AGENDA...AGENDA OPEN SESSION BOARD MEETING Wednesday, February 26, 2020 Bluewater Health Board Room – R-4-810 5:05 pm Directors: Marg Dragan, Treasurer Anthony Iafrate Bill …

AGENDA OPEN SESSION BOARD MEETING

Wednesday, February 26, 2020 Bluewater Health Board Room – R-4-810

5:05 pm Directors:

Marg Dragan, Treasurer Anthony Iafrate Bill Gillam Jenny Greensmith

Louis Guimond Brian Knott, Vice-Chair Katherine Mantha Bob McKinley

Rachael Simon Fred Vanderheide Paul Wiersma, Chair Kirk Wilson

Ex-Officio Directors: Mike Lapaine Dr. Michel Haddad

Shannon Landry Dr. Andre Rudovics

Dr. Lincoln Lam

Participants: Samer Abou-Sweid Julia Oosterman

Laurie Zimmer Kathy Alexander

Paula Reaume-Zimmer Dr. Dhiraj Dhanjani

Recorder: Melissa Rondinelli *attached

NO. TOPIC ACTION TIME PRESENTER

1.0 CALL TO ORDER: WELCOME AND OPENING REMARKS

1.1 Traditional Territory Acknowledgement 5:05 Paul Wiersma

1.2 Report on the January In-Camera Board Meeting

2.0 AGENDA APPROVAL

2.1 Approval of Agenda Decision Paul Wiersma

2.2 Declaration of Conflict of Interest Decision Paul Wiersma

3.0 CONSENT AGENDA Paul Wiersma

3.1 ITEMS TO BE RECEIVED

3.1.1 Board Chair Report* Information Paul Wiersma

3.1.2 Professional Staff Association Report* Information Dr. A. Rudovics

3.1.3 Analysis of Loans and Investments* Information Marg Dragan

3.2 ITEMS FOR APPROVAL

3.2.1 Open Session Board Minutes – January 22, 2020* Decision Paul Wiersma

3.2.2 Chief Financial Officer Certificate* Decision Marg Dragan

4.0 PRESIDENT AND CEO REPORT* Information 5:08 Mike Lapaine

https://www.bluewaterhealth.ca/sites/default/files/Board%20Agendas%20and%20Packages/Board%20policies/Approved%20-Bluewater%20Health%20-%20Corporate%20By-law%20-%20Feb%2028%2C%202018.pdf

NO. TOPIC ACTION TIME PRESENTER

5.0 BOARD DECISIONS/OVERSIGHT

5.1 Governance and Nominating Committee Highlights* Information 5:15 Anthony Iafrate

5.2 Quality Committee Highlights* Information 5:20 Brian Knott

5.3 Quality Committee Performance Scorecard and 2019/20 Quality Improvement Plan Update*

Discussion

5.4 2020/21 Quality Improvement Plan Update* Decision

5.5 Resource Utilization & Audit Committee (RUAC) Highlights*

Discussion 5:35 Marg Dragan

5.6 Accountability Amending Agreements* Decision

5.7 Financial Statement* Decision

5.8 2020-21 Human Resources Plan* Decision

5.9 RUAC Performance Scorecard* Discussion

5.10 2020-21 Physician Human Resources Plan* Decision 6:00 Dr. M. Haddad

5.11 Chief of Professional Staff Report* Information

5.12 Bluewater Health Foundation Report* Information 6:10 Kathy Alexander

6.0 POLICY FORMATION – None

7.0 OPEN FORUM Opportunity for Directors to reflect on how patients, families and community were considered in discussions

6:15 Paul Wiersma

8.0 REPORT ON IN-CAMERA AGENDA ITEMS Information 6:20 Paul Wiersma

9.0 ADJOURNMENT: Next Meeting – March 25, 2020 6:20 Paul Wiersma

Bluewater Health Board of Directors

Open Session Meeting February 26, 2020 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 – January 22, 2020

• Chief Financial Officer Certificate

5.4 2020/21 Quality Improvement Plan Update to approve the indicators and targets move forward as presented

5.6 Accountability Amending Agreements to approve: • the Board Chair and CEO to sign

the HSAA Amending Agreement between the ESC LHIN and BWH effective March 31, 2020 to June 30, 2020; and

• the Board Chair and the CEO to sign the M-SAA between the ESC LHIN and BWH effective March 31, 2020 to June 30, 2020.

5.7 Financial Statements to approve the Financial Statement for the period ended December 31, 2019 as presented

5.8 2020-21 Human Resources Plan to approve the 2020-21 Human Resources Plan as presented

5.10 2020-21 Physician Human Resource Plan to approve the 2020-21 Physician Human Resources Plan as presented

Board Chair Report

I would like to highlight my activities as Chair for the period of January 22, 2020 to February 21, 2020: January 22, 2020 Prepared for and chaired the BWH Board meetings January 23, 2020 Participated in Board Chair at the Helm Series: Influencing

and Shaping Board Culture January 27, 2020 Participated in Board Chair at the Helm Series: The Pivotal

Role of Primary Care Physicians in Integration February 5, 2020 Attended the Lambton County Council Meeting to observe the

grant presentation request by Mike Lapaine and the foundations

February 6, 2020 Prepared for and chaired the Nomination Committee meeting February 6, 2020 Attended and participated in the Governance and Nomination

Committee Meeting February 11, 2020 Participated in the OHA webinar, Advocacy for Action February 21, 2020 Met with the President and CEO to prepare for the February

Board meeting and to discuss hospital and Board business Various dates Communicated with BWH staff and Board members regarding

hospital and Board business

Paul Wiersma

1

President of the Professional Staff Association (PSA) Report

February 2020 I would like to highlight my activities as PSA President: January 22, 2020 Prepared for and attended the Bluewater Health Board meeting February 14, 2020 Attended the Valentine’s Day Physician Wellness Breakfast

February 2020 Prepared agenda for the quarterly Professional Staff meeting

(March 2, 2020) Dr. Andre Rudovics

Bluewater HealthBank Loan AnalysisFor the period ending December 31, 2019

Bank Loan Description Purpose Dec 19 Sep 19 Jun 19 Mar 19 Dec 18 Approved Limit

Bank Loans - Long TermDemand loan, 2.39%, repayable in blended monthly Honeywell Energy Project 727,657 861,532 994,611 1,126,898 1,258,397 3,800,000 payments of principal and interest of $46,252, matures April 2021Demand loan, 2.38%, repayable in blended monthly payments of principal and interest of $53,083, 1,394,210 1,544,568 1,694,035 1,842,616 1,990,317 4,500,000 matures March 2022TOTAL DEBT 2,121,866 2,406,100 2,688,646 2,969,514 3,248,714 8,300,000

Less: Current Portion of Long Term Debt (285,932) (570,165) (852,711) (1,133,579) (279,200) 1,835,935 1,835,935 1,835,935 1,835,935 2,969,514

TOTAL LONG TERM DEBT 1,835,935 1,835,935 1,835,935 1,835,935 2,969,514 TOTAL CURRENT PORTION OF LONG TERM DEBT (OTHER LIABILITIES) 285,932 570,165 852,711 1,133,579 279,200

2016/17 Capital Expenditures

Charlotte Eleanor Englehart Hospital of Bluewater HealthEnglehart Estate InvestmentsAs at December 31, 2019

Cash Accounts:Revenue Cash 2,144.52 Capital Cash 16,289.74

Total Endowment Cash per TD Waterhouse Stmnt 18,434.26

Original Cost FMV Held for Trading Investments

Money Market Funds 15,062.34 15,062.34 Bond Funds 394,316.46 401,477.00 Equity Funds 318,459.08 347,343.00

Total Held for Trading Investments 727,837.88 763,882.34

Total Investments and Cash Accounts 746,272.14 782,316.60

MINUTES

OPEN SESSION BOARD MEETING Wednesday, January 22, 2020

Directors:

Marg Dragan, Treasuer Anthony Iafrate Bill Gillam -R Jenny Greensmith

Louis Guimond - R Brian Knott, Vice-Chair Katherine Mantha Bob McKinley

Rachael Simon Fred Vanderheide Paul Wiersma, Chair Kirk Wilson

Ex-Officio Directors:

Mike Lapaine Dr. Michel Haddad

Shannon Landry Dr. Andre Rudovics

Dr. Lincoln Lam – R

Participants: Samer Abou-Sweid Julia Oosterman

Laurie Zimmer Kathy Alexander – R

Paula Reaume-Zimmer – R Dr. Dhiraj Dhanjani - R

Recorder: Melissa Rondinelli (*attached in the minute record book)

1.0 CALL TO ORDER

Paul Wiersma called the meeting to order at 5:00 pm and welcomed everyone to the meeting.

1.1 Traditional Territory Acknowledgement Paul read the traditional territory acknowledgement.

1.2 Report on the November In-Camera Board Meeting Paul reported the Board made decisions regarding Professional Staff credentialing and received information updates on:

• Ontario Health Teams • Critical Incidents • Quality of Care Information Protection Act and Quality Care Reviews • Integrated Risk Management • Quarterly Financial Risk Management • Director and Executive Expenses • Health Infrastructure Renewal Fund Program Allocation

2.0 BOARD EDUCATION

Laurie Zimmer introduced representatives of the St. Joseph’s Hospice, Larry Lafranier, Executive Director and Dr. Leslie Potts, Board Chair. Larry provided the Board with an overview of the history of St. Joseph’s Hospice, its Mission, Vision and Values, and the role of the St. Joseph’s Health Care Society – the owner and sponsor of the Hospice.

Bluewater Health – Open Meeting January 22, 2020 Page 2 ____________________________________________________________________________

St. Joseph’s Hospice offers residential care, community based programs and services, and a Palliative Care Clinic. See overview of services below: 1. The Residence: includes 10 private rooms with bathrooms, and public home-like areas

such as a kitchen and dining rooms, reception area. Services offered include: massage, Reiki, music therapy, reflexology, etc.

2. The Resource Centre: private rooms used for personal use, support groups, education and meetings for community based programs and services such as illness support, bereavement programs, etc.

3. Palliative Care Clinic – end-of-life support provided 24/7 within the home, Bluewater Health or Hospice residence.

Next, Larry highlighted how volunteerism, partnerships and philanthrophy support the St. Joseph’s Hospice. He noted the Hospice has 240 active volunteers averaging 22K hours per year, and their Foundation raises approximately $1.6M annually (55% of budget). Current challenges include recruitment and lower occupancy. Opportunities to partner are being explored, including a pilot shared management role with BWH.

The Board was appreciative for the presentation and asked questions about admission criteria, how Hospice manages cultural sensitivities, and if there are integration opportunities with long-term care homes. It was explained admissions are based on a clinical scoring system and the average length of stay for a patient at the Residence is 14 days. Approximately 50% of admissions are made through the hospital, following a home and community care assessment through the ESC LHIN. There has been an increase in non-cancer patients with more chronic lung, kidney and heart disease patients than before. Hospice staff participate in cultural sensitivity training and services are offered to everyone. It was noted there is opportunity to provide more education/community awareness about palliative care to better support patients in Sarnia-Lambton. The Board was encouraged to tour St. Joseph’s Hospice.

3.0 AGENDA APPROVAL

3.1 Approval of Agenda*

Motion duly made, seconded and carried: to approve the agenda as presented. 3.2 Declaration of Conflict of Interest - None declared.

4.0 CONSENT AGENDA 4.1 ITEMS TO BE RECEIVED

4.1.1 Board Chair Report* 4.1.2 Professional Staff Association Report*


4.1.3 Board Meeting Effectiveness Survey Results* 4.1.4 Facilities Report*

4.2 ITEMS FOR APPROVAL

4.2.1 Open Session Board Minutes – November 27, 2019* 4.2.2 Annual General Meeting Location*

Motion duly made, seconded and carried: to receive the reports presented and to approve the following items in the Consent Agenda: Open Session Board Minutes – November, 2019, and that the Annual General Meeting be held at the Lambton College Event Centre on June 24, 2020.

5.0 PRESIDENT AND CEO REPORT* Mike Lapaine presented his report and indicated patient volumes are similar to last year, with all surge beds at 100% occupancy since the holiday season. He noted the difference between this year and last, is the hospital’s ability to move patients much more quickly, which is attributed to the work of the No One Waits (NOW) initiative. Mike then shared appreciation for the teams involved in improving well-being throughout the organization. He brought attention to impressive changes in the survey question“the organization promotes staff health and wellness” which increased from 51.6% to 78.6%. Questions about vaccination rates and the future of NOW followed. It was reported 52% of staff are vaccinated, which is up from last year. Mike indicated there is still opportunity for the NOW initiative to create capacity, with this year’s focus on Expected and Actual Length of Stay.

6.0 BOARD DECISIONS/OVERSIGHT

6.1 Governance and Nominating (G&N) Committee Highlights* Anthony Iafrate presented the highlights and reported most of meeting was focused on

Board succession planning. He then presented the revised Nominations Process Policy below. Paul Wiersma added the Nominating Committee will be determining whether to advertise for positions in 2020, as there may not be any openings on the Board next year.

6.2 Board Succession Planning* Anthony presented the proposed changes to the Nominations Process Policy which now

includes an exception for the Board Chair/Vice-Chair to be part of the Nominating Committee if their term is expiring. He also presented a recommendation to approve the ad-hoc Nominating Committee membership for 2020.

Bluewater Health – Open Meeting January 22, 2020 Page 4 ____________________________________________________________________________ Motion duly made, seconded and carried: to approve the revisions to the draft

Nominations Process Policy as presented. Motion duly made, seconded and carried: to approve the ad-hoc Nominating Committee

membership for 2020 to include: Paul Wiersma, Brian Knott, Marg Dragan, Anthony Iafrate, Jenny Greensmith, Louis Guimond and Mike Lapaine.

There were no questions, concerns or comments. 6.3 Quality Committee Highlights* Brian Knott presented the Quality Highlights and reported Diagnostic Services plans to

replace an automation line in February/March. There are plans to provide the Board with a tour of the second floor to see the areas that will be impacted. Brian noted the Committee also received updates on the Indigenous Patient Navigator (IPN) program and emergency and pandemic planning. The IPN saw a peak in referrals in November. In regards to emergency planning, the hospital is up-to-date on its Code drills, and is working to update emergency equipment and develop a new code Trauma. There were no major revisions following the hospital’s annual pandemic plan review and coronavirus planning is underway. If coronavirus becomes epidemic, planning will be directed at federal, provincial and local levels.

6.4 Quality Improvement Plan (QIP)*

Brian referenced the briefing note included in the agenda package and explained the QIP is required annually, with a submission deadline of March 31, 2020. This year, Health Quality Ontario (HQO) has mandated two indicators – Number of Workplace Violence Incidents and Time to Inpatient Bed. In addition, HQO has encouraged alignment of indicators amongst Ontario Health Team partners. Staff are working with stakeholders to evaluate and assess recommended indicators and targets, with a plan to update the Board in February, and bring forward a final QIP for Board approval before the submission deadline. Discussion regarding patient experience indicators and the idea of a shared collaborative palliative care indicator followed. It was noted local palliative care services are exceptional and opportunities to strengthen this care are being explored.

6.5 Quality Committee Performance Scorecard*

Brian presented the scorecard. He highlighted BWH’s access to care indicators slightly increased this month, yet the hospital has been close to reaching the two hour target some weeks. There is no data for indicators 8-10 due to a National Research Corporation


software issue. For overall incidents of workplace violence, there have been 257 documented incidents, averaging nearly one incident per day. There were no questions or comments raised.

6.6 Resource Utilization & Audit Committee (RUAC) Highlights* Marg Dragan presented the RUAC Committee Highlights. She reported the Committee received three educational presentations: Procurement Guidelines, Cost per Weighted Case, and Absenteeism. Marg explained the presentations illustrated how the Procurement Guidelines create a lag in the purchasing process, the importance of coding, and how the hospital’s new absenteeism policy is creating positive results. Next, Marg noted the Facilities Report was included in the consent agenda and all hospital projects are tracking on time, including work at both sites being funded through the Ministry of Health’s Health Infrastructure Renewal and Exception Circumstances Funds. The Committee also received an update on the regional Hospital Information System project. The coding process was questioned. It was explained cases are coded upon discharge, the data is then sent to the Canadian Institute of Health Information (CIHI) for processing, before the results are shared on the scorecard.

6.7 Financial Statements*

Marg presented the financial statement for the period ended October 31, 2019 and noted a current deficit of $1.28M. She reported the year-end forecast is $300K with an expectation to balance. Marg explained the hospital received a large energy rebate which made a positive impact. The statements do not include additional funding of $2.1M received for ending hallway medicine, as the reporting requirements are not yet clear. BWH is not currently achieving its forecasted Quality Based Procedures (QBP), yet expects to achieve more QBP funding as the year continues. The hospital continues its focus on reducing expenses despite annual cost increases. Lastly, Marg noted the current ratio and adjusted working capital is positive.

