AGENDA OPEN SESSION BOARD MEETING Wednesday, January 27, 2021 Zoom Videoconference 5:00 pm Directors: Marg Dragan, Vice-Chair Louis Guimond, Treasuer Rachael Simon Anthony Iafrate Brian Knott, Chair Fred Vanderheide Bill Gillam Katherine Mantha Paul Wiersma Jenny Greensmith Bob McKinley Kirk Wilson Ex-Officio Directors: Mike Lapaine Shannon Landry Dr. Lincoln Lam Dr. Michel Haddad Dr. Andre Rudovics Invited Participants: Samer Abou-Sweid Laurie Zimmer Paula Reaume-Zimmer Julia Oosterman Kathy Alexander Dr. Dhiraj Dhanjani Recorder: Melissa Rondinelli *attached NO. TOPIC ACTION TIME PRESENTER
1.0 CALL TO ORDER: WELCOME AND OPENING REMARKS 5:00 Brian Knott
1.1 Traditional Territory Acknowledgement
2.0 AGENDA APPROVAL
2.1 Approval of Agenda Decision Brian Knott 2.2 Report on In-Camera Board Meeting – Nov. 25, 2020 Information 2.3 Declaration of Conflict of Interest Decision 3.0 CONSENT AGENDA Brian Knott 3.1 INFORMATION ITEMS TO BE RECEIVED 3.1.1 Board Chair Report* Brian Knott 3.1.2 Professional Staff Association Report* Dr. Andre Rudovics 3.1.3 Resource Utilization and Audit Committee Performance Scorecard* Samer Abou-Sweid 3.1.4 Quality Committee Performance Scorecard* Shannon Landry 3.1.5 Foundation Report* Kathy Alexander 3.2 ITEMS FOR APPROVAL 3.2.1 Open Session Board Minutes – Nov. 25, 2020* Decision Brian Knott 4.0 PRESIDENT & CEO REPORT* Information 5:03 Mike Lapaine NO. TOPIC ACTION TIME PRESENTER
5.0 BOARD DECISIONS/OVERSIGHT 5.1 Board Work Plan* Decision 5:08 Brian Knott 5.2 Monthly Financial Statement* Decision 5:13 Samer Abou-Sweid 5.3 Pandemic Response & Hospital Operations Information Scorecard* 5.4 COVID-19 Update Information 5:25 Mike Lapaine Dr. M. Haddad 5.5 Ontario Health Team Update Information 5:40 Mike Lapaine 6.0 CHIEF OF PROFESSIONAL STAFF REPORTS Information 5:43 Dr. M. Haddad • December* • January* 7.0 POLICY FORMATION – None 8.0 OPEN FORUM 5:48 Brian Knott Opportunity for Directors to reflect on how patients, families and community were considered in discussions. 9.0 ADJOURNMENT: Next Meeting – Feb. 24, 2021 5:53 Brian Knott
Bluewater Health Board of Directors Open Session Meeting January 27, 2021 Proposed Motions
AGENDA ITEM MOTION 2.1 Agenda to approve the agenda as presented 3.0 Consent Agenda to receive the reports presented and to approve the following items in the Consent Agenda: • Open Session Board Minutes of November 25, 2020 5.1 Board Work Plan to approve the following: 1. Cancellation of the February Quality and Resource Utilization and Audit Committee meetings; 2. A condensed Governance & Nominating Committee meeting in February to focus on Board Succession Planning; 3. Re-assess the Board Work Plan priorities on a monthly basis. 5.2 Financial Statements to approve the Financial Statement for the period ended November 30, 2020 as presented.
Board Chair Report
I would like to highlight my activities as Chair for the period of November 26, 2020 to January 27, 2021.
November 26 Met with President and CEO for follow up on Board meeting
November 26 Attended Virtual Speaker Series re Importance of Laboratory to Bluewater Health
December 1 Prepared for and chaired Board meeting on Strategic Plan
December 3 Prepared for and participated in Professional Staff Quarterly meeting
December 7 Attended and participated in OHA seminar on Fundamentals of Chairing- Stewarding the Chair/CEO relationship
December 7 Participated in Board Trivia Holiday Special
December 8 Prepared for and participated in Bluewater Foundation Board meeting
December 17 Met with President and CEO and Chief of Staff to discuss hospital and Board business
December 18 Met with President and CEO to discuss hospital and Board business
December 22 Prepared for and recorded New Year’s Message on behalf of Board of Directors
January 6 Met with President and CEO to discuss hospital and Board business
January 7 Prepared for and attended SL-OHT meeting on Decision-Making Framework Agreement
January 14 Met with President and CEO to discuss Withdrawal Management facility
January 15 Prepared for and chaired Executive Committee meeting on Withdrawal Management facility
January 19 Met with President and CEO to prepare for January Board meeting and to discuss hospital and Board business
January 20 Met with Chair of G&N and staff to review Succession Planning for Board
January 22 Prepared for and chaired Executive Committee meeting regarding a property matter
January 27 Prepared for and chaired BWH Board meetings
Brian Knott
President of the Professional Staff Association (PSA) Report December 2020 and January 2021
I would like to highlight my activities as PSA President:
December 3, 2020 Prepared for and chaired the quarterly Professional Staff Association meeting
January 11, 2021 Prepared for and attended the quarterly Hospital On-call Committee meeting
January 20, 2021 Prepared for and attended the Medical Advisory Committee meeting
Dr. Andre Rudovics
1
FOI Masked due to n size <5 Meets/Exceeds Target Italics n size between 5 - 29 Meeting baseline but not meeting target Resource Utilization & Audit Committee Performance Scorecard * no established target Performance not meeting baseline ⱡ corporate target Data Unavailable YTD Q2 19/20 Q3 19/20 Q4 19/20 Q1 20/21 Q2 20/21 Q3 20/21 Performance # Key Performance Indicators Baseline Target Trending Comments
REF. Peer JUL AUG SEP OCT NOV DEC JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV Report
Desired Desired
UPDATED Period YTD Trending Comparator 19 19 19 19 19 19 20 20 20 20 20 20 20 20 20 20 20 Quality Care - Assure the right care, in the right place, at the right time, by the right provider Improve access to care QIP/ 26.1 14.2 <=13.9 Jan - 1 90th Percentile Time to Inpatient Bed Sarnia 19.0 15.4 7.8 11.7 15.0 8.7 14.8 15.2 7.5 3.5 3.4 3.6 3.8 7.0 7.7 4.4 3.3 5.7 t P4R hrs hrs hrs Dec SP/ 9.6 4.9 Jan - 2 Average Time to Inpatient Bed Sarnia ⱡ 2 hrs 6.5 4.8 3.5 4.2 4.8 3.5 4.5 4.8 3.7 1.9 1.9 2.0 2.1 2.9 3.2 2.4 1.8 2.9 t NOW hrs hrs Dec Exceptional Relationships - Expand innovative partnerships and collaborations to improve experiences, services, transitions and community health Build sustainable partnerships and collaborations ALC Rate - All Inpatient Services HSAA/ Jan- 3 12.7% 13.6% 13.6% 11.9 13.1 12.3 15.2 14.0 9.1 10.6 12.2 14.2 14.6 16.9 16.7 15.2 14.2 12.0 12.8 13.8% t (Sarnia and Petrolia) QIP Dec Inspired People - Advance our culture of kindness with an intention to learn, lead, collaborate and celebrate Focus on the experience of care and caring Jan- 4 Absenteeism Rate - (avg # 7.5 hr. sick days) All Staff SP 2.8 3.34 3.03 2.97 3.34 3.26 3.66 2.93 0 Dec Outstanding Performance - Optimize roles, resources, revenues, technology and innovation Demonstrate accountability and efficiency The baseline and target are based on 9 months of data Apr to Dec Apr- 5 Gross Conservable Days All Acute QIP 6466.0 6,626.0 5,251.0 754.6 572.7 729.5 614.4 778.9 657.2 925.9 732.2 695.1 273.5 333.9 622.8 611.8 596.7 616.5 677.5 3,732.7 2019. Monthly results may change due to enhancements in data t Oct quality. Our overall expenses for this indicator have increased by $1.97M Acute Inpatient & Day Surgery (53% of Apr - compared to Q2 19/20 and our weighted cases have decreased by 6 SP $5,431 $6,052 $5,800 $6,052 $6,197 $6,090 $7,505 $7,505 t overall activity) Mar 1,126 cases for the same period. The variance is attributed to the Cost per COVID pandemic. Weighted Case Our overall expenses for this indicator have increased by $395K (Actual YTD) Rehab Inpatient Apr - compared to Q2 19/20 and our weighted cases have decreased by 7 $14,121 $14,493 $13,930 $14,493 $13,765 $13,705 $19,061 $19,061 t (4% of overall activity) Mar 95 cases for the same period. The variance is attributed to the COVID pandemic. Apr- Petrolia n/a $97 $94 $95 $94 $94 $95 $96 $97 $97 $97 $100 $334 $285 $207 $187 $175 $164 $161 $162 $162 Baseline is $97.00; Target is $94.00 t 8 Emergency Department Cost per Visit Mar Apr- Sarnia n/a $156 $150 $150 $154 $154 $154 $156 $156 $157 $158 $162 $293 $243 $217 $209 $204 $203 $201 $200 $200 Baseline is $156.00 t Mar Our overall expenses for this indicator have increased by $1.75M Apr - 9 Continuing Care Cost per Weighted Patient Day $637 $552 $566 $552 $598 $601 $722 $722 compared to Q2 19/20. The weighted patient days have increased t Mar by 421 weighted days for the same period. The variance is Apr - attributed to the COVID pandemic. 10 Mental Health Inpatient Cost per Patient Day $327 $367 $350 $370 $367 $378 $378 $374 $367 $368 $362 $359 $484 $433 $418 $428 $419 $404 $405 $402 $402 t Mar QBP Financial Exposure (Potential lost revenue related to Apr - 11 n/a -$359 $0 -$100 -$419 -$359 -$611 -$391 -$449 -$504 -$885 -$369 $0 $0 $0 -$52 -$65 $143 $130 $117 $117 t QBP achievement) Actual YTD in 000s Mar Apr - 12 Surplus/(Deficit) Actual YTD in 000s n/a -$105 $461 -$1,452 -$1,028 -$791 -$1,277 -$1,536 -$1,347 -$1,581 -$2,569 $885 -$536 -$463 -$1,240 -$1,489 -$1,743 -$2,495 -$3,312 $15 $15 t Mar Ensure continuous investment in strategic infrastructure Apr - 13 Adjusted Working Capital Actual YTD in 000s HSAA n/a $1,512 $0 $951 $844 $1,512 $1,219 $844 $481 $806 $26 -$741 -$1,193 -$1,055 -$2,201 -$2,774 -$1,698 -$162 $222 $82 $82 t Mar Apr - 14 % of Capital Budget Spent Actual YTD n/a 17% 100% 9 13 17 18 24 26 45 48 53 18 18 19 24 24 29 33 46 46% t Mar FOI Masked due to n size <5 Meets/Exceeds Target Italics n size between 5 - 29 Meeting baseline but not meeting target Quality Committee Performance Scorecard * no established target Performance not meeting baseline ⱡ corporate target Data Unavailable YTD Q2 19/20 Q3 19/20 Q4 19/20 Q1 20/21 Q2 20/21 Q3 20/21 Performance # Key Performance Indicators Baseline Target Trending Comments
