Motion 1B Collaborative

TSH‐RVHS Integration Initiative

Final Report: Motion 1b Collaborative

January 2015 Executive Summary

Background:

On March 26, 2013 the Central East Local Health Integration Network (LHIN) passed the following motion (Motion 1b) and directed The Scarborough Hospital and Rouge Valley Health System to fulfill the following:

“…in partnership with the Rouge Valley Health System, local stakeholders and physician leaders, TSH is to develop a Service Delivery Model for Maternal‐Child‐Youth (MCY) services (which includes obstetrics, neonates and pediatrics) for the Scarborough Cluster. Additionally, consider a LHIN‐wide centre for Advanced in‐patient Paediatric care as recommended in the 2009 Hospital Clinical Services Plan* co‐located with the advanced Level 2c in‐patient Neonatal centre and sited in the Scarborough cluster. The Centre will act as a LHIN wide resource and be accountable for coordinating sub‐specialty programs to meet the needs of the North East, Durham and Scarborough clusters. The deliverables of this Service Delivery Model for Maternal‐Child‐Youth (MCY) services process will include:

• Providing an overview of the current state of Maternal‐Child‐Youth services within the Scarborough Cluster; • Providing a future state for an Integrated Maternal‐Child‐Youth Service Delivery Model in the Scarborough Cluster (see pg.12 “Summary of Motion 1b Deliverables and Final Report Content for details) …be it resolved that the LHIN approves an amendment to the March 27th 1b motion and confirms that the timing be realigned with the Scarborough Cluster Hospitals integration planning process with the clear expectation that a proposed integrated service delivery model for Maternal Child Youth (MCY) services in the Scarborough cluster and a LHIN wide advanced Neonatal and paediatric program, which will consider the findings of the Expert Panel and be developed in partnership with stakeholder and physician leaders, be submitted to the LHIN no later than March 2014.”

Motion 1b was subsequently aligned to the timing of The Scarborough Hospital and Rouge Valley Health System facilitated integration process. Once the facilitated integration process concluded in March 2014, Rouge Valley Health System (RVHS) and The Scarborough Hospital (TSH) worked in partnership with local stakeholders and physician leaders that represent the Scarborough Cluster, to develop an approach to address Motion 1b.

This motion represents a significant undertaking that requires close collaboration between RVHS and TSH. The work from this initiative demonstrates considerable success in the joint development of important planning documents such as; the co‐creation of a vision statement, a detailed environmental scan, a current state analysis which includes quality of care metrics, service utilization data, a physician/midwife supply analysis, future state population growth projections, key performance indicators to measure attainment of the vision and a detailed set of criteria to support the selection of a preferred model of service delivery. Both RVHS and TSH would like to acknowledge the commitment and dedication of each individual who worked to move Motion 1b forward.

To support the Motion 1b Collaborative, RVHS and TSH completed a detailed environmental scan of the hospitals’ catchment areas examining; population characteristics, health behaviors and health status. With a population of 659,500, the Scarborough cluster represents 40% of the Total Central East LHIN population of 1,604,100 with a younger distribution than the northern Central East LHIN. The projected 10 year growth rate for Central East LHIN is 17.4%% which is higher than that of Ontario as a whole. This consists of a projected 10 year growth rate of 11.1% for Scarborough and 17.8% for Durham. The region displays linguistic, cultural and ethnic diversity with a higher percentage of the population with no knowledge of both official languages and greater visible minority population than the rest of the province. This diversity needs to be a consideration in both health service development and delivery to achieve equitable access to care.

This report represents the output of the RVHS and TSH Motion 1b Collaborative and includes the following information: 1. Overview of the RVHS‐TSH approach to address Motion 1b 2. Description of the outcomes from each phase of the Motion 1b Collaborative 3. Detailed documentation of each output from the work of the Motion 1b Collaborative

Vision Statement:

“We will create a regional program of excellence, including advanced neonatal and paediatric care, renowned for delivering an integrated continuum of community and hospital services that exceeds expectations and delivers an outstanding patient and family experience. The system will continually evolve to use resources efficiently and effectively and instill confidence in our community to ensure that services are sustainable into the future.”

The following table summarizes the key working group feedback to provide initial guidance on how TSH and RVHS can monitor progress toward our shared vision:

Table of Contents Mandate ...... 1 May 26th, 2014. Letter ...... 1 Central East LHIN Memorandum ...... 8 Our Approach to Addressing Motion 1b ...... 10 Motion 1b Collaborative Planning Principles...... 10 Motion 1b Collaborative Working Group...... 10 Motion 1b Collaborative Supports and Project Structure...... 11 Motion 1b Governance and Decision Making ...... 12 Results of Motion 1b Collaborative ...... 13 Summary of Motion 1b Deliverables and Final Report Content ...... 13 Phase 1: Creating the Enablers of Success ...... 14 Phase 2: Designing the Model ...... 50 Phase 3: Implementing the Model ...... 285 Phase 4: Evaluating the Model...... 287

Harwood Plaza Harwood Plaza 314 Harwood Avenue South, 314, avenue Harwood Sud Suite 204A Bureau 204A Ajax, ON L1S 2J1 Ajax, ON L1S 2J1 Tel: 905 427-5497 Téléphone : 905 427-5497 Fax: 905 427-9659 Sans frais : 1 866 804-5446 Toll Free: 1 866 804-5446 Télécopieur : 905 427-9659 www.centraleastlhin.on.ca www.centraleastlhin.on.ca

Memorandum

To: Marla Fryers, Executive Vice President, Clinical Operations, The Scarborough Hospital; Michele James, Vice President, Women’s and Children’s Program, Clinical Support Services, Rouge Valley Health System;

From: James Meloche, Senior Director, System Design and Implementation, Central East LHIN

Date: August 21, 2014

Subject: Motion 1B: TSH and RVHS Maternal Child Work Group Facilitated Discussions

In response to your July 31st enquiry regarding Motion 1B: TSH and RVHS Maternal Child Work Group Facilitated Discussions, please note the Central East LHIN’s response to your questions.

1. Would you have a definition of the “Advanced/Regional center” and how it is different from a level 2C?

When the 2009 Clinical Services Plan (CSP) recommendation for an “advanced” regional program was supported by stakeholders, there were no official definitions of paediatric and neonatal levels of care that were implemented uniformly in Ontario. In 2011 PCMCH defined levels of care and individual hospitals in Ontario conducted self-assessment against those standards. These self- assessments inform our understanding of current levels of care at TSH and RVHS.

Recognizing there is no intent of stakeholders to establish a Level III paediatric and/or neonatal program in the CE LHIN, RVHS and TSH should continue to work in conjunction and support what is best for the patients and families and their health care providers in Scarborough and the Central East LHIN. This includes identifying gaps in “advanced” neonatal and paediatric care in both in-patient and out-patient programs. Solutions will consider both existing capacity, and the roles of Level III tertiary care providers in the Greater Toronto Area.

…/2

-2-

Subject: Motion 1B: TSH and RVHS Maternal Child Work Group Facilitated Discussions

2. Would the CE LHIN be considering reallocating dollars to support the center or would there be new dollars?

Yes, the LHIN will consider reallocation of existing funding, and will consider new resources – dependent on the details and strength of the business case presented.

3. Would the CE LHIN commit to keeping the current functioning of all centers at their current level?

The capacity of hospital sites should not be diminished through this exercise. Specifically, all sites in the Scarborough Cluster will remain at Level IIB or higher. Based on the proposed model brought forward for LHIN decision making, some limited resources may be shifted from one site to another for the collective benefit of the cluster/LHIN. This may include reorganization of out-patient clinics, specialized human resources, etc.

4. Would we be able to circulate the Letter from the CE LHIN Board chair (Dated May 26) on this matter?

Yes.

5. Could the LHIN clarify the suggestion of co-location of advanced paediatrics?

It is our view that a regional model most likely of success and acceptance of stakeholders (patients, community members, providers in Scarborough and other areas of the Central East LHIN) will present a ‘win-win’ scenario for advanced paediatrics and neonatal. This includes wins for patients, providers and the health system. Such a scenario may be achieved through coordination of existing services, targeted service enhancements, and clarity of roles and responsibilities for complex patient care.

The CSP recommendation states that future planners “consider” the co-location of an advanced neonatal and paediatric program onto a single hospital site. However, while co-location is an option, the hospitals should also consider options that are premised on a highly integrated service/program distributed among more than one hospital site. This is especially true given that Scarborough cluster sites will retain their Level IIb status (or better) in neonatal and paediatric services. With regard to paediatric care, a networked distributive model of specialized services (e.g., mental health, cancer, palliative) may also be considered given the co-dependency on other specialized hospital programs. Regardless of the option considered, all should be evaluated according to pre-defined decision making criteria that include population health, quality, efficiency, effectiveness, as well as feasibility of implementation and stakeholder support. Further, any model must present a clear physician and organizational management/governance structure that reflects the best practices of “regional programs

Attachments:  Letter of May 26th, 2014 Our Approach to Addressing Motion 1b:

Motion 1b Collaborative Planning Principles: Senior leaders and board members from the two hospitals worked together to create a common set of planning principles that were utilized to develop and implement the process to address the Central East LHIN Board motion. These included:  An ongoing commitment to integration of services and belief in the ‘ CASE for change’ to improve services for our communities through better Collaboration, Accessibility, Sustainability and Excellence  To build on and leverage the strong foundation created by the 2013 RVHS‐TSH merger discussions and workbook process to enhance service delivery  A commitment to continue active community engagement and participation in system redesign  Maintain focus on opportunities that align with Central East LHIN priorities as identified in the 2009 Integrated Health Services Plan  A commitment to working with each other as well as advancing broader health system transformation  Acknowledgement of the significant change management challenges and a commitment to leverage our shared cultures of continuous improvement to mitigate risks that threaten timely and effective implementation of integration opportunities

Motion 1b Collaborative Working group:

The Motion 1b Collaborative membership was composed of staff, physicians, and midwives from RVHS and TSH, as well as representation from the Central East LHIN, the Central East LHIN Maternal Child Working Group, health system partners and community members. The Collaborative working group was composed of 17 stakeholders from each organization. mThis tea was designed to ensure a balanced perspective across the Scarborough region and create linkages to the broader Central East region. Operationally, executive co‐sponsorship was provided by Marla Fryers (EVP – TSH), Michele James (VP – RVHS).

This group met 4 times with the support of external facilitators for the final three sessions. A detailed description of the purpose, role, authority and membership of the Motion 1b Collaborative can be found in the Terms of Reference here.

Motion 1b Collaborative Supports and Project Structure:

To support the work of the Collaborative team, RVHS‐TSH formed a Planning Committee to lead the conceptualization, planning and execution of the Motion 1b work plan. Membership of the Planning Committee included Maternal Child Youth (MCY) Administrative Directors, Clinical Vice Presidents, Chiefs of Staff and internal change management and improvement experts from each organization.

Figure 1: Motion 1b Committee Structure

RVHS and TSH collectively supported progress on key deliverables through the use of project management tools and principles with the engagement of the TSH Project Management Office (PMO). The Planning Committee met on a weekly basis, and submitted comprehensive project status reports to the Central East LHIN on a quarterly basis. The Planning Committee and Collaborative also benefitted from ongoing guidance, feedback and support from Central East LHIN staff.

RVHS and TSH jointly engaged external, independent consultants, Leading Edge, to facilitate discussions at three of the workshops and to design detailed workshop plans driven by the goals and objectives of each phase.

The RVHS‐TSH plan to address Motion 1b builds on several years of planning discussions; including the extensive stakeholder engagement and consultation process that occurred in 2013. As part of the RVHS‐ TSH facilitated integration process, a workbook for Maternal Child services was completed with input from approximately twenty‐four stakeholders. This level of collaborative engagement and relationship‐ building provides a solid foundation on which to implement a plan for integration of maternal/child

11 services. In light of the scope, complexity and challenges involved in integrating neonatal, pediatric and maternal services a phased approach was adopted:

• Phase 1 – Creating the Enablers of Success • Phase 2 – Designing the Model • Phase 3 – Implementing the Model • Phase 4 – Evaluating the Model

Motion 1b Governance and Decision Making: Each hospital board will be reviewing the work of the Motion 1B Collaborative and recommend next steps.

Summary of Motion 1b Deliverables and Final Report Content

Motion 1b Deliverables Section of Final Report

Overview of the current state of Maternal‐Child‐Youth  TSH‐RVHS Environmental Scan 2014 1 services within the Scarborough Cluster  TSH‐RVHS Current State Overview 2014

Provides a future state that: Informs siting and sizing  TSH‐RVHS Current State Overview 2014 2 of in‐patient and out‐patient programs and volumes

Provides a future state that: Includes performance  Motion 1b Workbook (2014) 3 goals related to access and quality

Provides a future state that: Details patient  TSH‐RVHS Current State Overview 2014 4 demographics and need for the next five‐ten years

Provides a future state that: Details physician supply  TSH‐RVHS Physician and Midwifery Supply Report 5 and need for the next five‐ten years

Provides a future state that: Addresses hospital  Clinical Services Survey Results 6 consultation and emergency services coverage

Provides a future state that: Identifies opportunities  Motion 1b Workbook (2014): Vision Statement 7 for integration, innovation and practice changes  Motion 1b Workbook (2014): Future State  Maternal Child Workbook 2013 Provides a future state that: Identifies risk and  Motion 1b Workbook (2014): Enablers and 8 relevant mitigation strategies Barriers

Provides a future state that: Demonstrates various  TSH‐RVHS Motion 1b Design Criteria options considered for the future state, and a  TSH Three Proposed Service Delivery Models preferred option using the Central East LHIN decision  RVHS Three Proposed Service Delivery Models making framework and other relevant analysis  RVHS Synopsis of 1 Preferred Service Delivery 9 Model  TSH Synopsis of 2 Preferred Service Delivery Model  Motion 1b Collaborative Service Delivery Model Evaluation Results Provides a future state that: Includes Stakeholder  Motion 1b Collaborative Terms of Reference: 10 input and commitment page #1  Motion 1b Workbook (2014): Voice of Customers  Leading for Patients website Provides a future state that: Outlines an Action Plan 11 to implement the future state

PHASE 1: Creating the Enablers of Success

PAGE 14 Phase 1 – Creating the Enablers of Success

Based on our learning from integration in this area over the last several years and our experience with transformation, there are a number of foundational enablers that must be in place to facilitate successful execution of a new service delivery model. The work in Phase 1 focused on developing key enablers such as creating a clear scope and objectives, a shared vision for service delivery and quality. Each is described below:

Clear Scope and Objectives Success of this initiative began with a clear articulation of the objectives and a robust project management approach. A detailed description of the purpose, role, authority and membership of the Motion 1b Collaborative can be found in the Terms of Reference.

Shared Vision for Service Delivery and Quality Development of a shared vision for a new model of care delivery was an important early step in this planning process. A vision was drafted at the first workshop and was later posted for community input.

The new vision:

We will create a regional program of excellence, including advanced neonatal and paediatric care, renowned for delivering an integrated continuum of community and hospital services that exceeds expectations and delivers an outstanding patient and family experience. The system will continually evolve to use resources efficiently and effectively and instill confidence in our community to ensure that services are sustainable into the future.

The Collaborative also developed a set of key performance indicators to monitor progress on the achievement of the vision. This work can be found in the 2014 Maternal Child Youth Workbook.

Table of Contents Section 1: Motion 1b Collaborative Terms of Reference ...... 17 Section 2: 2014 Maternal‐Child‐Youth Workbook ...... 23

Section 1 Motion 1b Collaborative Terms of Reference

PAGE 17

Teerms of Reference: Motion 1b Maternal Child Youth Working Group

Motion 1b Maternal Child Youth Working Group Page 1 of 5

1. Context and Purpose

On March 27, 2013, the Central East LHIN Board of Directors approved the following motion:

“At the same time, in partnership with the Rouge Valley Health System, local stakeholders and physician leaders, TSH is to develop a Service Delivery Model for Maternal-Child-Youth (MCY) services (which includes obstetrics, neonates and pediatrics) for the Scarborough Cluster, as well as a plan for a LHIN regional program for advanced Neonatal and pediatric care as recommended in the 2009 Hospital Clinical Services Plan and endorsed by the respective hospital boards at that time, with a report back to Central East LHIN Board in no more than 90 days.”

1.0 Purpose

The establishment of the Motion 1b Maternal Child Youth (MCY) Working Group is to address the requirements set out by the Central East LHIN Board Motion 1b (March 2013). The Motion 1b MCY Working Group will provide structure and guidance for development and implementation of a patient-centered, high quality, Scarborough model for hospital-based obstetrics and paediatric services. This activity will: • Develop a Service Delivery Model for Maternal-Child-Youth (MCY) services (which includes obstetrics, neonates and pediatrics) for the Scarborough Cluster; • Consider a LHIN-wide centre for Advanced in-patient Paediatric care co-located with the advanced Level 2c in-patient Neonatal centre and sited in the Scarborough cluster. The Centre will act as a LHIN wide resource and be accountable for coordinating sub-specialty programs to meet the needs of the North East, Durham and Scarborough clusters; • Providing an overview of the current state of Maternal-Child-Youth services within the Scarborough Cluster; • Providing a future state for an Integrated Maternal-Child-Youth Service Delivery Model in the Scarborough Cluster that: . Informs siting and sizing of in-patient and out-patient programs and volumes; . Includes performance goals related to access and quality; . Details patient demographics (obstetrics, neonates and pediatrics) and need for the next five-ten years, as well as physician supply; . Addresses hospital consultation and emergency services coverage; . Identifies opportunities for integration, a higher degree of service coordination between specialized services in both inpatient and outpatient programs, innovation and practice changes which will support a designated advanced MCY center; . Identifies risk and relevant mitigation strategies; . Demonstrates various options considered for the future state, and a preferred option using the Central East LHIN decision making framework and other relevant analysis; . Includes Stakeholder input and commitment and outlines an Action Plan to implement the future state.

Motion 1b Maternal Child Youth Working Group Page 1 of 1

1.1 Process Implementation

The Motion 1b MCY Working Group deliverables and timing will be aligned to, and given direction by, the Scarborough Integration Leadership Committee. The Leadership Committee has overall responsibility for coordination of the planning process. The Motion 1b MCY Working Group will undertake a comprehensive, health system planning process that builds on previous facilitated integration work and moves forward in a phased approach, as follows: • Phase 1 – Creating the Enablers of Success • Phase 2 – Designing the Model • Phase 3 – Implementing the Model • Phase 4 – Evaluating the Model

2. Role & Authority of the Motion 1b MCY Working Group

2.0 Role of the Motion 1b Maternal Child Youth Working Group

The Motion 1b MCY Working Group represents key Scarborough MCY stakeholders who will be lead the development of an integrated Scarborough hospital MCY service delivery model to be presented to the Scarborough Integration Leadership Committee for decision making. With the support of a Facilitator, the Motion 1b MCY Working Group will: • Complete the deliverables outlines in Section 1.0: Purpose • Engage and update the Scarborough Integration Leadership Committee on their activities • With the confirmation of the Scarborough Integration Leadership Committee, and with the support of the TSH-RVHS communications departments, the Motion 1b MCY Working Group will engage stakeholders for feedback and support communication strategies • Draft the Motion 1b MCY integration plan and recommendations

2.1 Authority of the Motion 1b Maternal Child Youth Working Group

The Motion 1b MCY Working Group is advisory in nature, and its authority does not extend beyond the individual authorities of its members and their respective decisions and spheres of influence. The authority of the Motion 1b MCY Working Group is delegated through the Scarborough Integration Leadership Committee and is articulated in this Terms of Reference.

The Motion 1b MCY Working Group does: • Have the authority to share information about their organizations’ services, governance, management and operations • Have the authority to recommend, on behalf of their organizations, plans and actions associated with the integration of services • Have the authority to establish time-limited focus or work groups, as required, to explore specific issues related to integration of MCY services in Scarborough.

The Motion 1b MCY Working Group does not: • Have the authority to eliminate obstetrical services at any of the three Scarborough campuses • Have the authority to make changes (downgrading or upgrading) to the Provincial Council for Maternal and Child Health (PCMCH) standardized maternal and newborn levels of care definitions • Not have the authority to approve the MCY service delivery model as this is reserved initially for the Scarborough Integration Leadership Committee, then the Boards of Directors of each organization, and ultimately the Central East LHIN.

3. Membership of the Motion 1b MCY Working Group

3.0 Membership

The Motion 1b MCY Working Group membership will be composed staff, physicians, and midwives from RVHS and TSH, as well as representation from the Central East LHIN, health system partners and community members. This team was designed to ensure a balanced perspective across the Scarborough region. An external facilitator will be jointly engaged by TSH-RVHS to support the activities of the working group.

The Motion 1b MCY Working Group’s ultimate sponsorship will be the Scarborough Integration Leadership Committee. Operationally, executive co-sponsorship will be provided collaboratively by the Marla Fryers (VP – TSH), Michele James (VP – RVHS).

RVHS TSH

1. Michele James VP (Co‐lead) 1. Marla Fryers EVP (Co‐lead) 2. Sue Fyfe, Program Director, Women’s and 2. Barb Scott, Patient Care Director, Maternal Children’s Program Newborn, Childcare & Critical Care 3. Dr. Terry Logaridis, Chief of Obstetrics and 3. Dr. Peter Azzopardi, Chief of Pediatrics/Medical Gynecology, RVC Director of MNCC 4. Dr. Joanne Ma, Dr. David Samra, Ob/Gyn, RVC 4. Dr. Nathan Roth, Acting Chief of Obstetrics, 5. Dr. Karen Chang, Chief of Paediatrics, RVC Birchmount

6. Dr. Hubert Wong, Paediatrician 5. Dr. Georgina Wilcock, Acting Chief of

7. Dr. Yehuda Nofech‐Mozes Paediatrician Obstetrics, General 8. Carolynn Prior, Midwifery Lead, RVHS 6. Dr. Vinode Raghubir, Lead Paediatrics, 9. Deb MacInnes, Manager, RVC Birthing Centre Birchmount 10. Elena Nikolsky, Manager, RVC Paediatrics 7. Janine Jackson , Corporate Perinatal Clinical 11. Kim Eeuwes, Resource Nurse, NICU & Paediatrics Resource Leader, Obstetrics 12. Robyn Kirkwood, Clinical Practice Leader NICU 13. Patrice Farray‐Taylor, Resource Nurse, Birthing 8. Sarah Thomas, Corporate Clinical Resource Centre Leader, Paediatrics and NICU 14. Dr Moigan Davaltov ‐ Anaesthesia 9. Myrna Henry, Patient Care Manager/Bev St. 15. Hajara Kutty ‐ Community Member Martin, Patient Care Manager 16. Yvonne Jagarnauth – Community Member 10. Laurie Hintzen, Chief Midwifery 17. Lily Olipher – Community Member 11. Dr. Winston Wong, Chief of Anaesthesia 18. 12. Liz Nunes ‐ Community Member 13. Josie Lee – Community Member

RVHS TSH

14. Kathryn Sabate – Community Member 15. Dr. David Law ‐ Family Physician 16. Dr. Chris Jyu – Family Physician

Ad Hoc members: 17. Nurallah Rahim, Patient Care Director, Surgical Services, Orthopaedics, Sterile Processing Dept., Endoscopy, Surgical Clinics and Rehabilitation Services 18. Radiologist CELHIN

1. James Meloche, Acting CEO, CE LHIN 2. Sheri Ferkl, CE LHIN Mat Child Advisory Group 3. Lisa Kitchen. CE LHIN

4. Logistics and Processes

4.0 Recommendation Making Process

Recommendations will be guided by the CELHIN decision making framework. The preferred approach to developing recommendations will be through consensus-building. Consensus does not mean unanimity. Working group input and recommendations will be recorded and reflected in the Motion 1b workbook and members will speak with one voice on these decisions. Issues that cannot be resolved through consensus will be discussed by the co-sponsors, and resolution sought.

The Working Group Co-Sponsors will bring forward unresolved issues or matters where consensus was weak, to the Scarborough Integration Leadership Committee for direction and decision making.

4.1 Quorum Requirements

All Motion 1b MCY Working Group members are committed to attending Team meetings. To constitute a formal working group meeting, at least one of the co-sponsors must be present. Recommendations or actions taken in the absence of a quorum are not binding on the Team.

4.2 Meeting Materials

The preparation and distribution of meeting materials will be the responsibility of the Motion 1b Planning Committee and Facilitator. Every effort will be made to prepare and distribute meeting agendas and related materials at least 1 business days in advance of Motion 1b MCY Working Group meetings. Every effort will be made to post the outputs of a Motion 1b MCY Working Group meeting on the ‘Leading for Patients’ website within 7 business days.

Section 2 2014 Maternal Child Youth Workbook

PAGE 23

Rouge Valley Health System and The Scarborough Hospital Motion 1b Collaborative 2014 Maternal Child Youth Workbook

Version #: 2 Updated : Sept. 18, 2014

Table of Contents

INTRODUCTION: ...... 1 1. PHASE 1 – CREATING ENABLERS OF SUCCESS ...... 2 1.1. Establish a Shared Vision for a new MCY model of service delivery and quality...... 2 2. PHASE 2 – DESIGNING THE MODEL OF CARE ...... 22 3. 2014 MCY WORKBOOK SIGN-OFF ...... 23 Identify the individuals that were involved in the completion of the 2014 MCY Workbook...... 23

INTRODUCTION:

Since receipt of the March 26, 2014 Central East LHIN motion, RVHS and TSH have worked closely to prepare a joint plan for moving ahead with integration opportunities in the absence of an amalgamation of our two hospitals. Both hospitals are committed to moving forward with integration opportunities which were previously identified by the Central East LHIN including developing a service delivery model for maternal‐child‐youth (MCY) services for the Scarborough Cluster (which includes obstetrics, neonates and pediatrics), as well as a plan for a new CE LHIN‐wide centre for advanced level 2c inpatient neonatal care and an advanced CE LHIN‐wide centre for inpatient paediatric care. 1

We will continue to build on previous facilitated integration work and move forward in a phased approach as follows:

• Phase 1 – Creating the Enablers of Success • Phase 2 – Designing the Model • Phase 3 – Implementing the Model • Phase 4 – Evaluating the Model

These four phases will be completed through approximately four working sessions designed as a mixture of open dialogue and interactive planning exercises to allow for the material to resonate with participants and objectives to be achieved. The RVHS‐TSH Motion 1b Collaborative is centered on presenting participants an in‐depth presentation about the case for working together to create strong sustainable services to meet our community’s needs.

This effort is designed to not replicate activities that were completed last year (ex. data analysis). Our approach aims to achieve implementation of a new care delivery model with local and LHIN‐wide elements in approximately nine months. Segments within this Workbook which may be populated with pre‐existing information are starting points for the MCY Working Group to consider and expand upon.

1 CELHIN March 2013 Board Meeting‐ Motion 1b

RVHS/-TSH Motion 1b Collaborative – 2014 Workbook – Maternal Child youth Page 1 of 27

1. Phase 1 – Creating Enablers of Success

1.1. Establish a Shared Vision for a new MCY model of service delivery and quality

The Central East Local Health Integration Network (CE LHIN) Board passed a motion at the March 2013 meeting directing Rouge Valley Health System (RVHS) and The Scarborough Hospital (TSH) to participate in a facilitated integration process to design and implement a hospital services delivery model for the Scarborough Cluster in order to improve client access to high quality services and evidence‐based practices, create a readiness for future health system transformation, and make the best use of the public’s investment.

Motion 1b mandate from the CE LHIN Board

“In partnership with the Rouge Valley Health System, local stakeholders and physician leaders, TSH is to develop a Service Delivery Model for Maternal‐Child‐Youth (MCY) services (which includes obstetrics, neonates and pediatrics) for the Scarborough Cluster. Additionally, consider a LHIN‐wide centre for Advanced in‐patient Paediatric care* co‐located with the advanced Level 2c in‐patient Neonatal centre and sited in the Scarborough cluster. The Centre will act as a LHIN wide resource and be accountable for coordinating sub‐specialty programs to meet the needs of the North East, Durham and Scarborough clusters. The deliverables of this Service Delivery Model for Maternal‐Child‐Youth (MCY) services process will include: • Providing an overview of the current state of Maternal‐Child‐Youth services within the Scarborough Cluster; • Providing a future state for an Integrated Maternal‐Child‐Youth Service Delivery Model in the Scarborough Cluster that: ‐ Informs siting and sizing of in‐patient and out‐patient programs and volumes; ‐ Includes performance goals related to access and quality; ‐ Details patient demographics (obstetrics, neonates and pediatrics) and need for the next five‐ten years, as well as physician supply; ‐ Addresses hospital consultation and emergency services coverage; ‐ Identifies opportunities for integration, a higher degree of service coordination between specialized services in both inpatient and outpatient programs, innovation and practice changes which will support a designated advanced MCY center; ‐ Identifies risk and relevant mitigation strategies; ‐ Demonstrates various options considered for the future state, and a preferred option using the Central East LHIN decision making framework and other relevant analysis; ‐ Includes Stakeholder input and commitment;

RVHS/-TSH Motion 1b Collaborative – 2014 Workbook – Maternal Child youth Page 2 of 27

‐ Outlines an Action Plan to implement the future state.”2 Both RVHS and TSH are committed to moving forward with integration and building on prior work in creating the new shared vision for MCY care in the CE LHIN. In doing this, we would utilize the guiding vision collaboratively developed by RVHS and TSH in 2013 as well as the scope statement from the 2013 Maternal Child Workbook that were developed to support identification and evaluation of integration options. These are both starting points for the group to consider and expand upon.

Guiding Vision by RVHS and TSH to Support Facilitated Integration Activities

“We wish to create an integrated system of health care services that meets the needs of the people in our community, provides appropriate access to care, delivers an outstanding experience for patients and their caregivers, and uses our resources efficiently so that these services are sustainable into the future.”3

Scope Identified in the 2013 Maternal Child Workbook:

“Creating a Regional Program of Excellence that would offer a continuum for integrated specialized patient care (including primary, secondary, and specialized paediatric services as well as general and high risk obstetrical care). Some specialized care services would have a strong regional focus and be designed to meet the need of the Central East LHIN. Patients would benefit by having these services closer to home, minimizing the need to travel outside of the Central East LHIN for these services.” 4

2 CELHIN March 2013 Board Meeting‐ Motion 1b 3 RVHS and TSH Preferred Integration Plan – Final Report. 2013. Pg. 1. 4 RVHS and TSH Facilitated Integration Maternal Child Due Diligence 2013 Workbook – Final Report. Pg. 47.

RVHS/-TSH Motion 1b Collaborative – 2014 Workbook – Maternal Child youth Page 3 of 27

Voice of Our Customers

This section captures the voice of a sample of our customers and demonstrates a commitment to leading for patients. During Session #1, a panel was convened including three community members who have experienced the maternal/child system s and two family physicians. The panel was moderated by Dr. Nathan Roth. Panellists were asked a series of questions focussed on both positive patient experiences and opportunities for improvement in service delivery in order to assist in the development of a shared vision that is reflective of community needs and preferences. During the discussion, facilitators documented the ‘voice of our customers’ which has been transcribed into the table below organized under the ‘CASE’ framework.

Collaboration Patient/ Voice of our Customers Community GP Summary of Key Points Member We value the ability to refer to local medical consultants to support care Accessibility and integration of X delivery close to home services across providers to the Patients care about the range of services available, not market share X community is important to Breastfeeding clinics could be located in the community where the patient patients X does not have to pay for parking Providers need to communicate to the community about locally available services. At present, it is not easy for patients to know what services are available. X Patients perceive that it limits choice when provider privileges at specific hospitals dictate the location of service delivery

RVHS/-TSH Motion 1b Collaborative – 2014 Workbook – Maternal Child youth Page 4 of 27

Accessibility Patient / Voice of our Customers Community GP Summary of Key Points Member Improve access to services with minimal wait times for Hospital choice based on provider privileges is limiting for patient choice X emergencies, postpartum and Patients expect no waiting for Paediatric Emergency Care X paediatric mental health issues, Local access to services for high risk pregnancies is an important factor in X and high risk patients ‘capturing market share’ There is a need to provide greater options for midwifery and reproductive X mental health issues Local access to services, in good proximity to public transit, is crucial for low X income families Hospital staff is unsure of what type of clinics are available and how to book appointments. There is a need to clarify the referral process to X facilitate access for patients. When contacting hospitals, there is a preference for talking to a person X rather than a machine for both patients and community partners. Community partners expect reasonable wait times for appointments X General practitioners are happy to refer to consultants as they are interested in providing input in care planning and also respect the role of X family physicians Community partners, such as family physicians, value access to a choice of X subspecialty care Access to antenatal care via GPs as the first contact X Value initiatives such as the ‘Shared Care’ program to teach residents and X

RVHS/-TSH Motion 1b Collaborative – 2014 Workbook – Maternal Child youth Page 5 of 27

GPs to provide antenatal care

Sustainability Patient / Voice of our Customers Community GP Summary of Key Points Member There is a perception amongst some members of the community that Modern and aesthetically women’s and children’s facilities outside the region are nicer and more X pleasing facilities influence modern than in Scarborough. patient choices Regular maintenance and upgrades to existing facilities is important to X remain competitive with downtown Toronto hospitals It is suggested that TSH and RVHS communicate about the great work being X done and the improvements in care delivery to the local community

Excellence Patient / Voice of our Customers Community GP Summary of Key Points Member Providers need to respect the patient’s birth plan X Patients/families expect a high TSH and RVHS need to work to establish a reputation of excellence as this level of clinical quality of care X perception is not widely known in the community in all hospitals. Other aspects of Provide regional Pediatric service excellence X quality such as customer Staff need to consistently be compassionate, respectful and provide good service, respect and choice can X quality care make a big difference in

RVHS/-TSH Motion 1b Collaborative – 2014 Workbook – Maternal Child youth Page 6 of 27

Many patients value a breastfeeding friendly organization and may choose differentiating hospitals. X a hospital based on their reputation with respect to breastfeeding. For many women, natural child birth is their preferred choice and to not X wish to be pushed into a C‐Section unless absolutely necessary. Birthing space/ patient room needs to feel comfortable and safe. X Labouring and recovering in the same room is important. The patient/family experience would be enhanced if more support could be provided to parents of hospitalized children on isolation (for example, X provide meals to patients so they do not have to leave their child’s room)

New Vision Statement

Our vision statement defines the optimal desired future state of what both RVHS and TSH want to achieve over time to enhance our healthcare system across the CE LHIN. It will provide guidance and inspiration as to what we are collectively focused on achieving. The working group reviewed the Guiding Vision by RVHS and TSH to Support Facilitated Integration Activities, Scope Identified in the 2013 Maternal Child Workbook and the Voice of the Customer in advance of drafting the following vision statement:

RVHS/-TSH Motion 1b Collaborative – 2014 Workbook – Maternal Child youth Page 7 of 27

2013 Guiding Principles and Measures

Using the framework of the four guiding principles5 – Collaboration, Accessibility, Sustainability, and Excellence (CASE)—both hospitals identified significant opportunities and benefits during the 2013 facilitated integration sessions to improve care, access, and value for our patients. We will continue to exemplify leadership in health care transformation by continuing to following these guiding principles which illustrate the CASE for change:

COLLABORATION ACCESSIBILITY SUSTAINABILITY EXCELLENCE We believe that collaboration We believe in providing We believe that we must We believe that we must never waver will lead us to better solutions. accessible patient care to our find new solutions to sustain from our responsibilities to provide community. our health care system. quality patient care and to be accountable to our stakeholders.  Stronger together  Improve patient access to  Maximizing opportunity  Established care practice protocols care for funding (i.e. ambulatory care, low‐risk  Allowing staff to work well midwifery services) together  Patient access to own chart  Use BORN metrics  Performance scorecard  Create strategic alliances  Flexible staffing models to  Develop appropriate support patient care needs funding model  High volume can mean high quality  Quality of work life for all staff

(fluctuating census/acuity) service  Recruitment/Retention of  staff Seamless access to care across the 3 Scarborough Rationale  Partnerships with Central East Hospitals LHIN Hospitals  Cross site bed management  Maximize/align current system Medical specialty resources  /services thereby increasing Common referral and intake access to patients system

5 RVHS and TSH Facilitated Integration Maternal Child Due Diligence 2013 Workbook – Final Report. Pg. 49‐51 RVHS/-TSH Motion 1b Collaborative – 2014 Workbook – Maternal Child youth Page 8 of 27

 Necessary support services  Develop quality metrics  Care delivery model that is patient (i.e. paediatric anaesthesia for ambulatory services centered, where patients are support) (current focus is on engaged in their care inpatient activity)  Seamless outpatient services  Increased critical mass to improve  Develop funding model for quality and safety  Seamless care across hospital based paediatrics continuum (1‐800‐ find a provider to meet needs  Ability to attract critical (patient navigator) mass

(continued)  Electronic records  Opportunity to explore

economies of scale  Patients access “high risk” programs within the  Alignment of clinical

Rationale Scarborough boundaries services with community (currently patient are and Central East LHIN leaving Scarborough and the needs Central East LHIN)  Reduced unnecessary  Increased ambulatory duplication volumes

RVHS/-TSH Motion 1b Collaborative – 2014 Workbook – Maternal Child youth Page 9 of 27

 Recruitment and retention  Number of new referrals  Bed occupancy  Patient satisfaction  Number of physician referral  Wait times for outpatient  Cost per case  Emergency room wait times sources services  Length of stay  BORN indicators  Staff and physician satisfaction  Number of transfers  Market share between sites

Indicators  Dollars raised through  Repatriate patients who fundraising seek care outside of Scarborough catchment  BORN indicators

Measures/ area and outside of Central East LHIN  Market Share

RVHS/-TSH Motion 1b Collaborative – 2014 Workbook – Maternal Child youth Page 10 of 27

Session 2: Wednesday August 13th, 2014 Questions to spark dialogue on the potential future state of Level 2b NICU and Advanced pediatric care in the Scarborough Community were posed to working group participants:

1. What does the ideal future state of neonatal and pediatric clinical services look like? 2. What can be accomplished by consolidating volumes? 3. What can be established through collaboration and integration? 4. What are the clinical opportunities offered by Motion 1b?

