for its accuracy by at least two other Program staff (senior staff if possible) before release
• All requests for information from external sources are documented in a communication record and forwarded to the Program spokesperson for response
• All information being prepared for external release, including written reports and updates for government funding agencies, is checked for accuracy by at least one other Program staff and a member of the community leadership
• Information released to the general community is approved by the community leadership and the First Nations and Inuit Home and Community Care Program management before release
• The annual report is checked for accuracy and relevance by the community leadership and the First Nations and Inuit Home and Community Care Program management

All staff is fully aware of the communications policy of the Program and refers all information requests to the Program spokesperson. This understanding begins during orientation and is reinforced during ongoing training sessions. Staff are also fully aware of any information released to media and other external sources in a timely way.

Performance Measurement Suggestions

Indicator: This information is to be developed by communities as they work with their Programs. For an example of the kind of measures that should be identified, refer to the Hiring Policy template.

Formula:

Related Standards

1.1 Community Needs Assessment
3.7 Confidentiality
6.4 Information Exchange
6.5 Program Changes and Improvements
6.6 Confidentiality of Information

Some Suggested References

The First Nations and Inuit Home and Community Care Planning Resource Kit: Program criteria, sections 1, 2, 3A and 4
Draft Liability Documents: May, sections 3.2.1, 4.9, 6.5; June, pgs 7- 13, 22, and 28

CCHSA AIM Standards, 1999 -- Leadership and Partnerships, Information Management
Provincial/Territorial and Federal Legislation
DIAND/FNIHB Home and Community Care Directives

Review Process:
Dates:

Each community is responsible for developing and putting in place their own procedures. These procedures need to outline the practical steps to be taken to carry out the process guidelines for this policy.

Suggested Procedures

1. Procedure for the release of information (including client, staff or Program information).
   Suggested tools:
• Consent form for informed consent for release of information
2. Procedure for processing communication requests from outside sources, including the recording of the request, the response and any follow-up required. A specific procedure that is more detailed exists for processing media requests.
   Suggested tools:
• Communication log
3. Procedure for communication of mission, vision, values and goals to community and staff.
4. Procedure for preparing and sharing the Program annual report.

First Nations and Inuit Home and Community Care Program
Policies Template Manual
Community Logo

Part 3: Operations
Community Name

Policy: Annual Program Summary
Policy Number: 6.4

Approval:
Date:

Policy

The First Nations and Inuit Home and Community Care Program prepares an annual report and submits this report, as required, to the community leadership and the appropriate government agency.

Policy Rationale

To ensure that Program services are regularly evaluated and carefully planned, based on the trending of data, and that there are quality improvement activities concerning service delivery, resource management, fiscal management, and other activities of the Program.

Policy Details

The First Nations and Inuit Home and Community Care Program prepares the annual summary of activities throughout the year. Information is collected on a monthly basis, and is pulled together at the end of the year to provide the annual summary of activities. The annual summary provides the community leadership and the government funding agency with an analysis of:

• The previous year's activities
• The strengths and weaknesses of the Program
• Recommendations for on-going development of the Program

Information appearing in the annual report may include but is not limited to:

• Data related to community needs assessment activities
• Trending of incidents and related actions
• Quality improvement activities
• Educational opportunities for staff
• Data related to community complaints
• Any pending legal issues
• Evaluation of the confidentiality of client and staff information
• Human resources statistics including:
• Turnover
• Recruitment and retention challenges/successes
• Specific training gaps
• Workforce data, such as RN/LPN ratio, supportive care qualifications, rehabilitation staff (if applicable), administrative and management needs
• Service delivery information
• Service volumes provided
• Efficiency of service
• Costs of services provided
• Services required and not provided
• Waiting lists
• Linkages with other services, providers and agencies required to deliver continuum of care to community
• Accreditation progress and/or activities, if applicable
• Recommendations for further development and/or the contracting of current services provided, and for the addition of any new services

Process Guidelines

The First Nations and Inuit Home and Community Care Program prepares for the annual Program summary throughout the year by ensuring that there is a process for the collection of relevant data and information.

The First Nations and Inuit Home and Community Care Program regularly evaluates community response to services provided through the Program. This evaluation is achieved through:

• Community needs assessment activities
• Client satisfaction analysis
• Complaints analysis
• Incident analysis
• Review of the Program's mission and vision statements

The data gathered through this process forms the basis for recommendations for further development of the First Nations and Inuit Home and Community Care Program.

The First Nations and Inuit Home and Community Care Program designates, within the Program, an individual/position that is responsible for the collection, summarizing and reporting of relevant information. This individual ensures the accuracy of all information prior to the release of the annual summary.

Performance Measurement Suggestions

Indicator: This information is to be developed by communities as they work with their Programs. For an example of the kind of measures that should be identified, refer to the Hiring Policy template.