REF. Peer JUL AUG SEP OCT NOV DEC JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV Report
Desired
UPDATED Period YTD Trending Comparator 19 19 19 19 19 19 20 20 20 20 20 20 20 20 20 20 20 Quality Care - Assure the right care, in the right place, at the right time, by the right provider Improve access to care QIP/ 26.1 14.2 <=13.9 Jan - 1 90th Percentile Time to Inpatient Bed Sarnia 19.0 15.4 7.8 11.7 15.0 8.7 14.8 15.2 7.5 3.5 3.4 3.6 3.8 7.0 7.7 4.4 3.3 5.7 t P4R hrs hrs hrs Dec SP/ 9.6 4.9 Jan - 2 Average Time to Inpatient Bed Sarnia ⱡ 2 hrs 6.5 4.8 3.5 4.2 4.8 3.5 4.5 4.8 3.7 1.9 1.9 2.0 2.1 2.9 3.2 2.4 1.8 2.9 t NOW hrs hrs Dec 34.2 20.8 <=20 Jan- Sarnia P4R 26.3 21.2 15.8 17.6 21.6 16.3 21.6 20.3 16.2 9.9 10.4 11.4 12.4 14.8 15.0 13.0 11.7 14.2 t 90th Percentile ED Length of Stay (LOS) 3 hrs hrs hrs Dec (Admitted Patients) 19.4 7.6 7.5 Jan - Petrolia 11.6 7.5 5.1 8.6 8.9 11.3 9.3 5.4 8.6 6.1 8.1 6.6 6.1 6.1 9.3 10.3 7.7 8.0 t hrs hrs hrs Dec Ingrain patient safety Total High Severity Patient Safety Incidents Jan - Incident was a Level 5 ADR in August 4 n/a 5 0 0 1 1 0 1 2 (Level 4 - 5) Dec Exceptional Relationships - Expand innovative partnerships and collaborations to improve experiences, services, transitions and community health Build sustainable partnerships and collaborations ALC Rate - All Inpatient Services HSAA/ Jan- 5 12.7% 13.6% 13.6% 11.9 13.1 12.3 15.2 14.0 9.1 10.6 12.2 14.2 14.6 16.9 16.7 15.2 14.2 12.0 12.8 13.8% t (Sarnia and Petrolia) QIP Dec Apr - This is preliminary data and subject to change Sarnia HSAA 19.0% 16.5% 16.2% 15.4 14.1 16.7 18.0 20.8 19.6% t Repeat Visits to ED within 30 days for Mar 6 Mental Health condition Ages 12-25 Apr- QIP 16.4% 16.1% 14.7 15.7 12.1 18.4 19.0 18.8% t yrs. Mar Jan- OMHRS assessments: 30 days or less since last discharge from this 7 30-Day Mental Health Readmission 12.4% 13.6% 12.1% 15.2 13.1 13.4 17.3 21.5 19.4% t Dec facility; excluding short-stay assessments Strengthen Patient and Family-Centred Care Jan- ED n/a 51.8% 52.0% 53.5 52.2 61.0 66.7 56.8 43.1 43.5 58.5 60.4 66.0 55.4 61.0 65.6 51.6 50.0 60.0 56.7% Positive score = 9 - 10 t 8 Overall Rating of Experience SP Dec Inpatient Jan- 67.4% 70.8% 72.2% 73.4 72.3 70.0 60.5 74.0 72.0 57.8 64.2 64.2 65.1 63.9 80.0 60.3 57.6 65.4 71.4 64.5% Positive score = 9 - 10; Oct n size: 21 t Med/Surg Dec Jan- ED 83.1% 84.1% 85.0% 88.7 83.1 85.2 92.7 80.4 77.0 75.0 84.6 88.5 88.0 83.1 77.2 83.1 82.5 74.6 80.0 81.2% Positive score = Yes t Leaving hospital did patients receive 9 Dec enough information - NRC Health Survey Inpatient Jan- 58.5% 57.5% 58.0% 52.4 62.9 56.7 56.1 63.3 65.4 54.3 57.4 54.9 45.2 66.7 63.8 42.4 54.5 57.4 34.8 53.6% Positive score = Completely; Oct n size: 23 t Med/Surg Dec Leaving hospital did patients receive Inpatient Collecting internal data for this question within our patient and 10 QIP n/a n/a n/a enough information - Internal Survey Med/Surg family phone call survey. Inspired People - Advance our culture of kindness with an intention to learn, lead, collaborate and celebrate Focus on the experience of care and caring Jan- ED n/a 66.7% 68.0% 62.5 67.6 71.2 69.8 60.9 62.7 70.8 75.6 79.2 84.0 75.4 82.1 76.7 63.5 66.2 69.0 74.2% Positive score = Yes, definitely; Oct n size: 29 t Dec 11 Was patient/family treated with kindness SP Jan- All Inpatient n/a 82.0% 83.6% 87.2 85.9 78.8 75.9 88.7 80.0 75.4 76.6 76.5 70.3 84.8 92.9 72.9 69.6 72.1 64.3 79.5% Positive score = Yes, definitely; Oct n size: 28 t Dec Jan- This indicator tracks the total number of incidents reported 12 Overall Incidents of Workplace Violence QIP n/a 335 * 22 8 17 28 46 32 26 49 25 18 26 20 43 26 21 10 24 288 t Dec organization wide. Collecting baseline Outstanding Performance - Optimize roles, resources, revenues, technology and innovation Demonstrate accountability and efficiency The baseline and target are based on 9 months of data Apr to Dec Apr- 13 Gross Conservable Days All Acute QIP 6466.0 6,626.0 5,251.0 754.6 572.7 729.5 614.4 778.9 657.2 925.9 732.2 695.1 273.5 333.9 622.8 611.8 596.7 616.5 677.5 3,732.7 2019. Monthly results may change due to enhancements in data t Oct quality. Report to the Board January 2021
The COVID-19 pandemic continues to impact and affect the day to day operations of both Bluewater Health and CEEH Foundation. As per provincial lockdown, the foundation office remains closed to the public and staff are working remotely. The charitable sector as a whole has been greatly impacted by the pandemic. We have included a summary of a report compiled by Imagine Canada that highlights key findings and recommendations. A full copy of the report can be downloaded at imaginecanada.ca/en/covid19. Bluewater Health Foundation has contributed to this report and we ask that you take some time to review it. Some of the findings are reflective of what we are seeing and experiencing in our foundations. What stood out in the report is the notion that if our communities are to heal, the charitable sector needs to be strong to be part of that. As a team, Bluewater Health Foundation has chosen to be innovative and creative in response to the pandemic. We have established new ideas, commenced virtual events when applicable and formally (and finally!) launched our grateful patient program. The foundations are cautiously optimistic and see both opportunities and challenges ahead as we continue to respond and adapt.
As you know, the hospital and foundations approached the County of Lambton for funding last year in the amount of $10 million over 10 years. We were asked to provide additional information this year. That additional information, coupled with a report from County staff was shared and discussed at council and a recommendation made “That the Bluewater Health $10 million capital grant investment/request be considered in the 2021-2031 budget forecast period and balanced against all other County Capital and Operating Budget priorities.”
This does not mean approval at this stage but what it does mean is that our request will be part of budget deliberations. Together with the hospital and board leadership, we are now working on next steps and further information has been shared with county council for inclusion in their February board package. We will be asking board members to assist us in connecting with councilors to speak to the impact that a county investment will have on Bluewater Health. If you have any questions or would like to be a part of those efforts, please let me know. A very special thank you to Rob Jenkins, Brian Knott, Mike Lapaine and Julia Oosterman for their insight and involvement.
This year’s Dream Home Lottery has started off very strong and in a year with so many unknowns, we are extremely grateful to all who are buying tickets in support of Bluewater Health. Below is a chart comparing last year’s sales for the first month of sales to this year’s. It is difficult to compare since we are currently living in a different world but it is safe to say we are off to a great start. The web tour of the home is up on the website and here is a link as well: https://www.youtube.com/watch?v=SgoYbibgzhg
facebook.com/bwhfoundation instagram.com/bwhfoundation Follow Our Stories facebook.com/ceehfoundation twitter.com/bwhfoundation Report to the Board January 2021
Dream Home Dream Home Dream Home Comparison 2020 2021 Dates of October 1-31 December 1-31 ticket sales 2019 2020
Dream Home 1,801 5,439 Tickets Sold
50/50 4,932 21,500 Tickets Sold
50/50 $9,622.50 $35,685.00 Take Home
Lastly, we are beginning to plan for next year’s lottery. Our hope is to get back on track for an October launch (fingers crossed). If you have any ideas or contacts with respect to lots and/or interested builders please let us know.