Motion duly made, seconded and carried: to approve the Financial Statement for the period ended October 31, 2019 as presented.

6.8 Resource Utilization and Audit Committee Performance Scorecard*

Marg presented the scorecard and highlighted the following:

• ALC Rate - meets/exceeds target • Absenteeism – off target, yet trending in right direction • Cost per weighted case – not meeting target • QBP Financial Exposure – not meeting target, improvement expected over the year • Surplus deficit – not reaching target


• Working capital – meets/exceeds target • Capital budget – at 18% with projects underway

It was questioned whether a surge in patients could positively affect cost per weighted case. The answer was yes, if patients are moved through the system (high turn over). Clarity about the absenteeism rate was sought. Mike clarified the indicator is the number of days absent per quarter for full-time and permanent part-time staff.

6.9 Chief of Professional Staff Reports*

Dr. Haddad reported the Annual Physician Human Resources Report has been finalized by the Medical Advisory Committee and will be forwarded to the Board next month. Medical Affairs is working to recruit Emergency Department (ED) physicians and currently have physicians interested in the positions. Also, hospital management has approved funding for another student in the ED. In the meantime, ED medical staff have done a great job supporting the department, with assistance of Health Force Ontario physicians. Dr. Haddad then highlighted the upcoming Mini Medical School sessions being offered to build better connections with the community, and discussed changes to medical rounds to improve knowledge sharing. Lastly, he reported there was no feedback from the Professional Staff Association regarding the By-Law revisions. Brian shared appreciation with the teams leading the Mini Medical School sessions. Rachael Simon asked about the recruitment process and if there were any trends in what brings physicians to Sarnia. Dr. Haddad explained the recruitment process, and reported all interested applications are toured within the community when considering a position. It was noted employment opportunities for their partner is often a consideration for applicants.

6.10 Bluewater Health Foundation Report* Paul presented the Foundation Report on behalf of Kathy Alexander. There were no questions or comments.

7.0 POLICY FORMATION - None 8.0 OPEN FORUM

Paul reported he and some other Directors have been participating in the Board Chair at the Helm Series being offered through the Ontario Hospital Association. He then presented a Board Culture Model slide shared at a recent session, and encouraged the group to assess their fit in the framework. Brief discussion followed.

Bluewater Health – Open Meeting January 22, 2020 Page 7 ____________________________________________________________________________ 9.0 IN-CAMERA MEETING AGENDA ITEMS The In-Camera meeting agenda includes the following items:

• Ontario HealthTeams • Professional staff credentialing

10.0 ADJOURNMENT Motion duly made, seconded and carried: to adjourn the meeting at 6:33 pm. ________________________ ____________________________ Paul Wiersma Mike Lapaine Chair Secretary Board of Bluewater Health Board of Bluewater Health

________________________ Melissa Rondinelli Senior Executive Assistant, Recorder

Preparedness for Respiratory Illness Over the past few weeks, news of the COVID-19 (novel coronavirus) has dominated the media. Canada has seen 8 confirmed cases as of Friday, February 21, with 3 having been isolated in Ontario and 5 in BC (there is currently an additional “presumptive positive” case in BC, under investigation for where the virus was contracted during travel). All of the confirmed cases identified in Canada had recent travel to the affected areas of China and currently, no further transmission of the virus has been seen in Canada. While the risk to residents of Sarnia-Lambton remains low, Bluewater Health continues to prepare for the possibility of cases presenting here. The Infection Prevention and Control team has provided educational in-servicing to the Emergency Department (ED), Environmental Services, etc. Flow sheets for quick reference for possible COVID-19 cases presenting to ED were created and posted in ED (both Sarnia and Petrolia) and our pandemic stock was reviewed with TransForm. In accordance with a Ministry of Health recommendation, signs asking visitors/patients for self-identification of possible COVID-19 symptoms with travel history, were posted at entrances and patient registration points in both hospitals. Ontario recommended that any patient presenting with a cough and/or fever and travel history to Mainland China be managed with: hand hygiene; the use of airborne infection isolation rooms; masking the patient with a surgical mask when outside of an airborne infection isolation room; and the use of gloves, gowns, fit-tested and seal-check N95 respirators and eye protection by healthcare workers when entering the same room as the patient or when transporting or caring for the patient. Residential Withdrawal Management/Addictions Centre In January 2018, a temporary withdrawal management facility was opened at Bluewater Health. The current facility costs just over $1M to operate annually for seven beds. Since its opening, the unit has been very busy with 665 unique individuals cared for totaling over 1,400 admissions. Re-admissions are an expected part of the recovery process for some clients. In December 2015, Bluewater Health applied for $8.5M in funding from the Ministry of Health to open a larger (and permanent) Addictions Centre in the community. Bluewater Health has completed an extensive site analysis with a consultant and we are prepared to submit our recommended site selection. We are ready to renovate and open doors to a permanent facility. Bluewater Health, the City of Sarnia and other partners, are meeting with the Minister of Health in March 2020.

Report to the Board from President & CEO Mike Lapaine

February 2020

New Intranet Launched Communications & Public Affairs launched a new interactive, mobile-friendly and accessible intranet in January. The new platform allows users to access the site remotely, and from their personal devices, which was not possible with the former 10-year-old intranet. Other capability upgrades include an enhanced search feature and people finder (powered by the Human Resources Information System, updated nightly) and closed groups to allow improved and secure information sharing among unit and department staff. News is presented with a social media feel, with users able to follow those areas of most interest to them.

Well-being Activities Pet therapy is now being offered to staff. Many people find spending time with animals, and dogs in particular, restorative. The program will be offered once per month in the Fountain Lobby, with hopes to expand as more dogs are trained. One day per week, yoga instructor Lindsay Hayes of Bhavatu Yoga goes to a variety of areas to offer employees an opportunity to participate in ‘yoga’ consisting of guided meditation, conscious breathing and gentle movement. These activities are offered to employees to boost their resilience and well-being. Chiefs of Ontario Presentation Nikki George, Indigenous Patient Navigator, is presenting to the Chiefs of Ontario’s 14th Annual Health Forum February 25 to 27, along with Sara Plain, Health Director, Aamjiwnaang First Nation. The presentation, entitled “A Collaborative Approach to Improving Patient and Family Experiences” details the evolution of the relationship between Bluewater Health and the local Indigenous community, resulting in improved engagement and trust.

Transitional Regional Lead Visit I had the opportunity to meet with Bruce Lauckner, Transitional Regional Lead in West Ontario, on Friday, February 21 to discuss Bluewater Health’s priorities. He visited Charlotte Eleanor Englehart Hospital of Bluewater Health to understand the redevelopment needs at the Petrolia hospital. I also provided him with an overview of the Sarnia hospital. His visit concluded with a one-hour meeting with the Sarnia-Lambton Ontario Health Team Steering Committee.

InterRAI Expertise Paula Reaume-Zimmer, Integrated Vice President of Bluewater Health’s Mental Health & Addiction Services and the Canadian Mental Health Association Lambton Kent (CMHA Lambton Kent), was invited to Belgium on February 5 to present at a global healthcare conference called World interRAI 2020. Reaume-Zimmer spoke at the international conference about CMHA and Bluewater Health’s experience in using the interRAI standardized suite of mental health and addiction assessment tools and highlighted the Mental Health Engagement and Response Team (MHEART) as a “real world” example of the interRAI tool at work. In the first three months of operation, MHEART teams responded to 256 mental health related calls and determined that only 16 individuals required an Emergency Department (ED) visit. With the interRAI Emergency Screener having been completed prior to arrival at the ED, the MHEART team was able to provide the attending ED physician with a direct report, resulting in 31% of individuals receiving immediate care and 61% of individuals receiving care within two hours. All 16 individuals were admitted to hospital. County Council Kathy Alexander, Mark Braet, Treasurer, CEEH Foundation, and I presented at the Lambton County Council meeting on February 5. During the presentation we made an official funding request of $10 million over 10 years for three major Bluewater Health related projects:

1. Redesign of Sarnia-Lambton’s Cancer Care Program 2. Redevelopment of the Charlotte Eleanor Englehart Hospital of Bluewater Health 3. Development of the Residential Withdrawal Management Program/Addictions Centre Pre-Budget Advocacy On January 17, the Ontario Hospital Association presented to the Standing Committee on Finance and Economic Affairs, recommending a significant investment in hospitals in the 2020 Ontario Budget to maintain access to hospital care and address overcrowding. Since then, there has been a great deal of media coverage across the province, including a localized version of a provincial story, through CBC Windsor in which Bluewater Health was featured. CBC outlets often take a broad provincial story and try to localize it to their markets. To be included in a CBC Windsor story is no small feat as their local hospitals dominate their news, and I was pleased to have been asked for our viewpoint. The media coverage is here.

Health Quality Partners Progress The Health Quality Partners of Sarnia Lambton, a regional quality improvement initiative, has developed a systems approach to improving care delivery. The partners are a working group of healthcare providers, service organizations and a patient experience partner that have been developing pathways over the past few years to improve communications, standardize action plans and create effective transitions for patients. The partners have worked collaboratively on a common Quality Improvement Plan (QIP indicator to establish best practice and standards of care for patients with chronic disease and in particular, Chronic Obstructive Pulmonary Disease (COPD). A key initiative from this team is a pulmonary rehab referral including a standardized process and form. This enables patients to have the best evidenced care for improved quality of life as well as connections for a social network. This integrated care plan for COPD is the first step in collaborating as cross-sectoral partners for patients with chronic disease to ensure coordinated, consistent, equitable and appropriate access. This initiative allowed the group to meet its QIP target, improving from 18.5% readmission within 30 days (versus our peer comparator group’s rate of19.2%) to 16.35% (versus its goal of 16.4%). The Health Quality Partners have chosen to continue having a collaborative QIP with the primary focus for 2020-2021 being the earlier identification and documented assessment of palliative care needs among patients with progressive, life-limiting illness who would benefit from palliative care. Fundraising Bluewater Health Foundation Dream Home Lottery sales are ongoing and two of three earlybird draws have taken place. The final draw takes place March 25 in the Bluewater Health atrium. Please join us we celebrate 25 years of Dream Home!

https://www.cbc.ca/news/canada/windsor/windsor-regional-hospital-data-1.5438315

Charlotte Eleanor Englehart Hospital Foundation and Auxiliary The CEEH Auxiliary reports raising $900 through its Apple Pie fundraiser in December and an additional $400 through its 50/50 sales. The Valentine Chocolate Walk was held Thursday, February 13. It sold out and raised more than $450. The implementation of a debit machine and extended hours has improved sales at Charlotte’s Boutique. New products are also being introduced weekly. Through hospital TV rentals the Auxiliary also raises between $4,000 and $6,000 annually.

1

Governance and Nominating (G&N) Committee Highlights

February 6, 2020

Board Evaluation A review of the Board’s evaluation practices was undertaken in an effort to find efficiencies and avoid survey fatigue. The review revealed the current evaluation tools are required in accordance with governance best practice, Accreditation Standards and Board Policies. Several improvement opportunities were identified including but not limited to plans to reduce the length of the surveys, a new timeline to administer several surveys during the month of April, moving to an informal exit interview versus an electronic survey tool, continued focus on achieving a 100% completion rate, and continued monitoring of recommendations and action plans. Historical evaluation results demonstrate the Bluewater Health Board is a high-functioning Board. G&N Committee Composition The Committee discussed a recommendation raised through the last Committee Evaluation Survey to increase the size of the Committee. A decision was made to leave the G&N membership composition as is. Board Education/Orientation/Team Building Board members participated in the following educational offerings held this past month:

• Miller Thomson Health Industry Group - Coffee Talk - Board of Directors Series - Collaborative Governance in Ontario Health Teams: What Directors Need to Know

• Miller Thomson Health Industry Group - Coffee Talk: Health Industry Seminar Series - Legislative Update: Recent Changes in the Law You Need to Know

• Board Chair at the Helm Sessions offered by the Ontario Hospital Association Governance Centre of Excellence ( OHA GCE)

Material received relevant to these sessions has been uploaded to the Resources folder within Share File. The Committee learned there is considerable interest from Board members to participate in upcoming OHA GCE educational offerings. As a result, management is investigating the idea of bringing a governance expert to Sarnia. More details will follow and planning for future Board education will continue. If there is an item you wish to learn more about, you are encouraged to share your ideas. In addition to the above, the following items will be coming forward separately for Board discussion:

• Board Succession Planning • Ontario Health Team Update

Submitted by: Anthony Iafrate

Quality Committee of the Board Highlights

February 18, 2020

Diagnostic Services Program Report

Deirdre Shipley, Director of Diagnostic Services, and Dr. Almalki, Medical Director of Diagnostic Services, presented the program report. Deirdre provided an update on the designation of BWH as a high risk breast cancer screening site. This designation will provide access closer to home for patients designated a high risk of breast cancer in the Sarnia-Lambton area. Dr. Almalki provided an update on the analysis and implementation of the Thyroid Imaging Reporting and Data System (TI-RAD) in reducing the unnecessary biopsy of thyroid nodules. BWH is ahead of our peer comparators in implementing this system, and Cancer Care Ontario (CCO) has requested that all hospitals move forward in utilizing the TI-RAD.

Education of the Committee: What if We Could Measure the Amount of Harm Caused by Lacking in Training in Palliative

Care? The Magnitude on Nonverbal Communication Narrated by a Patient’s Family Member (Barbara Antunes)

The above article was provided as education for the committee. The article explored the positive impact that a palliative assessment can have on patients and families in the extension of quality of life from the patient perspective. It served as a powerful reminder that palliative care is quality of life care. View the article here.

Submitted by: Brian Knott, Chair

Personal Reflection

What if We Could Measure the Amount of HarmCaused by Lacking in Training in Palliative Care?

The Magnitude on Nonverbal CommunicationNarrated by a Patients’ Family Member

Barbara Antunes, MSc1–4

Dear ER Doctor: my mother is ill and I’m worried. Shehas been unwell for a long time but is becoming pro-

gressively worse. Her chronic advanced illness and multi-morbidities have robbed her of doing many things sheenjoyed and, in general, we feel her overall status is deteri-orating physically and mentally, for example, she is moreforgetful, it is dangerous for her to continue to drive. You’veordered multiple screening tests to determine several bio-logical parameters to try to understand what’s making mymother confused. You have also come out and ask mequestions to help you understand how long certain issueshave been ongoing and how I feel how she has been doing.I’ve known my mother for decades, you’ve known her for afew minutes, so it makes perfect sense to me that you areasking all these questions. It’s reassuring. Thank you.

We also want to know what’s causing my mother beingunwell and when you find out we really want you to fix it.Forever. Well, forever is the fantasy, as long as possible, thenew reality we are hoping for.

You are about to go back inside and I ask you one morequestion: ‘‘don’t you think my mother might benefit from apalliative care consult?’’ you look straight into my eyes andfrown your eyebrows replying ‘‘Oh not at all! We are cer-tainly not there yet!’’ My thoughts: ‘‘Not there yet? Not there,where? At the terminal stage of her advanced heart failure?And 30 years of diabetes? And a few years of respiratorydisease? Being hypocoagulated for 16 years ever since twosynthetic heart valves were placed? And if you don’t have theresults back, what makes you so certain to give that answer?What makes you so secure to dismiss referring her to thisservice?’’ I don’t know because you ran inside, and I neversaw you again. I suspect you may not know exactly whatpalliative care is. I’m scared you might have confused it withterminal care.1

Results have come back, and you and a couple more col-leagues have made the decision that my mother has criteria tobe admitted to hospital. She is unwell. There is no definitediagnosis, but besides being confused and having low O2

saturation levels, she is also developing a fever. Immediate

treatment and further testing are prescribed. As for me, I mustcall home and let my family know the difficult news.

Once my mother is settled, I am allowed in to be with herfor a bit. An internal medicine doctor is now assigned to mymother’s case. She comes and talks to me explaining therewill be exploratory testing to try to diagnose the problem andrule out certain diseases. After a 10-minute conversation, inwhich I express my worries, I ask the same question aboutpalliative care referral. The answer sounds deceivingly re-assuring, as I stare at a pair of frown eyebrows, and hear‘‘What?! No, we’re not there yet! I believe this is going to bea very short stay at the hospital. We’ll sort things out.’’ As Iam thinking to myself ‘‘Humm. sort what exactly? None ofmy mother’s conditions have a cure. So, do you mean man-age, maybe’’2 but you are very busy and run away. Twelvedays later she is discharged, stays at home for seven days, andis admitted again with a stroke.