There were 5 common themes that emerged from the participants:

Theme Specific answers

Access Easy access One stop shop Enhance care close to home (decrease expenses, respect for time, etc.) All three sites have capacity Access to food services for patients After hours specialty clinics Geographical proximity of services Cohorting high needs patients with access to specialists and enhance services Accessibility to personal health information One touch point for access Improved wait times

Coordination Strong relationships Governance structure and stakeholder buy‐in IT infrastructure Seamless care ‐ better coordination of services Pediatrics and neonatal located near obstetrics Good information flow Interdisciplinary care coordination Required infrastructure for coordinated care Physician sharing Established referral patterns

RVHS/-TSH Motion 1b Collaborative – 2014 Workbook – Maternal Child youth Page 11 of 27

Safety Standardized, quality/evidence‐based care Opportunity to learn from each other ‐ develop expertise Ability to care for high risk mothers and babies Improved competencies with improved volumes Consolidate the care of high acuity volumes Improved Clinical breadth

Resources Improved human resource planning Leveraging expertise and experience Increased efficiencies Reduced costs due to economy of scale Better use of scarce resources – for example, beds Shared access to resources

Branding/Attracting Attract and support needed support services E.G Anesthesia, IV teams Promote centres of excellence, use sub‐specialties to attract providers and patients Attract people and attract funding Unified voice for the CE LHIN to enhance funding opportunities Rebrand and improve regional market share Create an identity for all three hospitals Improve our reputation and have sense of community Market our services to our community Develop a human resources plan to attract key staff Enable us to get out and hear our patients/communities

Patient Comprehensive continuum of care and services to meet the community choice/Patient needs centered Develop specialized services for pediatric complex care Keep the babies in our community Enhance current services and have more acute services in Scarborough Enhance sub‐specialty services Expand patient choice Provide more complex services

Different versus Preserved:

RVHS/-TSH Motion 1b Collaborative – 2014 Workbook – Maternal Child youth Page 12 of 27

Participants were asked to provide input on what was felt needed to be different and what should be preserved in our desired future state of Level 2C NICU and Advanced Pediatrics in the Scarborough Community.

Different Preserved Increased collaboration across all three Safe care hospitals Regional advanced pediatric and neonatal Basic pediatrics/neonatal/obstetric care at all three centre established sites

Improved pediatric services/skills in ED Timely support to the ED

Access to enhanced services (i.e. addictions, Current outpatient clinics autism, PPD, teen pregnancy, mental health, complex care)

True family‐centered care Quality, safety and care Improved standardization of care Regionalized/advanced centre Preserve what we have and our ability to care for level 2c Improved access to patient information Preserve our staff and not lose what we have (e.g. electronic access) Centre of excellence Quality of service Uniform practice Increased market share Increased complex services Relationship with other providers

RVHS/-TSH Motion 1b Collaborative – 2014 Workbook – Maternal Child youth Page 13 of 27

Requirements for our Future State

Specific elements required to successfully design for our future state were developed by the Working Group and summarized into themes of Cost, Efficiencies, Patient Centered, Technological; Capacity and Workforce

Theme Specific answers

Cost Affordability of new model Cost efficiencies to be gained Sustainability of programs offered Efficiencies No unnecessary duplication of services/processes Improve wait times for patients and families Reduce redundancies across sites in the cluster Standardize policies, procedures and best practices

Patient centered Patient experience focus for design Ability to labour and recover in the same room Ability for parents to room with child (new born to pediatrics) Diversity of services to meet patients’ needs Centrally located services Cheap parking Patient and family centered care to inform design on new model

Technological Need to innovate Use of phone and video for consultations E‐charting, E‐registration, scheduling, link with other providers E‐patient support Innovate to attract funding

Capacity and Workforce Capacity, human resources, workforce planning Consolidate human resources – for example, physician sharing 24/7 onsite availability of certain services (for example, IV teams) Access to support services Required infrastructure Ambulatory care outside of hospitals Strengthen relationships to maintain expertise

RVHS/-TSH Motion 1b Collaborative – 2014 Workbook – Maternal Child youth Page 14 of 27

Enablers and Barriers

Five emerging themes from the previous exercises were used to populate enablers and barriers to forward progress and achievement of our future state.

“One Stop Shop” Enablers Barriers Current Enablers Current Barriers Tailor model to communities – technology Siloed services (i.e. remote monitoring) needs Expertise/resources Unclear definition of one stop shop and validity of developing one – for example, for advanced neonates and pediatrics or all neonates and pediatric patients Geographically difficult to achieve Future Enablers The will to make it happen Funding Seamless referrals Seamless care Creation of one program with several sites Service to deliver complex care Chart record

Collaboration/Relationships Across Hospital Providers Enablers Barriers Future Enablers Current Barriers Seamless transfer of children re. specialty Decrease in desire to collaborate (fear of loss) care Joint governance model No single governance structure Motion 1B ‐ process Loss of patience Sharing of patient information to streamline Community anxiety Good communication No shared platform to access personal health info Improve diversity opportunities by sharing Lack of trust between the organizations among providers Helping communities understand that it is History of relationships between organizations not a loss but an enhancement of their services

RVHS/-TSH Motion 1b Collaborative – 2014 Workbook – Maternal Child youth Page 15 of 27

Future Barriers Patient‐driven perspective Provider risk (uncertainty that patients will follow) Increase in volumes, patient population Trust that resources will flow appropriately with growth service changes

Branding to Increase Market Share and Stakeholder Buy‐In Enablers Barriers Perceived value by consumers Poor understanding of available services Good communication about available Siloed and don’t promote each other’s services services Working together to enhance branding Poor communication of marketing services Confidence in outcome data that confirms Financially established families moving out of we are achieving desirable outcomes – Scarborough auditing and publishing performance to higher minimum standards of care to increase public and provider confidence Transparency of data No aggressive marketing strategy Increased branding Lack of branding Integrity to process Location of services Increase in complex services Competing agendas Technology Loss of purpose/apathy Provide improved increased provider Loss of celebration of events training, information for consumers Instill confidence in the community that care (Future) decrease in available funding close to home is where they should be Families need to know “What am I going to What we are do? Where can I get my care?” We will What we offer navigate you through the complex system Positive messaging around lives of families, care of families

Attract and Better Utilize Scarce Resources Enablers Barriers Joint fundraising across all three hospitals Competition with adult population (i.e. geriatrics) Operating at full scope of practice Relatively, obstetrics and pediatrics services are expensive Alternative providers (i.e. midwife, NPs) Fluctuating census adds cost Quality metrics Public perception of hospital reputation and desire to collaborate/partner with other organizations

RVHS/-TSH Motion 1b Collaborative – 2014 Workbook – Maternal Child youth Page 16 of 27

Easily recruit with existing expertise People compare community by hospital with specialized tertiary care (i.e. HSC, Mount Sinai) Linkage to Sick Kids/University of Toronto No aggressive marketing strategy Community fundraising Lack of branding Sense of community Decrease in volumes Funding (new or existing) No stability/confidence HHR competition Lack of collaboration Accuracy of volume projections May take initial investment and may be difficult to be successful MD incentive (i.e. OR time)

Regional Centre of Excellence Enablers Barriers Special environment that looks designed for Win/lose perspective pediatrics and families Strong people Lack of clarity Increased desire to improve services Lack of medical leadership to attract funding (volume proposition) Increase in market share Existing HHR – strong provider foundation Consolidated different clinical services at one Does this have to be stated this way? Implies site inferiority/superiority, not important terminology for our patients. Expand the program and do more Program system attracts excellent providers without financial burdens High quality Committed providers Regional relationships (i.e. community, political) Volume of activity Infrastructure (space, capacity growth) Leadership support (i.e. RVHS strategic plan)

RVHS/-TSH Motion 1b Collaborative – 2014 Workbook – Maternal Child youth Page 17 of 27

Session 3: Wednesday September 3rd, 2014 Each organization presented a preferred future state model and shared the rationale and key considerations for the proposal. These presentations can be found on the Leading for Patients website here.

The facilitator group presented a summary of the Motion 1b Collaborative clinical questionnaire that had been distributed prior to the September 3rd session. The results of the questionnaire are found in here.

The facilitators then asked the Motion 1b Collaborative to identify the existing services that form part of advanced regional neonatal and paediatric services. The Collaborative identified the following:

Inpatient Outpatient Both

Endocrinology – Diabetes, Dermatology – e.g. Oncology ‐ Ophthalmology Diabetic Ketoacidosis Stephen Johnson’s Chemotherapy, Syndrome, Burns ongoing follow up, diagnosis and care for patients with suspected sepsis

Gastroenterology ‐ Irritable Respirology ‐ Outpatient Gastroenterology ‐ Bowel Disease (unstable), Tracheotomy Care, Diabetes Paediatric rectal bleeding Asthma and Status gastroscopy, Asthmaticus, colonoscopy bronchiolitis, pneumonia, acute respiratory distress syndrome and pneumothorax

Oncology – Chemotherapy, Cardiology‐ Palliative care diagnosis and care for Supraventricular patients with suspected Tachycardia sepsis

Haematology – e.g. Sickle Orthopedic – Trauma, Paediatric Cell Crisis Scoliosis Interventional Radiology

Neurology ‐ Developmental Nephrology – acute Patients with Acute renal failure

RVHS/-TSH Motion 1b Collaborative – 2014 Workbook – Maternal Child youth Page 18 of 27

Episodes, Neurological Seizures

Surgery ‐ Scoliosis, gastroscopy, colonoscopy, pulse dye laser and surgery for children less than 1 Year of age

Complex care‐ Developmental Patients with Acute Episodes, Tracheotomy Care

The facilitators asked the Motion 1b Collaborative to identify the existing services that require further development which would form part of advanced regional neonatal and paediatric services. The Collaborative identified the following:

Inpatient Outpatient

Mental Health‐ Addictions Treatment Mental Health‐ Addictions Treatment

Respite Service Complex Care

Paediatric Complex Care Developmental ‐ Autism

Mental Health ‐ Eating Disorders

RVHS/-TSH Motion 1b Collaborative – 2014 Workbook – Maternal Child youth Page 19 of 27

To complete the exercise, the facilitators asked the Motion 1b Collaborative to identify new services that would require future development to create an effective advanced regional neonatal and paediatric services. The Collaborative identified the following:

Inpatient Outpatient

Paediatric Surgery Medicine Obesity

Respiratory – Complex Continuing Care Paediatric Complex Care Chronic Ventilatory Respite Care Neurology – Overnight EEG Complex Care Palliative Care (respite) Palliative Rehabilitation‐ Developmental Assessment and Treatment (regional Stable, post‐head injury focus) Autism Expanded Mental Health services Dermatology Adolescent medicine Adolescent Gynecology Teen (Sexual health, abortion services, sexual assault) Respite Service

RVHS/-TSH Motion 1b Collaborative – 2014 Workbook – Maternal Child youth Page 20 of 27

Session 4: Wednesday October 1st 2014

The RVHS‐TSH Motion 1B Collaborative inter‐professional team met for the fourth time on October 1st to continue the work outlined by the March 27th, 2013 Central East Local Health Integration Network (Central East LHIN) motion. This meeting achieved the following primary objectives: 1. The Collaborative reviewed current state information from TSH and RVHS. 2. The Collaborative discussed six proposed options by TSH and RVHS. The group completed a convergence exercise and agreed to consider three of the six proposed models. Rationale for rejecting a model was provided by the group. 3. Design criteria, against which the models will be evaluated, was reviewed and approved by the group pending incorporation of recommended modifications.

Current State

Both organizations presented a current state overview of Maternal Child and Youth Services. The presentations can be found on the Leading for Patients website here.

Proposed Regional Planning and Oversight Models

Each organization presented three proposed future state models and shared the rationale and key considerations for the proposal. These presentations can be found on the Leading for Patients website here.

Design Criteria

The facilitator group presented 23 design criteria against which the three proposed models would be evaluated. The Motion 1b Collaborative discussed each criterion and agreed to review a synopsis of the three proposed models by Oct 15, 2014 and to complete the evaluation individually via an online survey by October 21, 2014. The design criteria can be referenced on the Leading for Patients website here.

RVHS/-TSH Motion 1b Collaborative – 2014 Workbook – Maternal Child youth Page 21 of 27

2. Phase 2 – Designing the Model of Care

Details of the work completed in Phase 2 can be found in the Final Report for Motion 1b.

RVHS/-TSH Motion 1b Collaborative – 2014 Workbook – Maternal Child youth Page 22 of 27

3. 2014 MCY Workbook Sign-Off

Identify the individuals that were involved in the completion of the 2014 MCY Workbook.

NOTE: The following individuals participated in the completion of this workbook. It was agreed at the outset that individuals who are unable to attend meetings are welcome to send a delegate. It was the responsibility of the Working Group member and their delegate to keep each other up‐to‐date on Working Group discussions. In addition, draft workbooks were posted for broad stakeholder review and feedback after each meeting. It is understood that all Working Group members are supportive of the information contained in the 2014 MCY Workbook.

Organization ‐ Program Team Member:

Rouge Valley Health System – Women’s and Children’s Program

The Scarborough Hospital – Women’s and Children’s Program Community Member Community Member Community Member Community Member Family Physician Family Physician Family Physician CE LHIN Representative CE LHIN MCY Advisory Committee Representative Rouge Valley Health System – Women’s and Children’s Program The Scarborough Hospital – Women’s and Children’s Program Rouge Valley Health System ‐ Paediatrics Rouge Valley Health System – Anaesthesia Rouge Valley Health System ‐ Midwifery Rouge Valley Health System ‐ Paediatrics Rouge Valley Health System ‐ Obstetrics Rouge Valley Health System – Anaesthesia The Scarborough Hospital ‐ Paediatrics The Scarborough Hospital – Obstetrics The Scarborough Hospital – Obstetrics

RVHS/-TSH Motion 1b Collaborative – 2014 Workbook – Maternal Child youth Page 23 of 27

Organization ‐ Program Team Member: The Scarborough Hospital – Paediatrics The Scarborough Hospital – Obstetrics The Scarborough Hospital – Paediatrics The Scarborough Hospital – Midwifery The Scarborough Hospital ‐ Anaesthesia

RVHS/-TSH Motion 1b Collaborative – 2014 Workbook – Maternal Child youth Page 24 of 27

PHASE 2: Designing the Model

PAGE 49 Phase 2 – Designing the Model

The scope of work for this phase addressed the specific direction set out by the Central East LHIN in Motion 1B.

1. Overview of the current state of Maternal‐Child‐Youth services within the Scarborough Cluster Both RVHS and TSH decision support departments worked together to create detailed descriptions of the current state utilizing a common set of data sources and definitions. Data was gathered on community demographics and service utilization. Information about the current state can be found in the RVHS‐TSH Environmental scan, and the RVHS‐TSH Current State Overview 2014.

2. Provides a future state that: Informs siting and sizing of in‐patient and out‐patient programs and volumes The vision statement shown above describes the desired future state. The RVHS‐TSH Current State Overview 2014 provides a description of assumptions related to growth in the Scarborough cluster and Central East LHIN.

3. Provides a future state that: Includes Stakeholder input and commitment The Motion 1b Collaborative was structured to facilitate broad stakeholder input throughout the initiative. Membership in the collaborative group included a diverse set of stakeholders, including hospital physicians, management, consumers and community‐based primary care physicians. The first meeting of the Collaborative working group included a ‘voice of the customer’ panel discussion and the output of this conversation can be found in the 2014 Maternal Child Youth Workbook. Transparency was maintained between the Collaborative team and the community by posting the Motion 1b 2014 MCY Workbook on the Leading for Patients website, which was updated with the outcomes and key messages of each completed phase. Documentation providing a qualitative and quantitative representation of RVHS‐TSH MCY services was also posted on the website for public viewing and to assist in the evaluation process of the proposed future state.

4. Provides a future state that: Includes performance goals related to access and quality In a facilitated group session using the framework of the four guiding principles – Collaboration, Accessibility, Sustainability, and Excellence (CASE) members of the Collaborative identified significant opportunities to improve care, access, and value for our patients. Guiding principles and metrics, including Appendix A, can be found in the 2014 Maternal Child Youth Workbook.

5. Provides a future state that: Details patient demographics and need for the next five‐ten years Clinical experts worked with both the RVHS and TSH decision support departments to identify appropriate patient populations in order to develop growth projections. The RVHS‐TSH Environmental Scan provides an overview of patient demographics and description of future growth.

6. Provides a future state that: Details physician supply and need for the next five‐ten years Working together, RVHS and TSH sourced the content in this section of the Motion 1b final report from physician and midwifery leaders, medical affairs databases, literature and the Ontario Physician Human Resource Data Centre. Using the 2010 Ontario Population Needs‐Based Physician Simulation Model developed in 2010; the Motion 1b Collaborative projected physician supply and need into the Physician and Midwifery Supply Report.

7. Provides a future state that: Addresses hospital consultation and emergency services coverage Coverage for hospital consultation and emergency services mapping the future state for MCY of the Scarborough cluster are detailed in the “Summary of Work” report from Leading Edge.

8. Provides a future state that: Identifies opportunities for integration, innovation and practice changes Opportunities for integration are detailed within both the 2013 Maternal Child workbook and the 2014 Maternal Child Youth Workbook.

9. Provides a future state that: Identifies risk and relevant mitigation strategies Enablers and barriers to the potential future state can be found within the 2014 Maternal Child Youth Workbook.

10. Provides a future state that: Demonstrates various options considered for the future state, and a preferred option eusing th Central East LHIN decision making framework and other relevant analysis Using the Central East LHIN Decision Making Framework, RVHS and TSH worked together to develop twenty‐four (24) Motion 1b‐specific criteria to evaluate potential models. A detailed description and clear linkage between the framework and Motion 1b Design Criteria slide deck. Due to the number of potential options available for consideration, the Motion 1b planning committee agreed that both RVHS and TSH would initially propose three (3) preferred models each. The three RVHS models can be found in the presentation to the Collaborative, and the three TSH models can be found in the presentation. The Collaborative working group, with the facilitation support of Leading Edge, then collectively reviewed these models and further refined the potential options to three models: one originating from RVHS and two from TSH. In addition to the summary table below, a description of the RVHS model and descriptions of the TSH models are enclosed in this section of the report.

Table 1: Overview of Final 3 Evaluated models Central East LHIN TSH Center for RVHS Center for Integrated Regional Regional Advanced Regional Advanced Advanced Neonatal and Model Element Neonatal and Neonatal and Paediatric Program for Paediatric Care Paediatric Care Scarborough Cluster TSH Recommendation RVHS Recommendation TSH Recommendation Lead organization The Scarborough Rouge Valley Health Single Lead Agency not for regional Hospital System defined advanced paediatric program Lead organization The Scarborough Rouge Valley Health Advanced Neonatal for regional Hospital System programs within the advanced neonatal TSH‐G and RVHS‐C sites program Planning and Regional steering Regional planning, TSH‐G, TSH‐B and RVHS oversight structure committee coordinnation and jointly provide regional (governance) oversight committee leadership, governed by an accountability agreement and memorandum of understanding

To better understand the Collaborative’s preferences, the Central East LHIN administered a survey, on behalf of the two hospitals, using the Expert Choice tool and the twenty‐four (24) agreed upon Motion 1b criteria. The Central East LHIN staff took all possible steps to ensure the survey process was fair and equitable. Given the number of potential options available, having both RVHS and TSH independently identify the same model with a single organization leadership structure supported by a multi‐organizational planning and oversight committee is a significant accomplishment. Woorking together, the Motion 1b Collaborative have been able to gain broad agreement with 25 of the 31 survey respondents ranking this model type 90 points or higher using the Central East LHIN decision making framework. Some concern about the bi‐modal distribution of the survey responsees was expressed by members of the Planning Committee. To resolve this issue, Central East LHIN staff proposed a methodoloogy to remove outlier survey responses with the three highest and three lowest scores triimmed from the final scoring from each of the three models. Both the adjusted and unadjusted values from the survey responses are presented in the final report.

The Motion 1b Planning Committee expresses gratitude to the Central East LHIN staff for their generous offer to support the survey and analytical processes. Table of Contents Summary of Work from Leading Edge ...... 55 Section 1: TSH‐RVHS Environmental Scan 2014 ...... 107 Section 2: TSH‐RVHS Clinical Services Survey Results 2014 ...... 135 Section 3: TSH‐RVHS Current State Overview 2014 ...... 164 Section 4: TSH‐RVHS Physician and Midwifery Supply Report ...... 196 Section 5:H TS ‐RVHS Motion 1b Design Criteria ...... 204 Section 6: TSH Three Proposed Service Delivery Models ...... 212 Section 7: RVHS Three Proposed Service Delivery Models ...... 231 Section 8: TSH Synopsis of 2 Preferred Service Delivery Models...... 263 Section 9: RVHS Synopsis of 1 Preferred Service Delivery Model...... 271 Section 10: Motion 1b Collaborative Service Delivery Model Evaluation Results ...... 274

Facilitation Support for Maternal, Child, Youth Regional Planning Process Central East LHIN, Rouge Valley Health System and The Scarborough Hospital

Prepared and delivered by Leading Edge Group 1/19/2015

0 | Page

Table of Contents

Table of Contents ...... 1 1. Executive Summary ...... 2 2. Background and Client Requirements ...... 4 3. Approach ...... 7 4. Workshop Two ...... 8 5. Workshop Three...... 15 6. Workshop Four ...... 24 7. Conclusion ...... 29 8. Appendices ...... 30

1 | Page

1. Executive Summary.

Leading Edge Group (LEG), represented by Mr. John Whelton, Dr. Lorne Martin, Jane Bishop, and Patsy Morrow, was engaged by Rouge Valley Health System (RVHS) and The Scarborough Hospital (TSH) to provide the hospitals with facilitation services related to a regional planning process for maternal, child, and youth services for residents of the Central East Local Health Integration Network.

Dr. Lorne Martin is currently the Chief of Staff of Halton Healthcare Services and has experience in the development and deployment of regional clinical programs in Ontario’s Local Health Integration Network environment as well as extensive experience as a senior physician leader. Jane Bishop has expertise and experience in Lean Six Sigma project work and facilitation in health care in Ontario. Jane has a Master’s Degree in Strategic Quality Management and Lean Systems and is a registered nurse by background. Patsy Morrow has expertise in Lean Healthcare Quality Improvement and has assisted numerous organizations including the Ministry of Health and Long-Term Care in Ontario. Mr. John Whelton is the Vice President of North American Operations for Leading Edge Group and provided overall direction for the project.

LEG provided facilitation support for three workshop forums attended by representatives of the hospitals and the Central East LHIN. The project was developed by the hospitals in response to direction from the Central East LHIN to develop a service delivery model for Maternal-Child-Youth (MCY) services, as well as a plan for a LHIN regional program for advanced neonatal and paediatric care. A joint planning committee composed of RVHS and TSH senior leadership, staff and physicians, supported the facilitators.

Following a review of background materials and interviews of key stakeholders identified by the hospitals the facilitators led three intensive evening workshops attended by medical leadership, staff physicians, senior leaders, managers and staff as well as representatives from midwifery, the community and the Central East LHIN. The workshops focused on assisting the hospitals in responding to the Central East Local Health Integration Network’s direction as set out in the Central East LHIN Clinical Services Plan of 2009, the amended Motion 1b, and correspondence from the LHIN to the hospitals. The workshops

2 | Page

were structured so as to engage participants in active discussion around potential future models of MCY care in the context of the expectations established by the Central East LHIN.

The workshops were exceptionally well attended with all attendees actively participating. Both hospital organizations approached the facilitated project and workshops in good faith, actively representing their individual responsibilities to their respective service communities, as well as their responsibility to work together to collaboratively plan for and deliver MCY services to the region and the Central East LHIN.

Issues that arose during the workshops requiring further elucidation included: governance, program structure and operational leadership. While the workshops explored various options for siting of services they did not conclude with an agreed upon recommendation for the siting of advanced neonatal and paediatric services. The output of the final workshop was three models for further consideration by the respective organizations.

3 | Page

2. Background and Client Requirements

The client hospitals requested facilitation support for a joint planning process to guide a response to direction from the Central East LHIN to develop a service delivery model for maternal, child and youth services. Previously, the Central East LHIN had undertaken a Clinical Services Plan project to examine the feasibility of horizontal integration of health services within the region. The resulting Hospital Clinical Services Plan, published in 2009, articulated a vision of integrated healthcare that delivered high quality, safe and operationally efficient care. Included in the vision was an overarching goal of developing centres of excellence and, where appropriate, introducing new clinical services at one site in the LHIN, where such services would otherwise not be viable or sustainable at multiple sites. The Clinical Services Plan made recommendations to develop new program delivery models for cardiac, mental health and addiction, thoracic surgery, vascular surgery, and maternal-child-youth (MCY) services.

Recommendations within the Clinical Services plan for MCY services were intended to provide for enhanced subspecialty services, and a specific recommendation was made to “Establish a centre for Advanced Level 2 in-patient Neonatal care to be sited in the Scarborough cluster [and to] consider a centre for Advanced in-patient Paediatric care co-located with the advanced Level 2 in-patient Neonatal Centrei.” While horizontal integration has occurred to some extent in other clinical programs, to this point, despite much work and collaboration, the hospitals have not yet come to an agreed upon approach to respond to the MCY recommendations. During the more recent timeframe, while horizontal integration of the specified clinical programs was being undertaken, discussions were also underway with respect to the amalgamation of the two Scarborough hospital corporations. More recently amalgamation discussions have ceased, which has to some extent prompted the renewed focus of efforts to integrate clinical services within the Scarborough cluster of hospitals, as set out in the LHIN Clinical Services Plan.

In March of 2013 the Central East LHIN Board directed the hospitals with Motion 1b requiring the hospitals to work together with local stakeholders to develop a service delivery model for maternal- child-youth services for the Scarborough cluster, as well as a plan for a LHIN regional program for advanced neonatal and paediatric care. Motion 1b set out specific deliverables including the requirement to provide for a future state that informed siting and sizing of in-patient and out-patient

4 | Page

programs. In June of 2013 the LHIN subsequently approved the hospitals moving forward with a facilitated integration process and amended Motion 1b to include the requirement to consider the findings of the expert panel review of the Scarborough Hospital maternal newborn and women’s health and surgical models, as well as to develop the plan in consultation with physician leaders. In May of 2014 the Central East LHIN, in a letter to the Board Chairs of TSH and RVHS, recommended establishment of a shared governance model to strategically support all planned integration work between the two hospitals. In that correspondence the LHIN confirmed that the intent of the Clinical Services Plan was to provide for enhanced clinical services not currently provided for within the Central East LHIN and that there was an expectation that there not be any material change to the current delivery of MCY services at any of the hospital sites in the Scarborough Cluster.

Leading Edge Group was engaged to facilitate the two hospitals in their work to address the direction of the Central East LHIN as expressed in the amended Motion 1b, and in the context of the expectations set out in the Clinical Services Plan. Prior to the facilitated work the hospitals had undertaken a first workshop for the project – Workshop 1, at which time the voice of the customer was heard via presentations from former patients. Workshop 1 continued the work of developing a shared vision and commitment between the two hospitals to moving forward on planning for the delivery of MCY services.

Prior to the engagement of LEG, the hospitals had worked together via a joint planning committee structure and had developed a work plan for the facilitated project. The work plan set out the requirement to undertake three additional working group sessions, in a workshop format, subsequently referred to here in this report as Workshops 2, 3, and 4 (Workshop 1 having been completed prior to engagement). The work plan described four phases of activity, with Phase 2 encompassing the facilitated work of gaining consensus towards redesign of the clinical model for the delivery of maternal youth and child services. Phase 1 set out the need to establish a joint governance and oversight structure as referenced above (at this point pending) and continued the collaborative project related to Motion 1b. Phases 3 and 4 were intended to focus on implementation and evaluation respectively.

Expectations for the workshops included the requirement to create an environment of trust, promote open sharing of ideas, ensure engagement of participants and, to the extent possible, achieve consensus. The facilitators were requested to assist in ensuring the completion of the deliverables

5 | Page

related to Phase 2 and Motion 1b as well as assisting in both the preparation and documentation of the outcomes of the 3 workshops.

The planning committee provided extensive support to the facilitators, with TSH Executive Vice President Marla Fryers and RVHS Vice President Michele James undertaking lead responsibility on behalf of each organization. The work of the facilitators was directly supported by Scott Ovenden - Director of Transformation at RVHS, and Alfred Ng - Director, Innovation and Performance Improvement Office, Clinical Operations Support at TSH.

The work of this project has occurred within the broader provincial context of the guidance provided by the Provincial Council on Maternal Child Health (PCMCH). The PCMCH has, to this point in time, developed formal “Levels of Care Clinical Guidelines and Implementation Standards” for neonatal care. These guidelines set out 3 distinct levels of care. In recent years, via a process of self-identification and subsequent PCMCH review and confirmation, acute care hospitals in Ontario have received official designation with respect to the level of neonatal care they provide. The PCMCH is in the process of undertaking analogous work for paediatric clinical services. Prior to the work of the PCMCH the province, in partnership with the Hospital for Sick Children, created the Child Health Network, which established the initial regional system of care for paediatric services. The Child Health Network was subsequently supplanted by the PCMCH. In 2011,the General site of TSH and the Birchmount site of TSH were both designated level 2B for neonatal care. RVHS had been designated level 2C for neonatal care. In September 2014, during the course of the facilitated work the General site of TSH received a 2C designation similar to the RVHS designation but without the authorization to manage newborns delivered at 30 to 32 weeks gestation pending the completion of a provincial study

6 | Page

3. Approach

Planning committee meetings occurred on an approximately weekly basis and as needed to guide the project and the development and execution of the workshops. Structured agendas and materials to support the workshops were developed with the assistance of the planning team. Project support was provided by Stephanie Singh from the Project Management Office at The Scarborough Hospital, and administrative assistance was provided by Melissa Alvares from The Scarborough Hospital and Savannah Clancey from RVHS,

As part of the initial preparation for this engagement LEG facilitators were provided with and reviewed an extensive list of background and reference materials related both to the specific evolution of MCY services in Scarborough and, more generally, to the organization and delivery of MCY services in Ontario (see Appendix 1). In addition, the hospitals provided comprehensive data on health human resources; case volumes for obstetrics, paediatrics and neonatal care; market share data; average length of stay data and additional relevant metrics related to MCY services. The facilitators also toured of the clinical facilities at each of the 3 Scarborough hospitals.

The facilitators interviewed individuals responsible for the management, organization and delivery of MCY services in the Scarborough hospitals. Interviews were conducted at each of the 3 Scarborough hospitals over a two day period. Telephone interviews were utilized for additional interviews. A summary of the interviews was provided to planning committee and to workshop 3. A list of those interviewed can be found at Appendix 2.

The interviews were undertaken to provide the facilitators with sufficient background information to understand the major issues that would shape discussions during the workshops, and also to understand the role of the various workshop attendees. Interviews also allowed individuals an opportunity to provide opinion as to options for building consensus going forward, as well as opinions on various models of regional MCY services.

The workshops were intended to bring the teams from both hospitals together in a forum that would allow for:

7 | Page

• Building trust amongst the participants • Developing ideas for future MCY program structure and delivery • Discussing siting decisions related to the advanced neonatal and advanced paediatric services • Providing input to the planning committee for subsequent workshops and next steps.

The workshops were not intended to be decision-making forums, and did not have authority to make decisions or bind either Hospital Corporation or the LHIN.

Schedule of Events

Interviews July 3, 4, 2014 Workshop 2 - August 13, 2014 Workshop 3 - September 3, 2014 Workshop 4 - October 1, 2014

4. Workshop Two

Planning: Following the completion of stakeholder interviews, LEG facilitators commenced specific preparations with the planning team for the August 13th workshop (Workshop 2) to develop and agree upon a suitable approach.

As a part of the preparation, the planning team and LEG established a relevant agenda, the appropriate number and mix of participants and a seating plan to ensure that participants from each organization and the Central East LHIN were evenly distributed among the tables. Consideration was also given to achieving an even distribution based on organization, clinical specialty and discipline. It was felt that this format would be most conducive to ensuring that comprehensive and well-balanced opinions and ideas were generated at each table.

8 | Page

The participants were divided into four tables of 10 people each. Each table had its own facilitator who was a member of the planning team. For continuity across the workshops, the four table facilitators remained the same. They were:

Scott Ovenden - Director, Transformation Management Office, RVHS Alfred Ng - Director, Innovation and Performance Office, TSH Cassandra Koitsopoulos - Improvement Facilitator, TSH Catherine McConnachie - Change Management Specialist, RVHS

The Agenda for Workshop 2 is provided below:

9 | Page

The Agenda for Workshop 2 is provided below: Time Agenda Item Description/Method Approach/Desired Owner Outcome

5:00 – 5:10 Introduction • Marla/Michele introduction and welcome Marla/Michele • Facilitation Team introductions Lorne/Jane • Outline the roles of the facilitators and work undertaken to date Lorne/Jane • Outline the deliverables from this workshop

o Review of Workshop 1 Review of Environmental Scan/Community o Lorne/Jane Description o Consensus building towards a preferred future state model o Preparation for Workshop 3 and the siting decision • 5:10 – 5:25 Central East LHIN • Presentation by Sheri Ferkl PowerPoint Sheri Ferkl Maternal, Child, Youth Working Group Update

5:25 – 5.40 Current State Overview • Review outcomes of Workshop 1: Vision, Draft Metrics Alfred/Scott Environmental Scan/Community Description, and Voice of the Customer

05.40-6.40 Defining the Preferred • What does the ideal future state of neonatal and paediatrics Table given instructions and Lorne/Jane/ Future State Model (The clinical services look like?