Be well and stay safe,
Kathy Alexander Owen Byers Executive Director Chair, Board of Directors Bluewater Health Foundation Charlotte Eleanor Englehart Hospital Foundation
facebook.com/bwhfoundation instagram.com/bwhfoundation Follow Our Stories facebook.com/ceehfoundation twitter.com/bwhfoundation Highlights
Demand and capacity have increased for Charities are also experiencing challenges some charities and dropped for others due with volunteers. to physical distancing. • 49% report difficulty engaging volunteers • 35% have seen demand increase while in current working conditions. 37% have seen it decrease. • 33% say volunteers are less available. • Organizational capacity has decreased for 40% of charities, usually in conjunction Arts & recreation organizations are facing with significant decreases in demand. particular challenges. • They are more likely to report decreased Innovation is central to how organizations demand, organizational capacity and are responding to the pandemic. revenues, leading to greater layoffs and • 54% of charities have transitioned in- work reductions. person programs online and 42% have • They are having more difficulty transitioning developed completely new programs in their programs online and developing new response to need. programs. Instead, many are ceasing or • 54% are increasing their emphasis on suspending operations. existing online programs. Charities that depend on earned income Charities are experiencing significant and are particularly hard hit. broad-based declines in revenue. • They are more likely to report revenue and • Revenues have declined an average of expenditure decreases, staff layoffs and 30.6% since the onset of the pandemic, work reductions. with 69% of charities reporting decreased • This is also true for charities with diversified revenues. revenue bases. • Nearly three quarters (73%) report donations are down, 38% earned income, Most charities with paid staff believe they and 23% investment income. will qualify for the Canada Emergency • These declines are significantly greater than Wage Subsidy. during the 2008/09 recession, when 32% • 45% believe they do or will qualify - 24% saw revenue decline an average of 0.75%. think they might. • 75% of those potentially qualifying intend Organizations have already made to apply and another 15% say they might. significant reductions to paid staff and more cuts are likely. Overall, charities are fairly pessimistic for • 30% of charities have already laid off staff the future but they are continuing to and 55% say new or additional layoffs are a operate. possibility. • 45% believe their financial condition will be • We estimate that charities have already laid worse in three to six months; just 8% off 37,000 full-time and 46,400 part-time believe it will be better. paid staff. • 20% believe they will be able to continue • Again, these are much more significant their current level of operations for 3 to 6 than in 2008/09 when 23% of charities laid months; 25% for 6 to 12. off staff.
Imagine Canada’s Sector Monitor ● Charities & the COVID-19 Pandemic ● May, 2020 2
MINUTES OPEN SESSION BOARD MEETING Wednesday, November 25, 2020 Zoom Videoconference 5:00 pm Directors: Marg Dragan, Vice-Chair √ Louis Guimond, Treasuer √ Rachael Simon √ Anthony Iafrate √ Brian Knott, Chair √ Fred Vanderheide √ Bill Gillam √ Katherine Mantha √ Paul Wiersma √ Jenny Greensmith √ Bob McKinley √ Kirk Wilson √ Ex-Officio Directors: Mike Lapaine √ Shannon Landry √ Dr. Lincoln Lam - R Dr. Michel Haddad √ Dr. Andre Rudovics √ Invited Participants: Samer Abou-Sweid √ Laurie Zimmer √ Julia Oosterman √ Paula Reaume-Zimmer √ Kathy Alexander √ Dr. Dhiraj Dhanjani – R Recorder: Melissa Rondinelli (*attached in the minute record book)
1.0 CALL TO ORDER - Brian Knott called the meeting to order at 5:01 pm.
1.1 Traditional Territory Acknowledgement - Brian read the traditional territory acknowledgement.
2.0 AGENDA APPROVAL
2.1 Approval of Agenda* Brian invited members to remove any items from the consent agenda. There were no changes to the agenda.
2.2 Report on September 23 In-Camera Board Meeting Brian reported the Board made decisions regarding Professional Staff credentialing, and a new Medical Quality Committee that will require revisions to the By-Laws. The Board also received information updates regarding risk, and an update on Withdrawal Management Services.
2.3 Declaration of Conflict of Interest - There were no conflicts declared.
3.0 CONSENT AGENDA
3.1 INFORMATION ITEMS TO BE RECEIVED 3.1.1 Board Chair Report* 3.1.2 Professional Staff Association Report* 3.1.3 Analysis of Loans and Investments* 3.1.4 Hospital Parking Attestation*
Open Session Board Meeting November25, 2020 Page 2
______3.2 ITEMS FOR APPROVAL 3.2.1 Open Session Board Minutes – Sept 23, 2020* 3.2.2 Chief Financial Officer Certificate* 3.2.3 Draft Board Work Plan*
Motion duly made, seconded and carried: to approve the agenda including the items in the consent agenda; receive the reports presented and approve the Open Session Board Minutes, the CFO Certificate, and the draft Board Work Plan as presented.
Brian noted the Board Work Plan might need to be modified in the future in order to respond to the pandemic. He also mentioned members have shared feedback with a preference to shorter virtual meetings, therefore, the agendas have been set for one hour for each meeting this evening.
4.0 PRESIDENT & CEO REPORT*
Brian invited Mike Lapaine to present his report and share what is keeping him up at night as the CEO. Mike began by bringing attention to the hospital’s recent recognition week, which was scaled back due to the pandemic. He explained the week included celebrations for a number of award recipients and was a testament to staff excellence at Bluewater Health (BWH).
He then shared his concern for staff well-being. He suggested that with resilience beginning to wane across communities, and the potential for outbreaks within the community and the hospital, keeping staff healthy and positive will be the biggest challenge for BWH moving forward. He then recognized staff for working together to address backlogs and patient census, and shared hope with vaccines coming.
Questions about COVID-19 vaccine distribution and timing followed. Mike speculated on how the vaccination may be prioritized, but was unable to identify how the vaccine will be distributed or when. There was brief discussion about uptake for the vaccination in the future. It was noted BWH’s flu vaccination rate this year is at 42%, and there have been no local flu outbreaks yet this year. Discussion followed about community uptake for the flu vaccine and supply shortage.
Mike was asked what led to the COVID outbreak at London Health Sciences Centre and how BWH is ensuring an outbreak does not occur. Mike suggested protocols may have been breached, but was unable to confirm the origin of the outbreak. He indicated positive attitudes by BWH staff will help get the organization through the pandemic. When asked what the Board can do to assist through the pandemic, Mike suggested the Board continue to support BWH staff. Julia Oosterman indicated a Board appreciation note for all staff is scheduled after the New Year.
Open Session Board Meeting November25, 2020 Page 3
______5.0 BOARD DECISIONS/OVERSIGHT
5.1 Quality Committee Highlights* Jenny Greensmith presented the highlights. She reported the Committee received a presentation about the new geriatric services at BWH, and learned a grant application for a second geriatrician has been submitted. There was also a presentation from the Infection Prevention and Control Program, which included a review of flu vaccination rates and news of a new dedicated COVID Response Coordinator role at BWH. In addition, the Committee heard a patient story regarding visitor restrictions that has led to consideration of policy changes. There were no questions, concerns or comments.
5.2 Quality Committee Performance Scorecard and Quality Improvement Plan Update* Jenny presented the scorecard and highlighted the following: • Alternate Level of Care (ALC) rate – off target but moving in the right direction • Time to inpatient bed – off target • Overall rating of experience – off target, may be tied to dissatisfaction with visitor restrictions • Treated with kindness – off target, may be a reflection of staff exhaustion • Workplace violence incidents – increased incidents between July and September resulted in mitigation plans for a small group of patients with no repeat incidents reported
Shannon added that overall pandemic fatigue may be affecting the hospital’s patient experience and kindness indicators as well. There were no questions, concerns or comments.
5.3 Board Pandemic Response and Hospital Operations Scorecard* Brian noted an updated scorecard was shared with the Board today. Samer Abou-Sweid reported the hospital is currently in a positive “green” position. He explained the updated scorecard was shared with the Board to provide more real time data, and has been revised to include a comment box for more clarity on how the top indicator was determined, and additional colour coding for some indicators. The next iteration will show backlog presented as wait time instead of volume. It was explained BWH does not know what the backlog was prior to the pandemic, and has historically measured wait times. The hospital has done very well in addressing the backlog to date, and expects to be at pre-COVID wait times soon, unless another ramp down of services is required. Samer was asked if diagnostic tests are increasing with patients becoming more comfortable to see their primary care provider. Samer confirmed diagnostic tests are increasing; however, wait times have decreased with additional funding/hours allocated to address the issue. He also mentioned a question was raised at one of the sub-committee meetings about the sample size for patient surveys, and was able to confirm there is an average of 30 calls per week associated with this indicator. It was questioned how many local primary care physicians are seeing their patients. Dr. Haddad reported most are operating at approximately 90% pre-COVID levels, but he is hearing some patients are having difficulty accessing primary Open Session Board Meeting November25, 2020 Page 4
______care. As a result, he has sent a memo to primary care providers requesting they optimize their access to care.
5.4 Resource Utilization & Audit Committee (RUAC) Highlights* Louis Guimond presented the highlights and reported all recommendations to the Board were unanimously approved by the RUAC. He noted the Committee received an informative presentation from the Healthcare Insurance Reciprocal of Canada (HIROC) regarding coverage and liabilities, and suggested an information session to address any questions regarding Ontario Health Team (OHT) implications may be helpful. Louis also mentioned the Committee discussed Board Goals, and shared appreciation for the work of the hospital staff supporting the Committee.
Brian thanked the sub-committees for their feedback on Board Goals and reported an email will follow to solicit any additional thoughts, versus a survey tool as originally planned. There were no questions, concerns or comments.
5.5 Monthly Financial Statement* Louis presented the statement and reported BWH is doing quite well financially during these uncertain times. He noted the budget was prepared pre-COVID and all variances are explainable. In addition, new funding information suggests the hospital may have a surplus at year-end. Louis also recognized Marlene Kerwin for her presentation of the statements and balance sheet. There were no questions, concerns or comments.
Motion duly made, seconded and carried: to approve the Financial Statement for the period ended September 30, 2020 as presented.
5.6 Resource Utilization and Audit Committee Performance Scorecard* Louis presented the scorecard. He noted it is difficult to evaluate trends during the pandemic, and had nothing concerning to highlight. Samer suggested the hospital’s performance is better than expected under the circumstances. Efficiency indicators have been impacted due to reduced volumes and increased expenses. There were no questions or comments.
5.7 Governance & Nominating (G&N) Committee Highlights* Anthony Iafrate presented the G&N highlights. He noted the Committee reviewed the Ontario Hospial Association (OHA) Board Self-Assessment Survey Checklist as a key document to prepare for the survey, which BWH participates in every two years. Anthony asked Directors for 100 % participation in the survey, which is due December 8, 2020. He explained the OHA will prepare a report comparing BWH’s results to other participating hospitals. Next, Anthony thanked members for participating in the educational offerings for the Board this month, and advised the materials from the sessions have been uploaded to ShareFile. He also highlighted that the Committee discussed the Strategic Planning process and recommended a Board Director be added to the Strategic Planning Steering Committee. Open Session Board Meeting November25, 2020 Page 5
______Lastly, he brought attention to the Board Social Trivia event taking place on December 7, 2020. There were no questions, concerns or comments.