The next hospital admission will be much longer, over onemonth. We are very scared. Thanks to an excellent youngmale nurse in the stroke unit who heard me, heard my con-cerns, and understood my anguish, later that day, I was able tothen talk to one of my mother’s doctors and ask for palliativecare. I cried the whole time during the 15-minute talk with thenurse and during the 15-minute talk with the doctor. I’venever had my mother this ill and I’ve never had to talk abouther wishes to medical staff by expressing them out loud. Iknow you see elderly people in worse conditions every day,but I don’t. Having to ask about resuscitation criteria isn’tsomething I ever thought I would hear myself say. Never hadI heard that combination of words coming out of my mouth. Ifelt desolation and fear. But you said ‘‘no, your mother doesnot have resuscitation criteria, so if an event occurs and herheart stops, we will not try to revive her.’’

I don’t really have words to describe the relief I felt, al-though part of me was horrified, as now there was a realconcrete possibility that my mother could die soon. I sobbed‘‘I’m so relieved that you are saying this to me because I cansee her deteriorating every day and she did not want to be bedbound, dependent. it’s good to know this.’’ And we shared a

1Center for Health Studies and Research, Coimbra, Portugal.2Centre for Health Technology and Services Research, Porto, Portugal.3Faculty of Medicine of University of Porto, Porto, Portugal.4King’s College London, Cicely Saunders Institute, London, United Kingdom.

JOURNAL OF PALLIATIVE MEDICINEVolume XX, Number XX, 2019ª Mary Ann Liebert, Inc.DOI: 10.1089/jpm.2019.0549

1

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moment of silence. Your face seemed to reveal that you wererelieved too. I became calmer. There is power in knowing thatno drastic measures would be taken, no breaking ribs whilepounding on her chest, no life support with a dozen tubes andneedles. Her wishes, her autonomy will be respected. I askedwhether this was written in her chart. It was. Being given thisinformation made me feel much more confident in all thehealth care professionals.

So that’s when I asked again ‘‘will you be referring mymother to palliative care? Regardless of the outcome?Whether she recovers a bit, a lot, or not at all? Because in myhead it makes sense to have them involved now and notlater.’’ This was a Friday afternoon. You replied, ‘‘if yourmother doesn’t respond by Monday morning, we will callpalliative care.’’ Finally. In total it took asking six doctors,two nurses, two ER visits, two hospital stays, two hospitalservices, and 23 days, for my mother to be assessed by adoctor with palliative care training, and even longer, to have afamily conference with two doctors and a social worker.

Dear ER Doctor and colleagues with no palliative caretraining: when a family member asks about ‘‘collaborationwith the palliative care team,’’ please stop and considerasking them about the reasons of such a serious question.Listen, maybe say you are assessing all possibilities and onceyou have all the results you will come back to discuss thingsfurther. This will give you time to read/ask/liase and discusswith the palliative care team about referral criteria. Then,come back to talk to the relative and either say you will notcall palliative care just now because you have discussed withthem and it may be too early, but, a note will be made aboutthe request. If the situation further deteriorates, collaborationwith the palliative care team is a strong possibility. Or maybesay you’ve spoken with the palliative care team and they willassess the patient. Further decisions will be taken from there.

It takes courage to ask for palliative care from the rela-tive’s perspective because it is admitting that things aregetting worse—and even if things are not getting worse, itcould still be important to involve the palliative care team—that a reality in which their loved one will no longer be a partof is fast approaching. But maybe it also takes courage for amedical specialist to call for palliative care collaborationbecause it means it is the realization of not being able to curethe patient or making them much better than when they firstgot to the ER.

Dear Doctor, please notice the word ‘‘collaboration,’’ inwhich a group of health care professionals comes together totry and present the best options—which serve the best interest

of the patient and their family—to make the most appropriatedecisions with the patient and their family. Should the patientrecover, the palliative care team will discharge them untilthey are needed again, like any other specialty. Does thisscenario not bring you some sort of comfort? Dear Doctor, Iknow who you are. You are a human being, you are a lot ofmy friends, you are a lot of health care professionals withwhom I’ve collaborated in the past, you are permanently intraining, you will never know everything, you are over-stretched, you occasionally make mistakes and you some-times feel helpless. Dear Doctor, when I look at you I don’tsee authority, I see someone with extreme life and deathresponsibilities.

Please give your local palliative care team enough time tocollaborate on different care plans depending on how yourpatient responds, liase earlier than what you normally wouldso that all resources and expertise are used to their full ca-pacity. You may have better outcomes calling them soonerrather than 48 hours before death. You will also be giving thepatient and their family time to process things and time tomake decisions.

Fifty-six days from first ER visit till discharge to a reha-bilitation unit. Ninety days from first ER visit till she died. Nohealth care professional recognized she was in the last threemonths of her life. None. This will sit with us for the rest ofour lives.

If we could measure the amount of harm caused by poorcommunication and lacking in palliative care training, whatwould we find?

References

1. Murray SA, Kendall M, Mitchell G, et al.: Palliative carefrom diagnosis to death. Br Med J 2017;356:j878.

2. Caswell G, Pollock K, Harwood R, Porock D: Commu-nication between family carers and health professionalsabout end-of-life care for older people in the acute hospitalsetting: A qualitative study. BMC Palliat Care 2015;14:35.

Address correspondence to:Barbara Antunes, MSc

Center for Health Studies and ResearchAvenida Dias da Silva, 165

Coimbra 3000-512Portugal

E-mail: [email protected]

2 PERSONAL REFLECTION

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FOI

Italics

*

ⱡ

OCT

18

NOV

18

DEC

18

JAN

19

FEB

19

MAR

19

APR

19

MAY

19

JUN

19

JUL

19

AUG

19

SEP

19

OCT

19

NOV

19

DEC

19Report

PeriodYTD

1 SarniaQIP/

P4R

25.7

hrs

20.3

hrs

<=16

hrs19.4 19.0 6.3 12.9 18.2 17.2 11.3 13.6 15.9 19.0 15.4 7.8 11.4 15.0 8.1

Jan -

Dec14.2 t

2 SarniaSP/

NOW

9.7

hrs

7.9

hrs ⱡ 2 hrs 6.8 6.4 3.3 5.1 6.5 6.2 4.1 4.6 5.3 6.5 4.8 3.5 4.2 4.7 3.5

Jan -

Dec4.9 t

SarniaHSAA/

P4R

10.8

hrs

9.3

hrs

<=8

hrs8.9 9.1 8.0 8.9 9.7 9.4 9.2 8.9 9.2 9.1 8.7 7.6 8.1 8.4 8.1

Jan -

Dec8.7 t

Petrolia 0 04.0

hrs* 3.8 4.3 3.6 4.0 3.6 4.1 4.3 4.6 4.3 4.4 4.7 3.8 3.7 4.2 3.8

Jan -

Dec4.1 t

Sarnia P4R33.3

hrs

26.0

hrs

<=20

hrs24.5 24.9 14.2 20.3 25.5 24.1 18.6 19.5 22.6 26.3 21.2 15.8 17.9 21.4 16.2

Jan-

Dec20.8 t

Petrolia 0 07.9

hrs* 6.3 6.8 7.9 5.0 6.1 7.3 10.3 6.1 7.9 11.6 7.5 5.1 8.6 8.9 10.9

Jan -

Dec7.6 t

5 0.0 n/a 4 0Jan-

Dec7 t

6 QIP 12.3% 12.1% 12.1%Jan-

Dec14.0% t

7 QIP 19.2% 18.5% 16.4%Jan-

Dec21.3% t

ED n/a 51.1% 52.0% 50.0 56.4 50.8 47.0 49.2 52.3 53.1 53.4 42.9 53.5 42.9 63.0 73.3 56.8 46.2Jan-

Dec53.1% t

Inpatient

Med/Surg65.7% 65.9% 67.0% 65.5 69.8 63.8 64.1 62.8 71.4 81.4 66.7 73.6 73.4 72.3 71.7 62.5 71.1 73.3

Jan-

Dec70.3% t

ED SP 82.9% 83.5% 85.0% 82.8 91.2 87.9 78.5 75.4 86.4 80.4 87.9 92.0 88.7 83.1 85.7 93.3 81.6 84.6Jan-

Dec84.4% t

Inpatient

Med/SurgQIP 56.3% 56.7% 58.0% 63.5 61.8 61.7 47.6 54.8 56.1 65.2 61.7 63.0 52.4 62.9 54.7 60.5 67.4 66.7

Jan-

Dec58.5% t

ED n/a 71.7% 73.1% 64.4 72.2 72.7 66.2 68.9 56.8 67.3 67.2 69.4 62.5 67.6 74.1 74.2 60.5 69.2Jan-

Dec66.8% t

All Inpatient n/a 74.7% 76.0% 80.9 79.2 87.1 76.0 76.7 88.0 83.1 83.9 73.9 87.2 85.7 81.9 77.6 90.2 72.2Jan-

Dec82.0% t

11 QIP n/a 81 * 16 17 15 35 33 41 27 28 18 22 8 17 28 46 32Jan-

Dec335 t

0

0

0

1 2 2 3

Was patient/family treated with kindness

Overall Incidents of Workplace Violence

Positive score = 9 - 10; Dec n size: 13

Strengthen Patient and Family-Centred Care

Readmission with 30 days for COPD

17.5 10.8OMHRS assessments: 30 days or less since last discharge from this

facility; excluding short-stay assessments

This is preliminary data and subject to change21.3 9.3

12.830-Day Mental Health Readmission 15.2

24.5

This indicator tracks the total number of incidents reported

organization wide. Collecting baseline

15.8

Meets/Exceeds Target

Meeting baseline but not meeting target

Performance not meeting baseline

Data Unavailable

Q3 18/19 Q4 18/19

Quality Committee Performance Scorecard

REF

. Q1 19/20

Masked due to n size <5

n size between 5 - 29

no established target

corporate target

Key Performance Indicators

Pee

r

Co

mp

arat

or

Des

ired

Tren

din

gQ2 19/20

TargetBaseline CommentsTrending

Quality Care - Assure the right care, in the right place, at the right time, by the right provider

0Average Time to Inpatient Bed

Improve access to care

0

0

Total High Severity Patient Safety Incidents

(Level 4 - 5) 00

Build sustainable partnerships and collaborations

Ingrain patient safety

3

4

90th Percentile Time to Inpatient Bed

90th Percentile ED Length of Stay for

Complex Patients

90th Percentile ED Wait Times

(Admitted Patients)

Q3 19/20YTD

Performance

UP

DA

TED

#

8

9

10

Focus on the experience of care and caring

Positive score = 9 - 10; Dec n size: 15

Positive score = Yes; Dec n size: 13

Positive score = Completely; Dec n size: 15

SP

Positive score = Yes, definitely; Dec n size: 13

Overall Rating of Experience

Positive score = Yes, definitely; Dec n size: 18

Inspired People - Advance our culture of kindness with an intention to learn, lead, collaborate and celebrate

Exceptional Relationships - Expand innovative partnerships and collaborations to improve experiences, services, transitions and community health

SP

Leaving hospital did patients receive

enough information

n size: 48 n size: 50

n size: 64 n size: 61

Exceptional Relationships - Expand innovative partnerships and collaborations to improve experiences, services, transitions and community

Strengthen Patient and Family-Centred Care

Quality Committee Key Performance Indicators


Emergency

Received Enough Information

Emergency

Exceptional Relationships - Expand innovative partnerships and collaborations to improve experiences, services, transitions and community


Improve Access to Care

63.9%BWH Target

72.0%

BWH Target

83.0%

BWH Target

61.6%71.9%

58.3%

Overall Rating of Experience Inpatient

Units

Received Enough Information

Inpatient Units

BWH Target

50.6%90.0%


8.59.2

8.3

11.010.0

7.36.5 6.3

7.8

9.68.2

11.7

6.4 6.0

3.1Bluewater Health Target 2hrs by October 2019

0

2

4

6

8

10

12

14

Oct17

Nov17

Dec17

Jan18

Feb18

Mar18

Apr18

May18

Jun18

Jul18

Aug18

Sep18

Oct18

Nov18

Dec18

Q3 17/18 Q4 17/18 Q1 18/19 Q2 18/19 Q3 18/19

Average Time to Inpatient Bed

27.0

28.2

25.7

30.1

28.4

26.0

21.7

21.7

24.7

29.0

26.6

38.1

24.5

23.9

14.0

13.8

10.1

7.0 7.8 10.2

7.7

7.8

7.4

6.0 9

.6 12.2

10.9

5.9 6.9

7.9

Bluewater Health Target <=20hrs

Peer Comparator 33.2 hrs

0

10

20

30

40

50

Oct17

Nov17

Dec17

Jan18

Feb18

Mar18

Apr18

May18

Jun18

Jul18

Aug18

Sep18

Oct18

Nov18

Dec18

Q3 17/18 Q4 17/18 Q1 18/19 Q2 18/19 Q3 18/19

90th Percentile ED Wait Times (Admitted Patients)

Sarnia Petrolia

Bluewater Health ED 50.6%Bluewater Health IP Target 72.0%

0

10

20

30

40

50

60

70

80

90

100

Oct17

Nov17

Dec17

Jan18

Feb18

Mar18

Apr18

May18

Jun18

Jul18

Aug18

Sep18

Oct18

Nov18


ED InpatientBluewater Health ED

Target 83.0%

Bluewater Health IP Target 61.6%

0

10

20

30

40

50

60

70

80

90

100

Oct17

Nov17

Dec17

Jan18

Feb18

Mar18

Apr18

May18

Jun18

Jul18

Aug18

Sep18

Oct18

Nov18

Leaving Hospital did Patient Receive Enough Information

ED Inpatient

Bluewater Health ED Target 68.6%

Bluewater Health IP Target 81.0%

0102030405060708090

100

Oct17

Nov17

Dec17

Jan18

Feb18

Mar18

Apr18

May18

Jun18

Jul18

Aug18

Sep18

Oct18

Nov18

Was Patient/Family Treated with Kindness

ED Inpatient

n s

ize:

923

n s

ize:

1032

n s

ize:

826

n s

ize:

1060

Bluewater Health Target 55.7%

0

200

400

600

800

1000

1200

0%

10%

20%

30%

40%

50%

60%

70%

2011 2013 2016 2018

Organization Promotes Staff Health/Wellness

n size Organization Promotes staff health/wellness

Leaving hospital did patients receive enough information (Inpatient)

TARGET 58.0%

Q4, Q1, Q2

CURRENT PERFORMANCE

57.2% Unverified- Open Data Sept.

PEER COMPARATOR

56.3%

QIP CHANGE INITIATIVES

• Collaborative standardized discharge strategy to improve the information shared with patients

• Patient Oriented Discharge Summary (PODS) • Patient Experience and Chief Nursing Executive Patient Rounding

Project • Integrated Discharge and Health Links Role

.

UPDATED CHANGE INITIATIVES

• Patient Discharge Summary (PoDS) for stroke and ‘generic’ population in place on Rehab. Compliance audit completed – 79% of pts had a PoDS

• PEP phone calls / surveys continue on Rehab. Positive results of patients saying they received enough information about symptoms or health problems to look out for after hospital (69% responded “Yes”)

• Patient rounding PDSA in process

IDENTIFIED CHALLENGES

• Staff engaging patient and family when completing the PoDs. • Consistency in identifying and updating the Expected Discharge Date (EDD) • Aligning the discharge summary with all interdisciplinary roles

40%

50%

60%

70%

80%

90%

Apr17

May17

Jun17

Jul17

Aug17

Sep17

Oct17

Nov17

Dec17

Jan18

Feb18

Mar18

Apr18

May18

Jun18

Jul18

Aug18

Sep18

Oct18

Nov18

Dec18

Jan19

Feb19

Mar19

Apr19

May19

Jun19

Jul19

Aug19

Sep19

Oct19

Nov19

Dec19

Q1 17/18 Q2 17/18 Q3 17/18 Q4 17/18 Q1 18/19 Q2 18/19 Q3 18/19 Q4 18/19 Q1 19/20 Q2 19/20 Q3 19/20

Perc

ent o

f Pos

itive

Res

pons

es

Improve Information on Discharge

Peer Comparator BWH Target BWH Performance

Readmission rates within 30 days Chronic Obstructive Pulmonary Disease (COPD)

TARGET

16.4% Q4, Q1, Q2

CURRENT PERFORMANCE

15.8 % Q2 19/20

PEER COMPARATOR

18.2%


• Collaborative QIP action plan for community stakeholders and partners

• Improve effectiveness and communication across transitions • Coordinated, consistent and appropriate access for patients • Referral to appropriate pulmonary rehabilitation program • Health care provider to receive timely information • Access to care provider


• New referral form for pulmonary rehabilitation being piloted • Increase in referrals to pulmonary rehab at family health teams and

community health centers. IDENTIFIED CHALLENGES Patients that are admitted or return with pneumonia and have a diagnosis of COPD are classified as readmissions for COPD within coding guidelines.