10 | Page

What) • What can we accomplish through collaboration and 5 questions for consideration Table facilitators integration?

• What do we want to be different? What should be preserved? • What can be accomplished by consolidating volumes? Facilitators’ feedback key • What are the clinical opportunities offered by motion 1B? themes to the room. All participants can add ideas to key themes

06.40pm- Break 7.10pm

7.10- Design Considerations • What system design elements need to be considered? (Critical Group work and feedback Lorne/Jane/Table 07.45pm (The How) mass, levels of care designations, affordability, absence of via facilitators facilitators duplication, distributed services, consolidated services, management structure, human resources etc.) All participants can contribute to ideas

7.45-0.8.40 Getting There • What is required to allow for actualization of the vision? Enablers and Barriers – Lorne/Jane/Table pm • What decisions need to be made? Template for guidance facilitators • Who needs to make them? Group work and feedback session

8.40-8.45 Wrap up and summary • Have we missed anything required to move forward to Lorne/Jane Workshop 3?

8:45 – 8:50 Work plan • Determine work-plan leading to Workshop 3 Lorne/Jane • What other information is required to inform the siting decision?

8:50 – 9:00 Next steps and Close • Date/Location for next workshop Marla/Michele • AOB

11 | Page

Execution

Workshop Two was held in The Scarborough Hospital General site and attended by 40 participants. Michele James and Marla Fryers opened the session and introduced the facilitators to the participants. The facilitators advised the group as to the format for the evening and answered any initial questions from the audience.

The first presentation was delivered by Sheri Ferkl from the Central East LHIN Maternal, Neonatal & Paediatric and advisory committee who advised the participants as to the role of this committee in assisting with the work required to fulfill motion 1 b. The planning committee then provided an overview of the outcomes of Workshop 1 including the vision, draft metrics, environmental scan/community description and voice of the customer (VOC) considerations.

Following these presentations, the LEG facilitators advised the participants as to how the activities for the rest of the evening were to be delivered. The first activity was designed to engage the groups in thinking about the services that would be required for neonatology and paediatrics in the Central East LHIN in the future (the “What”). The second activity then required the participants to consider design criteria that would be required to develop the future state (The ‘How”). The final activity asked the participants to identify the future state enablers and barriers.

12 | Page

Activity 1 – The “What” Participants were presented with a set of predefined questions to assist with defining the ideal future state of neonatal and paediatric services in the Central East LHIN:

• What does the ideal future state of service delivery for neonatal and paediatrics look like? • What can we accomplish through collaboration and integration? • What do you want to be different? What should be preserved? • What can be accomplished by consolidating volumes? • What are the clinical opportunities offered by Motion 1b?

The questions were addressed by each table, with each facilitator feeding back key themes and ideas. All participants were then given an opportunity to comment on, or question, each table’s ideas.

Activity 2 – The “How” The participants were asked to discuss the design criteria that should be included when designing the future state of neonatal and paediatric services across the Central-East LHIN. Some of the design element ideas presented by the facilitation team for consideration at each table were: critical mass; levels of care designations; affordability; absence of duplication; distributed services; consolidated services; management structure and human resources. The ideas from each table were then reflected back to the wider audience for comments and questions

Activity 3 The final activity leveraged a template to record the participants’ views as to potential future state barriers and enablers. The themes from the previous two exercises were collated prior to the final activity and participants explored potential enablers and barriers to the following themes;

• “One stop shop” • Collaboration and relationships across hospital providers • Branding and stakeholder buy-in • Better use of scarce resources • Development of a regional centre of excellence

13 | Page

Workshop 2 Outputs

The outputs from the three break-out sessions (Appendix 3) were as follows:

• Multiple ideas as to what the preferred future state should look like and what opportunities were available through collaboration • The design criteria that the participants felt should be used when developing the preferred future state for regional services • A list of potential current and future enablers and barriers to the development of the preferred future state as identified by the participants

Workshop 2 concluded with an open discussion in order to develop a work plan to assist with planning for Workshop 3. Participants asked for clarity surrounding the term “Advanced Paediatrics” and also requested some descriptive metrics to identify current state patient volumes in the region. In addition to this information, the participants also felt it would be useful to have a list of services currently available at each hospital site.

14 | Page

5. Workshop Three

Planning Workshop 3 was scheduled to take place on September 3rd. In preparation for this workshop, the planning team and facilitators determined how best to utilize the outputs from Workshop 2 to inform the agenda and format.

The facilitators proposed, and were supported by the planning committee, to develop and execute a survey oriented to clinical determinants of an ideal future state for hospital delivery of MCY services in the Scarborough cluster. 31 individuals responded to the survey. The survey did not produce consensus opinion regarding siting of advanced neonatal or advanced paediatric clinical services. The survey did demonstrate two differing viewpoints on the optimal overall configuration of advanced neonatal and paediatric services, with some advocating for consolidating services at one site and others advocating for a distributed model of care. The survey responses supported consideration for distributing outpatient ambulatory paediatric services and paediatric surgical services.

It was agreed by the planning committee that the survey results should be presented to the workshop participants and this was added to the agenda.

The Agenda for Workshop 3 is provided below:

15 | Page

Time (PM) Agenda Item Description/Method Approach/Desired Owner Outcome

5:00 to 5:10 Introduction • Welcome and introductions Lorne/Jane • Review of the evening’s agenda, set expectations for the evening’s work • Set the tone – firm, commitment to complete the task; reminder of the consequences of failure • Reaffirm expectations of the evening’s work • Relentless focus on being patient-focused

Michele/Marla

5:10 to 5:30 Presentation • RVHS Michele/Marla • TSH

5:30 to 5:50 Clinical services • Overview of the clinical services Lorne/Jane • Physical plant

5:50 to 6:10 Clinical Definitions and • Advanced neonatal services Presentation of survey results Lorne Gap Analysis-Phase 1 • Advanced inpatient paediatric services

• Advanced paediatric outpatient services • Paediatric surgery services

16 | Page

• Consolidated services • Distributed services 6:10 to 6:40 Future State - Phase 2 • Design and evaluation criteria Lorne/Jane/table facilitators

6:40 to 7:00 Break

7:00 to 8.20 Future State – Phase 3 Facilitated mapping exercise Lorne/Jane/table What services facilitators Consolidated Services o o Where

Future State – Phase 4

Distributed services

8:20 to 8:40 Feedback Session • Outcomes of future state sessions Facilitated discussion to Lorne/Jane/table review outcomes of future facilitators

state mapping sessions

8:40 to 9:00 Next steps and Close • Date/Location for next workshop Michele/Marla • Homework • AOB

17 | Page

Workshop 3 was held at the Centenary hospital site. Participants were evenly divided across four tables with a seating plan reflective of the diverse group of participants. Each table again had its own facilitator.

Execution

Following a presentation of the current state of services at RVHS and at TSH, the facilitators provided an overview of the survey results. Participants had an open discussion following this presentation.

The list of clinical services to be considered in the future state model was made available to the participants at each table. Each table was then asked to use post-it notes and butcher-block paper to group the services that they felt should be consolidated. There was much discussion as to what clinical services could be distributed and what needed to be consolidated and co-located. James Meloche from the Central East LHIN answered many of the questions that arose in relation to LHIN expectations regarding the siting of clinical services.

At the end of this activity, each table fed back its ideas to the wider audience. Good discussion arose regarding services that are not currently available in the Central East LHIN and that would be of value to the local population in the future. This discussion allowed the group to identify services that are available now, services that are somewhat available now but need further development and services that are not available now but could be in the future.

The discussion allowed for a general agreement that a LHIN-wide solution could be achieved through a collaborative approach to the design of the future state for neonatal and paediatric services.

18 | Page

Outputs: The outputs from Workshop 3 (Appendix 4) included a list of neonatal and paediatric services in the Central East LHIN that • Currently exist • Exist but require further development • Will be required in the future state

In addition to the clinical services grouping a list of ideas to facilitate collaborative planning going forward was also collated based on ideas from the participants.

Motion 1b Collaborative Clinical Questionnaire Results

Survey Results - 31 respondents

60% of respondents (18) identified RVHS-Centenary as their primary association 40% of respondents (12) identified TSH as their primary association

61% of respondents identified themselves as leadership/management 29% of respondents identified themselves as clinicians 7% of respondents identified themselves as customers

10 of respondents identified RVHS as the preferred site for advanced regional neonatal services (Centenary site specifically noted in most answers) 7 respondents identified TSH as the preferred site for advanced regional neonatal services (General site specifically noted in most answers)

13 respondents identified RVHS as the preferred site for advanced regional inpatient paediatric services (Centenary site specifically noted in most answers) 1 respondent identified RVHS or TSH as the preferred site for advanced regional inpatient paediatric services

19 | Page

2 respondents identified that advanced regional inpatient services should be distributed between RVHS and TSH

Advanced Inpatient Paediatrics Clinical Services

Asthma Congestive Heart Failure Chronic ventilation respite care Complex care Dehydration Developmental Diabetes Diabetic keto-acidosis Dialysis Neurology – overnight EEG Oncology Paediatric Intensive Care Unit or step down unit Palliative Repatriation – trauma Respite care Stable sickle cell

Mental Health and Addictions Addictions Child and adolescent Counseling Eating disorders Post partum depression

Inpatient Paediatric Support Services

Breast-feeding Dietician Holistic and complementary therapies Occupational therapy Pharmacy Physiotherapy Psychology Respiratory therapy Registered Nurse PICC line care Sedation for diagnostics and procedures Social Work

General System Supports

Common intake system

20 | Page

Community paediatricians with hospital privileges Community paediatricians accepting new patients Dedicated transport service Electronic health record Enhanced cultural competency and responsiveness Paediatric after hour’s clinic Paediatrician privileges at all 3 hospitals Post Emergency Department hospital based clinic Simulation lab for teaching

Neonatal

Abstinence syndrome Cardiology Central line access/Image guided PICC line insertion Chronic ventilation Genetics Hernia repair, pyloric stenosis Interventional radiology Maternal fetal medicine Retinal

Repatriation of Stable ventilated or CPAP neonates PICC or central lines Tracheostomy Total Parenteral Nutrition Low birth weight or gestational age at 29 weeks corrected age, 800 grams Cardiac monitoring

Surgery

Anaesthesia Dentistry Ear Nose Throat General – hernia, GI, pyloric stenosis Gynaecology Ophthalmology Orthopedics, including scoliosis Plastics – cleft lip and palate Urology

Ambulatory

Adolescent Pregnancy Adolescent Teen Allergy

21 | Page

Anaesthesiology Autism Breast Feeding Cardiology Chronic Ventilation Complex care Dermatology Developmental Endocrinology/Diabetes Gastroenterology Gynaecology Hematology Infectious Diseases Medicine Nephrology Obesity Ophthalmology Outpatient endoscopy Paediatric emergency clinic Palliative Respiratory Syncytial Virus Sexual health

Mental Health and Addictions Addictions Child and adolescent Counseling Eating disorders Post partum depression

Diagnostics

Bone scan DMSA Echocardiology Interventional radiology – Ultrasound guided PICC line and port insertion Renal scan Sedated MRI Ultrasound guided biopsy of kidney, liver VCUG

General Themes

There was general disagreement with respect to the need to co-locate advanced neonatal and inpatient paediatric services with some advocating for consolidating all but basic services due to interdependencies and health human resource requirements, and others advocating for distributing

22 | Page

services across the 3 hospitals to support care close to home, avoiding separating mothers and babies, and enhancing the level of care at all 3 hospitals.

There was general disagreement regarding the need for paediatric surgical services to be co-located with the advanced in-patient paediatric service. There was general agreement that ambulatory specialty paediatric clinics do not need to be co-located with the advanced in-patient paediatric services, and/or the advanced neonatal centre. There was general agreement that RVHS should be designated as the advanced inpatient paediatric centre.

23 | Page

6. Workshop Four

Planning The task required by the planning committee as agreed after workshop 3 was for both organizations to design three potential models for delivery of paediatric and neonatal services across the Central East LHIN. This was proposed by the facilitators with a view to ensuring several different options were available for consideration to the participants at the next workshop and to maximize the opportunity for a model that would gain consensus from both RVHS and TSH.

The planning committee agreed to present a current state of the paediatric and neonatal services at each organization at the beginning of workshop 4 and then present the three proposed models that each organization had developed. The rest of the workshop agenda would then centre on evaluating the proposed models against agreed upon design criteria with a view to reaching consensus if possible regarding a preferred model for service delivery.

The Agenda for Workshop 4 is provided below:

24 | Page

Time (PM) Agenda Item Description/Method Approach Owner

5.00-5.10 A. Introduction • Welcome and introductions Michele/Marla • Review of the evening’s agenda, set expectations for the

evening’s work

5:10 – 5:20 B. Terms of Reference • A presentation to the Working Group of the Terms of Reference Copy of TOR on Table Michele/Marla for the Working Group 5:20 – 5:40 C. Review Current State • Current Data is presented to the group PowerPoint Planning Team Data Members • Feedback discussion Lorne/Patsy/Jane

5:40 – 6:00 D. Design Criteria/Likert • Presentation of agreed design criteria PowerPoint Patsy/Lorne/Jane Scale • Description of the creation and use of the Likert scale

6:00 – 6:45 E. Presentation of • A detailed description of each of the proposed models from PowerPoint Planning Team Proposed Models each organization Members

6:45 – 7:00 BREAK

7:00 – 7:45 F. Review of Models • Each table reviews the proposed models and uses Likert scale to Table Activity All Against Likert Scale prioritize preferred model • Results feedback 7:45 – 8:30 G. Discussion • Preferred models assessed for agreement/disagreement Facilitated Discussion Lorne/Jane/Patsy • Agree which models will be put forward to the LHIN/Governance committee 8:30 – 09:00 H. Next Steps and Close Michelle/Marla

25 | Page

Execution In Workshop 4 each organization presented proposed future state models for consideration.

The agreed upon design criteria were also presented and a Likert scale was proposed as a tool to assist with ranking the proposed models. However, due to time constraints, the participants agreed to narrow the proposed models from an initial list of 6 to 3, prior to applying design criteria for consideration.

This session involved all participants working as one large group. The reason for rejecting any proposed model by the group as a whole was discussed and documented. By the end of this session the group had identified three potential models for consideration going forward: one model was proposed by RVHS and 2 models were proposed by TSH.

Once the three models for consideration had been agreed upon the design criteria as developed by the planning committee was shared with the workshop participants. This allowed the wider audience to consider the criteria that would be used to rank the three models. The design criteria was discussed by the group as a whole and amended or changed as agreed upon by all participants. At the end of workshop 4 consensus had been gained amongst participants as to the criteria required for future decision making regarding the proposed models.

26 | Page

Outputs On completion of Workshop 4 it was agreed that the three proposed future state models and the design criteria (Appendix 5) would be distributed to stakeholders across both organizations and feedback would be collated by the organizations through the use of Survey Monkey. The models, referred to during the workshop as Option 1, Option 2, and Model C are as follows:

OPTION 1:

The Scarborough Hospital Centre for Regional Advanced Neonatal and Paediatric Care

• TSH assumes role of the Regional Advanced Neonatal Program (General Site) and Paediatric Program with the mandate to integrate care in Scarborough and address service gaps in the CE LHIN. • Establish a cooperative Regional Advanced Paediatric Program with a focus on the ongoing development of sub-specialty paediatric care delivery. • An integrated governance structure will establish a 3 year strategic plan and monitor achievement of the regional vision.

OPTION 2:

CE LHIN Integrated Regional Advanced Neonatal and Paediatric Program for Scarborough Cluster

• Develop the Scarborough Maternal Newborn and Paediatric Regional Program to integrate care in Scarborough and address gaps in service within the CE LHIN. • An MOU is structured and passed by both Boards, which clearly defines accountability of the joint program. • An integrated governance structure will establish a 3-year strategic plan and monitor achievement of the regional vision. • A Steering Committee will oversee the implementation of the strategic plan.

MODEL C:

Advanced Service Delivery

• Advanced inpatient neonatal and advanced paediatric services delivered at one site with innovative approaches to LHIN-wide regional access, outreach and creating a presence across the LHIN • Development of connecting mechanisms that link services and sites to optimize coordination for patients/families across the continuum of care

Advanced Designation

• One organization • Rouge Valley Centenary

27 | Page

Planning and Oversight

• Lead agency convenes and chairs, with a rotating co-chair from another organization a Regional multi-organizational committee for planning, coordination and oversight • Role would include planning, development and siting of new programs, facilitating adequate physician coverage across sites and monitoring and evaluation of the regional advanced maternal/child service delivery

28 | Page

7. Conclusion

Three facilitated workshops were undertaken by Leading Edge Group for The Scarborough Hospital and The Rouge Valley Health System with the guidance of the joint planning committee. The workshops explored opportunities for MCY service delivery in Scarborough and developed three models of service for further consideration and evaluation by the hospitals and the Central East LHIN. The workshops elucidated a number of new opportunities for clinical services at each hospital site and continued the process of developing a level of trust, cooperation, and mutual effort, which can be built upon to operationalize a new vision of MCY services in Scarborough. The workshops did not result in an agreed upon siting for advanced neonatal and advanced paediatric services in Scarborough.

29 | Page

8. Appendices

Appendix 1 – Reference Materials Provincial Council for Maternal and Child Health Standardized Maternal and Newborn Levels of Care Definitions July 8, 2011

Provincial Council for Maternal and Child Health Appendix III – Neonatal Retro-Transfer Minimal Criteria for Level II Care, Final Report of the Maternal-Newborn Advisory Committee’s Retro-Transfer Implementation Working Group

Born Ontario – Born Data Elements April 2011

Child Health Network Strengthening the Maternal, Newborn and Paediatric System by Design IRC Phase 3 Report: Final Advice and Recommendations of the Internal Review Committee A report to the Ministry of Health and Long-Term Care by the Child Health Network for the Greater Toronto Area, March 2005

Implementation of Standardized Levels of Maternal-Newborn Care Across Ontario, PCMCH

Final Report of the Maternal-Newborn Advisory Committee’s Retro-Transfer Implementation Work Group, December 16, 2013

Hospital Clinical Services Plan Detailed Report – Clinical Services Plan – February 17, 2009

Expert Review Panel Report The Scarborough Hospital Maternal Newborn and Women’s Health and Surgical Models, June 19, 2013

Map Central East LHIN

Correspondence from the Central East LHIN to the Chairs of the Boards of TSH and RVHS dated May 26, 2014, Re: Scarborough Cluster – Maternal Child Youth Services

The Scarborough Hospital and Rouge Valley Health System August 2013 Environmental Scan

Organization and Clinical Profile Summary RVHS/TSH Facilitated Integration Patient Care Integration Opportunities Session Distributed July 29, 2013

Program and Clinical Staff Profiles RVHS and TSH Integrated Planning Decision Support and Analytics Group

Rouge Valley Health System and The Scarborough Hospital Facilitated Integration Process Due Diligence Workbook: Maternal Child, October 17, 2013

30 | Page

Rouge Valley Health System and The Scarborough Hospital Motion 1b Collaborative – Facilitation Guide for Session 1

Professional Staff Health Human Resources, Paediatrics Staff, LOS data, Market share data, Obstetrical Volumes, Neonatal Volumes,

Appendix E: Summary of Opportunities RVHS and THS Preferred Integration Plan – Final Report

Rouge Valley Health System and The Scarborough Hospital Motion 1b Collaborative 2014 Maternal Child Youth Workbook

Correspondence from the Central East LHIN to Marla Fryers and Michele James from James Meloche dated August 21, 2014 re: Motion 1b: TSH and RVHS Maternal Child Work Group Facilitated Discussions

Appendix 2 - List of Interviews

Central East Local Health Integration Network

James Meloche, Senior Director, System Design and Implementation, Central East LHIN

Rouge Valley Health System

Dr. Joe Butchey, Chief, Emergency Department, RVHS - Centenary Cathy Campos, VP Finance and Chief Financial Officer, RVHS Dr. Karen Chang, Chief, Paediatrics, Medical Site Leader, Paediatrics, RVHS – Centenary Dr. Norman Chu, Medical Director Emergency Department, RVHS – Centenary Susan Fyfe, Program Director, Women and Children’s Program, RVHS Rik Ganderton, President and Chief Executive Officer, RVHS Dr. Elizabeth Hartley, Divisional Head, Anaesthesia, RVHS – Centenary Michele James, Vice President, Women’s and Children’s Program and Clinical Support Services, RVHS Dr. Terry Logaridis, Program Chief, Obstetrics and Gynaecology, RVHS - Centenary Dr. Naresh Mohan, Chief of Staff, RVHS Scott Ovenden, Director of Transformation, RVHS

The Scarborough Hospital

Dr. Peter Azzopardi, Chief, Paediatrics, Co-Medical Director of the MNCC Program, The Scarborough Hospital - Birchmount Dr. Tom Chan, Chief of Staff, TSH Dr. Mike Chapman, Corporate Chief of Surgery, Medical Director Surgical Program, TSH Susan Engels, Patient Care Director, Emergency and Mental Health, TSH Cara Fleming, VP Corporate Services, Chief Financial Officer, TSH Marla Fryers, Executive Vice President, Clinical Operations, TSH Dr. Neil Jamensky, Anaesthesia, TSH Rhonda Lewis, Vice President, Human Resources and Patient Relations, TSH Alfred Ng, Director, Innovation and Performance Improvement Office, Clinical Operations Support, TSH Dr. Vinod Raghubir, Deputy Chief of Paediatrics, The Scarborough Hospital - Birchmount

31 | Page

Nurallah Rahim, Patient Care Director, Surgical Services, TSH Dr. Nathan Roth, Interim Site Chief of Obstetrics, Co-Medical Director of MNCC, TSH Barbara Scott, Patient Care Director, Maternal, Maternal Newborn Childcare, TSH Rhonda Seidman-Carlson, Vice President Inter-professional Practice and Chief Nursing Executive, TSH Dr. Nina Venka, Obstetrician/Gynaecologist, TSH - General Dr. Winston Wong, Chief of Anaesthesia, TSH

32 | Page

Appendix 3- Outputs from workshop 2 CE LHIN: Maternal Child Program – Workshop 2 Outputs Wednesday August 13th 2014 (5 pm – 9pm)

1. Defining the Preferred Future State (The What)

Questions 1-4 posed to participants:

1. What does the ideal future state of neonatal and paediatric clinical services look like?

2. What can be accomplished by consolidating volumes?

3. What can be established through collaboration and integration?

4. What are the clinical opportunities offered by Motion 1b?

There were 5 common themes that emerged from the participants, not necessarily related to any particular question. For example, ease of access was an answer provided for more than one of the questions. Therefore, a summary of the responses to all 4 questions are grouped under common themes as follows:

Theme Specific answers

Access Easy access

One stop shop

Enhance care close to home (decrease expenses, respect for time, etc.)

All three sites have capacity

Access to food services for patients

33 | Page

After hours specialty clinics

Geographical proximity of services

Cohorting high needs patients with access to specialists and enhance services

Accessibility to personal health information

One touch point for access

Improved wait times

Theme Specific answers

Coordination Strong relationships

Governance structure and stakeholder buy- in

IT infrastructure

Seamless care - better coordination of services

Paediatrics and neonatal located near obstetrics

Good information flow

Interdisciplinary care coordination

Required infrastructure for coordinated care

Physician sharing

Established referral patterns

Safety Standardized, quality/evidence-based care

34 | Page

Opportunity to learn from each other - develop expertise

Ability to care for high risk mothers and babies

Improved competencies with improved volumes

Consolidate the care of high acuity volumes

Improved Clinical breadth

Resources Improved human resource planning

Leveraging expertise and experience

Increased efficiencies

Reduced costs due to economy of scale

Better use of scarce resources – for example, beds

Shared access to resources

Branding/Attracting Attract and support needed support services E.G Anaesthesia, IV teams

Promote centres of excellence, use subspecialties to attract providers and patients

Attract people and attract funding

Unified voice for the CE LHIN to enhance funding opportunities

Rebrand and improve regional market share

Create an identity for all three hospitals

Improve our reputation and have sense of community

35 | Page

Market our services to our community

Develop a human resources plan to attract key staff

Enable us to get out and hear our patients/communities

Patient choice/Patient centered Comprehensive continuum of care and services to meet the community needs

Develop specialized services for paediatric complex care

Keep the babies in our community

Enhance current services and have more acute services in Scarborough

Enhance sub-specialty services

Expand patient choice

Provide more complex services

2.Defining the Preferred Future State (The What)

Question 5

What do we want to be different? What should be preserved?

Different Preserved

Increased collaboration across all three Safe care hospitals

36 | Page

Regional advanced paediatric and neonatal Basic paediatrics/neonatal/obstetric care at centre established all three sites

Improved paediatric services/skills in ED Timely support to the ED

Access to enhanced services (i.e. addictions, Current outpatient clinics autism, PPD, teen pregnancy, mental health, complex care)

True family-centered care Quality, safety and care Improved standardization of care

Regionalized/advanced centre Preserve what we have and our ability to care for level 2c

Improved access to patient information (e.g. Preserve our staff and not lose what we have electronic access)

Centre of excellence Quality of service

Uniform practice Increased market share

Increased complex services Relationship with other providers

1. Design Considerations (The How)

What system design elements need to be considered - critical mass, levels of care designations, affordability, absence of duplication, distributed services, consolidated services, management structure, human resources, etc.?

Theme Specific answers

37 | Page

Cost Affordability of new model

Cost efficiencies to be gained

Sustainability of programs offered

Efficiencies No unnecessary duplication of services/processes

Improve wait times for patients and families

Reduce redundancies across sites in the cluster

Standardize policies, procedures and best practices

Patient centred Patient experience focus for design

Ability to labour and recover in the same room

Ability for parents to room with child (new born to paediatrics)

Diversity of services to meet patients’ needs

Centrally located services

Cheap parking

Patient and family centered care to inform design on new model

Technological Need to innovate

Use of phone and video for consultations

E-charting, E-registration, scheduling, link with other providers

38 | Page

E-patient support

Innovate to attract funding

Capacity and Workforce Capacity, human resources, workforce planning

Consolidate human resources – for example, physician sharing

24/7 onsite availability of certain services (for example, IV teams)

Access to support services

Required infrastructure

Ambulatory care outside of hospitals

Strengthen relationships to maintain expertise

4.Getting There What is required to allow for the actualization of vision?

Five emerging themes from the previous exercises were used to populate enablers and barriers to progress

“One Stop Shop”

Enablers Barriers

Current Enablers Current Barriers

Tailor model to communities – technology Siloed services (i.e. remote monitoring) needs

39 | Page

Expertise/resources Unclear definition of one stop shop and validity of developing one – for example, for advanced neonates and paediatrics or all neonates and paediatric patients

Geographically difficult to achieve

Future Enablers

The will to make it happen

Funding

Seamless referrals

Seamless care

Creation of one program with several sites

Service to deliver complex care

Chart record

Collaboration/Relationships Across Hospital Providers

Enablers Barriers

Future Enablers Current Barriers

Seamless transfer of children re. specialty Decrease in desire to collaborate (fear of care loss)

Joint governance model No single governance structure

Motion 1B - process Loss of patience

Sharing of patient information to streamline Community anxiety

Good communication No shared platform to access personal health info

Improve diversity opportunities by sharing Lack of trust between the organizations among providers

40 | Page

Helping communities understand that it is History of relationships between not a loss but an enhancement of their organizations services

Future Barriers

Patient-driven perspective Provider risk (uncertainty that patients will follow)

Increase in volumes, patient population Trust that resources will flow appropriately growth with service changes

Branding to Increase Market Share and Stakeholder Buy-In

Enablers Barriers

Perceived value by consumers Poor understanding of available services

Good communication about available Siloed and don’t promote each other’s services services

Working together to enhance branding Poor communication of marketing services

Confidence in outcome data that confirms Financially established families moving out of we are achieving desirable outcomes – Scarborough auditing and publishing performance to higher minimum standards of care to increase public and provider confidence

Transparency of data No aggressive marketing strategy

Increased branding Lack of branding

Integrity to process Location of services

Increase in complex services Competing agendas

Technology Loss of purpose/apathy

Provide improved increased provider Loss of celebration of events training, information for consumers

Instill confidence in the community that care (Future) decrease in available funding close to home is where they should be

41 | Page

Families need to know “What am I going to What we are do? Where can I get my care?” We will What we offer navigate you through the complex system

Positive messaging around lives of families, care of families

Attract and Better Utilize Scarce Resources

Enablers Barriers

Joint fundraising across all three hospitals Competition with adult population (i.e. geriatrics)

Operating at full scope of practice Relatively, obstetrics and paediatrics services are expensive

Alternative providers (i.e. midwife, NPs) Fluctuating census adds cost

Quality metrics Public perception of hospital reputation and desire to collaborate/partner with other organizations

Easily recruit with existing expertise People compare community by hospital with specialized tertiary care (i.e. HSC, Mount Sinai)

Linkage to Sick Kids/University of Toronto No aggressive marketing strategy

Community fundraising Lack of branding

Sense of community Decrease in volumes

Funding (new or existing) No stability/confidence

HHR competition Lack of collaboration

42 | Page

Accuracy of volume projections May take initial investment and may be difficult to be successful

MD incentive (i.e. OR time)

Regional Centre of Excellence

Enablers Barriers

Special environment that looks designed for Win/lose perspective paediatrics and families

Strong people Lack of clarity

Increased desire to improve services Lack of medical leadership to attract funding (volume proposition)

Increase in market share Existing HHR – strong provider foundation

Consolidated different clinical services at one Does this have to be stated this way? Implies site inferiority/superiority, not important terminology for our patients.

Expand the program and do more

Program system attracts excellent providers without financial burdens

High quality

Committed providers

43 | Page

Regional relationships (i.e. community, political)

Volume of activity

Infrastructure (space, capacity growth)

Leadership support (i.e. RVHS strategic plan)

5. Wrap Up Summary and Work Plan

What’s needed to progress?

• Clarity on: o What an advanced paediatric centre is o The components that need to be co-located with advanced paediatrics o Inpatient activities - what type of patients, an evaluation of the care o What fits best with inpatient paediatrics • List of services at each site - clarity on this. • Descriptive metrics – need a clear understanding of volumes as current state across the region (more descriptive than evaluative) • Comparative analysis to other hospitals outside the region • Discuss ambulatory clinics – a multi-site model makes sense • What needs to be co-located and what can be distributed Required for workshop 3:

• Looking for clarity on in-patient/out-patient, ambulatory wrap-around services • Thinking about advanced centres not only for obstetrics or NICU, but also the support services – radiology, diagnostic labs, etc. • Developmental clinics – complex care • Autism • Mental health (in-patient/out-patient) • Need to have clarity on all of the pieces you start moving items/services • What is the critical obstetrics mass to build an advanced centre and how are the gaps filled?

44 | Page

• Acknowledge the group that defined 2b/2c • Don’t redefine the whole service, maybe look at the gaps • List of services for advanced care (in documents already?) • Levels of care (provincial definition) • Need to negotiate • Planning team – LHIN, boards (decision making leverage) • Physician leadership governance structure • One-stop-shop definition (patient vs clinical) • Stop using term “one-stop-shop” • Could be three site “one-stop-shop” • Maybe an IT solution to make ‘one stop shop’ across 3 sites

Appendix 4-Outputs from Workshop 3

45 | Page

46 | Page

47 | Page

48 | Page

Appendix 5-Outputs from workshop 4

49 | Page

50 | Page

51 | Page

Section 1

TSH-RVHS Environmental Scan 2014

PAGE 107 Environmental Scan / Community Description

Rouge Valley Health System and The Scarborough Hospital

Motion 1b: Planning for Maternal, Child and Youth Services

August 2014 What is the purpose of the Environmental Scan / Community description?

1. This data helps the Motion 1b working group to understand the characteristics of the target patient population and where they access services

2. Informs the development of the preferred future state model: • Understanding market share and projected growth rate of target populations support the planning process • Understanding key socio‐economic factors informs the planning process, for example: • Diversity needs to be mirrored in the supporting structures that provide health services for communities to achieve equitable access • Education and income are key components of socioeconomic status and are positively associated with health behaviours and health status • Lone parent families headed by women are among the most economically vulnerable

3. Fulfills part of deliverable to Central East LHIN for Motion 1b

2 What information can be summarized from the Environmental Scan / Community Description? (1/2) Theme Key Points Size of Scarborough • The Scarborough area represents 40% of the Central East LHIN population. • Between 2014‐2025, it is anticipated that the percentage of women in childbearing years will increase by 4%, or 5258 women, in the Scarborough area • Between 2014‐2025, the annual number of newborns from the Scarborough area is expected to increase by 265 births • Between 2014‐2025, it is anticipated that the percentage of women in childbearing years will Population Growth increase by 11%, or 38,644 women, in the Central East LHIN. This is twice the rate of increase projected for Scarborough. • Between 2014‐2025, it is anticipated that the percentage of children / youth will increase by approximately 9.7%, or 12,897 children / youth in the Scarborough area. • Between 2014‐2025, it is anticipated that the percentage of children / youth aged 0‐17 will increase by 15.9%, or 49,512 children / youth, in the Central East LHIN. • Almost 65% of Scarborough area residents sought hospital obstetrical care in a Scarborough hospital (i.e. RVHS or TSH). 35% of Scarborough area residents sought hospital obstetric care outside of the Central East LHIN. • 65% of Scarborough area newborns born in a hospital were born in a Scarborough area hospital. Of the 15,358 Central East LHIN newborns born in a hospital in 2013/14, 32% were born Market Share in a Scarborough area hospital. • Over 50% of Scarborough residents sought paediatric care in a Scarborough hospital with over 40% going to the Toronto Central LHIN for care. Of the 7,252 Central East LHIN paediatric patients in 2013/14, 23% received care in a Scarborough hospital. That translates into 1718 patients 3 What information can be summarized from the Environmental Scan / Community Description? (2/2)

Theme Key Points • Over 7% of the population in the Scarborough area reports having no knowledge of English or Language French.

• The visible minority and recent immigration populations are notably higher in the Scarborough Cultural area than in the province as a whole. Background • Visible minority population distribution varies across the Scarborough area.

• The Scarborough area has a higher percentage of residents without a high school certificate Education and and with a low income. Families in the Scarborough area are also much more likely to have Income children living in a low income families than Ontario as a whole.

• Unemployment rate in the Scarborough area is significantly higher than Ontario as a whole. Employment

• The percentage of lone parent families in the Scarborough area is significantly higher than Family Structure Ontario as a whole.

4 How is the Scarborough catchment area defined for this project? Defined as a set of forward sortation areas (FSAs), which are the first three digits of the postal code based on: • Previous planning assumptions of catchment areas • Two FSAs have shared catchment areas for TSH / RVHS (i.e., geographies are not mutually exclusive)

FSA Common Name M1B Scarborough (Malvern / Rouge River)* M1C Scarborough (Rouge Hill / Port Union / Highland Creek) M1E Scarborough (Guildwood / Morningside / Ellesmere ) M1G Scarborough (Woburn) M1H Scarborough (Cedarbrae) M1J Scarborough (Scarborough Village) M1K Scarborough (Kennedy Park / Ionview / East Birchmount Park) M1L Scarborough (The Golden Mile / Clairlea / Oakridge / Birchmount Park East) M1M Scarborough (Cliffside / Cliffcrest / Scarborough Village West) M1N Scarborough (Birch Cliff / Cliffside West) M1P Scarborough (Dorset Park / Wexford Heights / Scarborough Town Centre) M1R Scarborough (Wexford / Maryvale) M1S Scarborough (Agincourt) M1T Scarborough (Clarks Corners / Tam O'Shanter / Sullivan) M1V Scarborough (Milliken / Agincourt North / Steeles East / L'Amoreaux East) M1W Scarborough (Steeles West / L'Amoreaux West) M1X Scarborough (Upper Rouge)*

5 How is the Scarborough catchment area defined for this project?

Area highlighted in white outlines the FSA’s identified in the previous slide 6 How much of the Central East LHIN population does Scarborough area represent?