5.8 Strategic Plan Update* Mike reported the Strategic Planning Steering Committee has kicked off its work, with a goal to present a new Strategic Plan by the Annual General Meeting. The Committee includes Kirk Wilson, two patient experience partners, as well as executive team members. He noted there have been several internal consultation sessions, a Board session is planned for December 1, 2020, and a Board retreat will follow. There were no questions, concerns or comments.
5.9 Foundation Report* Kathy Alexander presented the report and highlighted that Dream Home tickets go on sale December 1, 2020, they are hosting a virtual Christmas Concert on December 3, 2020 in partnership with YOURTV, and the County of Lambton has agreed to reconsider the Foundations’ ask of $10M over 10 years in their budget deliberations. It was questioned whether Board advocacy with the County Councillors would be helpful. Kathy indicated there will likely be some follow-up with the County by all three Boards.
6.0 CHIEF OF PROFESSIONAL STAFF REPORTS* Dr. Haddad presented his reports for October and November, which also included his Chief of Staff Goals for information. He highlighted he has been leading engagement with Professional Staff about the pandemic, working to fill Medical Leadership positions, has engaged with the College of Physicians and Surgeons of Ontario to identify ways to enhance quality care, and has been invited to provide input on a Curriculum Committee for Schulich. There were no questions, concerns or comments. Brian encouraged BWH’s leadership team to focus on balancing their work-home life.
7.0 POLICY FORMATION – None
8.0 OPEN FORUM - None.
9.0 ADJOURNMENT
Motion duly made, seconded and carried to adjourn the meeting at 5:57 pm
______Brian Knott Mike Lapaine Chair Secretary
______Melissa Rondinelli Senior Executive Assistant - Recorder
Report to the Board from
President & CEO Mike Lapaine January 2021
Quality Improvement Plan While the province did not require hospitals to submit a Quality Improvement Plan for 2020/2021, Bluewater Health prepared its QIP and has been actively engaged in meeting its targets. Bluewater Health has met its 90th percentile target for Time to Inpatient Bed for 10 months in a row, with November’s average at 1.8 hours and 90th percentile at 3.3 hours.
Holiday Surge Planning Results Bluewater Health’s annual holiday healthcare campaign focused on how the general public can prepare for their healthcare needs for the busy holiday season, and avoid unnecessary Emergency Department (ED) visits. This year, with the hospital facing the added pressures of the COVID-19 pandemic, proactive surge planning and strategies to avoid unnecessary visits to the hospital were put in place internally and with local partners. Volumes in the EDs broke from the norm, remaining at consistent levels over the holidays when historically visits go up to twice the normal daily average.
Promoting Stay Safe/Wear a Mask A video PSA was prepared and shared on social media leading up to the holidays, using frontline healthcare workers who are part of this community to deliver a clear and simple message about the need for residents to do their part in keeping us all safe. The compelling video was viewed more than 28,000 times through Facebook, Twitter and Instagram. Click here to watch the video.
COVID Unit Reopened The MED C unit was readied in anticipation of rising COVID-19 patient volumes, and opened for patients on Monday, January 11. The MED C unit is situated on Level 2, Norman Building in the space usually occupied by Inpatient Rehabilitation. Our Rehab patients were relocated to the Level 5, London Building as we had done in the first wave in 2020. Staffing will be adjusted based on the needs of the unit, looking at considerations such as skills set, background, and experience.
Census Reaches All-time Seasonal Low Bluewater Health’s inpatient medicine floors saw record breaking census reports in November. The census has never been as low at that time of year, and was particularly important heading into a potential flu or COVID surge. These numbers are attributed to a collaborative effort between the Bluewater Health team and community partners. Internally, there has been relentless attention given to estimated date of discharge, estimated length of stay, and average length of stay, while continuing to prioritize patient care and the care journey. Although November was at an all-time low, December and January have seen constant pressure for bed capacity. With all the work we’ve been doing with our community partners, we have been able to adjust daily and maintain services for many of our non-COVID patients.
Hospital Mobilizing Resources to Care Homes With an increase in COVID-19 outbreaks at local retirement and long-term care homes, Bluewater Health and partners are mobilizing resources to support care in place. Bluewater Health, along with Home and Community Care, Ontario Health, long term care and retirement home representatives and Lambton Public Health have created a response team to ensure area long term care homes and retirement homes have access to the supports and resources required. Bluewater Health resources are deployed in the areas of infection prevention and control (IPAC), risk assessment audits and management of COVID-positive residents, testing and swabbing of residents and staff and sharing processes, protocols and checklists, with weekly risk assessments in homes in outbreak, and monthly risk assessments for all others.
Regional Resource Support Bluewater Health admitted patients from outside the region to help with capacity issues brought on by COVID-19. Critical care and general inpatients from Windsor Regional Hospital, along with Chatham-Kent Health Alliance and Erie Shore HealthCare, have been transferred to Bluewater Health. We expect this to continue as regional needs require and our local needs permit.
Holiday Activities Aimed at Well-being Staff received poinsettias and other tokens of appreciation leading up to the holidays. The Children’s Holiday Party saw Santa greeting more than 100 children and sharing craft and goodie bags. One of the most important outcomes of the drive-by event was the multitude of donations that were collected for the Inn of the Good Shepherd. Bluewater Health Foundation’s Holly Jolly Holiday Concert was shown on TVs in the hospital. Meals were provided for those working Christmas Day and New Year’s Day, thanks to generous donors.
Resilience Check-ins Available through EFAP Bluewater Health has been offering Resilience Check-in sessions with our current Employee and Family Assistance Program provider, Family Counselling Centre (FCC), in Sarnia. On a trial basis, staff and Professional Staff may access a qualified counselling professional to help resolve personal and work-related issues during a time block set aside specifically for Bluewater Health employees beginning Monday, December 21. Sessions will be offered by phone or in a virtual platform. More sessions are currently underway.
After Action Review Findings Actioned To ensure we learned from the first wave of the pandemic while planning for future needs, we completed a debrief called an After Action Review (AAR). We captured what staff said worked and what we might do differently in future, through a confidential survey, several focus groups and individual interviews. Over 400 employees participated in the AAR process. While many improvement opportunities and personal impacts were surfaced, the feedback also indicated positive outcomes and feelings of pride, gratitude and collaboration and support. Several changes have already been made to address the feedback such as a straightforward communication about current inventories of personal protective equipment (PPE) posted weekly on the intranet, a mention in my weekly videos about PPE, a new resilience team to support the well-being of staff and Professional Staff, and assessing comments about communications processes and tools.
Phase II Residential Withdrawal Management Bluewater Health received confirmation of $325,000 to operate phase II of a Residential Withdrawal Management Service. This new service adds 12 more addiction support beds to Sarnia-Lambton. Bluewater Health will continue to operate its seven-bed unit for clients undergoing the immediate withdrawal process, with the new 12-bed facility offering a phase II, or stabilization and transitional phase. The program will provide 24/7 supervision and programming to effectively bridge the client’s withdrawal management plan into safe and affordable housing or longer-term treatment programs. Because of early preparations completed with community partners and donors, the facility is now already operational.
Recognition from City of Sarnia Alex Sullo, Director, Biomedical and Support Services, and Bill Beveridge, Manager, Security Services were among the recipients of Sarnia Emergency Management Appreciation Award certificates for those involved in preparing the community emergency response site. Photos of award presentations were shared publicly through social media. Dr. Haddad was named to the Mayor’s Honour List for his leadership in recruiting specialists to Sarnia and thereby allowing more people to receive care close to home, and elevating the Sarnia hospital’s reputation among medical professionals.
Sarnia-Lambton Ontario Health Team Reaches Milestone We were able to meet the January 14 deadline to submit the Collaborative Decision Making Agreement with 28 signatories. This is the final step before being declared an Ontario Health Team. We expect to receive approximately $375,000 in funding for 2021 to support projects that advance the care of the two targeted populations identified for Year One.
Vaccination Preparations Underway As COVID-19 vaccines begin to roll out across the province, Lambton Public Health and Bluewater Health are awaiting the initial delivery of COVID-19 vaccines. While a tentative date of the week of February 1 has been set by the province for Lambton County to receive vaccines, we are working closely on a comprehensive distribution plan, as supplies of vaccine start to increase sometime in the month of May. The initial focus will be on residents, staff and essential visitors at long-term care homes, followed by the hospital, in alignment with provincial frameworks.
Bluewater Health Briefing Note
Name of Committee: Board of Directors Date of Meeting: January 27, 2021 Submitted by: Mike Lapaine Subject: Work Plan Purpose of Report: Information Input Approval x
Situation
Bluewater Health (BWH) Executive Council has reprioritized the Board Work Plan items to ensure hospital resources are focused on the pandemic response, which will also support staff well-being and avoid staff burnout. See revised Board Work Plan attached.
Background
During the first wave of the COVID-19 pandemic, Board Committee meetings were cancelled and the Board Work Plan was adjusted to focus on mission critical decisions. Efforts were made to ensure work plan items were addressed via Board meetings and through Board Committee meetings once resumed. This strategy was supported by legal advice provided by Borden Ladner Gervais (see attached). An “all hands on deck” approach is required once again to respond to second wave pandemic pressures. Internal operations meetings have been cancelled unless they are mission critical/related to the pandemic response.
Analysis
BWH has maintained hospital services throughout the second wave of the pandemic, and is actively supporting local and regional partners. Members of the hospital leadership team are participating in daily internal, local and regional meetings regarding patient care, bed capacity, service planning, long-term care planning, vaccination planning and more.
With Sarnia-Lambton placing as one of the top three communities for highest weekly COVID cases per 100,000, BWH is preparing for a surge of COVID patients, and is continuing to closely monitor and support long-term care homes. Results from a recent inquiry with other hospitals indicate that approximately 30 percent of the respondents are taking a similar approach to their governance strategy, by reducing committee meetings/focusing on critical work plan items.
Recommendation
Bluewater Health Executive Council recommends the Board approve the following: 1. Cancellation of the February Quality and Resource Utilization and Audit Committee meetings; 2. A condensed Governance & Nominating Committee meeting in February to focus on Board Succession Planning; 3. Re-assess the Board Work Plan priorities on a monthly basis.
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BLUEWATER HEALTH WORK PLAN 2020-21 Alignment Status Board Agenda Responsible Board Policy/ (Complete No. Work Plan Item Category Comments May June June Committee Strategic Plan/ April In Progress March August January January October
(P=Public) February December November Legislation September Deferred) 1.0 Establishing Strategic Direction 1.1 Develop/Approve/Monitor Strategic Plan G&N A-2/E-3 Discussion (P) x x x x x x x x In Progress Deferred planning. Some external consultations have taken place.