Formula:

Related Standards

1.1 Community Needs Assessment
1.2 Development and Achievement of the Vision
2.2 Risk Management
3.7 Confidentiality
5.1 Planning
5.2 Recruitment and Retention
5.4 Education, Training and Development
6.2 Data Collection and Reporting
6.3 Analysis and Evaluation
6.4 Information Exchange
6.5 Program Changes and Improvements

Some Suggested References

The First Nations and Inuit Home and Community Care Planning Resource Kit: Program Criteria, Sections 2, 3A, 4 and 5
Draft Liability Documents: May, sections 1.3.1, 1.3.2, 1.3.3, 2,2; June, pgs 6-12, 27

CCHSA AIM Standards, 1999 -- Leadership and Partnerships
Provincial/Territorial and Federal Legislation
DIAND/FNIHB Home and Community Care Directives

Review Process:
Dates:

Each community is responsible for developing and putting in place their own procedures. These procedures need to outline the practical steps to be taken to carry out the process guidelines for this policy.

Suggested Procedures

1. Procedure for identifying, monitoring, and recording key indicators and reporting on the changes that have occurred from one year to another, and, as appropriate, from one quarter to another.
   Suggested tools:
• List of key indicators in clinical, financial, human resources and quality areas
• Tool to measure indicators on a regular basis for comparison purposes over time
2. Procedure for completing a community needs assessment and annually reviewing this assessment to identify any changes that suggest a need to adjust the Program to be more responsive.
3. Procedure for preparing the annual report, including an outline of the report information, a review process, and a time line to ensure it is ready and can be reviewed before it is shared.
4. Procedure for the communication of the Program summary results.

First Nations and Inuit Home and Community Care Program
Policies Template Manual
Community Logo

Part 6: Operations
Community Name

Policy: Financial Management
Policy Number: 6.5

Approval:
Date:

Policy

The First Nations and Inuit Home and Community Care Program has a financial management system that ensures all aspects of the Program are fiscally responsible and financially sustainable.

Policy Rationale

To ensure fiscal accountability in the delivery of all Program services.

Policy Details

Responsible financial management of the First Nations and Inuit Home and Community Care Program includes but is not limited to:

• An annual budget and financial forecasting report which outline projected expenses and funding expectations
• An analysis of key Program costs and recommendations for cost reductions (i.e. human resources, medical and office supplies, communications equipment, overhead, etc.)
• An analysis of financial indicators and recommendations for overall expense reductions (i.e. travel time expenses, training and in-service expenses, recruitment expenses, etc.)
• Monthly reports to community leadership and government funders on financial status of the First Nations and Inuit Home and Community Care Program
• Capacity building requirements and associated funding applications and cost outlines
• Written contracts are in place and regularly reviewed for the purchase of services and equipment

Process Guidelines

The First Nations and Inuit Home and Community Care Program has a well-defined process in place for the financial management of the Program. This includes but is not limited to:

• A clearly defined position within the Program that is assigned overall responsibility for the financial management of the Program, to the extent that this activity is managed within the Program. The individual with this accountability must have experience in financial analysis and budgeting.
• Clear and specific job descriptions that detail all positions with accountability for financial data analysis and spending authority.
• A budgeting process that involves the staff, management and community leadership associated with the First Nations and Inuit Home and Community Care Program
• Compiling an annual report for the community leadership and appropriate government agency

Performance Measurement Suggestions

Indicator: This information is to be developed by communities as they work with their Programs. For an example of the kind of measures that should be identified, refer to the Hiring Policy template.

Formula:

Related Standards

1.1 Community Needs Assessment
1.3 Capacity Building
1.4 Resource Management
1.5 Contract Management
4.3 Building/Physical Space
4.4 Partnerships/Community Linkages
6.1 Information Needs
6.3 Analysis and Evaluation
6.4 Information Exchange
6.6 Program Changes and Improvements

Some Suggested References

The First Nations and Inuit Home and Community Care Planning Resource Kit: Program Criteria and sections 2, 3A, and 4
Draft Liability Documents: May, sections 2.2 to 2.15; June, pgs 6-13

CCHSA AIM Standards, 1999 -- Leadership and Partnerships
Provincial/Territorial and Federal Legislation
DIAND/FNIHB Home and Community Care Directives

Review Process:
Dates:

Each community is responsible for developing and putting in place their own procedures. These procedures need to outline the practical steps to be taken to carry out the process guidelines for this policy.

Suggested Procedures

1. Procedure for preparing payroll on a regular, timely basis.
2. Procedure for managing accounts receivable and accounts payable.
3. Procedure for reconciling bank statements.
4. Procedure for preparing the annual capital budget.
   Suggested tools:
• Capital budget outline
5. Procedure for preparing the annual operating budget.
   Suggested tools:
• Operating budget outline
6. Procedure for the submission and reimbursement of expenses incurred by staff.
   Suggested tools:
• List of expenses and guidelines for reimbursement
• Expense reimbursement form
7. Procedure for monitoring variances in the budget to actual financial performance.
8. Procedure to ensure the confidentiality of information.