OPPORTUNITIES FOR IMPROVEMENT

• Consistent utilization of referral forms across the region • Enhanced data collection from community partners • Review data for each readmission to ensure it aligns with the

definition from health records

0%

5%

10%

15%

20%

25%

30%

Q3 16/17 Q4 16/17 Q1 17/18 Q2 17/18 Q3 17/18 Q4 17/18 Q1 18/19 Q2 18/19 Q3 18/19 Q4 18/19 Q1 19/20 Q2 19/20

COPD Readmission


Readmission rates within 30 days for patients with mental illness or an addiction

TARGET 12.1%

Q4,Q1,Q2

CURRENT PERFORMANCE

15.2 %

Unverified Q2

PEER COMPARATOR

12.9%


• Improve collaborative treatment planning and handover with community partners

• Utilize Residential Withdrawal Management (RWM) Beds • Improve access to urgent outpatient psychiatric appointments to avoid

admissions IDENTIFIED CHALLENGES

• Evening and weekend hour’s availability and access to community MH resources.

• Urgent access appointments • Psychiatry recruitment • OTN initiative being investigated to utilize OTN to decrease wait times • Pathways currently do not align- initiative to align all pathways no matter

where the patient presents


• OTN opportunities have increased for outreach clinics- assessment done in the PCP office • MHEART pathway standardization discussion for Child & Youth- in collaboration with St. Clair Child

and Youth- Meeting completed and will be standardized for youth population and they will have access to the shared appointments.

• Access Open Minds-Community collaboration for services Child & Youth- center selected, dates unknown of opening.

• Health IM for community police responder training- BWH PAN staff will have the same education- integration work with police

• Physician Assistant starting in February

Change Concepts being investigated: • CEEH OTN for ED patients assessment with PAN • Investigating a pathway for offering as a disposition for patients presenting to ED- a way of an

urgent or non-urgent way to access psychiatry.

Peer Comparator, 12.9%

BWH Target, 12.1%

0%

5%

10%

15%

20%

25%

Q4 16/17 Q1 17/18 Q2 17/18 Q3 17/18 Q4 17/18 Q1 18/19 Q2 18/19 Q3 18/19 Q4 18/19 Q1 19/20 Q2 19/20

30 Day Mental Health Readmission


90th Percentile Time to Inpatient Bed TARGET 16 hrs.

Q4, Q1,Q2, Q3

CURRENT PERFORMANCE (YTD)

14.2 hrs. (Jan-Dec.)

PEER COMPARATOR

25.8


• Collaborative planning team for improved transitions of care and time to inpatient bed through the No One Waits (NOW) collaborative hospital initiative

• Concerted effort on cultural changes within the organization for improved access for our patients


Summary of activities completed to December 2019 reviewed and new activities to align with drivers are being identified through consultation with key stakeholders.

Key activities- Driver Diagram for a pathway of identifying goals/initiatives and targets; Scientific calculation of conservable days & ALOS/ELOS- how long does a specific patient stay in hospital for specific diagnosis; Identifying P4R initiatives and flex culture recommendations. Concentrated effort on flex plan when beds are full will be the next focus.

IDENTIFIED CHALLENGES

• Estimated Date of Discharge (EDD), Actual Length of Stay and Expected Length of Stay (ALOS/ELOS)

• Discharge Practices • Bed Alignment using Simulation software • Admission Criteria for Clinical areas • Embedding a ‘flex’ culture to meet demand

0

5

10

15

20

25

30

35

Feb-

17

Mar

-17

Apr-

17

May

-17

Jun-

17

Jul-1

7

Aug-

17

Sep-

17

Oct

-17

Nov

-17

Dec-

17

Jan-

18

Feb-

18

Mar

-18

Apr-

18

May

-18

Jun-

18

Jul-1

8

Aug-

18

Sep-

18

Oct

-18

Nov

-18

Dec-

18

Jan-

19

Feb-

19

Mar

-19

Apr-

19

May

-19

Jun-

19

Jul-1

9

Aug-

19

Sep-

19

Oct

-19

Nov

-19

Dec-

19

Hour

s

Decrease Time to Inpatient Bed

Ontario High Volume Community Hospitals BWH Target BWH Performance

Overall Incidents of Workplace Violence TARGET

Collecting Baseline Q4,Q1,Q2,Q3

CURRENT PERFORMANCE

335

PEER COMPARATOR

n/a


• Education and training for workplace violence prevention for staff working in high-risk environments

• Improve awareness of workplace violence by providing quarterly reports and recommendations to improve

• Continual focus on building a reporting culture

DATA

WPV- e-learning 74% completed

237 staff trained in Non Violent Crisis Intervention


• Workplace Violence Prevention Team to started in January (subcommittee of Joint Occupational Health and Safety to review WPV incidents and strategies)

• Tips of the Month for Workplace Violence Prevention shared Bi-Monthly • CCCOG – Individual care plans for patients with multiple incidents • Mandatory training for Patient and Family-centered Care for all Mental Health staff to

improve communication during difficult discussions in an effort to reduce incidents of WPV. IDENTIFIED CHALLENGES

• Increase the number of people trained in NVCI and GPA in high risk identified areas • Collect all workplace violence data in RL6 to enhance data collection and analysis. • Workplace Violence policies being reviewed and updated. • Ongoing follow up with workers/departments when a SSC/WPV report is completed using

the wrong form.

05

101520253035404550

Num

ber o

f Wor

kpla

ce V

iole

nce

Inci

dent

s


1

Bluewater Health Briefing Note

Name of Committee: Board of Directors Date of Meeting: February 26, 2020 Submitted by: Linda Schaefer Subject: Quality Improvement Plan (QIP) Purpose of Report: Information Input Approval

Situation Under the Excellent Care for All Act (ECFAA), hospitals are required to develop an annual, publically reported Quality Improvement Plan (QIP) to commit to a continuous improvement process for all the patients served and for our community health. Bluewater Health (BWH) is required to submit a QIP on March 31, 2020 approved by the Board and CEO.

Background In developing the QIP, we are required to engage patients, key stakeholders and Board members. At BWH, a 2% executive compensation is linked to performance targets within the QIP pending a review of progress by the Board of Directors.

The indicators that have been set out by Health Quality Ontario (HQO), soon to be known as Ontario Health, were brought forward to the Quality Committee of the Board on January 13. As well these indicators have been vetted and discussed with various committees, and teams through the hospital, including the Patient Experience Partners Council. HQO has significantly reduced the number of indicators to allow for more focused corporate initiatives.

Analysis Within the 2020/2021 QIP, indicators chosen align with the following guidelines:

• Future OHT goals, directions and populations.• Hospital collaborative focus• Opportunities for system-wide expansion• Coordination across sectors of care• Improved patient outcomes

Targets were set based on a methodology that included the following considerations: • Current and past performance and trends• Peer comparators (where available)• The level of control or flexibility our hospital has over resource allocation• Other activities, apart from the hospital that are addressing particular issues

X X X

2

Quality Dimension

2020/2021 QIP Indicators Proposed Current Performance

2020-2021 Target Proposed

Timely Primary Indicator Time to inpatient bed (MANDATORY) - 90th percentile in

hrs.

14.2 hrs. 13.9 hrs.

Supporting Indicators 1. Conservable Bed Days- Acute Length of Stay/Expected Length of Stay –Target TBD2. Alternate Level of Care (ALC)- Target 13.3%3. Patient Experience- Leaving hospital received enough discharge information or similar

question. Target- Collecting baseline with an internal phone survey process4. Repeat Unscheduled Visits to Emergency Department (ED) within 30 days for Mental Health

Condition- Target 13.8%Safe Number of workplace violence incidents (MANDATORY) 335 Collecting Baseline

As per ministry recommendation

Effective Documented assessment of palliative care needs among patients identified to benefit from palliative care

No Baseline Measure

Collecting Baseline

Recommendation

To approve the indicators and targets move forward as presented.

Quality Improvement Program 2020/2021

Bluewater Health Hospital

The following document contains the current performance, target setting, and target justification process for each Quality Improvement Plan Program (QIP) Indicator.

Linda Schaefer [email protected]

Bluewater Health Target Setting

Primary Indicator- 90th Percentile Time to Inpatient Bed

This indicator measures the time interval between the decision to admit date/time as determined by the main service provider and the date/time the patient left the Emergency Department (ED) for admission to an inpatient bed or Operating Room (OR). The 90th percentile of this indicator represents the maximum amount of time nine out of 10 patients spend in an ED waiting for an inpatient bed. Most patients spend less time, while one out of 10 patients will spend more time.

2018

Q4

17/1

8 Jan-18 24.6 Feb-18 22.4 Mar-18 18.9

Q1

18/1

9 Apr-18 16.8 May-18 16.6 Jun-18 18.9

Q2

18/1

9 Jul-18 23.4 Aug-18 20.2 Sep-18 29.3

Q3

18/1

9 Oct-18 19.4 Nov-18 19.0 Dec-18 6.3

2019

Q4

18/1

9 Jan-19 12.9 Feb-19 18.2 Mar-19 17.2

Q1

19/2

0 Apr-19 11.3 May-19 13.6 Jun-19 15.9

Q2

19/2

0 Jul-19 19.0 Aug-19 15.4 Sep-19 8.1

Q3

19/2

0 Oct-19 11.4 Nov-19 15.0 Dec-19 8.1

Current Performance

14.2 hrs.

Current Target

16.0 hrs.

Proposed Target

13.9 hrs.

Target Justification:

Target is set as a relative 2 % improvement from our performance last year. This is 14 % improvement over last year’s set target.

Bluewater Health Results

0

5

10

15

20

25

30

35


Key Performance Indicator

TrendStandard/Goal

Surpassed (>5%)

Close (Within 5%)

Fair (<5%)

Improving X

No Change

Deteriorating

Ask these questions:

1. What have been our trends in performance over time?

Trending remains variable with an overall improvement in the number of hours. Month by month results are still variable.

2. What factors support or hinder improving performances?

Support – Collaborative hospital focus, resources dedicated and concerted effort Hinder – culture, community resources for patients ability to flex beds

3. Peer comparator or LHIN target? Peer Comparator – 25.7

4.

How much control or flexibility does our hospital have over resource allocation? (What improvement strategies are upcoming that are going to effect the measures?

Collaborative hospital initiative to improve the time for all care transitions which will impact the time to inpatient bed for admitted ED patients by creating improved access. Focus in 2020 will be the flex plan and conservable bed days.

5. Apart from the hospital, what other activities, if any, are addressing particular issues?

Health Quality Partner Community group work, ALC work, Discharge Strategy LHIN

How will it be linked to effort?

Past or current effort OR

To influence future effort required

How will we define success?

Meeting a target OR

Making meaningful progress towards a target

Current Performance

14.2 hrs.

Current Target

16 hrs.

Target

13.9 hrs.

Pref

erre

d Tr

endi

ng

Supporting Indicators for Time to Inpatient Bed

1. Acute Length of Stay (ALOS)2. Alternate Level of Care Rate (ALC)3. Repeat Unscheduled Visits to Emergency Department (ED) within 30 days for Mental Health Condition4. Patient Experience- Leaving hospital received enough discharge information

Indicator Current Performance

Target How we will get there

Conservable Bed Days

Acute Length of Stay (ALOS) / Expected Length of Stay (ELOS)

TBD TBD • Work will be done to improveconservable days.

• Acute Length of Stay (ALOS)compared to the Expected Length ofStay (ELOS)

• Meeting the Expected Day ofDischarge (EDD)

Alternate Level of Care Rate (ALC)

The rate at which patients who have been designated ALC occupy inpatient beds. ALC Rate = Total number of ALC Days in a given period/Total number of inpatient days in the same time period ×100%

13.6% 13.6%

• Early assessment of dischargeneeds.

• Complex discharge rounds• Home First strategy• Discharge Strategy

Repeat Unscheduled Visits to Emergency Department (ED) within 30 days for Mental Health Condition This indicator represents the percent of repeat unscheduled emergency visits to Ontario hospitals following an emergency visit for a mental health condition. A visit is counted as a repeat visit if it is for either a mental health or substance abuse condition, and occurs within 30 days of an index visit for a mental health condition. This indicator is presented as a proportion of all unscheduled mental health emergency visits. (age 12-25)

14.1 % To be

verified

13.8 % (subject to

change based on current

state verificaion)

How we will get there: • Community collaboration• Community program integration

with BWH• Physician Assistant in MH working

with high user population

Patient Experience- Leaving hospital received enough discharge information

No baseline CB

BWH will be collecting internal data for this question within our patient and family phone call survey. This will be aligned with work within the NOW project so that the projects we are doing are assessed by a survey to assess for the patient and family experience. Questions will be determined by a working group over the next two months.



This indicator measures the number of reported workplace violence incidents by hospital workers as defined by Occupational Health and Safety Act (OHSA). Workplace Violence is defined as the exercise of physical force by a person against a worker, in a workplace, that causes or could cause physical injury to the worker. It also includes an:

• Attempt to exercise physical force against a worker in a workplace, that could cause physical injury to theworker; and a

• Statement or behavior that a worker could reasonably interpret as a threat to exercise physical force against theworker in a workplace, that could cause physical injury to the worker

2018

Q1

18/1

9 Apr-18 4 May-18 10 Jun-18 6

Q2

18/1

9 Jul-18 5 Aug-18 3 Sep-18 5

Q3

18/1

9 Oct-18 16 Nov-18 17 Dec-18 15

Q4

18/1

9 Jan-19 35 Feb-19 33 Mar-19 41

2019

Q1

19/2

0 Apr-19 27 May-19 28 Jun-19 18

Q2

19/2

0 Jul-19 22 Aug-19 8 Sep-19 17

Q3

19/2

0 Oct-19 28 Nov-19 46 Dec-19 33

Current Performance Jan – Dec 2019

335229 = Q4, Q1 & Q2

Current Target

No Target Collecting Baseline

Proposed Target

No Target Collecting Baseline

Target Justification: We know that there were 336 incidents reported in RL6- of those 318 were deemed WPV incidents according to the Ontario Health and Safety Act. We would like to: 1. Ensure going forward that all cases not deemed

WPV according to the act are moved in the system so that all data will be similar.

Bluewater Health Results

05

101520253035404550



TrendStandard/Goal

Surpassed (>5%)

Close (Within 5%)

Fair (<5%)

Improving N/A

Increased number of reports has been seen. No Change

Deteriorating



Trending Increased number of reports has been trending since the implementation of the WPV risk report in RL6.


Support – speak up culture promotion, new sub-committee to help with reviewing incidents, making recommendations and defining the threshold for a needed care plan for an individual patient that has multiple incidents. Hinder – time to complete the form for individuals, assuming the present culture is the norm, resources for education

3. Peer comparator or LHIN target? There is no peer comparator results.

4.


Resources for education has always been a challenge.


N/A

How will it be linked to effort? Past or current effort

OR

To influence future effort required

How will we define success?

Meeting a target OR

Making meaningful progress towards a target

Current Performance

335 RL6

Current TargetNo Target Collecting

Baseline

TargetNo Target Collecting

Baseline

Documented assessment of palliative care needs among patients with progressive, life-limiting illness who were identified to benefit from palliative care.

Definition: This indicator measures the proportion of hospitalized patients with a progressive, life limiting illness are identified to benefit from palliative care and subsequently, within their episode of care, have their palliative care needs assessed using comprehensive and holistic assessment. Why? Early identification can improve quality of life by ensuring pain and symptom management as well as relief of burdens by employing active and person centered decision making.



Trending No current measurement


Support – Collaborative QIP indicator. Current palliative resources in community Hinder - Resources for increased needs generated by assessment evaluations.

3. Peer comparator or LHIN target? Peer Comparator – N/A LHIN Comparator – N/A

4.


Indicator initiatives will use current palliative resources supported by the palliative physicians.


Cross sector QIP initiatives.

BWH will be working collaboratively on this QIP indicator with our cross sector partners in the Health Quality Partners Committee.

Target Justification: Currently BWH does not have a measurement that they are collecting to obtain this information. This year will be focused on assessment of current practice, implementing pilot initiatives and collecting baseline data.