1.2 Monitor strategic goals and quality/resource Quality/RUAC ECFAA Discussion (P) x x x x x x x In Progress Continue to present monthly objectives via Balanced Scorecards and provide SP scorecards to the Board for oversight for remediation/improvement plans A-3/E-3 information.
1.3 Review/approve/monitor Quality Improvement Quality C-1/E-3 Decision (P) x x x x x x In Progress Deferred due to pandemic. Plan (QIP) ECFAA 1.4 Establish annual performance indicators and targets Quality/RUAC ECFAA Decision (P) x x Recommendation for 2021-22 SP indicators/targets to be A-3/C-1/E-3 presented to the Board in February. 1.5 Monitor development of local Ontario Health Team All F-2 Decision (P) x x x x x x x In Progress Updates to the Board to as required continue as required. 2.0 Providing for Excellence Management 2.1 Complete CEO/CoPS performance evaluation and Exec B-3 In-Camera x x x Deferred due to pandemic. approve goals/objectives 2.2 Establish annual CEO/CoPS performance Exec B-3 In-Camera x x expectations 2.3 Review/approve Executive Compensation Exec B-3 In-Camera x NA Framework 2.4 Ensure CEO/CoPS establish an appropriate Exec B-1/E-3 Minutes x x succession plan for BWH leaders and Professional Staff 2.5 Review/approve annual HR and Physician HR plans RUAC E-3 Decision (P) x Defer to March. MAC 2.6 Review/approve executive performance-based Exec B-3 In-Camera x x compensation relative to Quality Improvement Plan ECFAA 2.7 Review/approve salary recommendation for non- RUAC B-3 In-Camera x x Defer to March. union compensation EC ECFAA 2.8 Review/approve Medical Director and other MAC E-3 In-Camera x x x x x x x x In Progress Continue to present MAC medical leadership appointments as required recommendations to the Board as required.
1 BLUEWATER HEALTH WORK PLAN 2020-21 Alignment Status Board Agenda Responsible Board Policy/ (Complete No. Work Plan Item Category Comments May June June Committee Strategic Plan/ April In Progress March August January January October
(P=Public) February December November Legislation September Deferred) 3.0 Ensuring Program Quality and Effectiveness 3.1 Monitor Quality and Patient Safety Plan and Quality C-1/C-8 In-Camera x x Complete Program annually SP
3.2 Monitor accreditation activities and respond as Quality/G&N C-1/E-3/E-10 Discussion x x x In Progress required (timing aligned with accreditation cycle)
3.3 Review Critical Incident Aggregated Data reports Quality C-1 In-Camera x x In Progress and receive Quality of Care Information Protection ECFAA Act (QCIPA) & Quality Care Review Recommendations in aggregate twice per year (used to be combined within the Quality & Patient Safety Program report) 3.4 Monitor litigation claims Quality C-2/E-10 In-Camera x Complete 3.5 Monitor Risk Assessment Checklist Quality C-2/E-10 x 3.6 Monitor ethical framework outcomes and related Quality C-4 In-Camera x policies (minimum annually) 3.7 Monitor research being undertaken within the Quality C-3 Minutes x organization (minimum annually) 3.8 Monitor pandemic plan and emergency Quality C-1/C-8 Minutes x x In Progress preparedness (i.e. Disaster plan and other related activities) - annually 3.9 Monitor Quality Improvement Initiatives through Quality E-10 Minutes x x x x x x In Progress Deferred due to pandemic . program reports and education articles ECFAA
3.10 Review recommendations from MAC on any Quality/MAC C-1 In-Camera x x x x x x x In Progress Continue to present to the systemic/recurring issues related to quality of care PHA Board as required. provided by professional staff as required
3.11 Receive minutes from the Quality Interprofessional Quality E-10 IV Minutes x x x x x x x In Progress Deferred due to pandemic . and Patient Experience Committee
3.12 Monitor patient experience results via Quality C-2/C-5 Minutes x x x In Progress Deferred due to pandemic . Concerns/Compliments reports and 4 principles of ECFAA PFCC SP
2 BLUEWATER HEALTH WORK PLAN 2020-21 Alignment Status Board Agenda Responsible Board Policy/ (Complete No. Work Plan Item Category Comments May June June Committee Strategic Plan/ April In Progress March August January January October
(P=Public) February December November Legislation September Deferred) 3.13 Provide update on Workplace Violence (also Quality ECFAA Minutes x x In Progress incorporated into 2018_19 QIP & scorecard) - twice annually 3.14 Monitor staff, professional staff and volunteer Quality ECFAA Minutes x engagement survey results SP 3.15 No One Waits (N.O.W.) Initiative update - quarterly Quality/RUAC SP Minutes x x x x x In Progress Deferred due to pandemic .
3.16 Review/approve Professional Staff appointments, MAC PHA In-Camera x x x x x x x In Progress Continue to present MAC reappointments, privileges as required recommendations to the Board as required. 3.17 Review fairness/effectiveness of credentialing MAC In-Camera x x process annually 3.18 Receive reports from the CEO in relation to the 3rd RUAC C-7 Minutes x party whistleblower service 3.19 Monitor Integrated Risk Management (IRM) Quality C-2 Minutes x x x x In Progress Continue to present pandemic quarterly - include best practices' 3 corporate SP risk update to the Board on a priorities monthly basis.
3.20 Hospital Standardized Mortality Rate report - twice Quality SP Minutes x x annually 3.21 Health and Wellness Update RUAC SP Minutes x x 3.22 Receive annual Occupational Health and Safety RUAC OH&SA / HPPA Consent R (P) x Program Report C-8 3.23 Receive an update on environmental stewardship RUAC C-9 Consent R (P) x x In Progress 2019-20 report deferred to outcomes annually September 2020-21 report due in June 3.24 Receive annual report on AODA accountabilities, RUAC AODA Consent R (P) x progress and compliance E-3 3.25 Receive updates on Pandemic Response and Re- All Discussion (P) x x x x x x x In Progress Continue to present to the establishing Services and Programs Board. 3.26 Update on Indigenous Navigation and Relations Quality Discussion (P) x x x In Progress Deferred due to pandemic .
3.27 Placeholder for health equity, diversity….. Quality Timing of report to be determined. 4.0 Ensuring Financial Viability 4.1 Monitor financial performance via monthly financial RUAC D-1/D-2 Discussion (P) x x x x x x x In Progress Continue to present to the statements Board. 4.2 Review/approve annual operating plan RUAC/Quality C-1/D-1 Decision (P) x x x x In Progress Deferred to March.
3 BLUEWATER HEALTH WORK PLAN 2020-21 Alignment Status Board Agenda Responsible Board Policy/ (Complete No. Work Plan Item Category Comments May June June Committee Strategic Plan/ April In Progress March August January January October
(P=Public) February December November Legislation September Deferred) 4.3 Review/approve Hospital Accountability Planning RUAC D-1/D-2 Decision (P) x x x x In Progress Deferred to March. Submission (HAPS) (draf (Fin t al HAP HAP S) S) 4.4 Review/approve/monitor capital expenditure plan RUAC D-1/D-2 Decision (P) x x x x x x x In Progress Deferred to March. Internal planning to continue.
4.5 Review/approve Hospital Service Accountability RUAC D-1/D-2 Decision (P) x Agreement (H-SAA) 4.6 Review/approve Community Accountability RUAC D-1/D-2 Decision (P) x x x x In Progress Defer to March. Planning Submission (CAPS) and Multi-Sectoral (draf (Fin Accountability Agreement (M-SAA) t al CAPS CAP ) S) 4.7 Review/approve Chief Financial Officer Report - RUAC C-2/D-2/D-3/ Consent A (P) x x x x In Progress Present to Board for approval ensuring legislative requirements at met E-3/E-10 in February.
4.8 Monitor business/financial risk management RUAC C-2/D-2/D-3/ Consent A (P) x x x x In Progress Defer to March. E-3/E-10 4.9 Review/receive quarterly report on investments RUAC D-3/D-4/E-10 Consent R (P) x x x x In Progress Defer to March. and loans 4.10 Review/monitor physician bank loans annually D-3/D-4/E-10 In-Camera x Defer to March. RUAC 4.11 Review/receive Human Resources Report quarterly RUAC E-10 Consent R (P) x x x x In Progress Defer to March. 4.12 Review/receive Facilities Report quarterly RUAC D-1/E-10 Consent R (P) x x x x In Progress Defer to March. 4.13 Review/receive insurance annually RUAC D-3 Minutes x Complete 4.14 Review/approve banking arrangements/resolutions RUAC D-3 Consent R (P) x 4.15 Review/approve audit activities as required RUAC E-3/E-10 Consent R x x x In Progress (post-audit/management letter, management's response and action plan, audit plan, financial statements, firm/compensation)
4.16 Review/approve Executive and Director expenses RUAC BPSAA Consent R x x In Progress D-6/E-2/E-18 4.17 Review/approve Public Sector Salary Disclosure RUAC PSSDA Consent R (P) x Attestation E-2 4.18 Review/approve BPSECA Attestation - annual RUAC BPSECA Consent A (P) x executive compensation D-1
4 BLUEWATER HEALTH WORK PLAN 2020-21 Alignment Status Board Agenda Responsible Board Policy/ (Complete No. Work Plan Item Category Comments May June June Committee Strategic Plan/ April In Progress March August January January October
(P=Public) February December November Legislation September Deferred) 4.19 Review/approve BPSAA Attestation - consultant RUAC BPSAA Consent A (P) x use, perquisites, lobbyist rules, etc. D-6/E-18/E-2
4.20 Provide update on HIS or any other significant RUAC SP Minutes x x x x x x x In Progress Defer to March. technology investments as needed D-1 4.21 Provide update on cyber security annually RUAC C-2 Discussion (P) x 4.22 Monitor/approve decisions related to property RUAC D-1 In-Camera x x x x x x x In Progress Continue to report to Board as matters as required required.
4.23 Monitor status of the development of the 5-Year RUAC E-3 Minutes x Plan - services, facilities, capital equipment, and SP technology 5.0 Ensuring Board Effectiveness 5.1 Develop/approve/monitor annual work plan All E-15 Decision (P) x x In Progress
5.2 Develop/approve/monitor Board Goals G&N/All E-15/E-19 Decision (P) x x x x In Progress 5.3 Complete All E-11/E-12/E-13/E-14/E- Consent R (P) x x x x x x x In Progress Deferred due to pandemic . Board/Director/NDCM/Committee/Meeting 19 evaluations as required and address opportunities identified by results 5.4 Strengthen Board Orientation/Education/Team All E-9 Discussion (P) x x x x x x x In Progress Deferred due to pandemic . Building SP 5.5 Complete Board succession planning, recruitment G&N E-8/E-9 Minutes x x x x x Deferred in January. Address and nomination process at condensed G&N Meeting in February. 5.6 Review Board/NDCM member meeting attendance G&N E-19 Discussion (P) x 2019-20 and 2020-21 results and education record to be reviewed in April to align with nominations process.