The Scarborough area represents 40% of the Central East LHIN population

Source: Statistics Canada, 2011 Census of Population What is the projected growth rate for women of child bearing age (15-44 years) for the next 10 years in the Scarborough area?

Between 2014‐2025, it is anticipated that the percentage of women in childbearing years will increase by 4% in the Scarborough area

Assumptions: 1) 2011 is the number of females from Statistics Canada for Scarborough FSAs 8 2) Assumes same growth rate in 2012 as in 2013 (Due to one year missing from Intellihealth) 3) Assumes Scarborough female population has the same growth rate as the Toronto female population Source: Intellihealth What is the projected number of women of child bearing age (15-44) for the next 10 years in the Scarborough area?

Between 2014‐2025, the number of women in the Scarborough area aged 15‐44 is expected to increase by 5258

Assumptions: 1) 2011 is the number of females from Statistics Canada for Scarborough FSAs 9 2) Assumes same growth rate in 2012 as in 2013 (Due to one year missing from Intellihealth) 3) Assumes Scarborough female population has the same growth rate as the Toronto female population Source: Intellihealth What is the projected number of newborns for the next 10 years from the Scarborough area?

Between 2014‐2025, the annual number of newborns from the Scarborough area is expected to increase by 265 births

Assumptions: 1) Based on the number of women aged 15‐44 and the number of newborns in 2013 with a Scarborough area FSA. Hospital activity is not included in the calculation 10 2) Assumes birth rate remains constant at 2013 level 3) Assumes Scarborough female 15‐44 population has the same growth rate as the Toronto female population Source: Intellihealth What is the projected growth rate for women (age 15- 44) for the next 10 years in the Central East LHIN?

Between 2014‐2025, it is anticipated that the percentage of women in childbearing years will increase by 11% in the Central East LHIN. This is twice the rate of increase projected for Scarborough.

Source: Intellihealth What is the projected number of women (age 15-44) for the next 10 years in the Central East LHIN?

Between 2014‐2025, the number of women aged 15‐44 is expected to increase by 38,644 in the Central East LHIN. 14% of this increase (5258 women) will come from Scarborough.

Source: Intellihealth What is the projected growth rate for children/youth (0-17 years) for the next 10 years in the Scarborough area?

Between 2014‐2025, it is anticipated that the percentage of children / youth will increase by approximately 9.7% in the Scarborough area.

Assumptions: 1) 2011 is the number of children/youth (age<=17) from Statistics Canada for Scarborough FSAs 13 2) Assumes same growth rate in 2012 as in 2013 (due to one year missing from Intellihealth) 3) Assumes Scarborough children/youth population will grow at the same rate as the Toronto children/youth population Source: Intellihealth What is the projected number of children/youth (0-17 years) for the next 10 years in the Scarborough area?

Between 2014‐2025, the number of children in the Scarborough area aged 0‐17 is expected to increase by 12,897.

Assumptions: 1) 2011 is the number of children/youth (age<=17) from Statistics Canada for Scarborough FSAs 14 2) Assumes same growth rate in 2012 as in 2013 (due to one year missing from Intellihealth) 3) Assumes Scarborough children/youth population will grow at same rate as the Toronto children/youth population Source: Intellihealth What is the projected growth rate for children/youth (0-17 years) for the next 10 years in the Central East LHIN?

Between 2014‐2025, it is anticipated that the percentage of children / youth aged 0‐17 will increase by 15.9% in the Central East LHIN

Source: Intellihealth What is the projected number of children/youth (0-17 years) for the next 10 years in the Central East LHIN?

Between 2014‐2025, the number of children / youth aged 0‐17 is expected to increase by 49,512 in the Central East LHIN

Source: Intellihealth Where do Scarborough area residents currently seek hospital obstetric care? (2013/14)

Where Scarborough area residents sought hospital obstetric care

OTHER A HOSPITAL IN CENTRAL TORONTO CENTRAL Other SCARBOROUGH EAST LHIN CENTRAL LHIN LHIN LHIN TOTAL HOSPITAL Number of 4,777 70 1,446 1,069 27 7,389 Scarborough Residents Percent of 64.7% 0.95% 19.57% 14.47% 0.2% 100% Scarborough Residents *Home births are not included in this table

• Almost 65% of Scarborough area residents sought hospital obstetrical care in a Scarborough hospital (i.e. RVHS or TSH) • 35% of Scarborough area residents sought hospital obstetric care outside of the Central East LHIN

Assumptions: 1) Includes only those patients that are in the category "Pregnancy and Childbirth" (2013/14). Inpatients only 2) Subset from the patient's LHIN shows only those that reside in Scarborough (FSAs starting with "M1") 3) Subset from the LHIN where the hospital is located shows only the Scarborough hospitals (Rouge Valley‐Centenary, Scarborough Hospital‐General, Scarborough Hospital‐Birchmount) 17 4) Number of women in midwifery care that gave birth at home, by LHIN of maternal residence, 2011/12, CE LHIN = 282 (9.4% occurred in Central East LHIN) (n=2,990 for Ontario). Data source –BORN Ontario, 2011‐2012 (defined by billing date). Ontario residents only Source: Intellihealth At which hospitals were Scarborough area babies born? (2013/14)

Where the Scarborough newborn was born

OTHER A HOSPITAL IN CENTRAL TORONTO CENTRAL Other SCARBOROUGH EAST LHIN CENTRAL LHIN LHIN LHIN TOTAL HOSPITAL Number of Scarborough 4,330 64 1,210 1,010 21 6,635 Newborns Percent of Scarborough 65.3% 1.0% 18.2% 15.2% .32% 100% Newborns *Home births are not included in this table

• 65% of Scarborough area newborns born in a hospital were born in a Scarborough area hospital

Assumptions: 1) Includes only those patients that are admitted as entry type "Newborn ‐ born alive in reporting institution" (2013/14). Inpatients only 2) Subset from the patient's LHIN shows only those that reside in Scarborough (FSAs starting with "M1") 3) Subset from the LHIN where the hospital is located shows only the Scarborough hospitals (Rouge Valley‐Centenary, Scarborough Hospital‐General, Scarborough Hospital‐Birchmount) 18 4) Number of women in midwifery care that gave birth at home, by LHIN of maternal residence, 2011/12, CE LHIN = 282 (9.4% occurred in Central East LHIN) (n=2,990 for Ontario). Data source –BORN Ontario, 2011‐2012 (defined by billing date). Ontario residents only Source: Intellihealth What percentage of Central East LHIN newborns were born in a Scarborough area hospital?

• Of the 15,358 Central East LHIN newborns born in a hospital in 2013/14, 32% were born in a Scarborough area hospital

Source: Intellihealth Where do Scarborough residents currently seek paediatric care? (2013/14)

Where the Scarborough residents sought paediatric care

OTHER TORONTO A HOSPITAL IN CENTRAL CENTRAL Other CENTRAL SCARBOROUGH EAST LHIN LHIN LHIN TOTAL LHIN HOSPITAL Number of Scarborough 1,441 7 1,136 142 20 2746 Residents Percent of Scarborough 52.5% 0.3% 41.4% 5.2% .73% 100% Residents

• Over 50% of Scarborough residents sought paediatric care in a Scarborough hospital with over 40% going to the Toronto Central LHIN for care

Assumptions: 1) Includes only those patients that are less than 18 years old and excludes those that are in the category "Pregnancy and Childbirth", "Newborns and Neonates with Perinatal Conditions", "Mental Diseases and Disorders“. Inpatients only. 2) Subset from the patient's LHIN shows only those that reside in Scarborough (FSAs starting with "M1") 20 3) Subset from the LHIN where the hospital is located shows only the Scarborough hospitals (Rouge Valley‐Centenary, Scarborough Hospital‐General, Scarborough Hospital‐Birchmount) Source: Intellihealth What percentage of Central East LHIN paediatric patients received care in a Scarborough area hospital?

• Of the 7,252 Central East LHIN paediatric patients in 2013/14, 23% received care in a Scarborough hospital. That translates into 1,718 patients

Source: Intellihealth How much of the population has no knowledge of languages (English or French)?

Over 7% of the population in the Scarborough area reports having no knowledge of English or French

Source: Statistics Canada, 2010 Census of Population & 2011 National Household Survey How does the visible minority and recent immigration statistics compare with the rest of Ontario?

The visible minority and recent immigration populations is notably higher in the Scarborough area than in the province as a whole

Source: Statistics Canada, 2011 National Household Survey What is the diversity of the visible minority population across the Scarborough region?

Visible minority population distribution varies across the Scarborough area

Source: Statistics Canada, 2011 National Household Survey What is the overall cultural diversity across the Scarborough region?

Source: Statistics Canada, 2011 National Household Survey How does education and income in Scarborough compare with the rest of Ontario?

The Scarborough area has a higher percentage of residents without a high school certificate and with a low income. Families in the Scarborough area are also much more likely to have children living in a low income families than Ontario as a whole.

Source: Statistics Canada, 2011 National Household Survey (Education), 2006 Census of Population (Low Income) How does the unemployment rate and percent of lone parent families compare with the rest of Ontario?

Unemployment rate and percent of lone parent families in the Scarborough area are significantly higher than Ontario as a whole.

27 Section 2

TSH-RVHS Clinical Services Survey Results 2014

PAGE 135 Motion 1b Collaborative Clinical Questionnaire

Q1 Please identify below your primary association or relationship

Answered: 32 Skipped: 1

RVHS - Centenary

TSH

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Answer Choices Responses

RVHS - Centenary 59.38% 19

TSH 40.63% 13

Total 32

# Other (please specify) Date

There are no responses.

1 / 28 Motion 1b Collaborative Clinical Questionnaire

Q2 Please identify your role. If you have more than one role please choose the role that you believe is best suited to your responses.

Answered: 30 Skipped: 3

Patient/Consume r

Leadership - Manager/Dire...

Clinician - Midwife/Nurs...

Other (please specify)

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Answer Choices Responses

Patient/Consumer 6.67% 2

Leadership - Manager/Director/VP etc. 60.00% 18

Clinician - Midwife/Nurse/Physician etc. 30.00% 9

Other (please specify) 3.33% 1

Total 30

# Other (please specify) Date

1 Educator 8/22/2014 12:36 PM

2 / 28 Motion 1b Collaborative Clinical Questionnaire

Q3 What new inpatient paediatric services could be introduced to the Scarborough cluster that would provide advanced regional care to Central East LHIN patients? Please focus on services not currently available in the Central East LHIN.

Answered: 18 Skipped: 15

# Responses Date

1 Adolesent medicine 8/31/2014 8:24 PM

2 Advanced mental health services and counseling Palliative and Respite care Enhanced Paed Emerg Derm Clinic 8/22/2014 12:46 PM

3 I am not fully aware of all of the inpatient paediatric services available in CE LHIN but my sense is that is already 8/22/2014 12:27 AM quite good. Perhaps inpatient paediatric palliative care as well as various paediatric surgeries not currently done in the LHIN.

4 Developmental services, cardiac, epilepsy, autism, GI, infectious disease, Adolescent gynecology services, Child 8/21/2014 9:58 PM and Adolescent Psychiatry

5 Inpatient services that are closer to home vs having to go out of the LHIN would be helpful. More options for 8/21/2014 9:12 PM provision of complex care (perhaps a step down from level 3 care). More general paediatric surgery could be offered along with urology and an expanded offering of plastics. With a more extensive surgical program increased skill and comfort will be developed for anesthesia and we can also attract paediatric specialists in this area to support an increased array of diagnostics that first require heavy sedation..

6 Ability to repatriate chronic paediatric clients from tertiary centers Please note that centenary already provids 8/21/2014 5:58 PM services to client with diabetes, sickle cell and oncology

7 Developmental pediatrics General Pediatric Surgery 8/21/2014 1:32 PM

8 Neonatal abstinence program Palliative care program Chronic ventilation program for respite care for ventilated 8/20/2014 9:42 PM pediatric patients

9 Increase in Paediatric Mental Health beds Paediatric Palliative Care Adolescent Pregnancy Complex Care 8/20/2014 3:10 PM Paediatric Eating disorder children Paediatric Surgery expanded Ambulatory Clinic for Autism Ambulatory Clinic for Obesity Expanded Developmental Assessment Clinic

10 Increase Mental Health Beds Paeditric Pallaiative Care Complex Care Adolescent pregnancy Eating disorders 8/20/2014 2:26 PM Autism Obeisity

11 Enhanced surgical services ie pediatric general surgery, Pediatric urology, pediatric ophthalmology Pediatric 8/20/2014 1:15 PM anaesthesia Subspecialty services can be enhanced to include inpatient consultations and admissions ie neurology can do overnight video EEG monitoring, cardiology can cover patients with congestive heart failure and failure to thrive Diagnostic tools should include tests such as VCUG for all ages, bone scans, DMSA, renal scans, sedated MRI's, interventional radiology such as U/S guided PICC line insertion for all ages, U/S guided renal/ liver/ other biopsy Enhanced support services would include better PICC line care for nursing staff, enhanced dietician services for GI/ endocrine/ nephrology/ in patients, enhanced respiratory therapists who are pediatric specific for ventilation/ enhanced occupational therapy and physiotherapy/ in house teaching/ full time child life support/ full time all week breastfeeding support

12 My experience and input is more focused on maternal care and services. As a patient/consumer, I have not had 8/19/2014 10:10 PM to access paediatric services as of yet and so am unfamiliar with the inpatient paediatric services currently available. Therefore, I am unsuited to advise as to what inpatient paediatric services could be introduced that are currently not available.

13 Neonatal Abstinence Syndrome recognition and care Pediatric Complex Care Ambulatory Clinic for Autism 8/19/2014 3:31 PM

14 Respite care for chronic ventilated patients and their families Palliative care Specialty surgery such as cleft lip and 8/19/2014 12:51 PM pallet, urology and perhaps adolescent gyne surgery

3 / 28 Motion 1b Collaborative Clinical Questionnaire

15 Palliative Care Complex Care Autism Respite Care 8/19/2014 11:06 AM

16 paediatric palliative care respite care for complex children (c autism, developmental, obesity, mental health, 8/19/2014 11:04 AM addictions Paediatric urology and nephrology

17 complex care autism pallative care respite care 8/19/2014 11:04 AM

18 There are no dedicated pediatric Surgeons within TSH. There are surgeons who offer some pediatric surgeries. 8/19/2014 10:42 AM These include ENT, Urology, and some Plastic Surgery

4 / 28 Motion 1b Collaborative Clinical Questionnaire

Q4 What enhancements to existing inpatient paediatric services would improve clinical care within the Central East LHIN?

Answered: 17 Skipped: 16

# Responses Date

1 Neonatal MRI and infant MRI IV access program Updated infrastructure and equipment Ability to surge up when 8/31/2014 8:24 PM required

2 Provincial electronic health record for increased accessability Paed friendly emerg clinic with priority access 8/22/2014 12:46 PM increased paed surgical ability Paed ICU Enhanced Cultural competency

3 Improved coordination among hospitals. Increased sharing of tools and best practices. Common intake system. 8/22/2014 12:27 AM Increased culturally responsive services

4 Develop a clearer understanding among providers, families and the general community of the services that are 8/21/2014 9:58 PM currently available and how to use them more effectively. Make access easier or referrals between services more straightforward. Create a system where sick children can access specialized Paediatric care in a timely manner.

5 eating disorders treatment would blend well with our existing mental health program. Expanded investigational 8/21/2014 9:12 PM radiology especially to support PICC line sedation vs having to wait for this service to be done at sick kids.

6 Continue to grow already existent services and staff expertise. Develop closer partnership with The Hospital for 8/21/2014 5:58 PM Sick Children

7 INcreased community level pediatric surgery in specialities of General Surgery, ENT, Ophthalmology, Plastics. 8/21/2014 1:32 PM Step-down level "critical care" . Unlikely to be able to staff and manage children requiring ICU care however. Volumes will be too low.

8 There is no definition of an enhanced pediatric unit in the literatue that can be applied to the situation that exist at 8/20/2014 9:42 PM our level. The need to enhance existing pediatric services when we have a level 4/5 pediatric centre 20 minutes away is a waste of money. The finances need to upgrade such a program would be too costly. To deliver a different type of service would be good. The unit does not have to be competing with other units to enhance services.... there are specific programs such as palliative care/ chroonic ventilation for respite care etc which would be good to have. Pediatric surgery is always good, butit also would be an expensive program to maintain.

9 increase beds, increase staffing to allow for palliative, cnronic disease children Electronic documentation so that 8/20/2014 3:10 PM files can be shared between all Scarborough Hospitals.

10 increase inpatient beds for palliative patients/ chronic illness increase nursing Staffing and support services(i.e 8/20/2014 2:26 PM social workers) Electronic documentation inorder for patient files to be shared across the LHIN IS/ IT eCHN paediatric surgery

11 same as above 8/20/2014 1:15 PM

13 As Above 8/19/2014 12:51 PM

14 development screening and clinics seamless care- access to medical records amongst all hospitals 8/19/2014 11:06 AM

15 navigation through the sysetm of ambulatory and inpatient services electronic records, sharing of records 8/19/2014 11:04 AM amongst care providers strong partnerships with community to ensure seamless transition back regular education sessions within CELHIN hosted by Scarborough Hospitals- reach out to rest of LHIN, promote consistent standards of practice.

16 developmental screening and clinics community paediatricians with hospital privilideges 8/19/2014 11:04 AM

17 Recruitment fo Pediatric Surgeons. Aggregation fo all peditaric services into one centre so that appropriate 8/19/2014 10:42 AM programs and supports can be in place to meet the needs of the pediatrci patients.

5 / 28 Motion 1b Collaborative Clinical Questionnaire

Q5 What paediatric inpatients would be suitable for repatriation from other centers?

Answered: 13 Skipped: 20

# Responses Date

1 Stable, and complex care, central lines (PICC and Ports), oncology, some acute care 8/22/2014 12:46 PM

2 inpatients in tertiary centres whose needs have stabilized to the point where they can been safely managed in a 8/22/2014 12:27 AM 2C facility. (perhaps traumas, acute exacerbations of chronic illnesses)

3 Stable, non-critical patients 8/21/2014 9:58 PM

4 Some simple inpatient chemotherapy treatments, PICC line insertions, complex medicine requiring longer length 8/21/2014 9:12 PM of stay.

5 Patient who require complex care closer to home Palliative patients Please note that centenary already provide 8/21/2014 5:58 PM services to client with diabetes, sickle cell and oncology

6 Palliative care Chronic ventilation for respite care 8/20/2014 9:42 PM

7 If expanded - repatriate Oncology patients, Mental Health patients, chronic /complex care children. Any child that 8/20/2014 3:10 PM no longer requires a Level 3 care treatment

8 oncology patients/ chronic care patient who no longer require level 3 care Palliatve beds 8/20/2014 2:26 PM

9 this question is too broad. we already repatriate a large group of patients that include premature infants and 8/20/2014 1:15 PM stable pediatric patients on treatment.

10 From what I gather in the discussions to date, if a regional centre were to be operational at the level desired (level 8/19/2014 10:10 PM 2b?), then those paediatric inpatients undergoing care and treatment that fall under that category would be suitable for repatriation.

11 Stable sickle cell Newly diagnosed diabetics Stable Diabetic ketoacidosis Asthmatics Severe dehydration 8/19/2014 3:31 PM

12 complex needs paliative complex surgical cases mental health 8/19/2014 11:04 AM

13 Aggregation of all Pediatric Care into one centre 8/19/2014 10:42 AM

6 / 28 Motion 1b Collaborative Clinical Questionnaire

Q6 What support services are required to sustain new and improved advanced regional inpatient paediatric care in the Central East LHIN?

Answered: 16 Skipped: 17

# Responses Date

1 electronic documentation commitment to ongoing education upgrade SIM lab for practice and scenarios 8/22/2014 12:46 PM enhanced child life specialist involvement, dietitian involvement incorporation of holistic and complementary therapies

2 - Access to as many in-house paediatric subspecialties as possible - Strong links to ambulatory care clinics for 8/22/2014 12:27 AM follow-up and monitoring, ideally in the same physical setting to support the one-stop shopping that patients/families value - Paediatric speech language pathology for inpatient assessment and consultation - Links to mental health supports - Child Life Specialist support

3 A multidisciplinary team of professionals including registered nurses, paediatricians and other specialists, social 8/21/2014 9:58 PM workers, respiratory therapists, physiotherapists, occupational therapists, child life specialists, other allied health professionals and dedicated volunteers, all providing a progressive treatment plan toward wellness.

4 more social work, RRT, RT, OT. Psychology would be helpful to support autism and developmental services. 8/21/2014 9:12 PM

5 Paediatric dedicated anaesthesia Paediatric dedicated Respiratory Therapist 8/21/2014 5:58 PM

6 Infrastructure investments- dedicated clinical spaces Additional monitoring equipment Additional specialty trained 8/21/2014 1:32 PM nuirses Additional sub-speciality pediatricians

7 What do you mean by a "regional advanced inpatient pediatric care centre".....? Are you developing a new 8/20/2014 9:42 PM pediatric hospital? If so then look at HSc and get all the inpatient programs.... inpatient general, surgery, urology, cardilogy, ICU, oncology, etc with all the staff being able to be contacted at all the times. If not, then what.... Why not wait the definition of the levels of care being developed by the PCMHC and go from there. Services for even an mild enhancement would be : 24/7 availablity of surgery, pediatric medicine, anesthesia, Step up units, with adequate and approriate staffing and services( RT/IV/Lab/echo/ CT, 24/7), What an advanced unit is NOT is the transfer of all inpatients to that unit ..... local community hospitals need not transfer uncomplicated cases to this unit so as the boost numbers/ figures. This goes against the grain of patient oriented care. care

8 Lab DI Social Work Paediatric OT/physio Dietician support IS eg. eCHN 8/20/2014 3:10 PM

9 DI/Lab Social Work Paediatric OT/Physio Dietitician 8/20/2014 2:26 PM

10 As above. Enhanced support services would include better PICC line care for nursing staff, enhanced dietician 8/20/2014 1:15 PM services for GI/ endocrine/ nephrology/ in patients, enhanced respiratory therapists who are pediatric specific for ventilation/ enhanced occupational therapy and physiotherapy/ in house teaching/ full time child life support/ full time all week breastfeeding support

11 My experience and input is more focused on maternal care and services. As a patient/consumer, I have not had 8/19/2014 10:10 PM to access paediatric services as of yet and so am unfamiliar with the inpatient paediatric services currently available. Therefore, I am unsuited to advise as to what support services are required to sustain new and improved advanced regional inpatient paediatric care.

12 Increased OT support Increased Physio therapist support Increased RRT coverage Dietician continued support 8/19/2014 3:31 PM Pharmacy support after hours Social Work support after hours

13 Strong RRT, SW, Mental Health support 8/19/2014 12:51 PM

14 24 hour in house paediatricians RTs with paediatric specialty's and training Diagnostic Imaging access to 8/19/2014 11:06 AM speciality consults nephrology, cardiology, medicine, opthamology

15 navigation through the system of ambulatory and inpatient services electronic records, sharing of records 8/19/2014 11:04 AM amongst care providers

16 in house paediatricians RT with paediatric training diagnosistic imagining access to speciality consutls including: 8/19/2014 11:04 AM nephrology, cardiology, medicine etc ICU- inhouse intensivist

7 / 28 Motion 1b Collaborative Clinical Questionnaire

Q7 What advanced regional inpatient paediatric services should be co-located in the same hospital as the advanced level 2C NICU?

Answered: 17 Skipped: 16

# Responses Date

1 PICC and central line insertion (imagery guided) enhanced newborn follow up, enhanced breastfeeding support 8/22/2014 12:46 PM

2 All of them - there are significant clinical, access, team and efficiency benefits to having the regional inpatient 8/22/2014 12:27 AM paediatric service co-located in the same hospital as the advanced level 2C NICU

3 Because of limited resources, a critical mass of multidisciplinary services at one regional centre is key to the 8/21/2014 9:58 PM provision of services closer to home for our Scarborough patients.

4 It is important to collocate the full range of paediatric specialty services. To ensure you have rapid access to the 8/21/2014 9:12 PM appropriate array of services available to support the NICU you need to have enough of a critical mass from a business sense to attract and retain the specialty. This is created through the ED patient flow and or clinic development.

5 Inpatient paediatrics, satellite clinics and outpatient services should be co-located with advanced level NICU 8/21/2014 5:58 PM

6 All subspecialty pediatric services. This is important to be able to recruit pediatricians to the area. They would not 8/21/2014 1:32 PM be willing to go to isolated units e.g. Advanced Neonatal Unit by itself

7 There is NO need to have to co locate the level 2c NICU with a regional pediatric unit...... Different hospitals can 8/20/2014 9:42 PM serve different purposes..... for example both Sunnybrook and Mt. Sinai hospital have high level NICUs but no pediatrics. Credit Valley has a level 2c, but no advanced peds program.... it chooses HSC as its advanced unit. So the services can be separated.... any NICU patient needing advanced care above the level of service of a level 2c unit will go to HSC for the advanced pediatric service...... that is.. if a pt in the NICU needs surgery...that type of surgery will not be available in the "regional pediatric unit".

8 Paediatric inpatient services does not need to be co-located with an advanced Level 2C NICU. Paediatrics can be 8/20/2014 3:10 PM diversified throughout the Scarborough Cluster.

9 Paediatrics inpatient services does not need to be co-located within an advanced level 2C NICU Pediatric 8/20/2014 2:26 PM services can be diversified throughout the Scarborough culster to service the Central East LHIN.

10 All advanced inpatient pediatric services should be co located with the level 2C NICU. This is already the case 8/20/2014 1:15 PM and it includes enhanced surgical services and subspecialty service. The services that are not available are not available anywhere in the LHIN and it would create an additional barrier to care to not co locate advanced services in the same hospital.

11 This may require additional study to determine how much overlap/crossover in patient population exists, if any. 8/19/2014 10:10 PM Services that are delivered to both paediatric patients and advanced level 2C NICU probably should be co- located in the same hospital.

12 Cardiac monitoring ventilation Pediatric Orthopedics Pediatric Cardiolgist 8/19/2014 3:31 PM

13 Co-location with neonatal care is not necessary 8/19/2014 12:51 PM

14 Diagnostic Imaging with paediatric trained staff RTs with speciality in paediatrics 24 hour In house Paediatrician 8/19/2014 11:06 AM

15 there is no clinical requirement or benefit of a clinical adjacency to co-locate any services there is sufficient 8/19/2014 11:04 AM activity to support paediatric coverage at any of the sites and this would certainly not require any additional funding to support paeds callschedules

16 it is not nessesary in my opioion to co-locate advanced paediatrics and the NICU in the same hospital 8/19/2014 11:04 AM

17 Yes To really develop a centre of Excellence for Pediatric services, It is imprtant to have all levels of NICU in one 8/19/2014 10:42 AM location

8 / 28 Motion 1b Collaborative Clinical Questionnaire

Q8 What new neonatal clinical services should be introduced to the Scarborough cluster that would provide advanced regional care to Central East LHIN patients? Please focus on services not currently available in the Central East LHIN.

Answered: 18 Skipped: 15

# Responses Date

1 Central line access/ image guided insertions increased surgical capability 8/22/2014 12:51 PM

2 Dedicated paediatric respiratory therapists Dedicated paediatric speech language pathologists 8/22/2014 12:27 AM

3 developmental services, 8/21/2014 10:07 PM

4 All services are currently available however there is a need to market the service to others in the LHIN 8/21/2014 9:12 PM

5 Support for patients who have drug and alcohol problems, and whose babies may have neonatal withdrawal 8/21/2014 6:25 PM syndromes.

6 Developmental care Neurology 8/21/2014 6:04 PM

7 Interventional radiology 8/21/2014 1:35 PM

8 Abstinence programs Expansion of OT/PT/dietician services in theunits Early fetal program/ early assessment 8/20/2014 9:54 PM programs genetics

9 We need to colocate , fine tune and make our current services easily accesible to the population of Scarborough 8/20/2014 3:57 PM and East Durham before we contemplate adding more services .

10 Neonatal Abstinence program 8/20/2014 3:10 PM

11 Neonatal Abstinence Syndrome recognition program Level 2 C at 2 sites in Scarborough . 8/20/2014 2:33 PM

12 PICC line insertion and care resuscitation and support for infants as young as 28 weeks ventilation beyond 5 8/20/2014 1:19 PM days pediatric surgery for hernia's et et

13 My experience and input is more focused on maternal care and services. As a patient/consumer, I have not 8/19/2014 10:15 PM needed to access much in the way of neonatal services as of yet and so am unfamiliar with the neonatal services currently available. Therefore, I am unsuited to advise as to what neonatal services should be introduced.

14 Complicated Patient Clinic-with multiple anomalies and needs Neonatal Abstinence Syndrome recognition and 8/19/2014 3:43 PM care

15 Some neonatal surgery such as hernia repairs Extended ventilator support for acute illness Ambulatory support 8/19/2014 12:55 PM for chronic conditions, developmental delay Genetics assessment

16 maternal fetal medicine Neonatal abstinence follow up clinics follow up accessibility for families who do not have 8/19/2014 11:27 AM primary health care providers

17 all 3 centers are capable of offereing leve 2C. 8/19/2014 11:19 AM

18 maternal fetal medicine high risk clinics postpartum depression clinics newborn follow up for patients without 8/19/2014 11:15 AM family physicians - this could be NP lead

9 / 28 Motion 1b Collaborative Clinical Questionnaire

Q9 What enhancements to existing neonatal services would improve clinical care within the Central East LHIN?

Answered: 17 Skipped: 16

# Responses Date

1 electronic health record, access provincially Paed friendly ED with priority access to Paed/meonatal patients 8/22/2014 12:51 PM

2 Increased anaesthesia support Increased culturally responsiveness services 8/22/2014 12:27 AM

3 enhanced supports for breast feeding, nutrition. expand overall neonatal program. 8/21/2014 10:07 PM

4 Other hospitals in the LHIN need to see the regional centre in Scarborough as an option for transfer vs referral to 8/21/2014 9:12 PM one of the downtown hospitals

5 Critical care transport team to provide services for Scarborough and Durham Dedicated Neonatal Respiratory 8/21/2014 6:04 PM Therapy service

6 INcreased retinal support and cardiology support 8/21/2014 1:35 PM

7 NIcu being a closed unit Cohorting of neonatologists/ and developing a FFP for these doctors sothat they care 8/20/2014 9:54 PM provide good care. Developing standardised protocols realise that there are mitigating factors that influenced reverse transfers, and realise that close to home is always the ideal for pt care.

8 Have one stop shopping for the consumer s. Considering that RVC and TSH are 6 kms apart these services 8/20/2014 3:57 PM should all be in one site and that is RVC

9 Level 2C at 2 sites in Scarborough Cluster 8/20/2014 3:10 PM

10 IS /IT eCHN 8/20/2014 2:33 PM

11 dedicated pediatric focused respiratory therapists 8/20/2014 1:19 PM

12 My experience and input is more focused on maternal care and services. As a patient/consumer, I have not 8/19/2014 10:15 PM needed to access much in the way of neonatal services as of yet and so am unfamiliar with the neonatal services currently available. Therefore, I am unsuited to advise as to what enhancements to neonatal services would improve care.

13 Increased hours to RRT coverage, OT coverage and pharmacy in house coverage. More availability of 8/19/2014 3:43 PM pediatricians in the area that are accepting new patients.

14 Genetics Complex care coordination 8/19/2014 12:55 PM

15 access to developmental clinic to include diagnosis and treatment in timely manner - in scarborough cluster 8/19/2014 11:27 AM access to health records across all hospitals for seamless care

16 inprove nutritional support to NICU's recruit additional neonatologists to Scarborough system move towards 8/19/2014 11:19 AM breast feeding friendly status, role model for rest of LHIN

17 if a 2c NICU was co-located with a labour and delivery with volumes and expertise, less patients would be 8/19/2014 11:15 AM transfered to level 3 beds. This would allow Scarborough residents to receive the right care close to home

10 / 28 Motion 1b Collaborative Clinical Questionnaire

Q10 What neonatal patients would be suitable for retro-transfer or repatriation?

Answered: 14 Skipped: 19

# Responses Date

1 all neonatal patients, 8/22/2014 12:51 PM

2 Those whose needs stabilize so that tertiary care is no longer required and level 2C care or level 2B care is 8/22/2014 12:27 AM appropriate

3 potential patients are well described in the PCMCH levels of care document. 8/21/2014 9:12 PM

4 Stable neonates on mechanical ventilation or CPAP Neonate with PICC or Central Lines on TPN Neonates with 8/21/2014 6:04 PM complex needs Low birth weight or gestational age neonates 29 weeks corrected age +

5 The patient population being repatriated is appropriate at thiis time.... allowing for the level 2c unit to keep and 8/20/2014 9:54 PM accept the younger pt is important. At this time all the units manage PICC lines, trach, g-tubes etc..

6 The pediatricians can answer that but a Regional well serviced unit with colocated Peds and NICU should be able 8/20/2014 3:57 PM to take care of all the retrotransfers.

7 Any Neonate that does not require further Level 3 care from a teritary Centre Acceptance from CELHIN hospitals 8/20/2014 3:10 PM that would allow the infant to be closer to home.

8 Any neonatal patient that no longer require level 3 care 8/20/2014 2:33 PM

9 we already receive infants as young as 30 weeks 8/20/2014 1:19 PM

10 Neonatal patients that fall under the level the potential regional centre is aiming to achieve. 8/19/2014 10:15 PM

11 Ventilated CPAP TPN PICC line in situ Continual feeds or slow bolus feeds Cardiac monitoring Require ROP 8/19/2014 3:43 PM examination even weekly Born less that 30 weeks and still less than 30 wks but now stable Weight criteria as determined case by case but approx. >800 gm on transfer

12 according to guidlines for Level 2c NICU as set by PCMCH 8/19/2014 11:27 AM

13 stable babies from tertirary centers all 30-32 week gestations 8/19/2014 11:19 AM

14 all patients that currently meet the guidelines for a level 2c unit 8/19/2014 11:15 AM

11 / 28 Motion 1b Collaborative Clinical Questionnaire

Q11 What support services are required to sustain new and improved advanced regional neonatal care within the Central East LHIN?

Answered: 17 Skipped: 16

# Responses Date

1 electronic documentation education programs and support, SIM Lab for practice upgrades to equipment, facilities 8/22/2014 12:51 PM

2 Dedicated emergency transportation service for CE LHIN for neonates and children 8/22/2014 12:27 AM

3 Multidisciplinary services including physio, RT, Aneasthetist, N.P. 8/21/2014 10:07 PM

4 SW, OT, PT, NP, neonatologist, RRT, child life specialist. interventional radiologist 8/21/2014 9:12 PM

5 Critical care transport team to provide services for Scarborough and Durham Dedicated Neonatal Respiratory 8/21/2014 6:04 PM Therapy service

6 As noted previously 8/21/2014 1:35 PM

7 cohorting neonatologists RT/ OT/ PT/ dieticians/ ECHO ophthalmology 8/20/2014 9:54 PM

8 We need to have whatever services are needed to make it a seamless service for the consumer. 8/20/2014 3:57 PM

9 DI Lab Paeds OT/physio Social Work IS Dietician 8/20/2014 3:10 PM

10 DI Lab SW IS/ IT OT/ PT Dietician 8/20/2014 2:33 PM

11 dedicated full time dietician, dedicated full time respiratory therapists, dedicated full time social worker 8/20/2014 1:19 PM

12 My experience and input is more focused on maternal care and services. As a patient/consumer, I have not 8/19/2014 10:15 PM needed to access much in the way of neonatal services as of yet and so am unfamiliar with the neonatal services currently available. Therefore, I am unsuited to advise as to what support services are required to sustain new and improved neonatal care.