Resource Utilization and Audit Committee (RU&AC)

February 13, 2020 Highlights

Wellness Report The Committee received a presentation on BWH’s commitment to well-being in the work place and why it is important. It was noted provincially one in five workers suffer mental illness. The presentation highlighted the efforts being made for staff to speak with their Managers about mental health; the current state; challenges; and opportunities, in particular, education and training. It was noted well-being is a complex combination of a person’s physicial, mental, emotional and social health factors which is linked to happiness and life satisfcation. The Well-Being Advisory Team will follow the Excellence Canada Framework to ensure BWH is meeting the National Standard. The 2019 Mental Health and Well-Being Survey Results were shared with the Committee. The results showed improvements to the Culture of Kindness; Safety; Trust; Health and Wellness mental health indicators. The Committee learned staff are coming together sooner to help each other. Analysis of the Loans and Investments The Committee received an update on the status of the bank loans and Englehart estate investments. 2020-21 – Targets for RUAC Indicators The Committee was informed the 2020-21 RUAC performance indicator targets will be brought to the March meeting for approval to align with the Quality Committee of the Board approval process. The Committee received updates on the following items: - e-VOLVE (Hospital Information System) - Ontario Health Teams In addition, the following items will be coming forward separately for Board approval/discussion: - 2020-21 – Annual Human Resources Plan - 2020-21 – Annual Physician Human Resources Plan - Hospital Service Accountability Amending Agreement and Multi-Sector Accountability

Amending Agreement - Chief Financial Officer Certificate - Balanced Scorecard - Monthly Financial Statement Submitted by: Marg Dragan Chair, Resource Utilization and Audit Committee

1


Name of Committee: Board of Directors Date of Meeting: February 26, 2020 Submitted by: Marlene Kerwin Subject: Hospital Accountability Amending Agreement and Multi-

Service Accountability Amending Agreement Purpose of Report: Information Input Approval

Situation

The Ministry of Health requires Board approved accountability agreements between the Erie St. Clair Local Health Integration Network (ESC LHIN) and Bluewater Health (BWH) to allow for the continued flow of funding for hospital operations and community sector programs managed through the hospital.

Background

Each year, the Board is asked to approve the Hospital Service Accountability Agreement (HSAA) and the Multi-Service Accountability Agreement (M-SAA). BWH received HSAA and M-SAA Amending Agreements from the ESC LHIN on February 12, 2020. The Amending Agreements are to be signed and returned to the ESC LHIN by March 15, 2020.

Analysis

The requested approval of the Hospital Service Accountability Agreement (HSAA) Amending Agreement is an extension for the period of March 31, 2020 to June 30, 2020 (See Appendix A). The HSAA Amending Agreement does not include any funding schedules. The major amendments are transitions in language (i.e. “LHIN” references have been replaced with “Funder”) to align with government structural changes. The Agreement is an extension to June 30, 2020. As such, it is anticipated that a revised HSAA with supporting funding schedules and performance targets will be made available before then.

The Board is also asked to approve a new Multi-Service Accountability Agreement (M-SAA) Amending Agreement for the period of March 31, 2020 to March 31, 2022 (See Appendix B), to allow for the continued flow of funding for community sector programs managed through the hospital. The M-SAA Amending Agreement does not include any funding schedules. Similar to the HSAA, the major amendments to the M-SAA are transitions in language to align with government structural changes. A revised M-SAA with supporting funding schedules is anticipated before June 30, 2020 that will include supporting funding schedules.

X

2

Recommendation The Board authorizes:

• the Board Chair and CEO to sign the HSAA Amending Agreement between the ESC LHIN and BWH effective March 31, 2020 to June 30, 2020; and

• the Board Chair and the CEO to sign the M-SAA between the ESC LHIN and BWH effective March 31, 2020 to June 30, 2020

180 Riverview Drive Chatham, ON N7M 5Z8 Tel: 519 351-5677 • Fax: 519 351-9672 Toll Free: 1 866 231-5446 www.eriestclairlhin.on.ca

Delivered by email

February 12, 2020

Mr. Mike Lapaine President & Chief Executive Officer Bluewater Health 89 Norman Street Sarnia, ON N7T 6S3

Dear Mr. Lapaine,

As the Interim Chief Executive Officer of Ontario Health indicated on November 14, 2019, it is expected that your 2020/21 Hospital Service Accountability Agreement (HSAA) will be with Ontario Health. This letter provides further information on the process, timeline and plan going forward.

Attached please find a Notice of Amendment and an Amending Agreement with respect to your HSAA to extend it to June 30, 2020 with minimal amendments to reflect legislative changes and to simplify the anticipated transition of the HSAA to Ontario Health from your LHIN. You are asked to have the Amending Agreement duly signed on behalf of your hospital and returned to Huy Vu, Performance Analyst, at [email protected] no later than March 15, 2020. While your HSAA will remain with the LHIN, as of March 31, 2020, it is our expectation that your HSAA will be transferred to Ontario Health by Minister’s transfer order. The three-month extension will help to enable changes to the HSAA that will address the Ministry of Health and Ontario Health priorities.

Ontario Health and the LHINs are working closely to effect a smooth transition process and have consulted with the Ontario Hospital Association. Until you are notified otherwise, the Erie St. Clair Local Health Integration Network and your usual LHIN contact will be responsible for the administration of your HSAA. Please continue to direct all communications to that person.

Yours sincerely,

Bruce Lauckner, Transitional Regional Lead (West and CEO of Erie St. Clair, South West, Hamilton Niagara Haldimand Brant and Waterloo Wellington LHINs) Ontario Health

cc. Matthew Anderson, CEO, Ontario Health

Attach (2): (1) Notice of Amendment and (2) HSAA Amending Agreement

Appendix A

mailto:[email protected]


Delivered by email

February 12, 2020

Dear Health Service Provider, LHSIA S.20 NOTICE

The Local Health System Integration Act, 2006 requires the Erie St. Clair Local Health Integration Network (ESC LHIN) to notify a health service provider when the LHIN proposes to enter into, or amend, a service accountability agreement with that health service provider.

The LHIN hereby gives notice that it proposes to amend one or more existing service accountability agreements currently in effect between the LHIN and your organization, on or before March 31, 2020.

Should you have any questions, please contact Erin Link, Director, Performance & Accountability, at [email protected].

Sincerely yours,


Cc: Health Service Provider Board Chair Nicole Robinson, Vice President, Performance and Accountability


HSAA Amending Agreement – Amendments, Extending Term and Schedules to June 30, 2020 Page 1

HSAA AMENDING AGREEMENT

THIS AMENDING AGREEMENT (this “Agreement”) is made as of the 31st day of

March, 2020.

B E T W E E N:

ERIE ST. CLAIR LOCAL HEALTH INTEGRATION NETWORK (the “LHIN”)

AND

BLUEWATER HEALTH (the “Hospital”)

WHEREAS the LHIN and the Hospital (together the “Parties”) entered into a hospital service accountability agreement that took effect April 1, 2018 (the “HSAA”);

AND WHEREAS the Parties wish to amend the HSAA in the manner set out in this Agreement;

NOW THEREFORE in consideration of mutual promises and agreements contained in this Agreement and other good and valuable consideration, the Parties agree as follows:

1.0 Definitions. Except as otherwise defined in this Agreement, all terms shall have the meaning ascribed to them in the HSAA. References in this Agreement to the HSAA mean the HSAA as amended.

2.0 Amendments.

2.1 Agreed Amendments. The HSAA is amended as follows.

a) All references to “LHIN” are deleted and replaced with “Funder”, withthe exception of the defined term “LHIN” as a party to theagreement, and section 7.1.1 “will be aligned with the LHIN’s currentintegrated health service plan” which remain unamended.

b) The first four paragraphs of the part of the HSAA entitled“Background” are deleted and replaced with the following.


“This service accountability agreement is entered into pursuant to the Local Health System Integration Act, 2006, with the expectation that it will be transferred by means of a transfer order issued by the Minister of Health under the Connecting Care Act, 2019 (the “CCA”), from the LHIN as funder to Ontario Health, which is a Crown agency which, pursuant to the CCA, has the power to provide funding to health service providers and integrated care delivery systems in respect of health services.

The Hospital and the Funder are committed to working

together, and with others, to achieve evolving provincial

priorities including building a connected and sustainable

health care system centred around the needs of patients,

their families and their caregivers.

In this context, the Hospital and the Funder agree that the Funder will provide funding to the Hospital on the terms and conditions set out in this Agreement to enable the provision of services to the health system by the Hospital.”

c) All references to “LHSIA” are deleted and replaced with “theEnabling Legislation”, with the exception of the defined term “LHSIA”in section 1.1, and section 7.1.1 in reference to the integrated healthservice plan as defined in LHSIA which remains unamended.

d) The defined term “MOHLTC” and its definition are deleted andreplaced with the following.

“Ministry means, as the context requires, the Minister or the Ministry of Health and Long-Term Care or such other ministry as may be designated in accordance with Applicable Law as the ministry responsible in relation to the relevant matter or the Minister of that ministry, as the context requires;”.

e) All references to “MOHLTC” are deleted and replaced with“Ministry”.

In addition to the foregoing, the HSAA is further amended as follows.

f) In section 1.1, the definition of “Accountability Agreement” isamended by deleting “, currently referred to as the “Ministry LHINAccountability Agreement””.


g) In section 1.1, the definition of “Applicable Policy” is amended bydeleting “Local Health Integration Network” and replacing it with“local health integration networks”.

h) In section 1.1, the definition of “Digital Health” is deleted andreplaced with:

“Digital Health means the coordinated use of digital technologies toelectronically integrate points of care and transform the way care isdelivered, in order to improve the quality, access, productivity andsustainability of the healthcare system;”.

i) In section 1.1, the definition of “Digital Health Board (DBH)” isdeleted.

j) In section 1.1, the definition of “Indemnified Parties” is amended bydeleting “her Majesty the Queen in Right of Ontario and herMinisters,” and replacing it with “Her Majesty the Queen in right ofOntario and Her Ministers,”.

k) The following definitions are added to section 1.1:

“CCA means the Connecting Care Act, 2019, and the regulations under it, as it and they may be amended from time to time;”

Article 1. “Enabling Legislation before the date a Transfer

Order takes effect means LHSIA, and after the date a

Transfer Order takes effect means the CCA;”

“Funder before the date a Transfer Order takes effect means the LHIN, and after the date a Transfer Order takes effect means Ontario Health;”

“Minister means such minister of the Crown as may be designated as the responsible minister in relation to this Agreement or in relation to any subject matter under this Agreement, as the case may be, in accordance with the Executive Council Act, as amended;”

“Ontario Health means the corporation without share capital under the name Ontario Health as continued under the CCA;”

Article 2. “Transfer Order means a transfer order issued pursuant to subsection 40(1) of the CCA transferring this


Agreement from the LHIN to Ontario Health;”.

l) In section 2.1, “section 20(1) of” is deleted.

m) In section 2.2, “March 31, 2020” is deleted and replaced with “June30, 2020”.

n) In section 3.5, “Guide to Requirements and Obligations Pertainingto French Language Services” is deleted and replaced with “Guideto Requirements and Obligations Relating to French LanguageServices”.

o) In section 3.7(a), “annual” is deleted.

p) In section 3.7, the last paragraph is deleted and replaced with:

“Despite Article 9 of this Agreement, to the extent that the Hospitalis unable to comply, or anticipates it will be unable to comply withthe foregoing without adversely impacting its ability to perform itsother obligations under this Agreement, the Hospital, inconsultation with the Funder, may refer the matter to the Ministryfor resolution.”

q) In section 5.1.3 and section 5.3, all references to “section 7.2.7”are deleted and replaced with “section 7.2.6”:

r) The first sentence of the last paragraph of section 7.1.1 is deletedand replaced with:

“The Hospital’s Planning Submission will be aligned with theLHIN’s current integrated health service plan, as defined in LHSIA,if applicable, and will reflect the Funder’s priorities and initiatives.”

s) In section 7.2, “and 8.9” is deleted, “,” after “8.7” is deleted, and“and” is added before the number “8.8”.

t) In section 7.2.1 “whether within or outside of the geographic areaof the LHIN” is deleted and replaced with “anywhere”.

u) In sections 7.2.2, and 8.4.1 , “local” is deleted.

v) In sections 7.2.4, 7.2.5, 7.2.7(d) and 7.3.2, the words “section 27of” are deleted.

w) In section 7.2.4, “section 25 or section 26 of” is deleted.


x) In section 7.2.4(b), “or the Minister” is added before the words “willnot issue”.

y) In section 7.2.5, “or the Minister, as applicable” is added before thewords “with notice of integration”.

z) Section 7.2.6 is deleted.

aa) In section 7.2.7(a) (now section 7.2.6(a)), “, or integrated care delivery systems (“Other Providers”)” is added after “health service providers”.

bb) In section 7.2.7 (b) and (c) (now section 7.2.6(b) and (c)) “health service provider or providers, as the case may be, has or” is deleted and replaced with “Other Providers”.

cc) In section 7.2.7(c) (now section 7.2.6(c)) “other health service providers” is deleted and replaced with “of the Other Providers”.

dd) In section 7.3.2, “or Minister” is added before the word “under”.

ee) In section 8.1, “its local” is deleted and replaced with “the”.

ff) Section 8.9 is deleted.

gg) In section 11.3, “his or her” is deleted and replaced with “their”.

hh) In section 11.4, “sections 21 and 22 of” is deleted.

ii) In section 15.1.1(a), “Local Health Integration Network” is deletedtwice.

jj) In section 16.4, “of the Local Health Integration Networks or to the MOHLTC” is deleted and replaced with “agencies or ministries of Her Majesty the Queen in right of Ontario and as otherwise directed by the Ministry.”

kk) In section 16.7, “8.9 (LHIN Public Meetings),” is deleted.

ll) In section 16.7, “8.10” is deleted and replaced with “8.9” and “8.11” is deleted and replaced with “8.10”.

mm) The titles LHIN “Chair” and LHIN “CEO” are removed on the signature page.

2.2 Term. This Agreement and the HSAA will expire on June 30, 2020.


2.3 Schedules. The Schedules in effect on March 31, 2020 shall remain in effect until June 30, 2020, or until such other time as may be agreed to by Parties.

3.0 Effective Date. The amendments set out in Article 2 shall take effect on March 31, 2020. All other terms of the HSAA shall remain in full force and effect.

4.0 Appendix 1. Appendix 1 is the HSAA, incorporating all of the amendments set out in section 2.1 above, that is effective March 31, 2020.

5.0 Entire Agreement. This Agreement constitutes the entire agreement between the Parties with respect to the subject matter contained in this Agreement and supersedes all prior oral or written representations and agreements.

-SIGNATURE PAGE FOLLOWS -


IN WITNESS WHEREOF the Parties have executed this Agreement on the dates set out below.

ERIE ST. CLAIR LOCAL HEALTH INTEGRATION NETWORK

By:

________________________________ _______________________________

Nicole Robinson, Date VP-Integrated Delivery Systems

And by:

_______________________________ _______________________________

Bruce Lauckner, Chief Executive Officer Date

BLUEWATER HEALTH

By:

________________________________ ______________________________

Board Chair Date

I sign as a representative of the Hospital, not in my personal capacity, and I represent that I have authority to bind the Hospital.

And by:

________________________________ ______________________________

Mike Lapaine, CEO Date

I sign as a representative of the Hospital, not in my personal capacity, and I represent that I have authority to bind the Hospital.

APPENDIX 1

Attached to and forming part of the Amending Agreement between the LHIN and

the Hospital effective as of March 31, 2020.


(the “LHIN”)

and

BLUEWATER HEALTH (the “Hospital”)

____________________________________

Hospital Service Accountability Agreement for 2018 - 20

Hospital Service Accountability Agreement for 2018-20

2

TABLE OF CONTENTS

APPENDIX 1 ................................................................................................................. 1

ARTICLE 1. DEFINITIONS AND INTERPRETATION .................................................. 3

ARTICLE 2. APPLICATION AND TERM OF AGREEMENT ........................................ 9

ARTICLE 3. OBLIGATIONS OF THE PARTIES ........................................................... 9

ARTICLE 4. FUNDING ............................................................................................... 11

ARTICLE 5. REPAYMENT AND RECOVERY OF FUNDING ..................................... 13

ARTICLE 6. HOSPITAL SERVICES ........................................................................... 16

ARTICLE 7. PLANNING AND INTEGRATION ........................................................... 16

ARTICLE 8. REPORTING .......................................................................................... 19

ARTICLE 9. PERFORMANCE MANAGEMENT, IMPROVEMENT AND REMEDIATION ........................................................................................................... 21

ARTICLE 10. REPRESENTATIONS, WARRANTIES AND COVENANTS ................. 23

ARTICLE 11. ISSUE RESOLUTION ........................................................................... 24

ARTICLE 12. INSURANCE AND INDEMNITY ........................................................... 25

ARTICLE 13. REMEDIES FOR NON-COMPLIANCE ................................................. 27

ARTICLE 14. NOTICE ................................................................................................ 28

ARTICLE 15. ACKNOWLEDGEMENT OF FUNDER SUPPORT ............................... 29

ARTICLE 16. ADDITIONAL PROVISIONS ................................................................. 29

SCHEDULES

Schedule A: Funding Allocation Schedule B: Reporting Requirement Schedule C: Indicators and Volumes Schedule C.1: Performance Indicators Schedule C.2: Service Volumes Schedule C.3: Funder Indicators and Volumes Schedule C.4: PCOP Targeted Funding & Volumes


3

BACKGROUND

This service accountability agreement is entered into pursuant to the Local Health

System Integration Act, 2006, with the expectation that it will be transferred by

means of a transfer order issued by the Minister of Health under the Connecting

Care Act, 2019 (the “CCA”), from the LHIN as funder to Ontario Health, which is

a Crown agency which, pursuant to the CCA, has the power to provide funding to

health service providers and integrated care delivery systems in respect of health

services.