5.7 Review/revise/approve Board policies and By-Laws All E-1 Consent R (P) x x In Progress By-Laws last updated February 2020. Deferred due to pandemic. 5.8 Plan for Annual General Meeting G&N E-10 Minutes x x x x x Recommend virtual AGM to address required business only (no keynote speaker). 5.9 Review/receive annual FIPPA/PHIPPA compliance Quality C-6 Consent A (P) x report and complete FIPPA Delegation of Authority FIPPA PHIPPA 5.10 Complete Board meetings without Management Board E-17 Discussion x x x In Progress Deferred due to pandemic.
5 BLUEWATER HEALTH WORK PLAN 2020-21 Alignment Status Board Agenda Responsible Board Policy/ (Complete No. Work Plan Item Category Comments May June June Committee Strategic Plan/ April In Progress March August January January October
(P=Public) February December November Legislation September Deferred) 6.0 Fostering Relationships
6.1 Review/receive Global Communication and G&N E-2/E-3/F-1 Information (P) x Complete Item was deferred due to Community Engagement Plan pandemic. Reviewed in September vs February 2020.
6.2 Review/receive reports from CEO/Board liaison G&N E-2/E-3/F-1/F-2 Information (P) x x x x In Progress Deferred due to pandemic . representatives re: stakeholder relationships as SP necessary i.e.. Governance Advisory/Foundation Boards/CAP/RHAP
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Governance Advice During COVID 19 What Should the Hospital Board and Board Leaders Be Doing? 1. Re-Define Board Objectives
The board needs to re-set its priorities and defer all board work that is either not related to supporting the organization through the COVID-19 crisis, or not critical to the long term success and sustainability of the organization. The board should focus on where it can add value and be agile and responsive, while minimizing any unnecessary burden on management. The board might now define its key priorities as:
i. Ensuring the physical and mental health of its employees and professional staff as this will best ensure the organization delivers on its mission to provide patient care. ii. Making mission critical decisions that require a board decision in the most efficient manner possible such as decisions to support the availability of resources, both human and physical resources. iii. Ensuring that there are succession plans in place for key leadership roles including board leaders to cover a temporary unexpected absence. iv. Reducing the management resources required to support the board and its committees. At this time more than ever, the value the board brings to the organization must outweigh the costs (in terms of management’s time and energy) of supporting the board. 2. Board and Committee Meetings and Making Mission Critical Decisions
The board and its committees will not be meeting in person. Do they need to meet at all? Here are some considerations with respect to meetings:
i. Required Board meetings: There is no prescribed number of board meetings that must be held annually. You will need to check your by-laws if there are any specific requirements but this would be unusual. ii. Committees. The only required committees are the Medical Advisory Committee (MAC) and the Quality Committee. • The MAC is required to meet 10 times per year and it will likely be meeting more frequently than usual. It is required to report in writing to the board at every board meeting but those reports can come whenever the board next meets. • There is no mandated meeting frequency required for the Quality Committee. iii. Other Committees. No other board committees are required. They are established as a governance mechanism to assist the board with board work. Committees generally do not make decisions but rather
identify and evaluate matters that require a board decision. Committees also play a valuable role in exercising oversight. We make some comments below on how the board can continue to exercise an appropriate level of oversight in a manner that lightens the responsibility of management to support committees.
iv. Resolutions in writing in lieu of a meeting. A resolution in writing may substitute for a board meeting but it must be unanimous. If board members are not all immediately available this is not a practical way to get a quick decision.
v. Electronic Meetings: A meeting by electronic means may be a better option than a unanimous written resolution as long as you can get quorum. If you think there is a risk of not getting quorum then consider establishing an Executive Committee with broad delegated powers from the board. Some boards do not like to use Executive Committees however you can always revisit this once the crisis is over.
vi. Executive Committee.
a. Not all boards have an Executive Committee but your by-laws may enable one to be formed by the board and to have delegated decision making authority.
b. You will want to ensure you can get a quorum of the Executive Committee together on short notice if required. Review the membership and consider if the current membership has the availability to participate on short notice or if some members are now fully occupied in their own organizations.
c. Review the terms of reference and consider if you need to expand the Executive Committee’s authority so it has broad delegated authority to make decisions on behalf of the board. d. If you don’t have an Executive Committee you can establish one if the by-laws authorise the board to do so. The OHA prototype by-law contains an enabling provision authorizing the establishment of an Executive Committee.
vii. Management Committee under the Public Hospitals Act. If you don’t have a provision in your by-law enabling an Executive Committee, you can rely on section 15 of the Public Hospitals Act (PHA) to pass a bylaw enabling the board to elect a management committee and delegate any powers of the board to such committee. That by-law does not require member confirmation at a members meeting and accordingly it can be acted on immediately. While it has always been unclear why the PHA uses the term “management committee” and the Corporations Act uses the term “executive committee”, both appear to be available options to create a subcommittee of the board with delegated authority.
Practical Advice:
• Consider suspending all regularly scheduled board committee meetings for the foreseeable future. MAC will continue to meet as needed.
• Replace the oversight role of committees with individual meetings between the administrative lead to the committee and the committee Chair and Vice-Chair. For example, the Chair and Vice Chair of the Finance and Resources Committee could have a conversation with the CFO on financial matters that are mission critical and identify any needed board action such as a decision to draw down on a line of credit. A brief written note to the board could then be provided but it could be a communication prepared by the Chair of the Finance Committee to lighten the load on the administrative lead. Any mission critical decision requiring a board decision should be directed to the board Chair.
• If a committee Chair and the administrative lead feel a committee meeting is required, then it could be called for a specific purpose either COVID related or mission critical.
• Defer or at least re-evaluate routine reporting to the board on indicators. Determine, in consultation with the CEO, what is or should be being tracked internally at this time and what the board should see.
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• When a board decision is required on short notice consider if it can be made by an Executive Committee or if the full board is required. Limit the meeting agenda to critical business. For example, you can approve the minutes of your last meeting at a later date. • Some boards have a concern that Executive Committees lead to a “board within a board”. To address this concern of board members, consider calling an electronic meeting of the full board and notifying the board that if quorum is not achieved but there is a quorum on the phone for an Executive Committee, the meeting will proceed as an Executive Committee meeting with the other directors who are on the call participating but only Executive Committee members voting. This will give management the benefit of a wider range of board views while allowing prompt and timely decisions. • Remind board members that these are temporary measures. The Executive Committee can be a time limited committee. 3. Deciding What to Decide
Determining what requires a board decision is generally an art and not a science. Boards tend to receive information for three main purposes:
• To exercise their oversight role. This information includes committee reports, management reports and performance indictors. No decision is required to receive this oversight information. • To educate and inform the board often with a view to the board making a future specific decision or setting strategic priorities. No decision is required to receive this information. • To make a decision. What requires a board decision? In addition to specific matters that might be set out in the by-laws or board policy, the matters that would typically require a board decision include:
• Approvals above managements delegated authority which is usually a contract or transaction above a dollar threshold. • Matters where a third party wants evidence of the board’s approval. For example banks will require a board resolution to establish signing authorities. • Hiring the CEO (administrator) and Chief of Staff Chair (or MAC for some Hospitals). • Appointing board officers. • Establishing committees unless the by-laws have permitted the Chair to establish an ad hoc committee (this would be rare in our experience). • Approving by-laws (subject to member approval). • Appointing and re-appointing the members of the professional staff • Approving the annual audited financial statements. The board does not need to approve the quarterly statements. • Approving the strategic plan. • Any fundamental changes to governance such as the name of the corporation, the size of the board.
When is a board decision prudent but not necessary? This is a harder question to answer for most board and management teams. It would typically involve an analysis of a combination of factors such as:
• Are there any unusual risks to the organization including reputational risk? • Does it conflict with prior decisions of the board? • Does it put other strategic priorities at risk?
The board might also be asked to become involved in some COVID 19 specific issues such as ethical decision frameworks and human resource issues.
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Practical Advice:
• Required decisions in the next 30-60 days: Look at the board and committees annual work plans and ask what is mission critical in the next 30-60 days and what can be deferred. • Annual Audit. Consider if the annual audit can be deferred. This is normally a labour intensive matter. External auditors should not be on your premises in any event. Subject to your by-laws, the requirement in the Public Hospitals Act under Regulation 965 is to hold your annual meeting by July 31. It is possible the government could extend that date. • Annual Meeting Planning. We will advise separately on AGM timelines and holding virtual meetings. It is important to note the minimum requirement for an Annual Meeting is to place the financial statements before the members and appoint the auditors. The directors could be elected at a general meeting held at a later date—perhaps in September. • Board Stability. Consider extending the terms of the current directors, decreasing the size of the board or tolerating some vacancies. This would avoid distracting management with supporting the board recruiting new directors and this is probably not the best time to “on board” a new director. • Appointing Professional Staff Members. The OHA Prototype Professional Staff by-law, which many hospitals have adopted, allows for the CEO to make temporary appointments to the professional staff. If you have this provision in your by-laws, the CEO can make the appointment in the CEOs discretion and bring it to the next MAC and continue it beyond that meeting until the next board meeting on the recommendation of MAC. • Annual Quality Improvement Plan. Many organizations would be developing these at this time of year. Consider if that work should be suspended temporarily. 4. Assess Board Members Ability to Contribute and Ensuring Continuity
Hospital management should have access to board leaders when needed. Some board members may themselves have less time available given the increased demands in their professional and personal lives. Some might need to step back from a board leadership role and allow someone else to step in.