13 RRT coverage around the clock for NICU Increased pharmacy hours Increased SW coverage Increased OT 8/19/2014 3:43 PM support and PT support hours Neonatal Nurse Practitioner

14 Enhanced RRTs, SW and SLP support 8/19/2014 12:55 PM

15 24hr In house Paediatrician Access to Neonatology DI RTs with NICU specialty Access to speciality consults (ie 8/19/2014 11:27 AM opthamology) dieticians

16 with the small numbers of babies within the 2C critieria, and with each site in Scarborough able to care for these 8/19/2014 11:19 AM babies, why are we separating mothers and babies when the care could be provided in the delivering hosp. also if the care required is more than a 2C then tertiary centers are just 15 mins away. the majority of large community hosptials in Ontario are 2C and having any thing other than 2C within the GTA is really not acceptable. Need to consider the impact of separating mothers and babies, breastfeeding rates, post partum mood disorders and impact to family, bonding and separation issues, cost to health system and cost to families with travel, parking etc

17 obstetrical services including: - RT - DI - interventional radiology which is currently located at the TSH General 8/19/2014 11:15 AM Campus NICU - RT with skill level for 2c - DI - neonatal dieticians - neonatal pharmacy - neonatologist - NP

12 / 28 Motion 1b Collaborative Clinical Questionnaire

Q12 What other clinical services should be co-located in the same hospital as the advanced level 2C NICU?

Answered: 17 Skipped: 16

# Responses Date

1 advanced paed clinics follow up clinics 8/22/2014 12:51 PM

2 Advanced paediatric services Services outlined in the PCMCH guidelines for level 2C NICU 8/22/2014 12:27 AM

3 Advanced inpatient and out patient peadiatrics and high risk level 2C Birthing centre. 8/21/2014 10:07 PM

4 a complete range of service including, anesthesiology, cardiology, ophthalmology, genetics, neurology, 8/21/2014 9:12 PM nephrology, neonatology, endocrinology, GI, OBS

5 Inpatient and outpatient Paediatrics, DI 8/21/2014 6:04 PM

6 as noted before 8/21/2014 1:35 PM

7 MRI/ CT scan/ Plastics/ ophthalmology/ Cardiology availabilty Hematology availablity 8/20/2014 9:54 PM

8 All the other Peds Clinics should in the same location as the regional NICU 8/20/2014 3:57 PM

9 Level 2C Obstetrics 8/20/2014 3:10 PM

10 Level 2C OB 8/20/2014 2:33 PM

11 same as previous question 8/20/2014 1:19 PM

12 Isn't neonatal care and NICU the same thing? So whatever services are needed for the NICU would also likely be 8/19/2014 10:15 PM needed for neonatal care and therefore should be co-located in the same hospital.

13 Echo, MRI availability Neonatal Follow Up clinic RSV Clinic 8/19/2014 3:43 PM

14 Strong obstetric program potential to support some high risk obstetric patients 8/19/2014 12:55 PM

15 High Risk Obstetrics MFM DI- Internvential Radiology ICU RTs 8/19/2014 11:27 AM

16 definately need to co-locate high risk OBS with 2C. Based on expert review of 2013, need to consider high risk 8/19/2014 11:19 AM OBS center with Interventional Radiology on site. TSH General campis is the only Scarborough center with IR on site and on call. As stated in preveious Paeds questions, no need to co-locate advanced paeds with 2C center, there is enough activity and clinical programs in all of the sites to support paeds coverage of ED without additonal cost and burden to the system

17 high risk obstetrics MFM DI - interventional radiology ICU Intensivists 8/19/2014 11:15 AM

13 / 28 Motion 1b Collaborative Clinical Questionnaire

Q13 What new ambulatory specialty paediatric clinics should be introduced to the Scarborough cluster that would provide enhanced regional clinical services to patients of the Central East LHIN?

Answered: 16 Skipped: 17

# Responses Date

1 new? not sure 8/22/2014 12:53 PM

2 Dermatology clinic Infectious diseases clinic Neurology clinic Adolescent medicine clinic Autism clinic 8/22/2014 12:27 AM

3 Developmental, Autism 8/21/2014 10:08 PM

4 Restarting infectious disease, and medical adolescent clinical would be helpful. Dermatology clinic is needed and 8/21/2014 9:12 PM would be supportive of the current allergy clinic. Neurology is a gap and an enhancement to developmental assessment and treatment (including autism) is essential.

5 More autism and developmental delay services. More general pediatrics clinics or walk-in clinics for pediatrics. 8/21/2014 6:26 PM Adolescent medicine. More mental health services.

6 Developmental Care, Dermatology, Neurology 8/21/2014 6:04 PM

7 Dermatology Juvenile diabetes Autism 8/21/2014 1:36 PM

8 Ambulatory : Developmental pediatric assessment and treatment program Obesity/ Wellness pediatric clinic 8/20/2014 10:00 PM Chronic ventilation program for respite care for ventilated pediatric patients Palliative program Complex care pediatric clinic.... with team approach A large pediatric after hours clinic, such as the one at Leslie/Sheppard

9 Basic Peds serviuces should be at the other sites also covering emerge. 8/20/2014 4:00 PM

10 Autism Obesity Mental Health Adolescent Teen clinic/ sexual health care 8/20/2014 3:10 PM

11 Autism Obiesity Mental Health Adolescent Teen Clinic Adolescent Sexual Health 8/20/2014 2:39 PM

12 infectious disease dermatology additional neurology additional development medicine adolescent/ teen medicine 8/20/2014 1:30 PM

13 My experience and input is more focused on maternal care and services. As a patient/consumer, I have not 8/19/2014 10:16 PM needed to access ambulatory specialty paediatric services as of yet and so am unfamiliar with the services currently available. Therefore, I am unsuited to advise as to what services should be introduced.

14 Complex care Palliative care Developmental care Obesity Transition clinics to support movement from the 8/19/2014 1:04 PM pediatric hospitals to the adult hospitals After hours clinic to avert ED visits

15 autism diagnosis and treatment obesity/eating disorders paediatric mental health clinics enhanced developmental 8/19/2014 11:33 AM clinics

16 autism, expand developmental, mental health, addictions for youth and newborns, nutrition-obesity, complex care 8/19/2014 11:19 AM

14 / 28 Motion 1b Collaborative Clinical Questionnaire

Q14 What new ambulatory specialty paediatric clinics should be co-located with the advanced regional in-patient paediatric service?

Answered: 15 Skipped: 18

# Responses Date

1 all of them...access to clinics and follow up post admission is essential 8/22/2014 12:53 PM

2 As many as possible 8/22/2014 12:27 AM

3 Developmental, Autism 8/21/2014 10:08 PM

4 Medical adolescent blends well with the mental health services and would fit best being collocated. Dermatology 8/21/2014 9:12 PM would also be well supported by the allergy clinic as many of the same patients are seen in each service. Mental health can also support these patients re self image etc.

5 Developmental Care, Dermatology, Neurology 8/21/2014 6:04 PM

6 as above 8/21/2014 1:36 PM

7 The advanced regional inpatient program should not need to have ambulatory services to sustain it. However in a 8/20/2014 10:00 PM distributed care model, there are areas of excellence that would be best serviced.... diabetes etc All of the above new Ambulatory programs do not need to be co located with an inpatient unit.

8 That can be determined at a later date as the Advanced Regional centre grows. 8/20/2014 4:00 PM

9 Ambulatory Specialty Paediatric clinics do not need to be co-located with an advanced Inpatient paediatric 8/20/2014 3:10 PM service. These specialty can be diversed throughout the scarborough cluster for easy accessibility

10 Not alll ambulatory specialty clinic need to be colocated with in the advanced regional in patient paediatric service 8/20/2014 2:39 PM Specialty clinics can be diversified across the Scarborough cluster, for easy accessibility.

11 all of the above 8/20/2014 1:30 PM

12 My experience and input is more focused on maternal care and services. As a patient/consumer, I have not 8/19/2014 10:16 PM needed to access ambulatory specialty paediatric services as of yet and so am unfamiliar with the services currently available. Therefore, I am unsuited to advise as to what services should be co-located.

13 Co-location with inpatient peds care not necessary, a distributed model could be implemented for both inpatient 8/19/2014 1:04 PM and outpatient advanced care.

14 speciality clinics to match/support inpatient activity 8/19/2014 11:33 AM

15 every center to house some specialty related to existing or new programs voice of customer clearly stated 8/19/2014 11:19 AM regardless of location, importance of seamless entry and access to information was most important and wait times

15 / 28 Motion 1b Collaborative Clinical Questionnaire

Q15 What new ambulatory specialty paediatric clinics should be co-located with the advanced regional level 2C NICU?

Answered: 17 Skipped: 16

# Responses Date

1 Best to have all clinics co located 8/22/2014 12:53 PM

2 As many as possible 8/22/2014 12:27 AM

3 Developmental, Autism 8/21/2014 10:08 PM

4 all clinics would support the NICU 8/21/2014 9:12 PM

5 Developmental Care, Dermatology, Neurology 8/21/2014 6:04 PM

6 as noted previously 8/21/2014 1:36 PM

7 Developmental clinic 8/20/2014 10:00 PM

8 Ambulatory services do not need to be colocated each hosp can provide that in conjuction withER coverage. 8/20/2014 4:00 PM

9 Ambulatory Specialty Paediatric clinics do not need to be co-located with an level 2C NICU. 8/20/2014 3:10 PM

10 None, Ambulatory specialty clinics should not be co located in the advanced regional level 2C NICU. 8/20/2014 2:39 PM

11 all of the above 8/20/2014 1:30 PM

13 Complex Care Clinic 8/19/2014 3:44 PM

14 Co-location is not necessary 8/19/2014 1:04 PM

15 developmental neonatal abstinence neonatal follow up 8/19/2014 11:33 AM

16 none of hte clinics referenced to are specifically tied to a 2C. Paeds should be separated as stated within the 8/19/2014 11:19 AM various questions earlier in survey no need to co-locate advanced paeds with 2C center, there is enough activity and clinical programs in all of the sites to support paeds coverage of ED without additonal cost and burden to the system

17 developmental neonatal abstinence optomology 8/19/2014 11:17 AM

16 / 28 Motion 1b Collaborative Clinical Questionnaire

Q16 What new paediatric surgery services should be introduced to the Scarborough cluster that would provide enhanced regional clinical services to patients of the Central East LHIN?

Answered: 17 Skipped: 16

# Responses Date

1 image guided therapy (PICC insertion, etc) port insertion 8/22/2014 12:55 PM

2 Expansion of existing paediatric surgery volumes through repatriation of market share Urology Paediatric general 8/22/2014 12:28 AM surgery

3 GI, 8/21/2014 10:08 PM

4 enhanced anesthesia can assist with expanded interventional radiology options. A general expansion of surgical 8/21/2014 9:12 PM procedures can be considered along with general surgery, orthopaedics, urology.

5 Urology Low risk general surgery Please note that ENT, Plastic, Gastroenterology scopes and Scoliosis surgeries 8/21/2014 6:06 PM are already conducted at RVHS

6 Orthopedics, General Surgery, ENT- already exist. Need to be expanded 8/21/2014 1:38 PM

7 General surgery Plastics expansion pediatric urololgy expansion Dentistry expansion Interventional radiology, for 8/20/2014 10:03 PM PICC lines , investigation etc

8 To be determined later pending the need and in consultation with HSC. 8/20/2014 4:02 PM

9 Enhanced Orthopedic General paediatric Surgeries Cleft Lip and Palate Surgeries Pyloric Stenosis surgeries 8/20/2014 3:10 PM Minor GI surgeries

10 enhanced orthopedic General paediatric surgery ie Pyloric stenosis / Cleft lip and palate Minor GI surgery 8/20/2014 2:45 PM

11 general surgery urology plastics ophthalmology 8/20/2014 1:31 PM

12 My experience and input is more focused on maternal care and services. As a patient/consumer, I have not 8/19/2014 10:17 PM needed to access paediatric surgery services as of yet and so am unfamiliar with the services currently available. Therefore, I am unsuited to advise as to what services should be introduced.

13 Cleft lip and palet hernia urology 8/19/2014 1:07 PM

14 urology cleft palate opthomology 8/19/2014 11:36 AM

15 consider those surgical procedures that currently have wait times. no need to develop programs that are offered 8/19/2014 11:22 AM at other organizations with no wait times ie cleft lip and palate scoliosis, orthopedic

16 cleft palate urology 8/19/2014 11:19 AM

17 Please refer to page one of the Survey regarding Pediatic Surgery 8/19/2014 10:43 AM

17 / 28 Motion 1b Collaborative Clinical Questionnaire

Q17 What paediatric surgery services should be co-located with the advanced regional in-patient paediatric service?

Answered: 16 Skipped: 17

# Responses Date

1 some diagnostic procedures 8/22/2014 12:55 PM

2 All of them 8/22/2014 12:28 AM

3 GI 8/21/2014 10:08 PM

4 All surgery to encourage development of specialty in surgery, nursing and allied health as well as anaesthesia 8/21/2014 9:12 PM

5 Day surgery program: ENT, Plastics, Scoliosis, Gastroenterology General Surgery 8/21/2014 6:06 PM

6 Any that may require inpatient stay 8/21/2014 1:38 PM

7 Above 8/20/2014 10:03 PM

8 Again to be determined later. 8/20/2014 4:02 PM

9 Any surgery that would require extensive treatments following the surgeries such as one to one nursing 8/20/2014 3:10 PM

10 Any surgery that requires extensive nursing care post op 1:1 8/20/2014 2:45 PM

11 all of the above 8/20/2014 1:31 PM

13 All advanced services should be distributed between TSH and RVHS depending on interest and medical 8/19/2014 1:07 PM manpower and capability.

14 In order to answer fully, a definition of what an advanced regional inpatient paediatric centre would look like 8/19/2014 11:36 AM would need to be included

15 only those have have a clinical fit with existing programs, ie ortho should be located in the site where adult 8/19/2014 11:22 AM specialty resides

16 this is challenging because there is no clear direction or definition on what an advanced regional paediatric 8/19/2014 11:19 AM center is

18 / 28 Motion 1b Collaborative Clinical Questionnaire

Q18 What paediatric surgery services should be co-located with the advanced regional level 2C NICU?

Answered: 17 Skipped: 16

# Responses Date

1 same as above line insertions 8/22/2014 12:55 PM

2 All of them 8/22/2014 12:28 AM

3 GI 8/21/2014 10:08 PM

4 as above because I feel it essential that advanced paeds be collated with the advanced level 2 NICU 8/21/2014 9:12 PM

5 PICC line insertion 8/21/2014 6:26 PM

6 Day surgery program: ENT, Plastics, Scoliosis, Gastroenterology General Surgery 8/21/2014 6:06 PM

7 No specific need to be except as noted above 8/21/2014 1:38 PM

8 Interventional radiology 8/20/2014 10:03 PM

9 Pediatric surgery should be part of the advanced NICU 8/20/2014 4:02 PM

10 None 8/20/2014 3:10 PM

11 no paediatrc surgery should be co-located with the advanced regional level2C NICU 8/20/2014 2:45 PM

12 all of the above 8/20/2014 1:31 PM

13 My experience and input is more focused on maternal care and services. As a patient/consumer, I have not 8/19/2014 10:17 PM needed to access paediatric surgery services as of yet and so am unfamiliar with the services currently available. Therefore, I am unsuited to advise as to what services should be co-located.

14 This is not necessary 8/19/2014 1:07 PM

15 Co-location is not neccesary 8/19/2014 11:36 AM

16 In my ecperience, paediatricians are not involved with surgical cases even though these patients reside in the 8/19/2014 11:22 AM inpatietn paeds beds. therefore I do not belive there is a need to co-locate any surgical services with 2C

17 in my opioion this would not be nessesary if there was a system for HR to be available at all sites 8/19/2014 11:19 AM

19 / 28 Motion 1b Collaborative Clinical Questionnaire

Q19 What clinical services should be consolidated together on the same campus?

Answered: 19 Skipped: 14

# Responses Date

1 all advanced care should be consolidated 8/22/2014 12:56 PM

2 Regional advanced neonatal program, Regional advanced paediatric program and high risk obstetrics 8/22/2014 12:28 AM

3 In patient and out patient clinics for Paeds, Level 2C NICU and high risk maternal. 8/21/2014 10:10 PM

4 OBS, neonatal and paediatrics. they all complement and support each other 8/21/2014 9:12 PM

5 NICU and advanced in patient care can support each other well. Critical care or high risk patients can allow one 8/21/2014 6:28 PM site to develop expertise and efficiencies.

6 Paediatrics inpatient and outpatient, NICU and Paediatric surgery 8/21/2014 6:07 PM

7 Advanced Pediatrics and Neonatal ICU Level IIC 8/21/2014 1:40 PM

8 Level 2c NICU on one campus Pediatric in patient on another campus I suggest that the two services can be 8/20/2014 10:06 PM separated

9 All the advanced Peds services should be colocated with the regional NICU 8/20/2014 4:04 PM

10 Level 2C NICU should to situated with the Level 2C Obstetrics (where volumes of deliveries exceed 2500 births 8/20/2014 3:10 PM per year)

11 level 2 C NICU with Level 2C OB where volume exceeds 2500 deliveries a year. 8/20/2014 2:49 PM

12 all of the advanced pediatric and neonatal services 8/20/2014 1:32 PM

13 Inpatient type clinics that require specialized equipment or personnel, such as dialysis. 8/19/2014 10:19 PM

14 Advanced Regional Pediatric and Neonatal Care 24 hour pharmacy full RRT coverage for Ped and NICU 8/19/2014 3:46 PM

15 TSH should be designated the advanced neonatal centre. The organization currently does 2/3 of the volumes and 8/19/2014 1:14 PM would quickly become designated as a level 2C at the general site. The general site has the advantage of being co-located with interventional radiology. The Birchmount will enhance its services related to midwifery care. Advanced pediatric care both inpatient and ambulatory should be distributed with a coordinated management team determining where the largest gaps are and where to ideally situate a particular service to ensure access for our community as well as prevent duplication of services between organizations. a solid navigation structure should be put in place to assist our community in finding and accessing the required resource quickly.

16 High Risk Obstetrics MFM DI-Interventional radiology Level 2c NICU 8/19/2014 11:38 AM

17 2C, high risk OBS and Diagnostic services/Interventional radiology 2C should be available at all Scarorough 8/19/2014 11:24 AM centers

18 high risk ob with high ob volumes and level 2c NICU 8/19/2014 11:20 AM

19 All Peditric Services in one hospital campus 8/19/2014 10:43 AM

20 / 28 Motion 1b Collaborative Clinical Questionnaire

Q20 What clinical services should be distributed throughout the Scarborough hospitals?

Answered: 17 Skipped: 16

# Responses Date

1 standard care at some facilities with a specific advanced Paed/Neonatal care location at one site 8/22/2014 12:56 PM

2 Level 2B neonatal care Level 2B maternal care General inpatient and outpatient paediatrics (not advanced) 8/22/2014 12:28 AM

3 New programs can be added as the regional program grows. 8/21/2014 10:10 PM

4 basic level 2 service needs to be at each hospital to ensure gyne and aped. coverage to the ED. 8/21/2014 9:12 PM

5 General pediatric and obstetric care, not high risk patients. More developmental and mental health support. 8/21/2014 6:28 PM

6 Level 2 B NICU, Emergency department support 8/21/2014 6:07 PM

7 Ambulatory Pediatric surgery Ambulatory clinics Short stay inaptient care (up to 48-72 hours) Basic diagnostics 8/21/2014 1:40 PM Neonatal care >34 weeks

8 TSH-g Level 2C/ inpatient peds TSH-B Level 2b/ inpatient peds/ large ambulatory cllinic/ miwifery program RVHS 8/20/2014 10:06 PM level 2b/ advanced peds

9 Basic Peds services that can cover emerge patients 8/20/2014 4:04 PM

10 Paediatric Ambulatory clinics should be diversifed throughout the Scarborough hospitals. They do not need to be 8/20/2014 3:10 PM all in one hospital.

11 Paediatric specialty clinics should diversified throughout the Scarborurough cluster. Potential to have a have 8/20/2014 2:49 PM expert physicians travel to different areas within Scarborugh and the LHIN

12 general pediatrics, level 2 neonatology, breast feeding support 8/20/2014 1:32 PM

13 Outpatient type clinics that do not require specialized equipment or personnel, such as breastfeeding clinics. 8/19/2014 10:19 PM

14 As above 8/19/2014 1:14 PM

15 High Risk Obstetrics Advanced Level 2c NICU Advanced Inpatient paediatrics and advanced paediatric 8/19/2014 11:38 AM ambulatory clinics

16 Paediatric inpatient and ambulatory programs should be distributed 8/19/2014 11:24 AM

17 Paediatric ambulatory clinics 8/19/2014 11:20 AM

21 / 28 Motion 1b Collaborative Clinical Questionnaire

Q21 Which hospital should provide advanced regional neonatal services?

Answered: 18 Skipped: 15

# Responses Date

1 Rouge Valley Centenary 8/22/2014 12:57 PM

2 Rouge Valley Health System - Centenary Site 8/22/2014 12:28 AM

3 Rouge Valley Health System 8/21/2014 10:10 PM

4 RVHS has many of the advanced services already in place and is the designated level IIc site. Criticall transfers 8/21/2014 9:30 PM patients as needed to our NICU and RVHS currently takes 90% of level 3 retro transfers. RVHS has listed the women's and children's program in their strategic plan as one of their priority programs every year. It consistently demonstrates its commitment and ability in maternal, neonatal and paediatric care.

5 Scarborough Centenary has the physical infrastructure (newest and most up to date birthing and NICU unit, 8/21/2014 6:52 PM Obtracevue) and caregiver experience (has been providing care for OB patients who have been transferred in and outside of LHIN to Centenary due to perceived need for level IIC) nursery. Centenary has these because the hospital also has the longstanding commitment of the hospital to funding the programs and renewing the facility as needed to keep the program up to date. Our latest commitment is starting a University of Toronto associated Maternal Fetal Medicine program, and though we hope to service the LHIN's high risk pregnancies, we would be open to servicing patients from outside the LHIN. We have purchased the special ultrasound, and ultrasound program after consultation with maternal fetal medicine specialists at the University of Toronto. Our chief of obstetrics has been asked to be on a steering committee for improving data collection and research to represent the East Toronto and Durham LHIN. The University recognizes the problems with the BORNE data but also feels improving the collection of BORNE data could present an awesome research opportunity. We have made arrangements for a University of Toronto perineonatologist to start our program in the near future (this year), and have relocated offices to make room for this program.

6 Rouge valley Centenary 8/21/2014 6:08 PM

7 THe one which already has the infrastructure and the established Level IIC unit- RVHS Centenary site 8/21/2014 1:43 PM

8 TSH -General 8/20/2014 10:07 PM

9 Roge Valley Centenary ....it has the infrastructure brand new LDRPs ,brand new NICU , has the human 8/20/2014 4:10 PM resources and the neonatologists .has the Clinics . has Board and financial support and has all the needed linkages with Sick Kids . As well there is a level 2c Obstetrical unit with well surgically trained Obstetricians providing high risk Obstetrical services to the region for pregnancies 30 weeks and up .RVC has also been part of th Criticall infrastructure for the last 3 years .

10 The Scarborough Hospital- General Campus 8/20/2014 3:10 PM

11 The Scarborough Hospital General Campus 8/20/2014 2:53 PM

12 rouge valley centenary already provides advanced neonatal services and this should continue 8/20/2014 1:33 PM

13 This depends on the types of services that are defined as neonatal and looking at which hospital currently 8/19/2014 10:21 PM delivers the majority of the services. Also, it would be useful to look at use patterns by patients/consumers as the hospital that houses the majority of the services may not necessarily be the one accessed the most for these services.

14 Rouge Valley-Scarborough Centenary 8/19/2014 3:48 PM

15 TSH 8/19/2014 1:14 PM

16 TSH- General Campus as they have the infrastructure, the volumes and the health Human Resources 8/19/2014 11:39 AM

17 TSH supported by advance ICU and IR program for high risk OBS 8/19/2014 11:28 AM

18 TSH - general campus because they have the infrastructure, volumes and human health resources 8/19/2014 11:22 AM

22 / 28 Motion 1b Collaborative Clinical Questionnaire

Q22 Which hospital should provide advanced regional inpatient paediatric services?

Answered: 18 Skipped: 15

# Responses Date

1 Rouge Valley Centenary 8/22/2014 12:57 PM

2 Rouge Valley Health System - Centenary Site 8/22/2014 12:28 AM

3 Rouge Valley Health System 8/21/2014 10:10 PM

4 RVHS has a significant breadth and depth of subspecialty paediatric services already in place. The physical plant 8/21/2014 9:30 PM can provide for close monitoring of more acutely ill patients, they have the support of sick kids with satellite clinics like sickle cell and oncology along with the inpatient programs to support that population. The paed unit also supports the NICU and when overflowing can absorb NICU patients who are stable to create space for more acute patents. Current paed and NICU staffing has developed an enhanced skill set already and they would not require additional education or development. RVHS has been seen as a leader in this area by SickKids, the LHIN and the CHN.

5 The NICU and advanced pediatrics work best by co-locating the services. Most of the inpatient services are being 8/21/2014 6:52 PM done, and most efficiently and cost-effectively at Centenary. The varying volumes of pediatrics make it difficult to have a small volume criticall care service at a medium sized community hospital. The Rouge Valley board has a very long standing commitment to pediatrics being a core program, and has developed this over many, many years, different boards, different CEOs. To change this now, particularly in light of the financial ability of the Scarborough Hospital to match what is existing at Scarborough Centenary, and in that the Scarborough hospital has never had pediatrics be a core program. To move the advanced services now, would be a huge waste of money, and since the Scarborough hospital cannot match the care, would result in poorer service. It is really time for the Scarborough hospital as an institution to stop obstructing the delivery of advanced women's and children. The Scarborough Hospital has many strong programs which the Rouge Valley does not try to compete with (i.e. nephrology and dialysis) and the Rouge Hospital does not try to obstruct.

6 Rouge valley Centenary 8/21/2014 6:08 PM

7 The hospital that is housing the advanced NICU primarily because it will not be an east task to attract pediatric 8/21/2014 1:43 PM subspecialist, particularly neonatologists to a unit that cannot provide on-site support by other sub-specialities. This is a practical reality of recruitment

8 TSH-G or RVHS 8/20/2014 10:07 PM

9 Rouge Valley Centenary for the reasons discussed above. 8/20/2014 4:10 PM

10 We need to continue to support the enhanced care for Paediatrics at RVHS but diversify the ambulatory clinics 8/20/2014 3:10 PM throughout the 3 Scarborough Hospitals.

11 Continue to support the excellent work done at RVHC (centenary)., with specialty clinics diversified throught out 8/20/2014 2:53 PM the 3 hospitals.

12 rouge valley centenary already provides advanced regional inpatient services and this should continue 8/20/2014 1:33 PM

13 This depends on the types of services that are defined as inpatient paediatric and looking at which hospital 8/19/2014 10:21 PM currently delivers the majority of the services. Also, it would be useful to look at use patterns by patients/consumers as the hospital that houses the majority of the services may not necessarily be the one accessed the most for these services.

14 Rouge Valley-Centenary 8/19/2014 3:48 PM

15 Distributed between RVHS and TSH 8/19/2014 1:14 PM

16 Rouge Valley Centenary 8/19/2014 11:39 AM

17 distributive model where specialty program align with existing resources- meeting the needs of the special 8/19/2014 11:28 AM population within the CELHIN

23 / 28 Motion 1b Collaborative Clinical Questionnaire

18 Rough Valley as they have a robust program that they could grow. 8/19/2014 11:22 AM

24 / 28 Motion 1b Collaborative Clinical Questionnaire

Q23 RVHS – Centenary

Answered: 18 Skipped: 15

# Responses Date

1 Advanced paed/neonatal care... in one location, specialty clinics and follow up care available Also, a special 8/22/2014 12:59 PM segment of the ED for Paed pts, child friendly with access to specialty clinics and care

2 Designate RVHS-Centenary as the regional advanced centre for neonatal and paediatric care. Leverage the 8/22/2014 12:34 AM advanced level of care designations and broad spectrum of paediatric services that currently exist at RVHS - Centenary. Centenary is the only level 2C centre in Scarborough. (TSH chose to maintain their level 2B status rather than upgrade to level 2C.) There are well-documented strong clinical, access, patient experience, recruitment and fiscal benefits to co-location of advanced neonatal care, advanced paediatric care and high risk obstetrics. In a 2005 report, the Child Health Network for the GTA formed an expert task group that recommended to the Ministry that RVC be designated as the regional centre for the East GTA with co-location of advanced neonatal, paediatric and obstetric services. The Galaxy Clinics at RVC offer a very wide range of paediatric clinics which would form a key component of the ideal future state model. They contribute greatly to RVHS' ability to attract more subspecialty paediatricians than any other hospital outside of SickKids and CHEO and to its strong partnership with SickKids. Leverage existing skills in providing care to children with specialized needs - e.g. RVC provides the vast majority of care in Scarborough to children with cancer, diabetes and sickle cell disease. We are Ontario's only provider of pulse dye laser surgery for children. We have an extensive child and adolescent mental health program, including classrooms for maintenance of formal education while in hospital, co-located at the Centenary site. The existing configuration of advanced neonatal and paediatric services would be enhanced to meet regional needs bringing advanced services closer to home for patients/families throughout Central East LHIN. Quality and access would be improved through increased collaboration with TSH and other hospitals in CE LHIN by creating mechanisms for coordination, timely and appropriate transfer of patients with advanced needs, repatriation protocols, clear intake processes, shared best practices, shared education, joint planning forums, joint marketing efforts, etc Our community wants and deserves, fiscally responsible growth and service enhancement. They also want to see timely progress. Leveraging existing advanced services is cheaper than creating, renovating, tearing down and relocating. Leveraging also allows for a shorter implementation curve and realizing benefits sooner. This is better for patients, families, taxpayers and cash-strapped hospitals. This model supports sustainment of current obstetrics, nurseries and paediatric services at all 3 Scarborough sites.

3 Regional Paeds and neonatal services high risk obstetrics. 8/21/2014 10:13 PM

4 advanced neonatal and paediatric services 8/21/2014 9:32 PM

5 NICU and Advanced pediatrics and to continue doing what we are doing. 8/21/2014 7:00 PM

6 Rouge Valley Centenary already provides advanced neonatal and paediatric services. The center would benefit 8/21/2014 6:22 PM from closer relationship with Sick Kids and potential development of program that will allow repatriation of chronic paediatric clients from tertiary center. Advanced centre should should provide developmental care services and in partnership with Sick Kids expand provision of satellite based care to bring costumers back to the region. Inpatient paediatrics, satellite clinics and outpatient services should be co-located with advanced level NICU (the system already exists at RVHS). The program will benefit from dedicated Critical Care Transport team for Scarborough and Durham regions. Surgical program would benefit from specialised paediatric surgeons to perform low risk Urology and General surgeries. Dedicated paediatric anesthesia and respiratory therapy program will be also an asset.

7 Low risk deliveries High risk deliveries High risk perinatal clinic Level IIC neonatal care Subspecialty pediatric 8/21/2014 1:47 PM clinics to support pediatric subspecialty recruitment Community level pediatric surgery Advanced pediatric orthopedics

8 Level 2b NICU Continued ambulatory program Consideration of advanced peds program 8/20/2014 10:10 PM

9 Nicu and Pediatrics should be at RVC for the reasons discussed previously 8/20/2014 4:13 PM

10 Maintain level 2B OB and Level 2B NICU Maintain existing clinics and inpatient beds Enhance Paediatric menatal 8/20/2014 3:11 PM health beds Plastics clinic Cleft lip and palate Autism Clinic

11 Maintain Level 2B OBS Maintain Level 2C Neonatal Maintain Paediatric existing clinics and inpatient beds 8/20/2014 3:11 PM Enhance designated Paediatric Mental Healthh beds Develop new paediatric Ambulatory care clinics eg. Paediatric Plastics clinic (Cleft Lip)

25 / 28 Motion 1b Collaborative Clinical Questionnaire

12 Advanced neonatal/ child and adolescent medicine center providing all of the services they are currently offering 8/20/2014 1:35 PM and more

13 This is difficult to answer by hospital without understanding what services are currently provided by each site and 8/19/2014 10:23 PM the use patterns of each site. As well, as a consumer of mainly maternal care services, I am unfamiliar with the range of neonatal and paediatric services available.

14 Full Level 2C NICU with a transitional care Nursery available for more stable infants. Improved hours for 8/19/2014 3:51 PM pharmacy and RRT coverage. Increased OT, and PT support hours Increased Lactation Consultant coverage Require a Nurse practitioner

15 Enhanced inpatient pediatric services Continued development of sub-specialty ambulatory clinics. 8/19/2014 1:19 PM

16 Advanced Paediatric Inpatient and distributed ambulatory clinics 8/19/2014 11:41 AM

17 level 2C, OBS program- no change distributed paeds ambulatory inpatietn and ambularory program no 8/19/2014 11:37 AM duplication programs are in alignment with resources at each site all Programs/sites to recapture market share and repatriate the approx 40% of Scarborough patients who leave Scarborough and CELHIN for services

18 Advanced Regional Paediatrics with shared (distrubitive) outpatient clinics 8/19/2014 11:24 AM

26 / 28 Motion 1b Collaborative Clinical Questionnaire

Q24 TSH – General Campus

Answered: 17 Skipped: 16

# Responses Date

1 Standard health care 8/22/2014 12:59 PM

2 Maintain level 2B obstetrics Maintain level 2B neonatal care Maintain existing paediatric clinics Create 8/22/2014 12:34 AM mechanisms for coordination, timely and appropriate transfer of patients with advanced needs, repatriation protocols, clear intake processes, shared best practices, shared education, joint planning forums, joint marketing efforts, etc

3 Level 2b 8/21/2014 10:13 PM

4 continue with level 2b care and basic paediatric services 8/21/2014 9:32 PM

5 Level II B services and general pediatric care. Continue what services they are providing. 8/21/2014 7:00 PM

6 Will continue to maintain their current neonatal and paediatric service and will work in partnership with advanced 8/21/2014 6:22 PM regional neonatal and paediatric centre to develop best practice guidelines and protocols.

7 Pediatric Surgery Ambulatory Pediatric clinics Existing Obstretic and Neonatal services within accepted 8/21/2014 1:47 PM guidelines

8 Level 2c NICU/ Obstetric unit to match Inpatient peds Developmental Clinic 8/20/2014 10:10 PM

9 Does not have the infrastucture ,dated NICU or the cohesivennes to act as the advanced centr 8/20/2014 4:13 PM

10 Level 2C OB high risk OB and Level 2C NICU Maiantain existing clinics Developmental clinic 8/20/2014 3:11 PM

11 Level 2C Neonatal Level 2C OBS/high risk Advanced Neonatal Centre Maintain 8 Inpatient Paediatric beds 8/20/2014 3:11 PM Maintain Existing clinics- eg. Paediatric Developmental Screening Develop MFM program Develop new Paediatric ambulatory care clinics eg Autism

12 Pediatrics at this hospital should be moved to the Grace site 8/20/2014 1:35 PM

14 Regional Advanced L2C Neonatal Centre ( TSH would quickly apply and receive designation) Enhanced 8/19/2014 1:19 PM pediatric inpatient service Enhanced pediatric ambulatory service. Pediatric service development between the hospitals would benefit from a coordinating oversight committee.