The Hospital and the Funder are committed to working together, and with others,

to achieve evolving provincial priorities including building a connected and

sustainable health care system centred around the needs of patients, their

families and their caregivers.

In this context, the Hospital and the Funder agree that the Funder will provide funding to the Hospital on the terms and conditions set out in this Agreement to enable the provision of services to the health system by the Hospital.

In consideration of their respective agreements set out below, the Funder and the Hospital covenant and agree as follows:

Article 1. DEFINITIONS AND INTERPRETATION

1.1 Definitions. The following definitions are applicable to terms used in this Agreement:

Accountability Agreement means the accountability agreement, as that

term is defined in the Enabling Legislation, in place between the Funder

and the Ministry during a Funding Year;

Agreement means this agreement and includes the Schedules, as amended from time to time;

Annual Balanced Operating Budget means that in each Funding Year of the term of this Agreement, the total expenses of the Hospital are less than or equal to the total revenue, from all sources, of the Hospital when using the consolidated corporate income statements (all fund types and sector codes). Total Hospital revenues exclude interdepartmental recoveries and facility-related deferred revenues, while total Hospital expenses exclude interdepartmental expenses, facility-related amortization expenses and facility-related interest on long-term liabilities;


4

Applicable Law means all federal, provincial or municipal laws, regulations, common law, any orders, rules, or by-laws that are applicable to the parties, the Hospital Services, this Agreement and the parties’ obligations under this Agreement during the term of this Agreement;

Applicable Policy means any rules, policies, directives, or standards of practice issued or adopted by the Ministry or other ministries or agencies of the Province of Ontario that are applicable to the Hospital, the Hospital Services, this Agreement and the parties’ obligations under this Agreement during the term of this Agreement and that are available to the Hospital on a website of a ministry or agency of the Province of Ontario or that the Hospital has received from the Funder, the Ministry, an agency of the Province or otherwise. (For certainty, Applicable Policy does not include any rules, policies, directives, or standards of practice issued or adopted unilaterally by one or more local health integration networks.);

Board means board of directors;

CCA means the Connecting Care Act, 2019, and the regulations under

it, as it and they may be amended from time to time;

CEO means chief executive officer;

Chair means the chair of the Board;

Confidential Information means information disclosed or made available by one party to the other that is marked or otherwise identified as confidential by the disclosing party at the time of disclosure and all other information that would be understood by the parties, exercising reasonable judgment, to be confidential. Confidential Information does not include information that: (i) is or becomes available in the public domain through no act of the receiving party; (ii) is received by the receiving party from another person who has no obligation of confidence to the disclosing party; or (iii) was developed independently by the receiving party without any reliance on the disclosing party’s Confidential Information;

Days means calendar days;

Digital Health means the coordinated use of digital technologies to

electronically integrate points of care and transform the way care is delivered, in

order to improve the quality, access, productivity and sustainability of the

healthcare system;

Effective Date means April 1, 2018;

Enabling Legislation before the date a Transfer Order takes effect

means LHSIA, and after the date a Transfer Order takes effect means

the CCA;


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Explanatory Indicator means a measure of the Hospital’s performance for which no Performance Target is set. Technical specifications of specific Explanatory Indicators can be found in the HSAA Indicator Technical Specifications;

Factors Beyond the Hospital’s Control include occurrences that are, in whole or in part, caused by persons or entities or events beyond the Hospital’s control. Examples may include, but are not limited to, the following:

(a) significant costs associated with complying with new or amended Government of Ontario technical standards or guidelines, Applicable Law or Applicable Policy;

(b) the availability of health care in the community (long-term care, home care, and primary care);

(c) the availability of health human resources;

(d) arbitration decisions that affect Hospital employee compensation packages, including wage, benefit and pension compensation, which exceed reasonable Hospital planned compensation settlement increases and in certain cases non-monetary arbitration awards that significantly impact upon Hospital operational flexibility; and

(e) catastrophic events, such as natural disasters and infectious disease outbreaks;

FIPPA means the Freedom of Information and Protection of Privacy Act,

Ontario and the regulations made under it, as it and they may be amended from

time to time;

Funder before the date a Transfer Order takes effect means the LHIN,

and after the date a Transfer Order takes effect means Ontario Health;

Funding Year means, in the case of the first Funding Year, the period commencing on the Effective Date and ending on the following March 31, and in the case of Funding Years subsequent to the first Funding Year, the period of 12 consecutive months beginning on April 1 following the end of the previous Funding Year and ending on the following March 31;

Funding means the funding provided by the Funder to the Hospital in each Funding Year under this Agreement;

GAAP means generally accepted accounting principles;

Health System Funding Reform has the meaning ascribed to it in the

Accountability Agreement, and is a funding strategy that features quality-based

funding to facilitate fiscal sustainability through high quality, evidence-based and

patient-centred care;


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Hospital’s Personnel and Volunteers means the directors, officers,

employees, agents, volunteers and other representatives of the Hospital. In

addition to the foregoing, Hospital’s Personnel and Volunteers include the

contractors and subcontractors and their respective shareholders, directors,

officers, employees, agents, volunteers or other representatives;

Hospital Services means the clinical services provided by the Hospital and the operational activities that support those clinical services, that are funded in whole or in part by the Funder, and includes the type, volume, frequency and availability of Hospital Services;

HSAA Indicator Technical Specifications means the document entitled “HSAA Indicator Technical Specifications” as it may be amended or replaced from time to time;

Indemnified Parties means the Funder and its officers, employees, directors,

independent contractors, subcontractors, agents, successors and assigns and

Her Majesty the Queen in right of Ontario and Her Ministers, appointees and

employees, independent contractors, subcontractors, agents and assigns.

Indemnified Parties also includes any person participating in a Review

conducted under this Agreement, by or on behalf of the Funder;

Improvement Plan means a plan that the Hospital may be required to develop under Article 9 of this Agreement;

Interest Income means interest earned on Funding that has been provided subject to recovery;

LHSIA means the Local Health System Integration Act, 2006 and the regulations made under it, as it and they may be amended from time to time;

Mandate Letter has the meaning ascribed to it in the Memorandum of Understanding and means a letter from the Ministry to the Funder establishing priorities in accordance with the Premier of Ontario’s mandate letter to the Ministry.

Memorandum of Understanding means the memorandum of understanding between the Funder and the Ministry in effect from time to time in accordance with the Management Board of Cabinet “Agencies and Appointments Directive”.

Minister means such minister of the Crown as may be designated as the responsible minister in relation to this Agreement or in relation to any subject matter under this Agreement, as the case may be, in accordance with the Executive Council Act, as amended;


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Ministry means, as the context requires, the Minister or the Ministry of Health and Long-Term Care or such other ministry as may be designated in accordance with Applicable Law as the ministry responsible in relation to the relevant matter or the Minister of that ministry, as the context requires;

Notice means any notice or other communication required to be provided pursuant to this Agreement or the Enabling Legislation;

Ontario Health means the corporation without share capital under the name Ontario Health as continued under the CCA;

Performance Corridor means the acceptable range of results around a Performance Target;

Performance Factor means any matter that could or will significantly affect a party’s ability to fulfill its obligations under this Agreement;

Performance Indicator means a measure of Hospital performance for which a Performance Target is set;

Performance Standard means the acceptable range of performance for a Performance Indicator or Service Volume that results when a Performance Corridor is applied to a Performance Target (as described in the Schedules and the HSAA Indicator Technical Specifications);

Performance Target means the planned level of performance expected of the Hospital in respect of Performance Indicators or Service Volumes;

person or entity includes any individual and any corporation, partnership, firm, joint venture or other single or collective form of organization under which business may be conducted;

Planning Submission means the Hospital Board-approved planning document submitted by the Hospital to the Funder. The form, content and scheduling of the Planning Submission will be identified by the Funder;

Post-Construction Operating Plan (PCOP) Funding and PCOP Funding means any annualized operating funding provided under this Agreement, whether by a funding letter or other amendment, to support service expansions and other costs occurring in conjunction with completion of an approved capital project, as may be set out in Schedule A and further detailed in Schedule C.4;

Program Parameter means, in respect of a program, any one or more of the provincial standards (such as operational, financial or service standards and policies, operating manuals and program eligibility), directives, guidelines and expectations and requirements for that program that are established or required by the Ministry; and that the Hospital has been made aware of or ought reasonably to have been aware of; and that are available to the Hospital on a website of a ministry or agency of the Province of Ontario or that the Hospital


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has received from the Funder, the Ministry, an agency of the Province or otherwise;

Reports means the reports described in Schedule B as well as any other reports or information required to be provided under the Enabling Legislation or this Agreement;

Review means a financial or operational audit, investigation, inspection or other form of review requested or required by the Funder under the terms of the Enabling Legislation or this Agreement, but does not include the annual audit of the Hospital’s financial statements;

Schedule means any one of, and “Schedules” mean any two or more, as the context requires, of the Schedules appended to this Agreement, including the following:

Schedule A: Funding Allocation Schedule B: Reporting Requirements Schedule C: Indicators and Volumes Schedule C.1: Performance Indicators Schedule C.2: Service Volumes Schedule C.3: Funder Indicators and Volumes Schedule C.4: PCOP Targeted Funding & Volumes

Service Volume means a measure of Hospital Services for which a Performance Target has been set.

Transfer Order means a transfer order issued pursuant to subsection 40(1) of the CCA transferring this Agreement from the LHIN to Ontario Health;

2008-18 H-SAA means the Hospital Service Accountability Agreement for 2008-10 as amended and extended to March 31, 2018.

1.2 Interpretation. Words in the singular include the plural and vice-versa. Words in one gender include all genders. The words “including” and “includes” are not intended to be limiting and mean “including without limitation” or “includes without limitation”, as the case may. The headings do not form part of this Agreement. They are for convenience of reference only and do not affect the interpretation of this Agreement. Terms used in the Schedules have the meanings set out in this Agreement unless separately and specifically defined in a Schedule in which case the definition in the Schedule governs for the purposes of that Schedule.

1.3 HSAA Indicator Technical Specification. This Agreement will be interpreted with reference to the HSAA Indicator Technical Specifications.


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1.4 Denominational Hospitals. For the purpose of interpreting this Agreement, nothing in this Agreement is intended to, and this Agreement will not be interpreted to, unjustifiably, as determined under section 1 of the Canadian Charter of Rights and Freedoms, require a Hospital with a denominational mission to provide a service or to perform a service in a manner that is contrary to the denominational mission of the Hospital.

Article 2. APPLICATION AND TERM OF AGREEMENT

2.1 A Service Accountability Agreement. This Agreement is a service accountability agreement for the purposes of the Enabling Legislation.

2.2 Term. The term of this Agreement will commence on the Effective Date and will expire on June 30, 2020, unless extended pursuant to its terms.

Article 3. OBLIGATIONS OF THE PARTIES

3.1 The Funder. The Funder will fulfill its obligations under this Agreement in accordance with the terms of this Agreement, Applicable Law and Applicable Policy.

3.2 The Hospital.

3.2.1 The Hospital will provide the Hospital Services and otherwise fulfill its obligations under this Agreement in accordance with the terms of this Agreement, Applicable Law, Applicable Policy and Program Parameters. Without limiting the foregoing, the Hospital acknowledges:

that all Funding will be provided in accordance with the requirements of the Enabling Legislation, including the terms and conditions of the Accountability Agreement;

that it is prohibited from using Funding for compensation increases prohibited by Applicable Law;

its obligation to follow the Broader Public Sector Procurement Directive issued by the Management Board of Cabinet as the same may be replaced or amended from time to time; and

its obligation to post a copy of this Agreement in a conspicuous public place at its sites of operations to which this Agreement applies, and on its public website if the Hospital operates a public website.

3.2.2 When providing the Hospital Services, the Hospital will meet all of the Performance Standards and other terms and conditions applicable to the Hospital Services that have been mutually agreed to by the parties.


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3.2.3 The Funder will receive a Mandate Letter from the Ministry annually. Each Mandate Letter articulates areas of focus for the Funder, and the Ministry’s expectation that the Funder and the health service providers it funds will collaborate to advance these areas of focus. To assist the Hospital in its collaborative efforts with the Funder, the Funder will share each relevant Mandate Letter with the Hospital.

3.3 Subcontracting for the Provision of Hospital Services.

3.3.1 Subject to the provisions of the Enabling Legislation, the Hospital may subcontract the provision of some or all of the Hospital Services. For the purposes of this Agreement, actions taken or not taken by the subcontractor and Hospital Services provided by the subcontractor will be deemed actions taken or not taken by the Hospital and Hospital Services provided by the Hospital.

3.3.2 The terms of any subcontract entered into by the Hospital will:

enable the Hospital to meet its obligations under this Agreement; and

not limit or restrict the ability of the Funder to conduct any audit or Review of the Hospital necessary to enable the Funder to confirm that the Hospital has complied with the terms of this Agreement.

3.4 Conflict of Interest. The Hospital has adopted (or will adopt, within 60 Days of the Effective Date) and will maintain, in writing, for the term of this Agreement, a conflict of interest policy that includes requirements for disclosure and effective management of perceived, actual and potential conflict of interest and a code of conduct, for directors, officers, employees, professional staff members and volunteers. The Hospital will provide the Funder with a copy of its conflict of interest policy upon request at any time and from time to time.

3.5 French Language Services. The Hospital shall comply with the requirements and obligations set out in the “Guide to Requirements and Obligations Relating to French Language Health Services”. This obligation does not limit or otherwise prevent the Funder and the Hospital from negotiating specific local obligations relating to French language services, that do not conflict with the guide.

3.6 Designated Psychiatric Facilities. If the Hospital is designated as a psychiatric facility under the Mental Health Act, it will provide the essential mental health services in accordance with the specific designation for each designated site of the Hospital, and discuss any material changes to the service delivery models or service levels with the Ministry.

3.7 Digital Health. The Hospital shall make best efforts to:

assist the Funder to prepare its Funder Digital Health plan that aligns with provincial Digital Health priorities;


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assist the Funder to implement the Funder Digital Health plan and include, in its annual Planning Submission, its plans for achieving the agreed upon Digital Health initiatives;

track the Hospital’s Digital Health performance against the Funder Digital Health plan; and

comply with any clinical, technical, and information management standards, including those related to data, architecture, technology, privacy and security, set for the Hospital by the Ministry within the timeframes set by the Ministry.

Despite Article 9 of this Agreement, to the extent that the Hospital is unable to comply, or anticipates it will be unable to comply with the foregoing without adversely impacting its ability to perform its other obligations under this Agreement, the Hospital, in consultation with the Funder, may refer the matter to the Ministry for resolution.

Article 4. FUNDING

4.1 Annual Funding. Subject to the terms of this Agreement, the Funder:

4.1.1 will provide the Funding identified in Schedule A to the Hospital for the purpose of providing or ensuring the provision of the Hospital Services; and

4.1.2 will deposit the Funding in equal installments, twice monthly, over the term of this Agreement, into an account designated by the Hospital provided that the account resides at a Canadian financial institution and is in the name of the Hospital.

4.2 Funding Limited. The Funder is not responsible for any commitment or expenditure by the Hospital in excess of the Funding that the Hospital makes in order to meet its commitments under this Agreement, nor does this Agreement commit the Funder to provide additional funds during or beyond the term of this Agreement.

4.3 Limitation on Payment of Funding. Despite section 4.1, the Funder will not provide any Funding to the Hospital in respect of a Funding Year until the agreement for that Funding Year has been duly signed on behalf of the Hospital, whether by amendment to this Agreement or otherwise. Despite the foregoing, if:

4.3.1 the Hospital is unable to obtain necessary approval of its Board prior to the beginning of a Funding Year; and

4.3.2 the Hospital notifies the Funder:

that it requires this Agreement to be extended to enable the Hospital to obtain the necessary approval of its Board; and,

of the date by which the Hospital Board’s approval will be obtained,


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then, with the written approval of the Funder, this Agreement and Funding for the then-current Funding Year will continue into the following Funding Year for a period of time specified by the Funder.

4.4 Rebates, Credits, Refunds and Interest Income. The Hospital will incorporate all rebates, credits, refunds and Interest Income that it receives from the use of the Funding into its budget, in accordance with GAAP. The Hospital will use reasonable estimates of anticipated rebates, credits and refunds in its budgeting process. The Hospital will use any rebates, credits, refunds and Interest Income that it receives from the use of the Funding to provide Hospital Services unless otherwise agreed to by the Funder.

4.5 Conditions on Funding.

4.5.1 The Hospital will:

use the Funding only for the purpose of providing the Hospital Services in accordance with the terms of this Agreement and any amendments to this Agreement, whether by funding letter or otherwise;

not use in-year Funding for major building renovations or construction, or for direct expenses relating to research projects; and,

plan for and maintain an Annual Balanced Operating Budget.