Practical Advice:
• Board Availability. The Chair should ask all board members what their availability is to support the work of the board when needed and consider sharing roles between board members for continuity purposes. For example, if there is no Vice Chair of a committee then ask a committee member to “shadow” the Committee Chair. • Board Chair Availability. The Chair needs to assess whether they have the time to support the board and the CEO and consider either greater Vice Chair involvement or asking another board member to be involved. • Management Succession plans. The Chair and Vice Chair or another board member should understand the management succession plan in the event key senior team members become ill and cannot work. This would include the plan to have an acting CEO. The plan should also contemplate who would stand in line behind the acting CEO. • Board Leadership Succession plans. Typically by-laws provide for the Vice Chair to perform the role of the Chair in the absence of the Chair. The board should have a contingency plan for replacing both the Chair and Vice Chair on short notice • Being available to Management. Where possible, and without delaying the CEO’s access to the board Chair, both the Chair and Vice Chair should be involved in key discussions with the senior team so there is continuity should one become unavailable, however, both must be able to promptly respond to management and if both cannot be available at the same time the meeting with management needs to go
4
forward on management’s timetable and availability and the Chair or Vice Chair should brief the other as required after the fact to stay current. 5. Communication and Director Due Diligence
Is there a role for board leaders in managing the information flow to and from management and the board?
If the board suspends its board and committee meetings, directors will feel a responsibility to ensure they are exercising their own personal due diligence at this time. Directors may want more frequent reporting from management as the situation rapidly changes yet this is a time when management has less time to prepare such reports.
Consider if board leaders can take responsibility to prepare weekly briefing notes to update the board. Similarly, directors need to know that they can raise their questions and concerns but these could be directed through the Chair to management.
If an Executive Committee is established, there should be reports prepared by the Chair to the board from the Executive Committee following each meeting. If the Chair and Vice Chair are having regular sessions with management, there should also be reports from the Chair to the board. These should also be prepared by the Chair if possible. Committee Chairs who are checking in with their administrative leads should also provide reporting to the full board in consultation with the Chair. 6. Stakeholder Relations
The board should turn its mind to key stakeholder relationships and what role the board can do to support those relationships. For example, is there a role for the board in staff and volunteer appreciation?
There may be a role for board members with the Foundation and its fundraising efforts at this time as the case to fund equipment has never been more compelling. 7. Eye to the Future
COVID 19 requires boards to suspend current priorities. Some directors may have a harder time setting that work down and others may want to pick it up sooner. Board members and board leadership will need to have tolerance for the different reactions of individual board members.
At some point in the future the board will need to start thinking about the hospital after COVID 19 and get back to a longer vision. Those are important board roles and the board will need to be ready to evolve back to something closer to business as usual. It is however likely that a return to “business as usual” may not mean simply picking up where we left off. It is too early to say. When the time is right, the board will need to work together and with management to bring the work of the board and the organization to its new future state, however, at the present time the board needs to ensure its focus is to support leadership to manage the COVID 19 crisis.
Author
Anne Corbett T 416.367.6013 [email protected]
Expertise
Health Care
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6 Bluewater Health Statement of Revenue and Expense Forecast surplus/(deficit) as at March 31, 2021 Based upon the eight (8) months ended November 30, 2020 (000's)
20/21 20/21 20/21 20/21 20/21 20/21 Projected 20/21 Notes YTD YTD YTD YTD % Annual Forecast Variance to Forecast % Budget Actual Variance Variance Budget Amount Budget Variance
Revenue $
Ministry Revenue 103,471 111,329 7,858 8% 155,550 165,639 10,088 6% 1 Cancer Care Ontario Revenue 5,858 6,618 760 13% 8,763 9,790 1,027 12% 2 Paymaster Funding 877 887 10 1% 1,311 1,322 10 1% OHIP Revenue 9,936 7,717 (2,220) -22% 14,863 13,294 (1,570) -11% 3 Patient Revenue - Other 1,144 1,397 253 22% 1,711 1,964 253 15% Room differential 1,909 1,153 (755) -40% 2,855 2,033 (822) -29% 4 Co-payment 323 268 (55) -17% 483 400 (83) -17% External Recoveries 1,544 1,316 (228) -15% 2,763 2,523 (241) -9% 5 Parking Revenue 710 227 (483) -68% 1,062 527 (535) -50% 6 Other Revenue 188 163 (25) -13% 292 266 (26) -9% Deferred Equipment Grants 1,164 1,087 (77) -7% 1,741 1,741 - 0% Interest and Donations 67 149 82 122% 100 182 82 82%
Total Revenue $ 127,191 132,311 5,120 4% 191,496 199,680 8,184 4%
Expenses $
Salaries and Wages 62,243 67,005 (4,762) -8% 93,276 99,555 (6,279) -7% 1 Medical Staff Remuneration 15,588 14,883 706 5% 23,371 22,825 546 2% 3 Employee Benefits 17,439 17,453 (14) 0% 26,349 26,580 (230) -1% 1 Employee Future Benefits 267 421 (154) -58% 400 621 (221) -55% 7 Utilities, Buildings & Grounds 2,264 2,578 (314) -14% 3,524 3,788 (263) -7% 8 Equipment Expense 4,305 5,195 (889) -21% 6,629 7,617 (988) -15% 9, 1 Supplies and Expenses 7,996 7,553 442 6% 11,958 11,510 449 4% 10 Contracted Out Services 2,623 3,831 (1,208) -46% 3,924 5,132 (1,208) -31% 11 Medical/Surgical Supplies 6,058 5,427 631 10% 9,062 9,062 - 0% 12 Drug Expense 4,818 5,343 (524) -11% 7,208 8,018 (810) -11% 2 Interest Expense 227 133 94 42% 339 245 94 28% Amortization 3,037 2,632 406 13% 5,331 4,981 350 7%
Total Expenses $ 126,867 132,454 (5,587) -4% 191,374 199,935 (8,561) -4%
Hospital Operating Surplus/(Deficit) $ 324 (144) (467) n/a 122 (255) (377) n/a
Net Marketed Service Surplus/(Deficit) 230 158 (72) -31% 339 320 (19) -6%
Net Other Vote Surplus/(Deficit) 9 - (9) n/a 0 0 - n/a
LHIN Operating Surplus/(Deficit) $ 563 15 (548) 461 65 (396)
Deferred Building Grants 6,012 6,025 14 0% 8,993 8,993 - 0% Building Amortization (7,231) (7,041) 190 -3% (10,817) (10,817) - 0% Interest on L/T Liabilities (64) (24) 41 -63% (96) (96) 0 0%
Operating Surplus/(Deficit) $ (721) (1,026) (305) (1,459) (1,855) (397) Bluewater Health Notes to Financial Statements November 30, 2020 Actual and Full Year Forecast
Bluewater Health is forecasting a balanced position for the 2020/21 fiscal year. The Ministry of Health has been flowing funding to cover incremental costs as a result of the COVID pandemic. These incremental costs are the main contributing factor to negative budget variances. The hospital had planned on an operating surplus of $461K for the year. At the end of November, the hospital had a surplus of $15K.
Note 1 Ministry Revenue is over budget by $7.8M at the end of November and is forecasted to be better than budget by $10M at year-end. This positive variance is primarily the incremental COVID funding as well as the temporary pandemic pay funding. There are offsetting expenses associated with this revenue. This funding is subject to final reconciliation and potential recovery from the Ministry. The Ministry has confirmed additional QBP volumes reallocated to Bluewater Health from within our region to help eliminate the regional back log of cases.
Note 2 Bluewater Health receives CCO funding for Oncology Drugs, QBPs, and the Ontario Breast Screening Program. CCO revised QBP funded volumes for the 20/21 fiscal year. The hospital is forecasting achieving all CCO QBP funding based on these revisions. The hospital is not forecasting achieving all OBSP funding due to COVID. CCO funded Oncology drugs are contributing to the positive variance. The Oncology program has a corresponding overage in drug expense. In September, the hospital was notified of additional QBP funding earned from the 19/20 year-end reconciliation which also contributes to the positive variance.
YTD Actual Annual Budget Year-End Forecast Description
Oncology Drug Funding $ 3,304,089 $ 3,890,000 $ 4,942,592 QBP Funding (Cancer Surgeries, Endoscopy, Systemic Therapy) $ 3,017,422 $ 4,668,975 $ 4,513,766 Ontario Breast Screening Program Funding $ 75,139 $ 204,258 $ 112,401 2019/20 QBP Reconciliation $ 221,098 $ - $ 221,098 Total Funding $ 6,617,748 $ 8,763,233 $ 9,789,857
Note 3 Bluewater Health does OHIP billings for various physician groups. There is an offsetting Med Staff Remuneration expense for these billings. Both OHIP Revenue and Med Staff Remuneration are under budget due to COVID primarily related to Diagnostic Imaging closures/slow downs. The forecast assumes the hospital will be better than budget for the remainder of the fiscal year.
Note 4 Room Differential revenue is under budget by $755K at the end of November. There was lower occupancy in the hospital due to COVID for the first part of the year. For patients in hospital, preferred accommodation billing processes were also disrupted due to COVID which contirbutes to this negative variance. The hospital is forecasting a negative variance of $822K as a result of anticipated ongoing lost revenue due to the impacts of COVID.
Note 5 External Recoveries are under budget by $228K at the end of November. This negative variance is primarily related to closures within the hospital due to the COVID19 pandemic for the first part of the year. As more services have re-opened, the hospital is forecasting being on budget for the remainder of the fiscal year.
Note 6 Parking Revenue is under budget by $483K at the end of November and forecasted to be under budget by $535K at year-end. The hospital removed paid parking due to the COVID19 pandemic for patients, visitors, physicians, and staff. Paid parking was reintroduced in October.
Note 7 Employee Future Benefits are over budget by $154K at the end of November and are forecasting to be over budget by $221K at year-end. This expense represents the future anticipated benefit liability for our current employees and it is driven by our annual actuarial valuation. This valuation occurred after the budget was completed for the 2020/21 fiscal year. Future budgets will be adjusted accordingly.
Note 8 Utilities are over budget $314K at the end of November. The hospital is forecasting a small improvement to this negative variance by year-end.
Note 9 Equipment expense is over budget by $889K at the end of November. This negative variance is forecasted to increase to $988K by year-end. The negative variance is a result of renovations and equipment purchases to refit the hospital to ensure social distancing as well as other safety precautions put in place for the hospital to re-establish services. This overage was included in reported incremental expenses to the Ministry of Health for reimbursement.
Note 10 Supplies and Expenses are under budget $442K at the end of November. This positive variance is attributed to the low occupancy in the hospital and the reduction of many services in the first part of the year due to the COVID19 pandemic. With the ongoing re-establishment of services within the hospital, it is anticipated that the hospital will be in-line with budget for the remainder of the fiscal year. Note 11 Contracted Out Services is over budget by $1.2M at the end of November and is forecasted to be over budget by $1.2M at year-end. The negative variance is attributed to contracted out staff assisting with COVID screening at hospital entrances as well as operations of local Assessment Centres. There is offsetting funding for the Assessment Centre operations from the Ministry.