15 High Risk Obstetrics MFM Advanced Regional Level 2 C NICU distributed paediatric ambulatory clinics 8/19/2014 11:41 AM

16 Advanced 2C center, high risk OBS program- Partner with and develop MFM program for Scarborough 8/19/2014 11:37 AM distributed paeds ambulatory inpatietn and ambularory program no duplication programs are in alignment with resources at each site all Programs/sites to recapture market share and repatriate the approx 40% of Scarborough patients who leave Scarborough and CELHIN for services

17 Advanced Regional Level 2C NICU and high risk obs 8/19/2014 11:24 AM

27 / 28 Motion 1b Collaborative Clinical Questionnaire

Q25 TSH – Birchmount Campus

Answered: 17 Skipped: 16

# Responses Date

1 Standard health care 8/22/2014 12:59 PM

2 Maintain level 2B obstetrics Maintain level 2B neonatal care Maintain existing paediatric clinics Promote 8/22/2014 12:34 AM excellence in midwifery Continue to develop expertise in culturally responsive services Create mechanisms for coordination, timely and appropriate transfer of patients with advanced needs, repatriation protocols, clear intake processes, shared best practices, shared education, joint planning forums, joint marketing efforts, etc

3 Level 2b 8/21/2014 10:13 PM

4 continue with level 2b care and basic paediatric services 8/21/2014 9:32 PM

5 Level II B services and general pediatric care. Continue what services they are providing. 8/21/2014 7:00 PM

7 Pediatric Surgery Ambulatory Pediatric clinics Existing Obstretic and Neonatal services within accepted 8/21/2014 1:47 PM guidelines

8 Level 2 b Inpatient peds Midwifery program, regional Ambulatory clinc development 8/20/2014 10:10 PM

9 Same as above ...it will require a lot of money to get that unit up to par. 8/20/2014 4:13 PM

10 Maintain level 2B OB and and 2B NICU Enhance Midwifery program for Scarborough with OB support maiantain 8/20/2014 3:11 PM and expand Early Pregnancy Clinic for the Scarborough region MFM clinic Maintain and enhance paediatric clinic Teen Clinic and Adolescent Sexual health clinic develop a PP depresion clinic in conjunction with the adult mental health program

11 Maintain Level 2B OBS Maintain Level 2B Neonatal Maintain 8 Inpatient Paediatric Beds Maintain existing clinics 8/20/2014 3:11 PM Enhance Midwifery program for all of Scarborough at the Birchmount Campus Develop new ambulatory paediatric care clinics such as Obesity, adolescent clinic Develop a post partum depression clinic in conjunction with the Adult Mental health program

12 Larger pediatric and neonatal site providing general care to the surrounding area 8/20/2014 1:35 PM

14 Enhanced midwifery care All current services in obstetrics neonatal and pediatric care. 8/19/2014 1:19 PM

15 Level 2 B NICU distributed paediatric ambulatory clinics 8/19/2014 11:41 AM

16 2C- with hybrid Midwifery OBS model distributed paeds ambulatory inpatient and ambularory program no 8/19/2014 11:37 AM duplication programs are in alignment with resources at each site all Programs/sites to recapture market share and repatriate the approx 40% of Scarborough patients who leave Scarborough and CELHIN for services

17 level 2b 8/19/2014 11:24 AM

28 / 28 Section 3

TSH-RVHS Current State Overview 2014

PAGE 164 Current State Overview Maternal, Child and Youth Services

Rouge Valley Health System and The Scarborough Hospital

Motion 1b: Planning for Maternal, Child and Youth Services January 2015 Introduction

As part of the requirement to fulfill Motion 1b issued by the Central East LHIN on March 26, 2013, The Scarborough Hospital and Rouge Valley Health System have worked collaboratively to provide “an overview of the current state of Maternal‐ Child‐Youth services within the Scarborough Cluster”. The contents presented in the subsequent slides address this request.

Both RVHS and TSH decision support departments worked together to create detailed descriptions of the current state utilizing a common set of data sources and definitions.

2 Organization of the presentation

Information provided in the document is a compilation of data, jointly reviewed and agreed upon from both TSH and RVHS. It focuses primarily on the fiscal years 2009 through 2014 and data is presented by Scarborough hospital site vs. organization.

Sections of the presentation include:

• Neonatal Care

• Paediatrics Description of volume, acuity, and market share for each clinical service area

• Obstetrics

• Measures of Quality ‐ key performance indicators for each service

3 Neonatal Care Scarborough Hospitals: Number of Newborns by Gestational Age (Pre-Term up to 32 weeks) Number of Discharges Gestational Hospitals FY FY FY FY FY Age 09/10 10/11 11/12 12/13 13/14 Gestational (3943) RVHS-CENTENARY 7 11 6 4 4 Age: < 28 (4152) TSH-SCAR.GEN.SITE 6 2 9 7 4 weeks (4154) TSH-BIRCHMOUNT SITE 63355 Gestational (3943) RVHS-CENTENARY 1 2 1 Age: 28 - (4152) TSH-SCAR.GEN.SITE 3 3 4 1 29+6 days (4154) TSH-BIRCHMOUNT SITE 122 Gestational (3943) RVHS-CENTENARY 3 9 9 8 9 Age: 30 - (4152) TSH-SCAR.GEN.SITE 11 9 5 3 1 31+6 days (4154) TSH-BIRCHMOUNT SITE 1 3 4 2 2

Over the last 5 FY, there have been 79 total newborns of 30 –31 + 6 days gestational age discharged from Scarborough Community Hospitals. In the 30‐31+6day age group, over the 5 years, TSH‐G volumes declined from 11 to 1 with a decline in each year of the 5 year period; RVC volumes increased from 3 to 9. These babies represent less than 1% of the newborn volume at any of the Scarborough hospitals

5 Acuity: Relative Intensity Weight (RIW)

# of Discharges Average RIW Gest. Age Hospitals FY FY FY FY FY FY FY FY FY FY 09/10 10/11 11/12 12/13 13/14 09/10 10/11 11/12 12/13 13/14 RVHS‐ CENT. 2483 2398 2253 2392 2339 0.49 0.55 0.56 0.55 0.56 Overall TSH‐ (up to 36 SCAR.GEN 2909 2889 2914 3024 2785 0.39 0.37 0.37 0.36 0.35 weeks) TSH‐ BIRCH. 2437 2402 2236 2316 2029 0.34 0.36 0.40 0.38 0.41

The Relative Intensity Weight (RIW) is a measure of the intensity of resource use (relative cost) associated with different diagnostic or surgical procedures and demographic characteristics of an individual. There is wide variation in the average RIW for newborns even within gestational age groups. The overall average RIW has remained fairly stable at each hospital site over the last five years.

6 Number of Pre-term Babies Remaining at Site of Delivery

• In 2013/14, 214 babies were born at 32 to 36 weeks and remained at the hospital of their birth (out of a total of 222 births). 90 out of 92 (98%) babies remained at RVC, 72 out of 74 (97%) babies remained at TSH-General and 52 out of 56 (93%) babies remained at TSH-Birchmount. • 21 babies of gestational age less than 32 weeks remained at the hospital of their birth. 11 out of 14 babies (79%) born at RVC remained at RVC, 4 out of 5 (80%) babies remained at TSH-General and 6 out of 7 (86%) babies born at TSH- Birchmount remained at TSH • RVHS and TSH transfer similar percentages of preterm babies to other organizations.

7 Number of Pre-term Babies Transferred to a Higher Level of Care

• In 2013/14, there were a total of 9 newborns <36 weeks transferred to a level 3 facility (3 from each Scarborough hospitals/sites) • The number of transfers to level 3 facilities has declined every year since 2011/12.

8 Babies Born at Another Institution Transferred to RVC or TSH-G and TSH-B

Hospital 2009/10 2010/11 2011/12 2012/13 2013/14 (3943) ROUGE VALLEY HEALTH SYSTEM‐ CENTENARY 51 67 55 70 66 (4152) SCARBOROUGH HOSPITAL (THE)‐ SCAR.GEN.SITE 23 22 28 18 19 (4154) SCARBOROUGH HOSPITAL(THE)‐ BIRCHMOUNT SITE 24 24 28 37 23

• Every year newborns are transferred to RVHS or TSH from other hospitals. • Over the last 5 years a total of 555 newborns were transferred to a hospital in Scarborough from a hospital elsewhere. • 56% of these transfers went to RVC (11% of RVC’s transfers came from Ajax site which is a lower level of care [2b] facility), 19% went to TSH-General and 25% went to TSH- Birchmount. • Most of the newborn transfers into Scarborough hospitals came from Sunnybrook or Mount Sinai Hospital.

9 Market Share of Scarborough Residents - Neonatal

• In 2013/14, 75% of neonatal patients discharged from the hospitals in Scarborough lived in Central East LHIN. Also, a significant number of neonatal patients discharged from hospitals in Scarborough live in Central LHIN, Toronto Central LHIN, Central West LHIN and Mississauga Halton LHIN.

10 Market Share of Scarborough Residents - Neonatal Hospital Discharges % (4152) SCARBOROUGH HOSPITAL ‐SCAR.GEN.SITE 1,925 24.9% (3943) ROUGE VALLEY HEALTH SYSTEM‐CENTENARY 1,581 20.5% (4154) SCARBOROUGH HOSPITAL(THE)‐BIRCHMOUNT 1,278 16.5% (1330) NORTH YORK GENERAL HOSPITAL 924 12.0% (1302) TORONTO EAST GENERAL HOSPITAL (THE) 735 9.5% (1423) MOUNT SINAI HOSPITAL 345 4.5% (3936) SUNNYBROOK HEALTH SCIENCES CENTRE 313 4.1% REST 625 8.1% Total 7,726

• In 2013/14, there were a total of 7,726 neonatal inpatient discharges for Scarborough residents. 4,784 of these discharges were from the 3 Scarborough hospital sites which represents a 62% market share. (this is approximately the same as in 2009/10 when the Scarborough market share was 63%)

11 Paediatrics Inpatient Paediatric Transfers to RVC, TSH-G and TSH-B

Hospital 2009/10 2010/11 2011/12 2012/13 2013/14 ROUGE VALLEY HEALTH SYSTEM‐ 50 52 42 65 40 CENTENARY SCARBOROUGH HOSPITAL (THE)‐ 35 35 24 14 11 SCAR.GEN.SITE SCARBOROUGH HOSPITAL(THE)‐ 26 17 12 18 10 BIRCHMOUNT

The facilities in Scarborough all receive paediatric transfers from other hospitals/sites. This includes newborns greater than 28 days. The volume of paediatric transfers has declined over the last five years which might be reflective of an overall decline in inpatient paediatric admissions. There were 40 paediatric transfers to RVC in 2013/14 (25% from Ajax site which is a lower level of care [2b] facility), down 10% from 2009. There were 11 paediatric transfers to TSH-General in 2013/14, a reduction of 69% from 2009. There were 10 paediatric transfers to the TSH-Birchmount site in 2013/14, down 62% from 2009. Most transfers come from SickKids or Sunnybrook.

13 Paediatric ED Visits and Admissions from the ED Fiscal Year Hospital Reason Type of Visit 2009/10 2010/11 2011/12 2012/13 2013/14 Total ED visits 11,165 11,184 12,317 12,393 12,742 ROUGE VALLEY HEALTH Medical Admitted 549 520 524 477 491 SYSTEM- % Admitted 4.9% 4.6% 4.3% 3.8% 3.9% CENTENARY Surgical Admitted 42 48 63 56 45 % Admitted 0.4% 0.4% 0.5% 0.5% 0.4% Total ED visits 8,308 7,973 8,555 8,035 8,033 SCARBOROUGH Medical Admitted 423 331 259 224 202 HOSPITAL(THE)- % Admitted 5.1% 4.2% 3.0% 2.8% 2.5% BIRCHMOUNT Surgical Admitted 41 37 34 31 30 SITE % Admitted 0.5% 0.5% 0.4% 0.4% 0.4% Total ED visits 11,210 10,795 11,414 10,835 11,198 SCARBOROUGH Medical Admitted 263 275 247 201 219 HOSPITAL % Admitted 2.3% 2.5% 2.2% 1.9% 2.0% (THE)- Surgical Admitted 41 39 50 35 43 SCAR.GEN.SITE % Admitted 0.4% 0.4% 0.4% 0.3% 0.4% •In 2013/14, among Scarborough hospitals, 40% of ED paediatric visits were seen at RVC, 35% at TSH‐G and 25% at TSH‐B •All sites show a decrease in the percentage of medical paediatric admissions over the past 5 years. For 2013/14, RVC had a medical admit rate of 3.9%, a reduction of 26% over the past 5 years, TSH‐B had a medical admit rate of 2.5%, a reduction of 104% and TSH‐G had a medical admit rate of 2.0% a reduction of 15% over the past 5 years 14 •The Surgical admit rate has remained stable over the past 5 years for all sites Market Share of Scarborough Residents – Inpatient Paediatrics

• In 2013/14, 83% of children (excluding newborns) discharged from the hospitals in Scarborough lived in Central East LHIN. Also, a significant number of children discharged from hospitals in Scarborough live in Central LHIN and Toronto Central LHIN.

15 Market Share of Scarborough Residents– Inpatient Paediatrics (cont) Hospital Discharges % (1406) HOSPITAL FOR SICK CHILDREN (THE) 1,118 37.3% (3943) ROUGE VALLEY HEALTH SYSTEM‐CENTENARY 597 19.9% (4152) SCARBOROUGH HOSPITAL (THE)‐SCAR.GEN.SITE 512 17.1% (4154) SCARBOROUGH HOSPITAL(THE)‐BIRCHMOUNT 367 12.3% (1302) TORONTO EAST GENERAL HOSPITAL (THE) 139 4.6% (1330) NORTH YORK GENERAL HOSPITAL 121 4.0% REST 141 4.7% Total 2,995 • In 2013/14, there were a total of 2995 paediatric inpatient discharges for Scarborough residents. 1476 of these discharges were from one of the 3 Scarborough facilities which represents a 49% market share. (in 2009/10, the Scarborough market share was 54%). The number of inpatient paediatric discharges from other Central East LHIN facilities was insignificant.

• 37% of inpatient paediatric discharges for Scarborough residents occurred at SickKids

16 Obstetrics Market Share of Scarborough Hospitals TSH RVHS‐CENTENARY GENERAL BIRCHMOUNT Number Number Number % of Births % of Births % of Births of Births of Births of Births FY09/10 2338 31.70% 2740 37.2% 2290 31.1%

FY10/11 2240 31.30% 2686 37.6% 2226 31.1%

FY11/12 2100 30.40% 2732 39.6% 2070 30.0%

FY12/13 2237 31.00% 2848 39.5% 2120 29.4%

FY13/14 2162 32.50% 2620 39.4% 1861 28.0%

• In 2013/14 there were a total of 6643 births across all 3 Scarborough facilities.

18 CritiCall Transfers of Obstetrical Patients to Scarborough Hospitals

Outcome Date Time Contacted Hospital Outcome Provisional Diagnosis Gestational Age Referring Hospital Rouge Valley Health System (RVHS): FCO Consult/Transfer Pre‐Term Labour/Premature 11/17/2013 21:23:21 30.5 William Osler Health Centre: Brampton Scarborough Centenary Accepted HLOC Rupture of Membranes Rouge Valley Health System (RVHS): FCO Consult/Transfer Pre‐Term Labour/Premature 3/10/2014 11:57:13 30.0 William Osler Health Centre: Etobicoke Scarborough Centenary Accepted HLOC Rupture of Membranes Rouge Valley Health System (RVHS): FPC Prior Consult/Transfer Pre‐Term Labour/Premature 9/17/2013 10:17:20 31.4 Mount Sinai Hospital Scarborough Centenary Accepted HLOC Rupture of Membranes The Scarborough Hospital (TSH): Grace FCO Consult/Transfer Pre‐Term Labour/Premature 5/13/2013 4:44:25 34.4 Mackenzie Health Birchmount Site Accepted Capacity Rupture of Membranes Rouge Valley Health System (RVHS): FCO Consult/Transfer Pre‐Term Labour/Premature 2/2/2014 7:31:46 30.5 Southlake Regional Health Centre Scarborough Centenary Accepted HLOC Rupture of Membranes The Scarborough Hospital (TSH): Grace FCO Consult/Transfer Pre‐Term Labour/Premature Rouge Valley Health System (RVHS): 5/30/2013 20:57:50 33.5 Birchmount Site Accepted HLOC Rupture of Membranes Ajax and Pickering Rouge Valley Health System (RVHS): FCO Consult/Transfer Pre‐Term Labour/Premature Rouge Valley Health System (RVHS): 6/20/2013 20:02:48 31.3 Scarborough Centenary Accepted HLOC Rupture of Membranes Ajax and Pickering Rouge Valley Health System (RVHS): FCO Consult/Transfer Pre‐Term Labour/Premature The Scarborough Hospital (TSH): General 1/12/2014 11:11:29 30.4 Scarborough Centenary Accepted HLOC Rupture of Membranes Site Rouge Valley Health System (RVHS): FCO Consult/Transfer Pre‐Term Labour/Premature 3/28/2014 14:05:52 31.5 Peterborough Regional Health Centre Scarborough Centenary Accepted HLOC Rupture of Membranes

The table above summarizes CritiCall transfers (total 9) for hospitals in Scarborough for the fiscal year 2013/14. RVHS – Centenary received 7 transfers through CritiCall . Other transfers to Centenary came from several different hospitals including 4 from outside of Central East LHIN. All 7 of the transfers to Centenary involved deliveries of less than 32 weeks gestation with a range from 30.0 to 31.5. TSH‐Birchmount site received 2 transfers through CritiCall ‐‐one from the RVHS Ajax site and one from McKenzie Health. One of these transfers was at 33.5 weeks gestation and the other at 34.4 weeks gestation. All of the transfers summarized above were for pre‐term labour/premature rupture of membranes. 19 Market Share of Scarborough Residents– Obstetrics • In 2013/14, 76% of women discharged from the hospitals in Scarborough lived in Central East LHIN. Also, a significant number of women discharged from hospitals in Scarborough live in Central LHIN, Toronto Central LHIN and Mississauga Halton LHIN.

20 Market Share of Scarborough Residents– Obstetrics (cont) Hospital Discharges % (4152) SCARBOROUGH HOSPITAL (THE)‐SCAR.GEN.SITE 1,971 24.8% (3943) ROUGE VALLEY HEALTH SYSTEM‐CENTENARY 1,616 20.3% (4154) SCARBOROUGH HOSPITAL(THE)‐BIRCHMOUNT 1,318 16.6% (1330) NORTH YORK GENERAL HOSPITAL 918 11.6% (1302) TORONTO EAST GENERAL HOSPITAL (THE) 769 9.7% (1423) MOUNT SINAI HOSPITAL 430 5.4% (3936) SUNNYBROOK HEALTH SCIENCES CENTRE 356 4.5% REST 568 7.1% Total 7,946 • In 2013/14, there were a total of 7,946 obstetrical discharges for women who reside in Scarborough. 4,905 of these discharges were from 3 Scarborough hospital sites which represents a 62% market share. (in 2009/10, the Scarborough market share was 64%).

• The out of area hospitals that had greater than 100 obstetrical discharges for women residing in Scarborough in 2013/14 were (in rank order), North York General Hospital, Toronto East General Hospital, Mount Sinai 21 Hospital, Sunnybrook, St. Michael's Hospital and Markham Stouffville Hospital Measures of Quality NICU Average LOS and Average RIW

Fiscal Year 2009 2010 2011 2012 2013 Average RIW Average RIW Average RIW Average RIW Average RIW Discharges Discharges Discharges Discharges Discharges Acute LOS Acute LOS Acute LOS Acute LOS Acute LOS Average Average Average Average Average # of # of # of # of # of

(3943) ROUGE VALLEY HEALTH 702 6.9 1.3 526 9.2 1.8 488 10.5 2.0 542 10.3 1.9 522 9.5 1.8 SYSTEM- CENTENARY (4152) SCARBOROUGH 441 7.3 1.3 404 7.2 1.2 385 7.7 1.3 360 8.1 1.4 294 8.8 1.5 HOSPITAL (THE)- SCAR.GEN.SITE (4154) SCARBOROUGH 377 6.0 1.1 343 7.3 1.3 345 8.4 1.6 332 7.8 1.4 308 7.9 1.5 HOSPITAL(THE)- BIRCHMOUNT SITE • In 2013/14 there were 1124 discharges from NICU’s of the three Scarborough facilities. 46% of these discharges were from RVC, 26% from TSH‐G, 27% from TSH‐B • Average acute LOS ranged from 7.9 days at TSH‐B, 8.8 days at TSH‐G and 9.5 days at RVC

23 Percent (%) of Same Day Surgery for Tonsillectomy

2009 2010 2011 2012 2013 % of Day Day % of Day % of Day % of Day % of Day % of Inpatient Inpatient Inpatient Inpatient Inpatient Surgery Surgery Surgery Surgery Surgery Surgery Surgery Surgery Surgery Surgery Day Day Day Day Day

Hospital (4139) ROUGE VALLEY HEALTH SYSTEM- 374 35 91% 339 62 85% 348 63 85% 379 70 84% 327 74 82% CENTENARY (3975) SCARBOROUGH HOSPITAL (THE)- 216 23 90% 263 15 95% 220 29 88% 222 36 86% 214 51 81% SCAR.GEN.SITE (3984) SCARBOROUGH HOSPITAL(THE)- 164 17 91% 143 13 92% 120 29 81% 120 26 82% 82 22 79% BIRCHMOUNT SITE

24 Maternal Mortality

Number of Number of Obstetrical Discharges Maternal Deaths Obstetrical Mortality Rate 2009 2010 2012 2013 2009 2010 2012 2013 2009 2010 2012 2013 Hospital 2011 2011 2011

(3943) ROUGE VALLEY HEALTH 2,584 2,486 2,345 2,495 2,370 0 0 0 0 0 0.00% 0.00% 0.00% 0.00% 0.00% SYSTEM-CENTENARY (4152) SCARBOROUGH 3,029 2,946 3,002 3,113 2,844 0 0 0 1 0 0.00% 0.00% 0.00% 0.03% 0.00% HOSPITAL (THE)- SCAR.GEN.SITE (4154) SCARBOROUGH 2,513 2,453 2,258 2,294 2,064 1 0 0 0 0 0.04% 0.00% 0.00% 0.00% 0.00% HOSPITAL(THE)- BIRCHMOUNT SITE

25 30-day Obstetric Readmission Rate

Hospital 2012/13 RVC 1.3% TSH-GEN 1.7% TSH-BIR 2.0%

Source: http://yourhealthsystem.cihi.ca/

26 Obstetric Trauma: Vaginal Delivery With Instrument

Hospital 2010/11 2011/12 2012/13 RVC 7.4% 5.3% 6.2% TSH-GEN 10.8% 16.6% 20.1% TSH-BIR 31.9% 24.7% 17.2%

Source: http://yourhealthsystem.cihi.ca/

27 Low Risk C-Section Rate

Hospital 2010/11 2011/12 2012/13 RVC 19.6% 20.7% 18.6% TSH-GEN 19.6% 20.7% 18.0% TSH-BIR 12.8% 14.8% 13.5%

Source: http://yourhealthsystem.cihi.ca/

28 TSH General: BORN Data

Aug‐2014 to Oct‐2014; Source: BORN Ontario, 2013‐2015

29 TSH Birchmount: BORN Data

Aug‐2014 to Oct‐2014; Source: BORN Ontario, 2013‐2015

30 Rouge Valley: BORN Data

Aug‐2014 to Oct‐2014; Source: BORN Ontario, 2013‐2015

31 Section 4

TSH-RVHS Physician & Midwifery Supply Report

PAGE 196 CURRENT AND PROJECTED FUTURE PHYSICIAN AND MIDWIFERY SUPPLY - FOR MOTION 1B - DRAFT

KEY MESSAGES

The availability of skilled clinicians is critical to the performance and sustainability of a service delivery system for newborns, children and expectant mothers.

Paediatrics:  The two hospitals report a total 46 paediatricians at Scarborough facilities; 23 have Active or Associate privileges.  54% are female and 28% are over the age of 55.  There are several subspecialties at both RVHS and TSH.  On-call responsibilities and the relative attractiveness of private community-based practice are factors in recruitment.  Provincial forecasts (2010) suggest that there might be a slight shortage of paediatricians over the next 10 years.

Obstetrics:  The two hospitals report a total of 34 obstetricians/gynecologists at Scarborough facilities; all have Active or Associate privileges.  59% are female and 44% are over the age of 55.  Provincial forecasts (2010) suggest that there will likely be more than enough obstetricians/gynecologists to meet population need over the next 10 years.  In the future, threats to the ability to recruit include the declining volume of births in Scarborough, the availability of operating room time and clinic time/space, cuts to provincial health care spending and clarity of vision at the regional level.

Midwifery:  The two hospitals report a total of 21 midwives; all have Active or Associate privileges.  All of the midwives are female and only one is over the age of 55.  Sage-Femmes Midwives practice at RVHS’ Centenary site and Ajax site. Diversity Midwives practice at both TSH sites.  The midwifery groups are not experiencing any recruitment challenges at the present time but recognize the importance of proactive succession planning.  The number of births attended by midwives in Ontario has been increasing each year since regulation. According to the College of Midwives of Ontario, last year approximately 10% of all births in the province were attended by midwives.  Over the next five to ten years, recruitment may be difficult if it is not possible to attain hospital privileges as midwifery practices grow but there is confidence that there will be an adequate supply of midwives in Scarborough.

CURRENT AND PROJECTED FUTURE PHYSICIAN AND MIDWIFERY SUPPLY - FOR MOTION 1B - DRAFT The availability of skilled clinicians is critical to the performance and sustainability of a service delivery system for newborns, children and expectant mothers. This section addresses the current and projected future supply of paediatricians, obstetricians and midwives in Scarborough. (Data for the Ajax site of RVHS is not included). The content in this section was provided by physician and midwifery leaders, medical affairs databases, literature and the Ontario Physician Human Resource Data Centre.

Paediatrics The table below provides a profile of the paediatricians currently practicing at RVHS Centenary Site and TSH. The two hospitals report a total 46 paediatricians. 54% are female and 28% are over the age of 55.

Hospital-Based Paediatricians as of August 2014 Primary Gender Age Group Privilege Category Sub-Specialties Recruitments Site M F 25-35 36-45 45-55 56-65 66+ Active Associate Courtesy (Type/Number) in Progress RVHS-RVC 8 12 2 5 5 7 1 5 5 10 Neonatology (3 active), Cardiology 7 (1 Active, 1 Courtesy), Respirology (1 courtesy), Endocrinology (1 Active), Allergy & Immunology (1 associate and 3 courtesy), Neurology (1 Courtesy), Genetics (1 Courtesy), Nephrology (1 active and 1 Courtesy), Gastroenterology 2 Courtesy), Haematology (2 Courtesy), Rheumatology (2 Courtesy), Infectious disease(1 courtesy), Adolescent Medicine (1 courtesy), Child Psychiatrists (5 active) TSH-B 5 8 3 4 3 3 0 6 0 7 Neonatology (1 Active, 1 Courtesy), 2 Cardiology (2 Courtesy), Nephrology (1 courtesy), Behaviour (1 Courtesy) TSH-G 8 7 3 3 6 2 1 6 1 8 Cardiology (1 active/ 2 courtesy), 3-Developmental Neonatology ( 1 Active, 1 Pediatrician, Courtesy), Neurology (2), Infectious Acute Care Diseases (1), Allergy (1) Specialist, Allergist Total 21 25 8 12 12 12 1 17 6 23 Notes: There are also 2 neonatologists based at the RVHS Ajax site who also work at the RVHS Centenary site. 2

There are no significant recruitment issues for paediatricians at the present time and Scarborough hospitals have been successful at recruiting new paediatricians.

Ensuring comprehensive on-call coverage is a challenge. This is not just an issue related to retirement, but is also an issue for new paediatricians joining the hospital, starting call, then developing private practices and deciding to decrease their on-call responsibilities.

In the future, it is anticipated that there will be ongoing difficulties attracting pediatricians to provide hospital on call services. Factors include strong competition from other hospitals with a variety of incentives including direct added payments, clinic activity, specialty clinic development, etc. Hospital based paediatrics supports ED and surgical care teams (especially ENT and dentistry). The number of pediatric admissions will continue to decrease; with the result that the number of pediatricians taking call will decrease since it does not compensate well. Other means of financial support to retain paediatricians may have to be explored.

Group discussion within the department with a focus on providing on call coverage drives recruitment planning. RVHS also has a corporate Clinical Prioritization Committee, which anticipates future needs for medical human resources and requires impact analyses for all new or replacement positions. The two Scarborough hospitals have no formal rules regarding retirement age or guaranteed call reductions with age.

Whether or not there will be an adequate supply of physicians over the next 5 to 10 years is dependent on a number of factors including role and activity levels of each hospital site, payment plan options and the relative attractiveness of office-based practice.

Obstetrics

The table below provides a profile of the obstetricians/gynecologists currently practicing at RVHS Centenary Site and TSH. The two hospitals report a total of 34 obstetricians/gynecologists. 59% are female and 44% are over the age of 55.

Obstetrician/Gynecologists Primary Gender Age Group Privilege Category Sub-Specialties Recruitments Site (Type/Number) in Progress M F 25-35 36-45 45-55 56-65 66+ Active Associate Courtesy RVHS-RVC 5 7 0 5 2 3 2 11 1 0 Urogynecology -2 2 TSH-B 5 5 0 0 3 6 1 10 0 0 MFM 1 5 TSH-G 4 8 2 5 2 3 0 12 0 0 MIS x1 0

Total 14 20 2 10 7 12 3 33 1 0 7

Currently, the supply of obstetricians/gynecologists at the hospitals in Scarborough is not an issue. Hospitals have the ability to offer locum privileges to potential candidates to assess organizational fit before finalizing an offer. Recruiting for specific skill sets or characteristics (e.g. sub-specialties or particular language capacity) can be more challenging.

In the future, threats to the ability to recruit include the lack of availability of operating room time and clinic time/space, cuts to provincial health care spending and clarity of vision at the regional level.

Hospitals in Scarborough use a number of approaches for proactive planning for obstetricians. For example, TSH regularly has Obstetrics/Gynecology residents doing electives in the hospital which gives medical leadership a chance assess abilities and dialogue with possible candidates. New recruits Could potentially come from this pool of people. RVHS has a corporate Clinical Prioritization Committee and requires impact analyses for all new or replacement positions. TSH has a corporate Performance Improvement Committee and requires and impact analysis for all new or replacement positions.

There are currently no department-specific rules regarding retirement or reduced call-obligations. However, RVHS Centenary site is exploring guidelines about reduced call responsibilities, especially night call, for high risk specialties such as Obstetrics after a certain age.

Leaders at the two Scarborough hospitals believe that there will be an adequate supply of obstetricians/gynecologists in Scarborough in the next 5 to 10 years. However, in light of the decreasing number of deliveries in the Scarborough cluster in recent years RVHS and TSH are actively engaging in the repatriation of Scarborough deliveries.

Midwifery

The table below provides a profile of the midwives currently practicing at RVHS Centenary Site and TSH. The two hospitals report a total of 21 midwives. All of the midwives are female and only one is over the age of 55.

Midwives Primary Gender Age Group Privilege Category Sub-Specialties Recruitments Site (Type/Number) in Progress M F 25-35 36-45 45-55 56-65 66+ Active Associate Courtesy RVHS-RVC 0 10 0 7 3 0 0 5 5 0 NA 1 TSH-B and 0 11+ 1 3 5+1 2 1 0 11 +1 0 NA 1 TSH-G (Oct 2014) Total 0 21 3 12+1 5 1 0 16 5+1 0 1 NOTE: Sage-Femmes Midwives practice at RVHS’ Centenary site and Ajax site. Diversity Midwives practice at both TSH sites.

The midwifery groups are not experiencing any recruitment challenges at the present time but recognize the importance of proactive succession planning.

The number of births attended by midwives in Ontario has been increasing each year since regulation. According to the College of Midwives of Ontario, last year approximately 10% of all births in the province were attended by midwives.

Over the next five to ten years, recruitment may be difficult if it is not possible to attain hospital privileges as midwifery practices grow. The future service delivery model may have an impact on this. Recruitment planning is based on client demand in the community, funding that is given to the practice by the Ministry of Health and succession planning requirements. There are no specific rules regarding retirement or reduced call-obligations.

There is confidence that there will be an adequate supply of midwives in Scarborough in the next five to ten years. Given that there are two practices in Scarborough and the quarterly reports generated by both practices to the Ministry do not suggest that there is a large number women who cannot receive care from a midwife. Both practices can continue to gradually grow as they have been and continue to effectively cover the demand for midwifery.

Demographic Trends Both paediatricians and obstetricians/gynecologists exhibit similar patterns with a larger proportion of males in higher in the older age brackets, and a larger number of females in the younger age brackets. This is consistent with the current distribution of students entering and graduating from Canadian Medical Schools and subsequently entering the workforce; approx. 58% of MD Degrees have been awarded to women by Canadian Universities since 20051. (AFMC 2013: "Graduates of MD Programs in Canadian Faculties of Medicine")

Female physicians exhibit different practice patterns, and may not assume the same level of full-time practice as male counterparts. They are more likely to take parental leave or leaves of absence, take less call and see fewer patients while on-call2. Females may also be retiring at a younger age, as there are fewer of them over the age of 55 than males. There is a very small proportion of doctors under 35 (only 1 out of 91 Obstetricians & Paediatricians practicing in Scarborough in 2012). There are limited vacancies and openings in hospitals, so many younger doctors may be working part time as locums, or women are taking time off after graduating to start families before fully establishing their practice.

Obstetrics & Gynaecology is a specialty that is dominated by women, with the greatest proportion between the ages of 35 and 54 (accounts for approximately 49% of Obstetricians & Gynaecologists practicing in Scarborough). This reflects medical school graduate patterns and the increasing demand for female Obstetricians. The number of female paediatricians is low in the 54-64 and the 45-54 age brackets.

Projections The Ontario Population Needs-Based Physician Simulation Model was developed in 2010. It is a planning tool for planners and policy makers to understand the impacts of health population trends and health policies on physician supply and need. This model is one of many pieces of evidence available to support health human resource planning and the results should always be combined with other evidence (both qualitative and quantitative). The final report includes the following caution: “Simulating the future in health human resources through modelling is not an exact science. Results will never be completely accurate; however the direction and magnitude of observed trends can provide insight into potential future circumstances.”

The table below shows the projected annual variance between the supply of physicians in Central East LHIN and estimated population need. A negative value represents a shortage.

2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 Obs/Gyn -2 -2 0 0 0 1 2 2 4 5 5 6 7 7 7 7 8 8 Paeds -1- -1 -1 -1 -2 -2 -2 -1 -1 -1 -1 -1 -2 -2 -2 -3 -3 -4 Note: The paediatric estimates do not include Pediatric General Surgery, Pediatric Respirology, Pediatric Rheumatology, Pediatric Nephrology, Pediatric Infectious Diseases, Pediatric Hematology, Pediatric Gastroenterology, Pediatric Endocrinology & Metabolism, Pediatric Critical Care, Pediatric Clinical Immunology, Pediatric Cardiology and Pediatric Neurology. 6

This data suggests that, in Central East LHIN, there will likely be more than enough obstetricians/gynecologists to meet population need but there may be a shortage of Paediatricians over the next 10 years.