Facilitating an Annual Balanced Operating Budget. The parties will work together to identify budgetary flexibility and manage in-year risks and pressures to facilitate the achievement of an Annual Balanced Operating Budget for the Hospital.

Waiver. Upon written request of the Hospital, the Funder may, in its discretion, waive the obligation to achieve an Annual Balanced Operating Budget on such terms and conditions as the Funder may deem appropriate. Where such a waiver is granted, it and the conditions attached to it will form part of this Agreement.

4.5.2 All Funding is subject to all Applicable Law and Applicable Policy, including Health System Funding Reform, as it may evolve or be replaced over the term of this Agreement.

4.6 PCOP. The Hospital acknowledges and agrees that, despite any other provision of this Agreement, unless expressly agreed otherwise in writing, all PCOP Funding is subject to all of the terms and conditions of the funding letter or letters pursuant to which it was initially provided and all of the terms and conditions of this Agreement. For certainty, those funding letters are attached as Schedule C.4.


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4.7 Estimated Funding Allocations.

4.7.1 The Hospital’s receipt of any “Estimated Funding Allocation” in Schedule A is subject to section 4.8 below and subsequent written confirmation from the Funder.

4.7.2 In the event the Funding confirmed by the Funder is less than the Estimated Funding Allocation, the Funder will have no obligation to adjust any related performance requirements unless and until the Hospital demonstrates to the Funder’s satisfaction that the Hospital is unable to achieve the expected performance requirements with the confirmed Funding. In such circumstances the gap between the Estimated Funding and the confirmed Funding will be deemed to be material.

4.7.3 In the event of a material gap in Funding, the Funder and the Hospital will adjust the related performance requirements.

4.8 Appropriation. Funding under this Agreement is conditional upon an appropriation of moneys by the Legislature of Ontario to the Ministry and funding of the Funder by the Ministry pursuant to the Enabling Legislation. If the Funder does not receive its anticipated funding, the Funder will not be obligated to make the payments required by this Agreement.

4.9 Funding Increases. Before the Funder can make an allocation of additional funds to the Hospital, the parties will: (1) agree on the amount of the increase; (2) agree on any terms and conditions that will apply to the increase; and (3) execute an amendment to this Agreement that reflects the agreement reached.

Article 5. REPAYMENT AND RECOVERY OF FUNDING

5.1 Funding Recovery. Recovery of Funding may occur for the following reasons:

5.1.1 the Funder makes an overpayment to the Hospital that results in the Hospital receiving more Funding than specified in this Agreement and any funding letters;

5.1.2 a financial reduction under section 13.1 is assessed;

5.1.3 as a result of a system planning process under section 7.2.6;

5.1.4 as a result of an integration decision made under the Enabling Legislation by the Funder; or

5.1.5 to temporarily reallocate Funding to cover incremental costs of another provider where the Hospital has reduced Hospital Services outside of the applicable Performance Corridor without agreement of the Funder and the services are provided by another provider; and

5.1.6 with respect only to Funding that has been provided expressly subject to recovery,

contractual conditions for recovery of such Funding are met; and


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if in the Hospital’s reasonable opinion or in the Funder’s reasonable opinion after consulting with the Hospital, the Hospital will not be able to use the Funding in accordance with the terms and conditions on which it was provided.

5.2 Process for Recovery of Funding Generally.

5.2.1 Generally, if the Funder, acting reasonably, determines that a recovery of Funding under section 5.1 is appropriate, then the Funder will give 30 Days’ Notice to the Hospital.

5.2.2 The Notice will describe:

the amount of the proposed recovery;

the term of the recovery, if not permanent;

the proposed timing of the recovery;

the reasons for the recovery; and

the amendments, if any, that the Funder proposes be made to the Hospital’s obligations under this Agreement.

5.2.3 Where a Hospital disputes any matter set out in the Notice, the parties will discuss the circumstances that resulted in the Notice and the Hospital may make representations to the Funder about the matters set out in the Notice within 14 Days of receiving the Notice.

5.2.4 The Funder will consider the representations made by the Hospital and will advise the Hospital of its decision. Funding recoveries, if any, will occur in accordance with the timing set out in the Funder’s decision. No recovery of Funding will be implemented earlier than 30 Days after the delivery of the Notice.

5.3 Process for Recovery of Funding as a Result of System Planning or Integration. If Hospital Services are reduced as a result of a system planning process under section 7.2.6 or an integration decision made under the Enabling Legislation, the Funder may recover Funding as agreed in the process in section 7.2.6 or as set out in the decision, and the process set out in section 5.2 will apply.

5.4 Full Consideration. In making a determination under section 5.2, the Funder will act reasonably and will consider the impact, if any, that a recovery of Funding will have on the Hospital’s ability to meet its obligations under this Agreement.

5.5 Consideration of Weighted Cases. Where a settlement and recovery is primarily based on volumes of cases performed by the Hospital, the Funder may consider the Hospital’s actual total weighted cases.


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5.6 Hospital’s Retention of Operating Surplus. In accordance with the Ministry’s 1982 (revised 1999) Business Oriented New Development Policy (BOND), the Hospital will retain any net income or operating surplus of income over expenses earned in a Funding Year, subject to any in-year or year-end adjustments to Funding in accordance with Article 5. Any net income or operating surplus retained by the Hospital under the BOND policy must be used in accordance with the BOND policy. If using operating surplus to start or expand the provision of clinical services, the Hospital will comply with section 7.2.1.

5.7 Funder Discretion Regarding Case Load Volumes. The Funder may consider, where appropriate, accepting case load volumes that are less than a Service Volume or Performance Standard, and the Funder may decide not to settle and recover from the Hospital if such variations in volumes are: (1) only a small percentage of volumes; or (2) due to a fluctuation in demand for the services.

5.8 Settlement and Recovery of Funding for Prior Years.

5.8.1 The Hospital acknowledges that settlement and recovery of Funding can occur up to seven years after the provision of Funding.

5.8.2 The Hospital agrees that if the parties are directed in writing to do so by the Ministry, the Funder will settle and recover funding provided by the Ministry to the Hospital prior to the transition of the funding for the services or program to the Funder, provided that such settlement and recovery occurs within seven years of the provision of the funding by the Ministry. All such settlements and recoveries will be subject to the terms applicable to the original provision of funding.

5.9 Debt Due.

5.9.1 If the Funder requires the re-payment by the Hospital of any Funding in accordance with this Agreement, the amount required will be deemed to be a debt owing to the Crown by the Hospital. The Funder may adjust future Funding instalments to recover the amounts owed or may, at its discretion, direct the Hospital to pay the amount owing to the Crown. The Hospital will comply with any such direction.

5.9.2 All amounts owing to the Crown will be paid by cheque payable to the “Ontario Minister of Finance” and mailed to the Funder at the address provided in section 14.1.

5.9.3 The Funder may charge the Hospital interest on any amount owing by the Hospital at the then current interest rate charged by the Province of Ontario on accounts receivable.


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Article 6. HOSPITAL SERVICES

6.1 Hospital Services. The Hospital will:

6.1.1 achieve the Performance Standards described in the Schedules and the HSAA Indicator Technical Specifications;

6.1.2 not reduce, stop, start, expand, cease to provide or transfer the provision of Hospital Services to another hospital or to another site of the Hospital if such action would result in the Hospital being unable to achieve the Performance Standards described in the Schedules and the HSAA Indicator Technical Specifications; and

6.1.3 not restrict or refuse the provision of Hospital Services that are funded by the Funder to an individual, directly or indirectly, based on the geographic area in which the person resides in Ontario, and will establish a policy prohibiting any health care professional providing services at the Hospital, including physicians, from doing the same.

Article 7. PLANNING AND INTEGRATION

7.1 Planning for Future Years.

7.1.1 Multi-Year Planning. The Planning Submission will be submitted to the Funder at the time and in the format required by the Funder and may require the Hospital to incorporate:

prudent multi-year financial forecasts;

plans for the achievement of Performance Targets; and

realistic risk management strategies in respect of (a) and (b).

The Hospital’s Planning Submission will be aligned with the LHIN’s current integrated health service plan, as defined in LHSIA, if applicable, and will reflect the Funder’s priorities and initiatives. If the Funder has provided multi-year planning targets for the Hospital, the Planning Submissions will reflect the planning targets.

7.1.2 Multi-Year Planning Targets. Schedule A may reflect an allocation for the first Funding Year of this Agreement as well as planning targets for up to two additional years, consistent with the term of this Agreement. In such an event:

the Hospital acknowledges that if it is provided with planning targets, these targets are:


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targets only;

provided solely for the purposes of planning;

subject to confirmation; and

may be changed at the discretion of the Funder in consultation with the Hospital. The Hospital will proactively manage the risks associated with multi-year planning and the potential changes to the planning targets; and

the Funder agrees that it will communicate any material changes to the planning targets as soon as reasonably possible.

7.2 System Planning.

“Pre-proposal” means a notice from the Hospital to the Funder that informs the Funder of a potential integration for the health system in sufficient detail to enable the Funder to assess how the integration would impact the Hospital Services, Funding and the health system, including access to, and quality and cost of, services.

The parties acknowledge that sections 8.7, and 8.8 may apply to a confidential pre-proposal.

7.2.1 General. As required by the Enabling Legislation, the parties will separately and in conjunction with each other identify opportunities to integrate the services of the local health system to provide appropriate, co-ordinated, effective and efficient services. The Hospital acknowledges the importance of advance notice for system planning purposes. If the Hospital is planning to significantly reduce, stop, start, expand or cease to provide clinical services and operational activities that support those clinical services or to transfer any such services to another site of the Hospital, anywhere , and such action does not result in the Hospital being unable to achieve the Performance Standards described in the Schedules and the HSAA Indicator Technical Specification, then the Hospital will inform the Funder of such change with a view to providing the Funder with time to mitigate adverse impacts.

7.2.2 Pre-proposal. The Hospital may inform the Funder, by means of a pre-proposal, of integration opportunities in the health system. The Hospital will inform the Funder by means of a pre-proposal if the Hospital is considering an integration of its services with those of another person or entity.

7.2.3 Further Consideration of Pre-proposal. Following the Funder’s review and evaluation of the pre-proposal and subject to section 7.2.5, the Funder may invite the Hospital to submit a detailed proposal and business case for further analysis. The Funder will provide the Hospital with guidelines for the development of a detailed proposal and business case.


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7.2.4 Funder Evaluation of the Pre-proposal not Consent. A pre-proposal will not constitute a notice of an integration under the Enabling Legislation. The Funder’s assent to develop the concept outlined in a pre-proposal does not: (a) constitute the Funder’s approval to proceed with an integration; (b) presume the Funder or the Minister will not issue a decision ordering the Hospital not to proceed with the integration under the Enabling Legislation; or (c) preclude the Funder from exercising its powers under the Enabling Legislation.

7.2.5 Act Prevails. Nothing in this section prevents the Hospital from providing the Funder or the Minister, as applicable, with notice of integration at any time in accordance with the Enabling Legislation.

7.2.6 Process for System Planning. If:

the Hospital has identified an opportunity to integrate its Hospital Services with that of one or more other health service providers, or integrated care delivery systems (“Other Providers”);

the Other Providers have agreed to the proposed integration with the Hospital;

the Hospital and the Other Providers have agreed on the amount of funds needed to be transferred from the Hospital to one or more of the Other Providers to effect the integration as planned between them and the Hospital has notified the Funder of this amount;

the Hospital has complied with its obligations under the Enabling Legislation, the integration proceeds or will proceed as planned in accordance with the Enabling Legislation;

then the Funder may recover from the Hospital, Funding specified in Schedule A and agreed by the Hospital as needed to facilitate the integration.

7.3 Reviews and Approvals.

7.3.1 Timely Response. Subject to section 7.3.2, and except as expressly provided by the terms of this Agreement, the Funder will respond to Hospital submissions requiring a response from the Funder in a timely manner and in any event, within any time period set out in Schedule B. If the Funder has not responded to the Hospital within the time period set out in Schedule B, following consultation with the Hospital, the Funder will provide the Hospital with written Notice of the reasons for the delay and a new expected date of response. If a delayed response from the Funder could reasonably be expected to have a prejudicial effect on the Hospital, the Hospital may refer the matter for issue resolution under Article 11.

7.3.2 Exceptions. Section 7.3.1 does not apply to: (i) any notice provided to the Funder or Minister under the Enabling Legislation, which will be subject to the timelines of the Enabling Legislation; and (ii) any report required to be submitted to the Ministry by the Funder for which the Ministry response is required before the Funder can respond.


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Article 8. REPORTING

8.1 Generally. The Funder’s ability to enable the health system to provide appropriate, co-ordinated, effective and efficient services, as contemplated by the Enabling Legislation, is dependent on the timely collection and analysis of accurate information.

8.2 General Reporting Obligations. The Hospital will provide to the Funder, or to such other person or entity as the parties may reasonably agree, in the form and within the time specified by the Funder, the Reports, other than personal health information as defined in the Enabling Legislation, that the Funder requires for the purposes of exercising its powers and duties under this Agreement, the Enabling Legislation or for the purposes that are prescribed under any Applicable Law. For certainty, nothing in this section 8.2 or in this Agreement restricts or otherwise limits the Funder’s right to access or to require access to personal health information as defined in the Enabling Legislation, in accordance with Applicable Law.

8.3 Certain Specific Reporting Obligations. Without limiting the foregoing, the Hospital will fulfill the specific reporting requirements set out in Schedule B. The Hospital will ensure that all Reports are in a form satisfactory to the Funder, are complete, accurate and signed on behalf of the Hospital by an authorized signing officer, and are provided to the Funder in a timely manner.

8.4 Additional Reporting Obligations.

8.4.1 French Language Services. If the Hospital is required to provide services to the public in French under the provisions of the French Language Services Act, the Hospital will submit a French language services report to the Funder annually. If the Hospital is not required to provide services to the public in French under the provisions of the French Language Service Act, the Hospital will provide a report to the Funder annually that outlines how the Hospital addresses the needs of its Francophone community.

8.4.2 Community Engagement and Integration. The Hospital will report annually on its community engagement and integration activities and at such other times as the Funder may request from time to time, using any templates provided by the Funder.

8.4.3 Reporting to Certain Third Parties. The Hospital will submit all such data and information to the Ministry, Canadian Institute for Health Information or to any other third party, as may be required by any health data reporting requirements or standards communicated by the Ministry to the Hospital. To the extent that the Hospital is unable to comply with the foregoing without adversely impacting its ability to perform its other obligations under this Agreement, the Hospital may notify the Funder and the parties will escalate the matter to their respective CEOs and Board Chairs, if so requested by either party.


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8.5 System Impacts. Throughout the term of this Agreement, the Hospital will promptly inform the Funder of any matter that the Hospital becomes aware of that materially impacts or is likely to materially impact the health system, or could otherwise be reasonably expected to concern the Funder.

8.6 Hospital Board Reports.

8.6.1 Hospital Board to be Informed. Periodically throughout the Funding Year and at least quarterly, the Hospital’s Board will receive from the Hospital’s Board committees, CEO and other appropriate officers, such reports as are necessary to keep the Board, as the governing body of the Hospital, appropriately informed of the performance by the Hospital of its obligations under this Agreement, including the degree to which the Hospital has met, and will continue throughout the Funding Year to meet, its Performance Targets and its obligation to plan for and achieve an Annual Balanced Operating Budget.

8.6.2 Hospital Board to Report to Funder. The Hospital will provide to the Funder, annually, and quarterly upon request of the Funder, a declaration of the Hospital’s Board, signed by the Chair, declaring that the Board has received the reports referred to in this Section.

8.7 Confidential Information. The receiving party will treat Confidential Information of the disclosing party as confidential and will not disclose Confidential Information except:

8.7.1 with the prior consent of the disclosing party; or

8.7.2 as required by law or by a court or other lawful authority, including the Enabling Legislation and FIPPA.

8.8 Required Disclosure. If the receiving party is required, by law or by a court or by other lawful authority, to disclose Confidential Information of the disclosing party, the receiving party will: promptly notify the disclosing party before making any such disclosure, if such notice is not prohibited by law, the court or other lawful authority; cooperate with the disclosing party on the proposed form and nature of the disclosure; and, ensure that any disclosure is made in accordance with the requirements of Applicable Law and within the parameters of the specific requirements of the court or other lawful authority.

8.9 Document Retention and Record Maintenance. The Hospital will:

8.9.1 retain all records (as that term is defined in FIPPA) related to the Hospital’s performance of its obligations under this Agreement for seven years after this Agreement ceases to be in effect, whether due to expiry or otherwise. The Hospital’s obligations under this section will survive if this Agreement ceases to be in effect, whether due to expiry or otherwise;

8.9.2 keep all financial records, invoices and other financially-related documents relating to the Funding or otherwise to the Hospital Services in a manner consistent with international financial reporting standards as advised by the Hospital’s auditor; and


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8.9.3 keep all non-financial documents and records relating to the Funding or otherwise to the Hospital Services in a manner consistent with all Applicable Law.