Note 12 Med/Surg supplies are under budget by $631K at the end of November. The Operating Room is the largest user of med/surg supplies in the hospital. The COVID19 pandemic caused a temporary closure of Operating Rooms which is the main contributor to this positive variance. The hospital is forecasting being on budget at year-end for Med/Surg supplies as surgeries have begun ramping up. Bluewater Health Balance Sheet As at November 30, 2020 Comparison to November 30, 2019 (000's)
2020/21 2019/20 Actual Actual % Nov-20 Nov-19 Change
Assets
Current Assets Operating Cash $ 10,303 9,491 9% Investments - CEE Site 758 998 -24% Accounts Receivable 5,166 4,661 11% Accounts Receivable - MOHLTC 129 0 #DIV/0! Inventories 1,715 1,036 65% Prepaid Expenses 2,085 1,921 9%
Total Current Assets 20,157 18,108 11%
Fixed Assets Land and Land Improvements 7,478 7,446 Building/Building services Equipment 342,120 335,505 Furniture and Equipment 82,560 80,125 Less: Accumulated Amortization (199,848) 232,309 (187,740) 235,337 -1% Construction in Progress 1,623 1,482 9% Other Non Current Assets 368 413 -11%
Total Fixed Assets 234,300 237,231 -1%
Total Assets $ 254,457 255,339 0%
Current Liabilities Accounts Payable 3,004 3,057 -2% Accounts Payable - MOHLTC 1,939 2,717 -29% Accrued Salaries & Vacation Pay 12,554 10,639 18% Current Portion - Long Term Debt 390 381 2% Other Liabilities 8,065 6,312 28%
Total Current Liabilities 25,951 23,106 12%
Long Term Liabilities Long Term Bank Loans Payable 4,175 1,836 127% Deferred Revenue 198,871 204,713 -3% Post Employment Benefits 15,265 15,331 0% Other L/T Liabilities 1,489 2,513 -41%
Total Long Term Liabilities $ 219,800 224,392 -2%
Equity Opening Equity 9,732 10,421 R&E Surplus/(Deficit) (1,026) (2,579)
Total equity 8,706 7,841 11%
Total Liabilities and Equity $ 254,457 255,339 0%
Hospital Accountability Agreement Indicators: Negotiated Target
Current Ratio 0.75 0.74 0.60
Adjusted Working Capital $ 82 $ 844 $ -
Note: Current ratio excludes CEEH Site Investments
Adjusted Working Capital is calculated using the definition of the Working Capital Funding Initiative Meets/Exceeds Target Meeting baseline but not meeting target Pandemic Response & Hospital Operations Scorecard Performance not meeting baseline Data Unavailable * no established target
Data Week of Week of Week of Week of Week of Week of Week of Week of YTD PERFORMANCE # Key Performance Indicators Baseline Target Trending Comments Source Nov 22, 2020 Nov 29, 2020 Dec 06, 2020 Dec 13, 2020 Dec 20, 2020 Dec 27, 2020 Jan 03, 2021 Jan 10, 2021 Report
YTD Desired
UPDATED Period Trending
Mon - This indicator is the result of the performance of a combination 1 Daily Hospital Operations Status G G G G G G t Fri of 5 key indicators that are reviewed on a daily basis
Quality Care - Assure the right care, in the right place, at the right time, by the right provider Improve access to care Average daily visits (all OP, SDAs & Short Stays) as a Meditech, Sat - 2 100% 103.9% 96.3% 106.3% 101.5% 78.5% 49.1% 88.7% 92.9% t percent of average pre-COVID volumes SETP Fri Weighted wait time average: OR case backlog 85 88 80 t
3 Weighted wait time average: Endo case backlog 163 221 119 Monthly t
Weighted wait time average: DI patient backlog 39 23 22 t Time to Inpatient Bed (all CTAS, Sarnia only) (weekly Winrecs Sun - 4 * 2.1 2.2 1.9 2.5 1.6 1.9 1.9 2.6 t average) (NACRS) Sat Sun - 5 Hospital Occupancy (all IP beds) (weekly average) Meditech * 73% 74% 73% 79% 69% 71% 76% 77% t Sat RWMS Beds Requested and Unavailable (weekly Sun - 6 RWMS * 5 8 33 26 9 32 61 32 t count) Sat Ingrain patient safety
PPE (green by default, will be adjusted if advised by PPE > 30 days' Mon - 7 G G G G G G G t PPE working group) Committee supply Fri Pharmacy (green by default, will be adjusted if advised > 30 days' Mon - 8 Pharmacy G G G G G t by Director of Pharmacy) supply Fri < 2021/01/03 Fri 9 COVID-19 presence (hospital) (confirmed patients) IPAC * 2 0 2 3 2 5 7 11 count; Sun-Sat t avg
Lambton County (new COVID-19 cases in the Lambton Sun - 10 * 6 20 21 73 138 304 297 378 t community) (weekly count) Public Health Sat
< 2021/01/03 Fri 11 Total Number of staff confirmed COVID-19 OCC Health * 3 3 3 4 6 10 13 13 count; Sun-Sat t avg Sun - 12 Actual and potential COVID 19 exposure incidents RL6 * 0 1 3 6 0 0 0 0 t Sat Meditech, Sun - 13 Total IPAC isolations (weekly average) * 25 30 33 42 31 41 40 63 t IPAC Sat Exceptional Relationships - Expand innovative partnerships and collaborations to improve experiences, services, transitions and community health Sun - 14 ALC for LTC (subset of all ALC) (weekly average) Oculys * 9 8 11 7 9 10 6 13 t Sat # Community facility outbreaks (LTC & Retirement) Lambton Sun - 15 * 0 0 0 0 1 4 8 10 t (weekly average) Public Health Sat
Build sustainable partnerships and collaborations COVID Testing - TAT (days, where tests are recorded Sun - 16 Meditech * 1.43 1.58 1.58 1.55 1.68 1.71 1.64 1.91 t on Result date) Sat Human Thu - 17 Staff deployed outside BWH * 0 0 0 0 0 0 1 1 t Resources Wed Human Thu - 18 Leave of Absence * 18 14 28 28 30 27 28 29 t Resources Wed Strengthen Patient and Family-Centred Care Patient survey: Overall, did you feel safe during your Patient Data collection Data collection Data collection Data collection Data collection Data collection Data collection Mon - 19 * 100% This indicator is the percentage of 'definitely' responses t hospital visit? Experience paused paused paused paused paused paused paused Fri Patient survey: Overall, please rate your experience Patient Data collection Data collection Data collection Data collection Data collection Data collection Data collection Mon - 20 * 92% This indicator is the percentage of '9' and '10' responses t coming to Bluewater Health Experience paused paused paused paused paused paused paused Fri Inspired People - Advance our culture of kindness with an intention to learn, lead, collaborate and celebrate Focus on the experience of care and caring Approved Family Care Partners Visiting Inpatients Volunteer Mon - 21 * 107 97 94 90 64 78 38 21 t (Weekly Average) Resources Fri Outstanding Performance Demonstrate accountability and efficiency
22 COVID Related Expenses Finance * $985,493 Monthly t Chief of Staff Report to the Board December 2020
At the Medical Advisory Committee meeting held on December 16, 2020, the following items were discussed:
Quality Improvement Initiatives • Approved recommendations made by the Infection Prevention and Control Committee • Approved the Physician Lead – Combined CCOT/Protected In-patient Adult Code Blue Policy • Received an update on Ontario Health Teams
COVID-19 Updates Discussed / reviewed / received updates on: • Expectations for physicians working at more than one hospital • COVID-19 screening at doors for staff/Professional Staff via the MESH app • London Health Sciences Centre–University Hospital Medical Students • Vaccination status
Committee Membership • Dr. Shoaib Khan was appointed to the Infection Prevention and Control Committee as the Hospitalist representative
Physician Education, Development and Engagement • Discussed quality improvement projects for the CPSO Quality Improvement Partnership Program
Recruitment/Succession Planning • Interviews in progress for Medical Director/Chief of Internal Medicine, Medical Director/Chief of Surgery, Medical Director/Chief of Emergency Medicine, Medical Director/Chief of Pathology, Chief of Anaesthesia • Recruitment efforts continue for anaesthesia, pathology, paediatrics, psychiatry, neurology, otolaryngology and cardiology
Submitted by:
Michel Haddad, MD, MSc, FRCSC Chief of Staff, Bluewater Health Chief of Staff Report to the Board January 2021
At the Medical Advisory Committee meeting held on January 20, 2021, the following items were discussed:
Quality Improvement Initiatives • Approved recommendations made by the Infection Prevention and Control Committee and the Patient Order Sets Committee • Received an update on Ontario Health Teams
COVID-19 Updates Discussed / reviewed / received updates on: • Approved revisions to the Medicine C Admission, Transfer Discharge Criteria Policy • Opening of Med-C, and status of Med Tele, Medicine, ICU • Provincial stay-at-home order • Regional patient transfers • Clinical and Ethical Advisory Committee (CEAC) • COVID-19 Vaccine Prioritization for BWH Healthcare Workers Committee
Committee Membership • Dr. Julie Lebert was appointed as Chair of the Patient Order Sets Committee and Drs. Jason Akindolire and Laura Allen were appointed as committee members • Dr. Nick Matlovich was appointed as Co-chair of the Ethics and Research Committee
Physician Education, Development and Engagement • Physician Leadership Institute course can be done virtually, however, it remains on hold given the state of the pandemic • Wellness Committee has upcoming conference call to learn more about Schulich’s Peer to Peer Well-being program
Linkages with Western University • Medical Resident and Student clinical rotations continue at Bluewater Health – all COVID-19 protocols are being followed
Recruitment/Succession Planning • Interviews in progress for Medical Director/Chief of Pathology • Recruitment efforts continue for anaesthesia, pathology, paediatrics, neurology, otolaryngology, cardiology, plastic surgery • Considering Infectious Disease (already on HR plan) to assist with IPAC and patient consults Celebrating Accomplishments • Appreciate that physicians are looking at different strategies to meet the needs of our patients during the pandemic • The orthopaedic surgeons have been working to decrease the use of inpatient resources: Dr. Matlovich recently did the first outpatient total hip Arthroplasty, Dr. MacKinlay did the first outpatient reverse TSA, Dr. March has been discharging total knees the day after surgery. The Surgery and Physiotherapy departments were integral in supporting the patients with these changes
Submitted by:
Michel Haddad, MD, MSc, FRCSC Chief of Staff, Bluewater Health