References:

1. "Graduates of MD Programs in Canadian Faculties of Medicine". 2013 Canadian Medical Education Statistics.

2. N Weizblit, J Noble, & MO Baerlocher,"The Feminisation of Canadian Medicine and its Impact upon Doctor Productivity." Medical Education 43:5 (May 2009): 442-448.

3. MOHLTC & OMA Simulation Report, Oct. 2010

Section 5

TSH-RVHS Motion 1b Design Criteria

PAGE 204 Design Criteria Maternal, Child and Youth Services Rouge Valley Health System and The Scarborough Hospital

Motion 1b: Planning for Maternal, Child and Youth Services October 6 2014 Domain CELHIN Criteria Motion 1b Siting Criteria Alignment: Degree of impact on advancing • Alignment: Degree of alignment with 2009 Clinical Integrated Health Services Plan and Annual Services Plan System Service Plan goals and priorities Alignment: Strategic Fit: Alignment with provider •Strategic Fit: Alignment with the site’s capacity to fulfill Determines system role. Extent to which mandate of a PCMCH Level 2C designation (or other alignment with program/initiative is consistent with the advanced level of care designation) both Ministry and provider(s) mandate and capacity local priorities compared to other providers in Ontario. • Strategic Fit: Degree of alignment to hospital strategic priorities Sustainability: Impact on health service •Sustainability: Capacity of site to absorb future growth delivery, financial, and human resources physically and financially capacity over time. The health system should have enough qualified providers, • Sustainability: Ability to attract market share funding, information, equipment, supplies System and facilities to look after people’s health • Sustainability: Degree of access to range specialists Performance: needs. and subspecialists relevant to advanced neonatal and Contributes to the paediatric care meeting of system goals and •Sustainability: Capacity of the physical plants’ ability to objectives support care providers in looking after people’s health needs

•Sustainability: IT systems’ ability to support care providers in looking after people’s health needs

2 Domain CELHIN Criteria Motion 1b Siting Criteria Integration: Extent to which • Integration: Degree to which a single point of access or ‘one program/initiative improves stop shop’ can be developed for regional services System coordination of health care among Performance: health service providers, including • Integration: Degree to which a single point of access and Contributes to LHIN funded and non‐funded coordinated care experience can be developed for regional the meeting of providers and community providers to services system goals ensure continuity of care in the local •Integration: Reduction of redundancies in service, where and objectives health system and provision of care in applicable (NB. Within advanced and leads care provision only) the most appropriate setting as determined by patient/client's needs. Quality: Extent to which •Quality: Extent of rapid access to wide array of paediatric sub‐ program/initiative improves safety, specialty services effectiveness, and client experience of System health services(s) provided. •Quality: Ability to create critical mass to develop a regional Performance: centre for advanced pediatrics and neonates Contributes to Access: Extent to which • Access: Geographical proximity to regional target population the meeting of program/initiative improves physical, system goals cultural, linguistic and timely access and objectives to appropriate level of health services for defined population(s) in the local health system.

3 Domain CELHIN Criteria Motion 1b Siting Criteria Equity: Impact on the health status • Equity: Range of ambulatory services available to target and/or access to service of population(s) recognized sub‐populations where there is a known health status gap between this specific population and the general population as System Values: compared to current practice/ Ensures local service. The absence of systematic and system and potentially remediable wide attributes differences in one or more aspects are being met of health across populations or including population groups defined socially, equity, economically, demographically, innovation and culturally, linguistically or community geographically. engagement Efficiency: Extent to which • Efficiency: Timeline to implementation for regional services program/initiative contributes to efficient utilization of health services, financial, and human • Efficiency: Ability to minimize investment for implementation resources capacity to optimize health and other benefits within the system.

4 Domain CELHIN Criteria Motion 1b Siting Criteria

Client‐Focused: Extent to which • Client‐Focused: Extent to which program/initiative meets the program/initiative meets the health needs of a defined population and the degree to which health needs of a defined patients/clients have a say in the type and delivery of care population and the degree to System Values: which patients/clients have a say Ensures local and in the type and delivery of care. system wide attributes are being met including Innovation: Impact on • Innovation: Mechanisms in place to support innovation equity, innovation generation, transfer, and /or and community application of new knowledge to engagement solve health or health system problems; encouraging leading practices and innovation, building on evidence and application of leading practices.

5 Domain CELHIN Criteria Motion 1b Siting Criteria Health status (Health outcomes & Quality of •Health status (Health outcomes & Quality of Life): Life): Impact on health outcomes for the Impact on health outcomes for the patient/client patient/client and/or community, including risk and/or community, including risk of adverse events, of adverse events, and/or impact on physical, and/or impact on physical, mental or social quality mental or social quality of life, as compared to of life, as compared to current practice or service. Population Health: current practice or service. Determines Prevalence: Magnitude of the •Prevalence: Magnitude of the disease/condition contribution to the disease/condition that will be directly that will be directly impacted by the improvement of impacted by the program/initiative as program/initiative as measured by prevalence (i.e., the overall health measured by prevalence (i.e., # of individuals # of individuals with the condition in the of the population with the condition in the population or population or subpopulation at a given time). subpopulation at a given time). Health promotion & disease prevention: •Health promotion & disease prevention: Impact Impact on illness and/or injury prevention and on illness and/or injury prevention and promotion promotion of health and well‐being as of health and well‐being as measured by projected measured by projected longer term longer term improvements in health and/or improvements in health and/or likelihood of likelihood of downstream service. downstream service.

6 Domain CELHIN Criteria Motion 1b Siting Criteria Partnerships: Degree to which appropriate • Partnerships: Ability to build on established levels of partnership and/or appropriateness of tertiary relationships and referral patterns partnerships, both LHIN funded and non‐LHIN • Partnerships: Ability to create partnerships with funded, will be achieved in order to ensure health service providers to deliver advanced System service quality enhancement, improved regional services. Performance: comprehensiveness, optimal resource use, Contributes to the minimal duplication, and/or increased meeting of system coordination. goals and Community Engagement: Level of involvement •Community Engagement: Ability to involve the objectives of target population and other key patient population, their families and other key stakeholders in defining the project and stakeholders in planning services and evaluating its planned involvement in evaluating its impact impact. on population health and key system performance.

7 Section 6

TSH Three Proposed Service Delivery Models

PAGE 212 Maternal Child and Youth Services

TSH Proposed Model For Regional Advanced Neonatal and Pediatric Service

October 1, 2014 Vision Statement June 2014

We will create a regional program of excellence including advanced neonatal and paediatric care, renowned for delivering an integrated continuum of community and hospital services that exceeds expectations and delivers an outstanding patient and family experience. The system will continue to evolve to use resources efficiently and effectively and instill confidence in our commitment to ensure that services are sustainable into the future. Obstetrical Volumes and Capacity

Obstetrical Volumes and Capacity

TSH is the largest single provider of obstetrical service in Scarborough and the CELHIN delivering up to 70% of Scarborough births over the last 5 years:

• 6400 obstetrical patients triaged (2013‐2014) • 4441 patients delivered (2013/2014) • largest number of Obstetricians, Midwives and Family Physicians in Scarborough

Obstetrical program can access support for high risk situations from ICU including in‐house intensivists and anaesthesiologists, 24 hour rapid response team, interventional radiologists, vascular surgeons and access to maternal fetal medicine. Inter‐professional team includes in‐ house paediatricians 24x7. TSH has the only interventional radiology program in Scarborough. Obstetrical Volumes and Capacity

Obstetrical Volumes and Capacity TSH has 2 sites for obstetric care creating additional capacity by seamlessly moving staff and resources within one organization, in the case of excessive volumes, or closure due to outbreak or unforeseen situations.

TSH has expertise and capacity to assume care of moms 30+ weeks gestation.

TSH General Campus has been designated as level IIC OBS and NICU.

Expert panel 2012 recommends high volume/acuity obstetrical program be supported by interventional radiology program.

VOC: “We want excellent care close to home.” Obstetrical Volumes and Quality

Indicator TSH Ontario (2013‐14) (2013‐14) C‐Section Rate 25% 28% VBAC Rate 25% 15% BORN (Key Performance Indicators) • Repeat C‐Section (37‐39 weeks, low risk) 6.6% 41.6% • Group B Streptococcus screening (at 35‐37 weeks) 96.1% 88.6% • Induction post‐dates (<41 weeks) 4.5% 21.0%

VOC: “We expect evidence based, high quality care. We want our preferences valued.” “Patients/families expect a high level of clinical quality of care.” Obstetrical Outpatient Service

• Antenatal fetal assessment/high‐risk clinic – 2013/14 assessed 2486 women, using SOGC best practice guidelines (NST, MFM, Rhogam, BPP and Venofer infusions)

• Early pregnancy assessment clinic – 2013/14 saw 630 patients diverting them from an ED visit into an environment with perinatal specialists including bereavement support (Leading Practice award 2012 Accreditation Canada).

• Gestational diabetes clinic with academic links. In 2013/14 there were 2414 visits.

• Mental health supports – inpatient peri‐partum mood disorder program. Collaborative inter‐professional teen pregnancy and community outreach program.

TSH has expertise and capacity to assume care of moms 30+ weeks gestation. VOC: “Great to have everything organized through the clinic including blood work and Chaplaincy support.” Neonatal Level 2B Volumes and Capacity In 2013/14 TSH was the largest provider of neonatal intensive care in Scarborough • 596 discharges • 133.4 ventilator days (BORN database) Access to staff neonatologist (largest number of paediatricians providing on‐call hospital coverage in Scarborough). Paediatricians do not require financial support from the global budget. Access to support services such as RRT, UA/UV insertions, PICC line insertion and maintenance, TPN, paediatric trained diagnostic imaging including MRI , non‐invasive/invasive ventilation. TSH has the capability and capacity to assume and enhance the regional role in neonatal care.

VOC: “Care close to home, means I am not separated from my baby.” NICU Outpatient Programs • Neonatal Follow‐up clinic (General Campus) – 2013/14 203 newborns assessed and followed at 3, 6, 12, 18 and 24 months. Patients seen by an inter‐professional team and referred to community support as required. • Newborn Assessment/Postpartum clinic – 2013/14 saw 4029 patients. Operates 365 days a year, all patients receive a post discharge phone call 2 days post clinic visit. • Breastfeeding support clinic – 2013/14 saw 680 patients. Lactation consultant supports NICU, Paediatrics and FMC • RSV Prophylaxis clinic – 2013/14 saw 630 visits and operated October–May to support vulnerable children. TSH has the capability and capacity to assume and enhance the regional role in neonatal care. VOC: “Integration of services across providers to the community is important to patients.” Comparison of Actual and Expected Admissions Admissions from ED – Paediatrics (HayGroup 2012-2013)

Inpatient Paediatric Care Comparison of Actual and Expected Admissions to Inpatient Acute Care from ED for (All) TSH is the largest provider of care for paediatric Diagnosis Group, CTAS (All), and Age Group 00-17 Admissions Admission Rate Ratio of Rank of Emergency department visits in Scarborough with Hospital Visits* Actual Expected Actual Expect. Actual to Act. To more than 19000 paediatric ED visits in 2013/14.Grand River Hospital 12,900 1,349 1,149 10.5% 8.9% 117% 2 Halton Healthcare 28,820 1,261 1,513 4.4% 5.3% 83% 12 Health Science North 8,377 619 693 7.4% 8.3% 89% 9 Establishment of best practice “paedlink program”Hotel-Dieu Grace, Windsor 4,368 176 295 4.0% 6.8% 60% 18 that is available 365 days of the year to pullHumber River Regional 16,301 687 1,033 4.2% 6.3% 66% 17 Lakeridge Health 27,420 1,340 1,448 4.9% 5.3% 93% 6 paediatric patients out of the Emergency North York General 21,329 1,084 1,479 5.1% 6.9% 73% 14 department and on to a paediatric floor forPeterborough Regional HC 12,639 639 653 5.1% 5.2% 98% 5 treatment. (Leading practice 2012 – AccreditationRouge Valley HS 26,305 1,222 1,326 4.6% 5.0% 92% 7 Royal Victoria Hospital Barrie 13,610 737 875 5.4% 6.4% 84% 10 Canada) Southlake Regional HC 18,906 1,268 1,035 6.7% 5.5% 122% 1 St. Joseph's HC, Toronto 18,249 776 1,072 4.3% 5.9% 72% 16 Thunder Bay Regional 21,126 1,084 1,189 5.1% 5.6% 91% 8 Best practices implemented to reduce the numberToronto East of General 11,991 568 681 4.7% 5.7% 83% 11 paediatric admissions from the ED, in 2013/14,Trillium 2.6% Health Partners 47,119 2,796 2,778 5.9% 5.9% 101% 4 William Osler HC 39,183 3,039 2,709 7.8% 6.9% 112% 3 of the 19000 paediatric ED visits resulted inWindsor Regional 13,963 726 1,000 5.2% 7.2% 73% 15 admissions. Lower than expected admissionYork rates Central Hospital 17,932 760 1,279 4.2% 7.1% 59% 19 Scarb. Hosp. - General 10,833 277 677 2.6% 6.2% 41% 20 of paediatric ED patients. Scarb. Hosp. - Birchmount 8,033 306 410 3.8% 5.1% 75% 13 Grand Total 379,404 20,714 23,295 5.5% 6.1% 89% Strategic development of paediatric outpatient clinics to support model of admission diversion. TSH has the capability and capacity to provide higher acuity care for paediatric inpatients. VOC: “I was so relieved when my child didn’t have to stay overnight and we could come back the next day for follow‐up.” Paediatric Outpatient Service Paedlink – 13/14 there were 1253 patients pulled from ED to the child friendly environment. Paedlink significantly reduces paediatric admission rates. Paediatric Day Surgery – 8 beds with capacity to 16. “‘Til I sleep” program (recognized by Accreditation Canada 2012, as a good work practice that will be used as an example in education tool development for other organizations). Paediatric Consult/Day Clinic – 2013/14 there were 6877 visits. Referral base from inpatient paediatrics, ED, family physicians and other paediatricians. Access to paediatric MRI with sedation.

Paediatric Orthopaedic Clinic‐ 2013/14 there were 2580 visits.

Paediatric Plastics Clinic – 2013/14 there were 1093 visits. VOC: “We were moved very quickly from the ED up to the Paediatric unit where we received phenomenal care from the physicians and the nurses.” Paediatric Outpatient Service Pre‐Admission Clinic – 13/14 prepared 324 children for surgery. Partnerships with child life, surgery and anaesthesia to deliver this service. Paediatric Speech Language Program – 13/14 there were 1197 children and families serviced in partnership with community agencies. Paediatric Developmental Screening Clinic – 13/14 there were 101 children assessed and routed to the most appropriate care. Targeted funding from CE LHIN provided for this service to address significant wait times for our Scarborough patients. TSH has the expertise and capacity to create a distributive outpatient service with robust sub‐specialty clinics.

VOC: “I was able to see all the different care providers who would be providing treatment to my child all in one clinic.” OPTION 1: The Scarborough Hospital Center for Regional Advanced Neonatal and Paediatric Care • TSH assumes role of the Regional Advanced Neonatal Program (General Site) and Paediatric Program with the mandate to integrate care in Scarborough and address service gaps in the CE LHIN. • Establish a cooperative Regional Advanced Paediatric Program with a focus on the ongoing development of sub‐ specialty paediatric care delivery. • An integrated governance structure will establish a 3 year strategic plan and monitor achievement of the regional vision.

OPTION 2: The Scarborough Hospital Advanced Neonatal Program (Defer decision for Regional Paediatric Inpatient Designation)

• TSH assumes role of Regional Advanced Neonatal Program residing at the General site to integrate care in Scarborough and address service gaps in the CE LHIN. • The decision related to the designation of a Regional Advanced Level Inpatient Paediatric Program should be deferred until the PCMCH defines the level of care included in this designation. • A collaborative approach should be taken to the development of sub‐ specialty out patient paediatric care delivery within the 3 Scarborough hospitals.

OPTION 3: CE LHIN Integrated Regional Advanced Neonatal and Paediatic Progam for Scarborough Cluster • Develop the Scarborough Maternal Newborn and Paediatric Regional Program to integrate care in Scarborough and address gaps in service within the CE LHIN. • An MOU is structured and passed by both Boards which clearly defines accountability of the joint program. • An integrated governance structure will establish a 3 year strategic plan and monitor achievement of the regional vision. • A Steering Committee will oversee the implementation of the strategic plan.

Section 7

RVHS Three Proposed Service Delivery Models

PAGE 231 Potential Models for Fulfilling Motion 1B

Prepared by Rouge Valley Health System September 29, 2014

For the confidential use of the Motion 1B Collaborative

1 Models for Consideration

Model A Model B Model C Advanced neonatal and All advanced neonatal Advanced neonatal and advanced paediatric and advanced advanced paediatric services delivered at one paediatric services services delivered at one site with LHIN-wide delivered at one site. site with LHIN-wide regional access and regional access and outreach . All planning, outreach. coordination and Lead agency convenes oversight provided by All planning, coordination and chairs (with a the designated site and oversight provided rotating co-chair from using existing by the designated site another organization) a governance structures using existing Regional multi- only. governance structures only. organizational committee for planning, coordination and oversight including development and siting of new programs, that provides advice to existing governance structures.

2 Common Features of All Models

Emergency Services for newborns, children and expectant  A hybrid model including mothers; links to primary care – In all 3 Scarborough sites; both consolidated and Scarborough resident focus distributed components

 A continued role for all 3 Scarborough sites Level 2b neonatal and maternal care (inpatient and outpatient); General paediatric inpatient  Alignment with consumer and ambulatory care – In all 3 Scarborough preference for ‘one stop sites; Scarborough resident focus shopping approach’ to access

 Leverage the benefits of critical mass for specialty services through co-location Advanced neonatal care (2c),  Development of connecting Advanced paediatric care, mechanisms that link Advanced maternal services and sites to care (2c, including ability optimize coordination for to deliver and manage patients/families across the 30-32 week continuum of care gestation age)

3 Model A

Model Characteristic

Advanced Service All advanced inpatient and outpatient neonatal and paediatric Delivery services delivered at one site. New advanced services situated at the designated site.

Advanced One organization Designation Rouge Valley Centenary

Planning and All planning, coordination and oversight provided by the designated Oversight site using existing governance structures only.

4 Model B

Model Characteristic

Advanced Service • Advanced inpatient neonatal and advanced paediatric services Delivery delivered at one site with innovative approaches to LHIN-wide regional access, outreach and creating a presence across the LHIN • Development of connecting mechanisms that link services and sites to optimize coordination for patients/families across the continuum of care Advanced • One organization Designation • Rouge Valley Centenary

Planning and • All planning, coordination and oversight provided by the Oversight designated site using existing governance structures only.

5 Model C Model Characteristic Advanced • Advanced inpatient neonatal and advanced paediatric services delivered Service Delivery at one site with innovative approaches to LHIN-wide regional access, outreach and creating a presence across the LHIN • Development of connecting mechanisms that link services and sites to optimize coordination for patients/families across the continuum of care

Advanced • One organization Designation • Rouge Valley Centenary Planning and • Lead agency convenes and chairs, with a rotating co-chair from another Oversight organization a Regional multi-organizational committee for planning, coordination and oversight • Role would include planning, development and siting of new programs, facilitating adequate physician coverage across sites and monitoring and evaluation of the regional advanced maternal/child service delivery • Membership would include hospital and community-based providers from across the LHIN, tertiary centres , consumers and Central East LHIN • Committee would provide advice to existing governance structures

6 Appendix

Supporting Information for Application of Design Criteria

7 All sites delivered babies with a range of gestational ages, but not all patients were managed at site delivered, some were transferred to a higher level of care. There are very wide ranges of birth weights by grouping at each site.

Of the years that RVC has been designated level 2C (11/12 onward) RVC has delivered 60% of the 43 neonates born between 30 to 31+6 weeks

Note: This data describes the pre-term and late pre-term gestational age groups that were delivered at hospitals in Scarborough. Full term births are not included in this data. Gestational age is an indicator of patient acuity and risk. 8 Acuity: Relative Intensity Weight (RIW)

# of Discharge Average RIW Gest. Age Hospitals FY FY FY FY FY FY FY FY FY FY 09/10 10/11 11/12 12/13 13/14 09/10 10/11 11/12 12/13 13/14 RVHS- CENT. 2483 2398 2253 2392 2339 0.49 0.55 0.56 0.55 0.56 RVHS- AJAX 1570 1536 1656 1586 1539 0.25 0.27 0.28 0.28 0.32 RVHS Overall (up to 4053 3934 3909 3978 3878 0.39 0.44 0.44 0.44 0.47 36 weeks) TSH- SCAR.GEN. 2909 2889 2914 3024 2785 0.39 0.37 0.37 0.36 0.35 TSH- BIRCH. 2437 2402 2236 2316 2029 0.34 0.36 0.40 0.38 0.41 TSH 5346 5291 5150 5340 4814 0.36 0.36 0.38 0.37 0.37

The Relative Intensity Weight (RIW) is a measure of the intensity of resource use (relative cost) associated with different diagnostic or surgical procedures and demographic characteristics of an individual. RVC has had the highest overall average RIW each year of the last five years.

9 Number of Pre-term Babies Remaining at Site of Delivery

• Newborns are more likely to remain at the hospital of their birth when they are close to full term.

• In 2013/14, 214 babies were born at 32 to 36 weeks and remained at the hospital of their birth. 90 remained at RVC, 73 remained at TSH-General and 50 remained at TSH-Birchmount.

• At the other end of the spectrum, 21 babies of gestational age less than 32 weeks remained at the hospital of their birth. 11 babies remained at RVC, 4 babies remained at TSH-General and 6 remained at TSH.

10 Neonatal Retro-Transfers

FY200 FY201 FY201 FY201 FY201 Gestational Age Hospital 9/10 0/11 1/12 2/13 3/14

(3943) ROUGE VALLEY HEALTH SYSTEM- CENTENARY 63 78 71 84 76

(4014) ROUGE VALLEY HEALTH SYSTEM-AJAX SITE 1 8 4 6 3 Overall ROUGE VALLEY HEALTH SYSTEM 64 86 75 90 79 (up to 36 weeks) (4152) SCARBOROUGH HOSPITAL (THE)- SCAR.GEN.SITE 35 30 30 27 24

(4154) SCARBOROUGH HOSPITAL(THE)- BIRCHMOUNT 33 34 35 47 31 SCARBOROUGH HOSPITAL(THE) 68 64 65 74 55

• Retro transfers involve transfer of neonatal patients from a higher level of care facility to a lower level of care facility. This typically occurs to allow babies to be transferred to a hospital in, or close to, their home community once their acuity and clinical needs have declined.

• In 2013/14, the hospitals in Scarborough received 131 retro transfers from other facilities. RVC received 58% of these retro transfers, TSH-General site received 18% of the retro transfers and TSH-Birchmount received 24% of the retro transfers.

11 Neonatal Retro-Transfers for other Level 2C Hospitals

FY2009 FY2010 FY2011 FY2012 FY2013 Hospital /10 /11 /12 /13 /14 (1330) NORTH YORK GENERAL HOSPITAL 60 79 89 98 71 (3587) MARKHAM STOUFFVILLE HOSPITAL 28 25 27 35 31 (3932) LAKERIDGE HEALTH -OSHAWA SITE 56 54 55 47 29 (3943) ROUGE VALLEY HEALTH SYSTEM- CENTENARY 63 78 71 84 76

This table compares retro transfer volumes in nearby 2C facilities with RVHS-Centenary site (bottom row), which is also a 2C facility. In 2013/14, RVC had more retro transfers than the 3 comparison facilities. RVC was designated a 2C facility in 2011/12. In the three years since 2011/12, RVC received a total of 231 retro transfers, compared to 258 at North York General Hospital, 93 at Markham Stouffville Hospital and 131 at Lakeridge Health Babies Born at Another Institution Transferred to RVHS or TSH

2009/10 2010/11 2011/12 2012/13 2013/14 Hospital (3943) ROUGE VALLEY HEALTH SYSTEM- CENTENARY 51 67 55 70 66 (4014) ROUGE VALLEY HEALTH SYSTEM- AJAX SITE 1 5 3 1 5 RVHS 52 72 58 71 71 (4152) SCARBOROUGH HOSPITAL (THE)- SCAR.GEN.SITE 23 22 28 18 19 (4154) SCARBOROUGH HOSPITAL(THE)- BIRCHMOUNT SITE 24 24 28 37 23 TSH 47 46 56 55 42

• Every year newborns are transferred to RVHS or TSH from other hospitals.

• Over the last 5 years a total of 555 newborns were transferred to a hospital in Scarborough from a hospital elsewhere.

• 56% of these transfers went to RVC, 19% went to TSH-General and 25% went to TSH-Birchmount.

• Most of the newborn transfers into Scarborough hospitals came from Sunnybrook or Mount Sinai Hospital.

13 Inpatient Paediatric Transfers

Hospital 2009 2010 2011 2012 2013 (3943) ROUGE VALLEY HEALTH SYSTEM- CENTENARY 50 52 42 65 40 (4152) SCARBOROUGH HOSPITAL (THE)- SCAR.GEN.SITE 35 35 24 14 11 (4154) SCARBOROUGH HOSPITAL(THE)- BIRCHMOUNT 26 17 12 18 10

•The facilities in Scarborough all receive paediatric transfers from other hospitals/sites. This includes newborns greater than 28 days. The volume of paediatric transfers has declined over the last five years which might be reflective of an overall decline in inpatient paediatric admissions.

•There were 40 paediatric transfers to RVC in 2013/14, down 10% from 2009. There were 11 paediatric transfers to TSH-General in 2013/14, a reduction of 69% from 2009. There were 10 paediatric transfers to the TSH-Birchmount site in 2013/14, down 62% from 2009. Most transfers come from SickKids or Sunnybrook.

14 Top Paediatric Case Mix Groups

Top 10 CMG came to our hospital - Paeds Top 10 CMG didn't come to our hospital - Paeds

CMG FY2013/14 CMG FY2013/14 (638) CHEMOTHERAPY/RADIOTHERAPY ADMISSION (138) VIRAL/UNSPECIFIED PNEUMONIA 156 FOR NEOPLASM 55 (249) NON-SEVERE ENTERITIS 123 (040) SEIZURE DISORDER, EXCEPT STATUS EPILEPTICUS 51 (147) ASTHMA 121 (086) ORAL CAVITY/PHARYNX INTERVENTION (141) UPPER/LOWER RESPIRATORY 48 INFECTION 98 (257) SYMPTOM/SIGN OF DIGESTIVE SYSTEM 41 (086) ORAL CAVITY/PHARYNX INTERVENTION 65 (138) VIRAL/UNSPECIFIED PNEUMONIA 35 (040) SEIZURE DISORDER, EXCEPT STATUS (147) ASTHMA 35 EPILEPTICUS 56 (141) UPPER/LOWER RESPIRATORY INFECTION 33 (257) SYMPTOM/SIGN OF DIGESTIVE SYSTEM 52 (249) NON-SEVERE ENTERITIS 31 (234) SIMPLE APPENDECTOMY 43 (739) REDUCTION/FIXATION/REPAIR UPPER (634) HEMOGLOBINOPATHY BODY/LIMB EXCEPT FIXATION/REPAIR OF 40 SHOULDER 31 (487) LOWER URINARY TRACT INFECTION 39 (487) LOWER URINARY TRACT INFECTION 26

There is significant overlap in terms of the top 10 paediatric CMGs seen at the hospitals in Scarborough and those CMGs for residents of Scarborough seen at other hospitals. But the relative ranking is different. For Scarborough hospitals the top paediatric CMG is pneumonia but for Scarborough children that go to other hospitals, the top CMG is related to cancer treatment. This data is for inpatient care only. 15 Paediatric Day Surgery

(3975) (3984) (4139) ROUGE SCARBOROUGH SCARBOROUGH VALLEY HEALTH Hospital HOSPITAL (THE)- HOSPITAL(THE)- SYSTEM- SCAR.GEN.SITE BIRCHMOUNT SITE CENTENARY # AM Visits # AM Visits # AM Visits 2009 699 681 1,612 2010 744 728 1,385 Day 2011 700 717 1,484 Surgery 2012 617 655 1,505 2013 586 575 1,423

All hospital sites in Scarborough provide paediatric day surgery. RVHS Centenary site has provided the highest volume of paediatric day surgery each year of the last five years, with day surgery visits that are more than double the volume at the other Scarborough facilities.

16 Paediatric ED Visits and Admissions from the ED

Fiscal Year Hospital Reason Type of Visit 2009/10 2010/11 2011/12 2012/13 2013/14 Total ED visits 11,165 11,184 12,317 12,393 12,742 ROUGE VALLEY HEALTH Medical Admitted 549 520 524 477 491 SYSTEM- % Admitted 4.9% 4.6% 4.3% 3.8% 3.9% CENTENARY Surgical Admitted 42 48 63 56 45 % Admitted 0.4% 0.4% 0.5% 0.5% 0.4% Total ED visits 8,308 7,973 8,555 8,035 8,033 SCARBOROUGH Medical Admitted 423 331 259 224 202 HOSPITAL(THE)- % Admitted 5.1% 4.2% 3.0% 2.8% 2.5% BIRCHMOUNT Surgical Admitted 41 37 34 31 30 SITE % Admitted 0.5% 0.5% 0.4% 0.4% 0.4% Total ED visits 11,210 10,795 11,414 10,835 11,198 SCARBOROUGH Medical Admitted 263 275 247 201 219 HOSPITAL % Admitted 2.3% 2.5% 2.2% 1.9% 2.0% (THE)- Surgical Admitted 41 39 50 35 43 SCAR.GEN.SITE % Admitted 0.4% 0.4% 0.4% 0.3% 0.4%

In 2013/14, the data shows that among Scarborough hospitals, 40% of ED paediatric visits were seen at RVC, 35% at TSH-G and 25% at TSH-B.

17 Transfers of Obstetrical Patients to Scarborough Hospitals

Hospital 2009 2010 2011 2012 2013 (3943) ROUGE VALLEY HEALTH SYSTEM- CENTENARY 19 6 6 7 7 (4152) SCARBOROUGH HOSPITAL (THE)- SCAR.GEN.SITE 6 3 5 5 2 (4154) SCARBOROUGH HOSPITAL(THE)- BIRCHMOUNT SITE 5 4 7 9 4

Over the last 5 years, 95 obstetrical patients were transferred to hospitals in Scarborough from hospitals elsewhere. 47% of these transfers went to RVC, 22% went to TSH-General and 31% went to TSH-Birchmount. These transfers came from several different hospitals and occurred for a variety of reasons including patient acuity and capacity limitations.

18 CritiCall Transfers of Obstetrical Patients to Scarborough Hospitals

Outcome Date Gestational Contacted Hospital Outcome Provisional Diagnosis Referring Hospital Time Age 11/17/2013 Rouge Valley Health System FCO Consult/Transfer Pre-Term Labour/Premature William Osler Health Centre: 30.5 21:23:21 (RVHS): Scarborough Centenary Accepted HLOC Rupture of Membranes Brampton Rouge Valley Health System FCO Consult/Transfer Pre-Term Labour/Premature William Osler Health Centre: 3/10/2014 11:57:13 30.0 (RVHS): Scarborough Centenary Accepted HLOC Rupture of Membranes Etobicoke Rouge Valley Health System FPC Prior Consult/Transfer Pre-Term Labour/Premature 9/17/2013 10:17:20 31.4 Mount Sinai Hospital (RVHS): Scarborough Centenary Accepted HLOC Rupture of Membranes The Scarborough Hospital (TSH): FCO Consult/Transfer Pre-Term Labour/Premature 5/13/2013 4:44:25 34.4 Mackenzie Health Grace Birchmount Site Accepted Capacity Rupture of Membranes Rouge Valley Health System FCO Consult/Transfer Pre-Term Labour/Premature 2/2/2014 7:31:46 30.5 Southlake Regional Health Centre (RVHS): Scarborough Centenary Accepted HLOC Rupture of Membranes The Scarborough Hospital (TSH): FCO Consult/Transfer Pre-Term Labour/Premature Rouge Valley Health System 5/30/2013 20:57:50 33.5 Grace Birchmount Site Accepted HLOC Rupture of Membranes (RVHS): Ajax and Pickering Rouge Valley Health System FCO Consult/Transfer Pre-Term Labour/Premature Rouge Valley Health System 6/20/2013 20:02:48 31.3 (RVHS): Scarborough Centenary Accepted HLOC Rupture of Membranes (RVHS): Ajax and Pickering Rouge Valley Health System FCO Consult/Transfer Pre-Term Labour/Premature The Scarborough Hospital (TSH): 1/12/2014 11:11:29 30.4 (RVHS): Scarborough Centenary Accepted HLOC Rupture of Membranes General Site Rouge Valley Health System FCO Consult/Transfer Pre-Term Labour/Premature Peterborough Regional Health 3/28/2014 14:05:52 31.5 (RVHS): Scarborough Centenary Accepted HLOC Rupture of Membranes Centre

The table above summarizes CritiCall transfers for hospitals in Scarborough for the fiscal year 2013/14. RVHS – Centenary received 7 transfers through CritiCall including one patient who was transferred from the TSH-General site at 30.4 weeks gestation. Other transfers to Centenary came from several different hospitals including 4 from outside of Central East LHIN. All 7 of the transfers to Centenary involved deliveries of less than 32 weeks gestation with a range from 30.0 to 31.5. This demonstrates the recognition by CritiCall of the level 2C designation that Centenary has held since 2011. TSH-Birchmount site received 2 transfers through CritiCall - -one from the RVHS Ajax site and one from McKenzie19 Health. One of these transfers was at 33.5 weeks gestation and the other at 34.4 weeks gestation. All of the transfers summarized above were for pre-term labour/premature rupture of membranes. Why Co-location of Advanced Services?

• A patient-centered, leading edge regional advanced centre should include advanced neonatology, advanced pediatrics, high risk obstetrics and child/adolescent psychiatry all located at the same site. • This in no way diminishes the other pediatric sites. • Puts the patients and families interests above all others. • One-stop shopping was a key theme at Workshop #2. • Many repatriated NICU patients have complex health issues and often require frequent follow ups in specialty clinics; co-location preserves the parent/provider relationships built in the NICU and smooths the transition from NICU to home and ambulatory care • Many of the same physicians deliver neonatology and pediatrics • Allows for subspecialty consultations to be concentrated at one site (e.g. endocrine, nephrology, GI, cardiology, respiratory, etc.) • Many of the nursing staff also work in neonatology and pediatrics and the skills they learn are complementary to each service (e.g. PICC line care and insertion in a premature infant is a skill that transfers to a 1 month newborn) • Having both advanced roles under one governance structure facilitates consistency and timely implementation • Expert reports have recommended co-location of these services • The few GTA hospitals (Mount Sinai and Sunnybrook) that have advanced NICUs but do not have paediatrics have a large critical mass of NICU services; more recently, high performing centers such as Hamilton Health Sciences have consolidated all neonatal, paediatric and high risk obstetrics at one site – McMaster Children’s Hospital.

20 Historical Expert Support for Co-location & Regional Advanced Role for RVHS • The Ontario Ministry of Health and Long-Term Care asked the Child Health Network for the Greater Toronto Area (CHN) to look at ways of providing better, more consistent, standardized and sustainable care for mothers and children through the obstetrical and paediatric services it delivers. In response to this request, the CHN established an extensive three-phased process to look at opportunities for combining maternal, newborn and paediatric hospital health services on fewer sites and establishing four (4) Regional Centres to propel needed changes forward.

• This 2005 report states:

21 Why RVC as the designated regional centre for advanced neonatal and paediatric care?

22 What will RVC offer the community as the regional advanced centre for neonatal and paediatric care?

 Track Record Providing the Most Advanced Care for Neonates and Children in Scarborough  Wide Range of Specialized Services and Supports including tertiary centre satellite clinics delivered in partnership with Sick Kids  State of the Art Infrastructure - Physical Plant, IT  Cost-Effective Expansion Potential  Regional Presence and Regional Access  Sustainability – Financial Stability, PCOP Funding  Strategic Priority

23 Track Record Providing the Most Advanced Care for Neonates and Children in Scarborough

• In 2011, RVHS responded to an opportunity from the Central East LHIN and PCMCH to change their level of care designation based on current activity levels and resources; RVHS chose to invest in increasing the designation at both of its sites to a more advanced level of care; moved RVC Centenary from 2+ to 2c and moved RVAP from 2 to 2b • Over the last 3 years (2011 to September 2014), RVC has successfully provided safe, high quality level 2c neonatal and maternal care as the only level 2c facility in Scarborough

• Historical data demonstrates the advanced role played by RVC Centenary • RVC Centenary has developed solid transfer relationships with CritiCall and other hospitals, including tertiary centres – RVC Centenary is an active participant in PCMCH’s development of best practices related to levels of care (e.g. only hospital in Scarborough to participate in the retro-transfer pilot) – RVC Centenary is only community hospital represented on the GTA Obstetrics Network – Strong partnership with Sick Kids through satellite clinics contributes to growth of subspecialty ambulatory clinics

24 Wide Range of Specialized Services and Supports

 Designated level 2C for neonatal and maternal care since 2011  20 isolette spots and one additional space for resuscitation with close proximity to the OR/C-Section room  2 negative pressure, isolation rooms  Ability to manage 30 weeks gestation and up (per PCMCH and Criticall), insert and manage PICC lines, umbilical catheters, Total Parenteral Nutrition (TPN) and up to 1 CPAP and 4 ventilated babies simultaneously  3 active neonatologists on staff in addition to multiple supporting sub-specialists  ICCA (fully integrated electronic documentation and monitoring system) to be implemented 2015.  Ronald McDonald (RM) Family Lounge (and sleep room) to be competed and operated by RM volunteers in fall 2014  2 care by parent rooms, 1 sleep rooms, 1 breast pumping room.  Electronic Security System and a closed/locked door system  Central monitoring

25 Wide Range of Specialized Services and Supports (cont’d)

 12 single inpatient patient rooms (can accommodate 28 children if patients are colocated).  4 acute care single inpatient rooms for intensive observation with central cardiac monitoring capability  2 (4 bed) day surgery rooms  Ronald McDonald Family Lounge (and sleep room) to be completed fall 2014  Cardiology, infectious disease, endocrinology and respirology provide consultation on an in and outpatient basis, with paediatric EEG and outpatient neurology services  Surgery – ENT, orthopaedic (including specialized scoliosis repair), plastic surgery, general surgery, dental, pulse dye laser surgery (RVC is the only hospital providing this surgery in Ontario besides Ottawa)  Oncology - (Paediatric Oncology Group Ontario [POGO] ) - Sickkids satellite program) - NP/nurse run outpatient clinic, 2 dedicated inpatient rooms specific to the paediatric oncology population (in addition to the 16); 8 nurses have chemo certification training and are proficient in portacath access.  Sickle Cell – (SickKids satellite program) - staffed by 2 paediatric haematologists and nursing  Short Stay Program – rapid access to specialized paediatric care from the ED  Child and Adolescent Mental health – 6 inpatient beds, day hospital, crisis team, First Episode Psychosis Program and an extensive outpatient mental health clinic (Shoniker Clinic) fully supported by a multidisciplinary team of child and adolescent psychiatrists, GPs, child and youth workers, social workers, addiction workers, nurses and an occupational therapist.  MOU in progress with Ontario Shores to provide acute care back-up for Ontario’s only residential adolescent eating disorders program

26 Wide Range of Specialized Services and Supports (cont’d)

Additional Paediatric Ambulatory Clinics 1. Diabetes – supported by a Paediatric endocrinologist and a team of RD/RN who provide 24/7 support to our patients. 2. Allergy and Immunology Clinic- 2 immunologists and nurses who provide assessment and immunology challenges on site 3. Paediatric Consult Clinic - 7 days a week 4. Gastroenterology Clinic - including paediatric scopes done by a paediatric gastroenterologist. 5. Asthma education Clinic 6. Constipation Clinic 7. Neonatal Follow-up Clinic 8. Nutrition Clinic 9. Haematology Clinic 10. Nephrology Clinic 11. Rheumatology Clinic 12. RSV prophylaxis Clinic 13. Genetics Clinic

Note: The above list is in addition to the Oncology Clinic, Sickle Cell Clinic and several child and adolescent clinics mentioned on the previous slide

27 State of the Art Infrastructure with Cost-Effective Expansion Potential • The newest NICU in Scarborough is located at RVC; opened only 5 years ago it offers patients/families state of the art facilities built at current standards with ample space for optimal care • The Scarborough community raised millions of dollars for this much needed facility • The NICU is immediately adjacent to the new birthing centre • Galaxy 12 is a suite of several paediatric clinics that gains efficiency through co-location with sharing of nursing and clerical resources • RVC offers the only birthing centre and NICU in Scarborough with a electronic health record for mothers and newborns (ObTraceVue) • Capacity to expand in a timely way without the need for major renovations is possible because we have maintained the space previously used for inpatient obstetrics before our new birthing centre opened– e.g. capacity for an additional 15 isolette spaces in nursery space on 4th level of RVC • Models exist that allow our community to value past investment of taxpayer dollars and build on what exists

28 Regional Presence and Regional Access • To be successful, a regional centre must have a strong regional presence that includes a deep understanding of the regional community, regional providers and regional stakeholders • RVHS has a presence in both Scarborough (RVC) and Durham (RVAP) and has a strong regional orientation • We already have established relationships with stakeholders in two of the regional municipalities in Central East LHIN • Our existing presence in Durham (i.e. links to family physicians, paediatricians, political representatives, hospitals, community agencies, etc ) will save time and mean that scarce resources will not have to be expended on establishing relationships in Durham and can be used for other things • A few examples of our collaborative relationships beyond Scarborough include: – Signed Memorandum of Understanding with Ontario Shores (Whitby) to provide acute care back up for the first residential adolescent eating disorder program in Canada – Regional Code Stemi program – Cardiac rehabilitation satellites at Ross Memorial Hospital in Lindsay and at Lakeridge – Several long-standing partnerships with Lakeridge in Human Resources and IT – Lean education provided to staff of Grandview Children’s Centre (Oshawa), Ross Memorial and Ontario Shores • The region of Durham is projected to experience the highest growth in births and the paediatric population in Central East LHIN; patient/families with advanced care needs which require urgent access and/or multiple visits over a long time period want the most timely access possible -- even saving minutes on travel time can make a difference to these families

• Centenary’s location in Scarborough is physically closer to the rest of Central East LHIN

29 Sustainability

• Financial stability – 6 consecutive years of budget surpluses to support investment in infrastructure, equipment and strategic priorities

• Post-construction Operating Plan (PCOP) funding from new NICU and birthing centre

• Have applied Lean in the Birthing Centre, NICU, Paediatric Clinics since 2008

30 Strategic Priority With limited resources, it is not possible for hospitals to give equal focus to the growth and development of all clinical areas; strategic plans are a commonly used to communicate what the hospital’s strategic priorities are; strategic priority and commitment of both Board and leadership are critical enablers of success

31 Section 8

TSH Synopsis of 2 Preferred Service Delivery Models

PAGE 263 Motion 1B Synopsis of Options for Consideration Against Design Criteria

I. How Each Option Fits within the CE LHIN’s Broader Strategic Context and Motion 1b Mandate

Option 1: The Scarborough Hospital Center for Regional Advanced Neonatal and Paediatric Care TSH has identified its Maternal Newborn and Child Care Program a priority and continues to invest in its resources and infrastructure.

Collaboration: We believe that collaboration will lead us to better solutions.  In Option 1, TSH would provide for a fair and equitable governance in the collaborative development of an integrated Advanced Neonatal and Paediatric system of care offering advanced services within the Scarborough Cluster and CE LHIN which is easily accessed, sustainable and achieves desired outcomes.

Accessibility: We believe in providing accessible patient care to our community.  This cohesive system will build on existing strengths and previous integration work to create advanced level programs within Scarborough and the CE LHIN to strengthen patients’ access to care as well as service provision capacity whilst addressing system bottlenecks.  Two locations covering north and south Scarborough would maximize outreach in the Scarborough Cluster  Services within the model would be viewed across the continuum and would take into account social health determinants

Sustainability: We believe that we must find new solutions to sustain our healthcare system.  Community engagement, strategic planning, and forging strong partnerships across the CE LHIN will support long-term service delivery.  Forging strong partnerships with innovative design thinkers to support creative ways of improving our patients’ experiences and our service delivery model  Value core services at each site  An innovative care model reduces costs and sustains public services

Excellence: We believe that we must never waver from our responsibilities to provide quality patient care and to be accountable to our stakeholders.  TSH endorses consistent use of evidence-based practices and unrestricted reporting of data to Ontario’s Better Outcomes Registry & Network (BORN), the Provincial Council of Maternal and Child Health, and the public.  TSH has a proven record of reducing MD dependence on payment, LOS, and admission rates 1 | P a g e

Motion 1B Synopsis of Options for Consideration Against Design Criteria

Option 3: CE LHIN Integrated Regional Advanced Neonatal and Paediatric Program for Scarborough Cluster TSH has identified its Maternal Newborn and Child Care Program a priority and continues to invest in its resources and infrastructure.

Collaboration: We believe that collaboration will lead us to better solutions.  In Option 3, TSH and RVHS would provide fair and equitable governance in the collaborative development of an integrated Advanced Neonatal and Paediatric system of care offering advanced services within the Scarborough Cluster and CE LHIN which is easily accessed, sustainable and achieves desired outcomes.

Accessibility: We believe in providing accessible patient care to our community.  As with Option 1, this cohesive system will build on existing strengths and previous integration work to create advanced level programs within the Scarborough Cluster and CE LHIN to strengthen patients’ access to care as well as service provision capacity whilst addressing system bottlenecks.

Excellence: We believe that we must never waver from our responsibilities to provide quality patient care and to be accountable to our stakeholders.  The joint entity will endorse consistent use of evidence-based practices and unrestricted reporting of data to Ontario’s Better Outcomes Registry & Network (BORN), the Provincial Council of Maternal and Child Health (PCMCH), and the public.

Option C:

II. The Proposed Planning and Oversight Structure

OPTION 1: Leadership Centralized at TSH.  The TSH leadership team will o establish the regional programs’ direction and develop a 3 year strategy; o continuously monitor partnerships for efficacy

2 | P a g e

Motion 1B Synopsis of Options for Consideration Against Design Criteria

o provide for fair, equitable and inclusive governance for all 3 hospital sites in the Scarborough Cluster and our LHIN partners o intentionally “nest” the Scarborough strategies in the CE LHIN-wide model of care delivery and work with our partners across the LHIN to prevent duplication of effort. o work with partners to develop and improve relevant programs; o report on regional progress, disseminate evidence, and deploy tools and knowledge necessary to drive collaborative change.  A well designed steering committee structure will oversee the implementation of the strategic plan and provide the infrastructure necessary to underpin regional integration efforts.  Subcommittees and advisory committees would serve as the forum for regional planning and building collaborative partnerships Option 3: Shared Governance Structure  TSH-G, TSH-B and RVHS will jointly and collaboratively provide regional leadership, and be governed by an accountability agreement as well as a memorandum of understanding.  The leadership team will: o establish the regional programs’ direction and develop a 3 year strategy; o continuously monitor partnerships for efficacy o work with partners to develop and improve relevant programs o report on regional progress, disseminate evidence, and deploy tools and knowledge necessary to drive collaborative change; o align with the CE LHIN Maternal, Neonatal and Paediatric Advisory Committee.  A TSH/RVHS leadership committee structure will oversee the implementation of the strategic plan and provide the infrastructure necessary to underpin regional integration efforts.  Subcommittees and advisory committees would serve as the forum for regional planning and building collaborative Option C

III. The Lead Organization for the Regional Advanced Paediatric Program

Option 1  TSH to provide leadership in establishing a cooperative Regional Advanced Paediatric Program with a focus on the ongoing development of sub-specialty paediatric care delivery.  TSH has capacity to enhance existing services to include advanced inpatient care. 3 | P a g e

Motion 1B Synopsis of Options for Consideration Against Design Criteria

 The TSH Maternal Neonatal Child Care Program performs continuous self- assessment with the intent of relentlessly pursuing optimization of our performance to ensure patients receive the best care and services available.  TSH offers enhanced paediatric developmental clinics with plans to expand to meet demand  In-house paediatrics at advanced centers and dedicated Child Life Specialists  TSH has an ER pod focused on paediatric care  TSH continues to mentor medical student Family Practice trainees teaching in pediatrics, with the goal of increasing opportunities for Pediatric trainees to provide community pediatric teaching  Streamline ambulatory referrals from ED to Community Pediatricians/GPs for non- urgent matters  Continue paediatric day clinic. An after-hours pediatric clinic has been approved by TSH’s CAP process  Partnership with Early Childhood Intervention programs  Seamless connection with East Toronto Development assessment clinic for behaviour problems and DD  Comprehensive pediatric assessment and short term treatment hub in the community to meet the developmental and disease specific needs of the infant- adolescent population  TSH offers PaedLink and Rapid Follow Up programs to reduce ER wait times, LOS, and paediatric admission rates  We augment specialty services: surgery, complex care, distributed across three sites in Scarborough to improve access  Paediatricians are entrenched within the community which provides seamless transitions of care  Opportunity to build a regional pediatric palliative care program Option 3  Leadership structure supports regional programs and is connected to the CE LHIN structure.  Continue working with PCMCH to define advanced paediatric services  Advanced inpatient/outpatient paediatric programs strategically located across 3 Scarborough sites providing streamlined access to other CELHIN hospitals and care providers.  Strong Social Work, Mental Health, and Respiratory Therapy Support  Development of programs within CELHIN that are aligned with community needs and address service gaps.  Leverages existing strengths and clinical cohesiveness. Option C

4 | P a g e

Motion 1B Synopsis of Options for Consideration Against Design Criteria

IV. The Lead Organization for the Regional Advanced Neonatal Program

Option 1: TSH General Campus  TSH is the largest provider of neonatal intensive care in Scarborough.  TSH delivered 70% of Scarborough births over the last 5 years.  Obstetrical practice has an impact on the prevention of iatrogenic late preterm deliveries. TSH has the lowest C/S rates in GTA at 25%; highest VBAC rate in GTA at 25%.  The TSH Maternal Neonatal Child Care Program performs continuous self- assessment with the intent of relentlessly pursuing optimization of our performance to ensure patients receive the best care and services available.  TSH metrics demonstrate evidenced based obstetrical practice leading to enhanced outcomes, efficient use of resources, as well as maximizing our patients’ range of choices  Access support for high risk situations from ICU including in-house intensivists and anesthesiologists, in-house paediatricians 24/7, 24 hour rapid response team, interventional radiologists, vascular surgeons and access to maternal fetal medicine and neonatologist.  Continue neonatal follow up clinic  TSH has the only interventional radiology program in Scarborough.  Two Scarborough locations offer the ability to decant volumes and resources within the community  TSH has subspecialty support for NICU (i.e. radiology, ophthalmology, OT), access to Neonatologists, and have nurses with expertise in Neonatology  TSH-G and TSH-B continues to remain open to retro-transfers

Option 3: Advanced Neonatal programs within the TSH-G and RVHS-C sites.  Regional System will support the CE LHIN in creating capacity, increasing access and addressing service gaps.  Enhance service provision to Scarborough through cooperative means to ensure the both Level 2C services are fully utilized and coordinated, and that at least one Level 2C is always “open” in Scarborough and the CE LHIN.  Collaborate to enhance women’s health services i.e. MFM, postpartum depression Option C

5 | P a g e

Motion 1B Synopsis of Options for Consideration Against Design Criteria

V. How Each Option Meets the Needs of Our Patients

Option 1 Our patients told us:  “We expect evidence based high quality care. We want our preferences valued.”  “Care close to home means I am not separated from my baby.”  “For many women, natural child birth is their preferred choice and do not wish to be pushed into a C-Section unless absolutely necessary”. Option 1 addresses the voices of our customers by:  Driving evidence-based care  Meeting or exceeding provincial performance targets and endorse transparency of performance metrics  Aligning services to community need  Helping patients who want to be involved with and choose their care path.  Strengthening Midwifery programs  Streamlining access to high level 24/7 care  Streamlining processes and standardizing practices where it makes sense  Making navigation through the system easier for our patients and their loved ones  PaedsLink avoids admissions and decreases length of stay

Option 3 Our patients told us:  “Integration of services across providers to the community is important to patients.”  “Patients perceive that it limits choice when provider privileges at specific hospitals dictate the location of service delivery” Option 3 addresses the voices of our customers by:  Creating a cooperative regional program within the three Scarborough sites. This addresses our patients’ feedback related to improving service access and quality.  Establishing an integrated regional advanced neonatal and paediatric system. This will expand access to services both within the Scarborough Cluster and CE LHIN.  Establishing cross-site privileges for all obstetricians, neonatologists, and paediatricians  Rotating clinics to various high need areas across Scarborough and CE LHIN  Establish a Navigator role to improve understanding and navigation of the healthcare system Option C

6 | P a g e

Motion 1B Synopsis of Options for Consideration Against Design Criteria

VI. Top 3 Advantages/Benefits

Option 1  TSH will establish a fair and equitable governance structure which actively pursues collaboration with its LHIN partners and stakeholders  Established community-based paediatric care model which supports acute model of care. Smooth transitions of care both to primary and secondary care in the community.  Centralized intake  Advanced care to the CE LHIN  Two Scarborough locations offer the ability to decant needed resources to paeds or NICU.  Creating capacity and excellence within Scarborough Cluster and CE LHIN. Option 3  A shared governance structure which actively pursues collaboration with its LHIN partners and stakeholders  Integration of an innovative Maternal Child Youth System within CE LHIN.  Creating capacity and excellence within Scarborough Cluster and CE LHIN.  Collaboration within CE LHIN to address service gaps. Option C

VII. Top 3 Possible Disadvantages

Option 1  Any model where there is a perception of loss of service to any given site or region.  Risk of community partners not participating in strategic planning. Option 3  Any model where there is a perception of loss of service to any given site or region.  Risk of community partners not participating in strategic planning. Option C

7 | P a g e

Section 9

RVHS Synopsis of 1 Preferred Service Delivery Model

PAGE 271 Synopsis of Rouge Valley Health System (RVHS) Model for Motion 1b

The model proposed by RVHS is a patient‐centered model that will offer great benefits to our community and deliver those benefits sooner. The model identifies RVHS as the lead agency and sites the regional advanced paediatric and regional advanced neonatal programs at the Centenary site within the context of a broader, collaborative regional program. It is model based on a continued role for all 3 Scarborough sites in the delivery of high quality services to newborns and children. It fulfills the CASE for change by ensuring Collaboration, Accessibility, Sustainability and Excellence.

Describe how this option fits within the CE LHIN’s Motion 1b  As the motion states, this option creates a “LHIN‐wide centre for Advanced in‐patient Paediatric care co‐located with the advanced Level 2c in‐patient Neonatal centre and sited in the Scarborough cluster”  Centenary has the expertise and has successfully maintained PCMCH level 2c status for over three years. It is currently the only site in the Scarborough cluster with a level 2c designation that allows the hospital to deliver and keep babies 30‐32 weeks gestation. According to PCMCH, no further changes to the designated facilities authorized to deliver and manage 30‐32 week gestation deliveries will be made for approximately 1 year.  Centenary is geographically closer to areas of greatest growth of the target population in the Central East LHIN. To be successful, a regional centre must have a strong regional presence that includes a deep understanding of the regional communities, providers and stakeholders. With campuses in both Scarborough and Durham, RVHS has had the historical opportunity to develop a regional orientation.

Describe the proposed planning and oversight structure The proposed model is about partnership and system‐thinking and supports collaboration to create a patient centred service. As the lead agency RVHS will convene and co‐chair, with a rotating co‐chair from another organization, a regional multi‐organizational committee for planning, coordination and oversight. Responsibilities of this committee would include planning, development and siting of new programs, facilitating adequate physician coverage across sites and monitoring and evaluation of the regional program. Membership would include representation from Central East LHIN hospital and community‐ based providers, tertiary centers, consumers and Central East LHIN staff. This committee would provide advice to existing governance structures to ensure the development of a coordinated care experience for regional services. Alignment or integration with the existing Central East LHIN advisory committee on maternal/child/youth services will be explored to minimize duplication.

Describe the lead organization for regional advanced paediatric / neonatal programs  RVHS is an organization that has publically stated in its existing Strategic Plan that maternal/child/ newborn services are a high corporate priority and there is a commitment to growth and integration of these services.  The new Centenary birthing centre and NICU opened in 2009.  Financially, RVHS is in the unique position of having Post‐Construction Operating Plan (PCOP) funding from the new NICU/birthing centre to support volume growth. Budget surpluses over 6 consecutive years have supported investment in infrastructure, equipment and strategic priorities.  RVHS is the only birthing centre in the LHIN with an electronic health record (ObTraceVue), which enables central patient/fetal monitoring and alerts staff to potential errors or concerns.  RVHS has three ‘negative pressure’ isolation rooms in the birthing centre and two in the NICU. The NICU layout also meets the current space requirements for NICUs which, in times of heightened public awareness of infectious diseases, provide a significant advantage in delivering care.

 The RVC Birthing Centre has purpose‐built Labour Delivery Recovery Post‐Partum rooms that provide a patient‐centred environment along with immediate access to state of the art equipment in each room.  Centenary has ample capacity for short‐term expansion that can be done without major renovations because the space formerly used for inpatient obstetrics and NICU has been maintained. There is also capacity for significant physical expansion because there are several acres of unused land available.  RVHS has a track record of successfully implementing regional programs and creating partnerships with tertiary centres and other providers, such as Sick Kids, Ontario Shores, Mount Sinai, Sunnybrook, Family Health Teams, Taibu Community Health Centre, Toronto and Durham Public Health Departments, community GPs and paediatricians.  The 2005 Expert Report by the Child Health Network recommended RVC to be 1 of 4 regional advanced centres for the GTA.

Describe how this option meets the needs of our patients  Patients/families will benefit from access to co‐located services across the continuum of care for advanced needs – i.e. ‘one stop shopping’. This is consistent with other leading institutions such as Hamilton Health Sciences Centre. Patients/families from across the LHIN will experience timely access to a wide array of paediatric sub‐specialty services that provide the critical mass necessary for a high quality advanced centre.  Due to significant historical investment in speciality services and infrastructure RVHS has 18 paediatric subspecialists (more than any other community hospital in Ontario)  Centenary has 17 ambulatory paediatric clinics: Diabetes, Oncology (Paediatric Oncology Group Ontario – SickKids satellite), Sickle Cell (SickKids satellite), Allergy and Immunology, Paediatric Consult, Gastroenterology, Asthma education, Constipation, Neonatal Follow‐up, Nutrition, Haematology, Nephrology, Rheumatology, RSV prophylaxis, Genetics, Adolescent Medicine, Scoliosis and Orthopaedics. In addition, the hospital’s Shoniker Clinic offers a range of Child and Adolescent Mental Health clinics.  Other paediatric subspecialties available are cardiology, neonatology, neurology, infectious diseases.  RVC is the only facility outside of Ottawa that offers Pulse Dye Laser surgery for children.  Patients/families will benefit from being served in a modern, state‐of‐the‐art NICU.

Describe the Top 3 advantages/benefits  The designation of RVHS as the lead organization leverages resources, infrastructure, expertise, experience and commitment. Building creatively on what we have is a fiscally responsible approach because it offers our community a less expensive and faster approach to implementation.  Co‐location to deliver ‘one stop shopping’ and coordinated care experience to patients/families.  A regional program featuring joint planning and monitoring as well as connecting mechanisms that link services and sites to optimize coordination for patients/families and collaboration amongst provider partners.

Describe the Top 3 possible disadvantages  Perceived loss of services by other organizations despite a clearly defined role for all three Scarborough sites.  Potential implementation barriers due to lack of full stakeholder buy‐in.  Potential impact on longstanding GP referral patterns.

Section 10

Motion 1b Collaborative Service Delivery Model Evaluation Results

PAGE 274 Motion 1B Survey Results UPDATED December 2014 & January 2015 Proposed New Data Analysis Methodology

In December 2014, both RVHS and TSH agreed to the following methodology based on three categories of data analysis. The categories have been established to address concerns raised by the planning table on how best to assess the initial results from the Motion 1B Survey. • Equalization of Responses: –As previously agreed upon, both hospitals will have equal representation in the final results (16 RVHS and 16 TSH ratings for a total of 32 ratings). For RVHS, a 16th respondent will be created with an average of the 15 existing RVHS ratings. This is a standard approach used in Expert Choice in the case of non‐response and will produce the same results as the ‘weighting’ methodology that was used in the original Excel spreadsheet shared with the planning team. •Extreme Values: –The following Extreme Values approach will be repeated for all three models: •The 32 ratings (16 RVHS and 16 TSH) will be ranked from highest to lowest. •The three highest and three lowest values for each model will be excluded (for a total of 6 values per model). This will result in the inclusion of 26 ratings per model (81% of respondents) allowing the integrity of the sample size to be maintained. This approach will be to mitigate potential bias from respondents (either RVHS and TSH). • Transparency: –The LHIN will publish both sets of results –both completely unmitigated (non‐equalized, all values included) AND mitigated (outcome of steps 2 and 3 above) –to all stakeholders.

2 Survey Results for 3 Models of Care

3 Extreme Values Approach Commentary

The following Extreme Values approach was repeated for all three models of care: •i. The 32 ratings (16 TSH and 16 RVHS) were ranked from highest to lowest. ii. The three highest and three lowest values for each model were excluded (a total of 6 values per model). As a result, 26 ratings were included per model (81% of respondents) allowing the integrity of the sample size to be maintained.

Included Ratings TSH Center Included Ratings RVHS Center Included Ratings LHIN Center Administrator 7 27% Administrator 7 27% Administrator 9 35% Physician 15 58% Physician 15 58% Physician 13 50% Other 3 12% Other 3 12% Other 3 12% Derived 1 4% Derived 1 4% Derived 1 4% Total 26 100% Total 26 100% Total 26 100%

•*Other category represents patients, and allied health professionals, i.e. midwives.

Rouge Valley Centenary Rouge Valley Ajax and Pickering 2867 Ellesmere Road 580 Harwood Avenue South Toronto, ON M1E 4B9 Ajax, ON L1S 2J4 (416) 284-8131 (905) 683-2320

January 19, 2015

Marla Fryers Executive Vice President, Clinical Operations The Scarborough Hospital and

James Meloche Senior Director, System Design and Implementation Central East LHIN

Dear Marla and James:

The purpose of this letter is to address the concerns about the Motion 1B Model Survey expressed in Marla’s letter of January 15th. I appreciate being copied on Marla’s letter and am pleased that even though we disagree, the lines of communication remain open for respectful dialogue.

Before responding to the specific objections noted in the letter, I have to express the disappointment of our team in the fact that this matter is being revisited in this manner after all parties very clearly declared our agreement with the approach proposed by the LHIN to adjust the reporting of the survey results. We had a number of conversations and email exchanges about this and James very deliberately sought our endorsement of the LHIN’s proposed approach. We had received ample time to do our detailed due diligence on the survey results and the adjustment methodology prior to endorsing the LHIN’s proposed approach. In emails of December 17th and December 23rd, Marla provided her written approval of this approach and it was on that basis that LHIN staff proceeded to invest valuable time in further work on the survey analysis.

The methodology for adjusting the survey results was never intended to eliminate all of our respective objections or to appease either of the parties involved. It was a compromise reached in the spirit of collaboration. The request to modify the survey results did not come from Rouge Valley as we were supportive of respecting and trusting the input of our stakeholders. However, we still agreed to an alternate approach. It is disappointing that TSH has now chosen not to uphold our agreement on the approach and it does not demonstrate the collaborative, good faith values noted in the January 15th letter. This makes it very difficult to trust the process, particularly since this is not the first time that we thought we were proceeding in a common collaborative direction only to learn at the eleventh hour that our partner decided to change paths.

The balance of this letter focuses on the specific concerns raised:

The January 15th letter states: “… we continue to hold to our two objections to the CE LHIN methodology”. However, only the first point is a methodological issue. The second point is a critique of RVHS respondents' integrity not the survey methodology.

Joan Wideman Rik Ganderton, C.A. Dr. Naresh Mohan, MBBS FRCS(C) Chair, Board of Directors President and CEO Chief of Staff www.rougevalley.ca

The first objection is that “TSH did not at any time agree to weighting the results”. This is untrue. The weighting methodology was shared with both hospitals in writing multiple times. It was explicitly stated in the email to all survey participants from Karen Poon on November 6th which advised invited participants that “Identification of your job type (physician vs. administrator) and hospital affiliation will allow for post-survey equalization of the ratings to ensure equal representation from each hospital.” I reminded both of you of this in my email of December 16th (below) after Marla raised this concern last month.

“Below is the November 6th email from Karen Poon at the LHIN that was issued to all of the work group members invited to fill out the survey. Karen's email states very clearly that there would be "post survey equalization". Alfred is copied on the RVHS email just as Scott was copied on the TSH email with both having the same wording. Its not appropriate to go back on this decision at this late stage and I thought we agreed yesterday that the decision on the weighting of respondents would stand but we would address the extreme scores using a method to be proposed by James.”

In addition, we did not set up the process “to ensure we had equal participation between RVHS and TSH”. Given the infinite number of things that could legitimately prevent one from being able to complete a survey it is impossible to ensure that an electronic survey administered in this manner will be completed by every single person. What if someone was ill or injured? We set up the process with the more realistic aim of ensuring that we invited an equal number of people from each hospital to participate in the survey.

The second objection is a dislike for how some stakeholders chose to answer the survey questions. Setting aside the inappropriateness of using anonymous survey responses to make assumptions about an individual’s character, there are a number of inaccuracies in the claim that is being made.

For example, the statement that “RVHS participants ranked TSH option as near zero on all 25 criteria and 100% on the RVHS option on all criteria” is inaccurate. Firstly, 3 out of 15 participants chose this type of response. Secondly, of the three models included in the survey, two were models proposed by TSH. In the spirit of collaboration, RVHS agreed to a survey that included two models proposed by TSH and only one model proposed by our own hospital. RVHS scores of TSH’s other model did not include any zeros.

The statement that “it is our view that it is impossible to rank TSH 0 on every criteria” is illogical given that we know that it definitely was possible to do so. The LHIN-designed survey contained no built in measures to prevent this.

To state that “it would be impossible for either organization to receive a score of zero considering that both meet many of the 25 criteria”, misrepresents how a zero score was defined in the survey. The LHIN-designed survey defined a zero score as ‘least positive’. A zero score was not defined as the model/hospital is devoid of all merit as TSH appears to be suggesting. Logically, if you can have a ‘most positive’ you can have a ‘least positive’.

Using the four examples provided in the January 15th letter it is possible to present a case for why an individual, acting in good faith and interpreting the definition for ‘zero’ literally, would consider it reasonable to view TSH as ‘least positive’ of the three models:

• Degree of Alignment with the 2009 CSP – The current RVHS strategic plan, approved by our Board in 2011, contains the following statement: “Supporting a regional approach to the delivery of health care services as identified in the Central East Local Health Integration Network Clinical Services Plan”. This statement makes the alignment with the CSP very clear and is well-known to RVHS stakeholders. In the RVHS synopsis that was provided to all survey participants we provided a link to our strategic plan to support participants in rating us on this criteria. The TSH synopsis did not make any references to alignment with the 2009 CSP. Even if a diligent survey participant were to take it upon themselves to locate the TSH strategic plan posted on the public website they would find one reference to the CE LHIN Clinical Services Plan on page 7 of the document where the CE LHIN Clinical Services Plan is categorized as a ‘threat’ in the hospital’s SWOT analysis. When faced with these two scenarios we feel that, in fairness, it is conceivable that an individual acting in good faith might consider the positioning of the 2009 CSP in TSH’s strategic plan as ‘least positive’.

• Level 2C designation – due to the fact that TSH only applied for the level 2C designation in September 2014, TSH’s designation does not, at this time, include authorization from PCMCH to manage babies born at 30-32 weeks gestation while RVHS does have authorization to manage these cases; at the time of survey administration, RVHS had held the level 2C designation for 3 years and TSH for 2 months. Again, it is conceivable that an individual acting in good faith would consider the option of having an advanced neonatal centre in a facility unauthorized to manage 30-32 week gestation infants a less positive option than a centre that is authorized to do so.

• Ability to attract market share – Even though TSH does more deliveries overall, Motion 1B is focused on patients requiring advanced care; RVC attracts a higher proportion of this particular segment of the maternal/neonatal population and sees more paediatric cases.

• Geographical proximity to the target population – the target population for a regional advanced centre is the Central East LHIN region; by virtue of being located further east than either TSH site and the fact that RVHS has a site in Durham, RVHS has the greatest geographical proximity to the target population and TSH has the least geographical proximity to the target population.

We agree that this survey is only one aspect of all the work we have completed together. For example, we believe that decision-making should also draw upon the results of the first survey completed by Motion 1B Collaborative members in August 2014. In this survey, designed by our external facilitator, when asked about siting, participants responded as follows:

Which hospital should provide advanced regional neonatal services? • 10 – RVHS • 7 – TSH • 1 – it depends

Which hospital should provide advanced inpatient paediatric services? • 13 – RVHS • 0 – TSH • 1 – TSH or RVHS • 2 – a distributed model • 1 – it depends • 1 – the hospital housing the advanced NICU

When these survey results were released to us in August 2014 there were objections raised by TSH, requests to include late respondents and a reluctance to share the results with all stakeholders. RVHS is very pleased to see that the detailed survey results will be appended to the final report. It is our belief that to truly value the input of the stakeholders that we engaged in this process, both sets of survey results (August 2014 and November 2014) should be included in a transparent fashion in the executive summary of the final report. The outcomes of the two separate surveys are consistent with each other and also consistent with the 2005 Child Health Network report to the MOHLTC which recommended that RVHS Centenary site be designated as the regional centre for the east GTA. Our team does not ascribe to the view that the consistency in the outcomes of the two independent surveys and the Child Health Network report is purely coincidental. We consider this to be evidence worthy of strong consideration.

It is unfortunate that we continue to struggle to realize the benefits of our collaborative efforts and that this is holding back the implementation of an improved service delivery model for our community. RVHS remains committed to an open and transparent process and I look forward to discussing this issue with you further.

Sincerely,

Michele James Vice-President, Women’s and Children’s Program and Clinical Support Services cc: A. Rik Ganderton, CEO, Rouge Valley Health System Dr. Naresh Mohan, Chief of Staff (Motion 1B Planning Group Member)

PHASE 3: Implementing the Model

PAGE 285 Phase 3 – Implementing the Model This phase involves the implementation of the service delivery model developed in Phase 2. A detailed implementation plan, project management approach and communication plan will be key elements of this phase. To date this phase has not been implemented.

PHASE 4: Evaluating the Model

PAGE 287 Phase 4 – Evaluating the Model This phase will involve execution of the evaluation plan developed in Phase 2. Consideration will be given to assigning the evaluation phase to an external, expert resource. Progress milestones will be reported to the hospital boards, CE LHIN and the community. To date this phase has not been implemented.