8.10 Final Reports. If this Agreement ceases to be in effect, whether due to expiry or otherwise, the Hospital will provide to the Funder all such reports as the Funder may reasonably request relating to, or as a result of, this Agreement ceasing to be in effect.

Article 9. PERFORMANCE MANAGEMENT, IMPROVEMENT AND REMEDIATION

9.1 General Approach. The parties will strive to achieve on-going performance improvement. They will follow a proactive, collaborative and responsive approach to performance management and improvement. Either party may request a meeting at any time. The parties will use their best efforts to meet as soon as possible following a request.

9.2 Notice of a Performance Factor. Each party will notify the other party, as soon as reasonably possible, of any Performance Factor. The Notice will:

9.2.1 describe the Performance Factor and its actual or anticipated impact;

9.2.2 include a description of any action the party is undertaking, or plans to undertake, to remedy or mitigate the Performance Factor;

9.2.3 indicate whether the party is requesting a meeting to discuss the Performance Factor; and

9.2.4 address any other issue or matter the party wishes to raise with the other party, including whether the Performance Factor may be a Factor Beyond the Hospital’s Control.

9.2.5 The recipient party will acknowledge in writing receipt of the Notice within seven Days of the date on which the Notice was received (“Date of the Notice”).

9.3 Performance Meetings. Where a meeting has been requested under section 9.2.3, the parties will meet to discuss the Performance Factor within 14 Days of the Date of the Notice. The Funder can require a meeting to discuss the Hospital’s performance of its obligations under this Agreement, including a result for a Performance Indicator or a Service Volume that falls outside the applicable Performance Standard.

9.4 Performance Meeting Purpose. During a performance meeting, the parties will:

9.4.1 discuss the causes of the Performance Factor;

9.4.2 discuss the impact of the Performance Factor on the local health system and the risk resulting from non-performance; and

9.4.3 determine the steps to be taken to remedy or mitigate the impact of the Performance Factor (the “Performance Improvement Process”).


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9.5 Performance Improvement Process.

9.5.1 The purpose of the Performance Improvement Process is to remedy or mitigate the impact of a Performance Factor. The Performance Improvement Process may include:

a requirement that the Hospital develop an Improvement Plan; or

an amendment of the Hospital’s obligations as mutually agreed by the parties.

9.5.2 Any Performance Improvement Process begun under a prior agreement will continue under this Agreement. Any performance improvement required by a Funder under a prior agreement will be deemed to be a requirement of this Agreement until fulfilled.

9.6 Factors Beyond the Hospital’s Control. If the Funder, acting reasonably, determines that the Performance Factor is, in whole or in part, a Factor Beyond the Hospital’s Control:

9.6.1 the Funder will collaborate with the Hospital to develop and implement a mutually agreed upon joint response plan which may include an amendment of the Hospital’s obligations under this Agreement;

9.6.2 the Funder will not require the Hospital to prepare an Improvement Plan; and

9.6.3 the failure to meet an obligation under this Agreement will not be considered a breach of this Agreement to the extent that failure is caused by a Factor Beyond the Hospital’s Control.

9.7 Hospital Improvement Plan.

9.7.1 Development of an Improvement Plan. If, as part of a Performance Improvement Process, the Funder requires the Hospital to develop an Improvement Plan, the process for the development and management of the Improvement Plan is as follows:

The Hospital will submit the Improvement Plan to the Funder within 30 Days of receiving the Funder’s request. In the Improvement Plan, the Hospital will identify remedial actions and milestones for monitoring performance improvement and the date by which the Hospital expects to meet its obligations.

Within 15 business Days of its receipt of the Improvement Plan, the Funder will advise the Hospital which, if any, remedial actions the Hospital should implement immediately. If the Funder is unable to approve the Improvement Plan as presented by the Hospital, subsequent approvals will be provided as the Improvement Plan is revised to the satisfaction of the Funder.

The Hospital will implement all aspects of the Improvement Plan for which it has received written approval from the Funder, upon receipt of such approval.


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The Hospital will report quarterly on progress under the Improvement Plan, unless the Funder advises the Hospital to report on a more frequent basis. If Hospital performance under the Improvement Plan does not improve by the timelines in the Improvement Plan, the Funder may agree to revisions to the Improvement Plan.

The Funder may require, and the Hospital will permit and assist the Funder in conducting, a Review of the Hospital to assist the Funder in its consideration and approval of the Improvement Plan. The Hospital will pay the costs of this Review.

9.7.2 Peer/Funder Review of Improvement Plan. If Hospital performance under the Improvement Plan does not improve in accordance with the Improvement Plan, or if the Hospital is unable to develop an Improvement Plan satisfactory to the Funder, the Funder may appoint an independent team to assist the Hospital to develop an Improvement Plan or revise an existing Improvement Plan. The independent team will include a representative from another hospital selected with input from the Ontario Hospital Association. The independent team will work closely with the representatives from the Hospital and the Funder. The Hospital will submit a new Improvement Plan or revisions to an existing Improvement Plan within 60 Days of the appointment of the independent team or within such other time as may be agreed to by the parties.

Article 10. REPRESENTATIONS, WARRANTIES AND COVENANTS

10.1 General. The Hospital represents, warrants and covenants that:

10.1.1 it is, and will continue for the term of this Agreement to be, a validly existing legal entity with full power to fulfill its obligations under this Agreement;

10.1.2 subject to Applicable Law, it has made reasonable efforts to ensure that the Hospital Services are and will continue to be provided by persons with the experience, expertise, professional qualifications, licensing and skills necessary to complete their respective tasks;

10.1.3 it holds all permits, licences, consents, intellectual property rights and authorities necessary to perform its obligations under this Agreement;

10.1.4 all information (including information relating to any eligibility requirements for Funding) that the Hospital provided to the Funder in support of its request for Funding was true and complete at the time the Hospital provided it, and will, subject to the provision of Notice otherwise, continue to be materially true and complete for the term of this Agreement; and

10.1.5 it does and will continue to operate for the term of this Agreement, in compliance with Applicable Law and Applicable Policy.

10.2 Execution of Agreement. The Hospital represents and warrants that:

10.2.1 it has the full power and authority to enter into this Agreement; and


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10.2.2 it has taken all necessary actions to authorize the execution of this Agreement.

10.3 Governance. The Hospital represents, warrants and covenants that it will follow good governance practices comparable to those set out in the Ontario Hospital Association’s Governance Centre of Excellence’s “Guide to Good Governance” as it may be amended; will undertake an accreditation process which will include a review of its governance practices; and will promptly remedy any deficiencies that are identified during that accreditation process.

10.4 Supporting Documentation. The Hospital acknowledges that the Funder may, pursuant to the Enabling Legislation, require proof of the matters referred to in this Article 10.

Article 11. ISSUE RESOLUTION

11.1 Principles to be Applied. The parties acknowledge that it is desirable to use reasonable efforts to resolve issues and disputes in a collaborative manner. This includes avoiding disputes by clearly articulating expectations, establishing clear lines of communication, and respecting each party’s interests.

11.2 Informal Resolution. The parties acknowledge that it is desirable to use reasonable efforts to resolve all issues and disputes through informal discussion and resolution. To facilitate and encourage this informal resolution process, the parties may jointly develop a written issues statement. Such an issues statement may:

11.2.1 describe the facts and events leading to the issue or dispute;

11.2.2 consider:

the severity of the issue or dispute, including risk, likelihood of harm, likelihood of the situation worsening with time, scope and magnitude of the impact, likely impact with and without prompt action taken;

whether the issue or dispute is isolated or part of a pattern;

the likelihood of the issue or dispute recurring and if recurring, the length of time between occurrences;

whether or not the issue or dispute is long-standing; and

whether previous mitigation strategies have been ignored; and

11.2.3 list potential options for its resolution, which may include:

performance management, in accordance with sections 9.4 through 9.7;

a Review of the Hospital or a facilitated resolution, which may involve the assistance of external supports, such a peers, coaches, mentors and facilitators (“Facilitation”).


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11.3 Escalation. If the issue or dispute cannot be resolved at the level at which it first arose, either party may refer it to the senior staff member of the Funder who is responsible for this Agreement and to their counterpart in the senior management of the Hospital. If the dispute cannot be resolved at this level of senior management, either party may refer it to its respective CEO. The CEOs may meet within 14 Days of this referral and attempt to resolve the issue or dispute. If the issue or dispute remains unresolved 30 Days after the first meeting of the CEOs, then either party may refer it to their respective Board Chairs (or Board member designate) who may attempt to resolve the issue or dispute.

11.4 Reviews and Facilitations. The Hospital will cooperate in every Review and Facilitation. The Hospital acknowledges that for the purposes of any Review, the Funder may exercise its powers under the Enabling Legislation.

11.5 Funder Resolution. Nothing in this Agreement prevents the Funder from exercising any statutory or other legal right or power, or from pursuing the appointment of a supervisor of the Hospital with the Ministry, at any time.

Article 12. INSURANCE AND INDEMNITY

12.1 Limitation of Liability. The Indemnified Parties will not be liable to the Hospital or any of the Hospital’s Personnel and Volunteers for costs, losses, claims, liabilities and damages howsoever caused arising out of or in any way related to the Hospital Services or otherwise in connection with this Agreement, unless caused by the negligence or wilful misconduct of the Indemnified Parties.

12.2 Same. For greater certainty and without limiting section 12.1, the Funder is not liable for how the Hospital and the Hospital’s Personnel and Volunteers carry out the Hospital Services and is therefore not responsible to the Hospital for such Hospital Services; moreover the Funder is not contracting with, or employing, any of the Hospital’s Personnel and Volunteers to carry out the terms of this Agreement. As such, the Funder is not liable for contracting with, employing or terminating a contract or the employment of, any of the Hospital’s Personnel and Volunteers required to carry out this Agreement, nor for the withholding, collection or payment of any taxes, premiums, contributions or any other remittances due to government for the Hospital’s Personnel and Volunteers required by the Hospital to perform its obligations under this Agreement.

12.3 Indemnification. The Hospital will indemnify and hold harmless the Indemnified Parties from and against any and all costs, expenses, losses, liabilities, damages and expenses (including legal, expert and consultant fees), causes of action, actions, claims, demands, lawsuits or other proceedings (collectively “Claims”) by whomever made, sustained, brought or prosecuted (including for third party bodily injury (including death), personal injury and property damage) in any way based upon, occasioned by or attributable to anything done or omitted to be done by the Hospital or the Hospital’s Personnel and Volunteers in the course of performance of the Hospital’s obligations under, or otherwise in connection with, this Agreement, unless caused by the negligence or wilful misconduct of an Indemnified Party.


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12.4 Insurance.

12.4.1 Required Insurance. The Hospital will put into effect and maintain, for the term of this Agreement, at its own expense, with insurers having a secure A.M. Best rating of B+ or greater, or the equivalent, all the necessary and appropriate insurance that a prudent person in the business of the Hospital would maintain including the following.

Commercial General Liability Insurance. Commercial general liability insurance, for third-party bodily injury, personal injury and property damage to an inclusive limit of not less than five million dollars per occurrence and not less than two million dollars for products and completed operations in the aggregate. The policy will include the following clauses:

The Indemnified Parties as additional insureds;

Contractual Liability;

Cross Liability;

Products and Completed Operations Liability;

Employers Liability and Voluntary Compensation unless the Hospital can provide proof of Workplace Safety and Insurance Act, 1997 (“WSIA”) coverage as described in section 12.4.2(b);

Non-Owned automobile coverage with blanket contractual and physical damage coverage for hired automobiles, except that such coverage may nevertheless exclude liability assumed by any person insured by the policy voluntarily under any contract or agreement other than directors, officers, employees and volunteers of the Hospital pertaining only to the liability arising out of the use or operation of their automobiles while on the business of the Hospital; and

A thirty-day written notice of cancellation, termination or material change.

All-Risk Property Insurance. All-risk property insurance on property of every description providing coverage to a limit of not less than the full replacement cost, including earthquake and flood. Such insurance will be written to include replacement cost value. All reasonable deductibles and/or self-insured retentions are the responsibility of the Hospital.

Boiler and Machinery Insurance. Boiler and machinery insurance (including pressure objects, machinery objects and service supply objects) on a comprehensive basis. Such insurance will be written to include repair and replacement value. All reasonable deductibles and/or self-insured retentions are the responsibility of the Hospital.


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Professional Liability Insurance. Professional liability insurance to an inclusive limit of not less than five million dollars per occurrence for each claim of negligence resulting in bodily injury, death or property damage, arising directly or indirectly from the professional services rendered by the Hospital, its officers, agents or employees.

Directors and Officers Liability Insurance. Directors and officers liability insurance to an inclusive limit of not less than two million dollars per claim, with an annual aggregate of not less than four million dollars, responding to claims of wrongful acts of the Hospital’s directors, officers and board committee members and of the Hospital’s volunteer association and auxiliary in the discharge of their duties on behalf of the Hospital or the volunteer association or auxiliary, as applicable.

12.4.2 Proof of Insurance. As requested by the Funder from time to time, the Hospital will provide the Funder with proof of the insurance required by this Agreement in the form of any one or more of:

a valid certificate of insurance that references this Agreement and confirms the required coverage;

a valid WSIA Clearance Certificate or a letter of good standing, as applicable, unless the Hospital has in effect Employers Liability and Voluntary Compensation as described above; and

copy of each insurance policy.

12.4.3 Subcontractors. The Hospital will ensure that each of its subcontractors obtains all the necessary and appropriate insurance that a prudent person in the business of the subcontractor would maintain.

Article 13. REMEDIES FOR NON-COMPLIANCE

13.1 Planning Cycle. The success of the planning cycle depends on the timely performance of each party. To ensure delays do not have a material adverse effect on Hospital Services or Funder operations, the following provisions apply:

13.1.1 If the Funder fails to meet an obligation or due date in Schedule B, the Funder may do one or all of the following:

adjust funding for the Funding Year to offset a material adverse effect on Hospital Services resulting from the delay; and/or

work with the Hospital in developing a plan to offset any material adverse effect on Hospital Services resulting from the delay, including providing Funder approvals for any necessary changes in Hospital Services.

13.1.2 At the discretion of the Funder, the Hospital may be subject to a financial reduction if the Hospital’s:


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Planning Submission is received by the Funder after the due date in Schedule B without prior Funder approval of such delay;

Planning Submission is incomplete;

quarterly performance reports are not provided when due; or

financial and/or clinical data requirements are late, incomplete or inaccurate.

If assessed, the financial reduction will be as follows:

if received within seven Days after the due date, incomplete or inaccurate, the financial penalty will be the greater of: (i) a reduction of 0.03% of the Hospital’s total Funding; or (ii) $2,000; and

for every full or partial week of non-compliance thereafter, the rate will be one half of the initial financial reduction.

Article 14. NOTICE

14.1 Notice. A Notice will be in writing; delivered personally, by pre-paid courier, by any form of mail where evidence of receipt is provided by the post office, or by facsimile with confirmation of receipt, or by email where no delivery failure notification has been received. For certainty, delivery failure notification includes an automated ‘out of office’ notification. A Notice will be addressed to the other party as provided below or as either party will later designate to the other in writing:

To the Funder: To the Hospital:

Erie St. Clair LHIN Bluewater Health 712 Richmond Street Chatham, ON N7M 5J5

89 Norman Street Sarnia, ON N7T 6S3

Attn: Bruce Lauckner, CEO Attn: Mike Lapaine, CEO

Fax: 519-351-5842 Fax: 519-464-4407

Email: [email protected] Email: [email protected]

14.2 Notices Effective From. A Notice will be deemed to have been duly given one business day after delivery if the Notice is delivered personally, by pre-paid courier or by mail. A Notice that is delivered by facsimile with confirmation of receipt or by email where no delivery failure notification has been received will be deemed to have been duly given one business day after the facsimile or email was sent.


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Article 15. ACKNOWLEDGEMENT OF FUNDER SUPPORT

15.1 Publication. For the purposes of this Article 15, the term “Publication” means: an annual report; a strategic plan; a material publication on a consultation about a possible integration; a material publication on community engagement; and, a material report to the community that the Hospital develops and makes available to the public in electronic or hard copy.

15.1.1 Acknowledgment of Funding Support.

The following statement will be included on the Hospital’s website, on all Publications and, upon request of the Funder, on any other publication of the Hospital relating to a Hospital initiative:

“The [Insert name of Hospital] receives funding from [Insert name of Funder]. The opinions expressed in this publication do not necessarily represent the views of [Insert name of Funder].”

Upon request of the Funder, the Hospital will include a statement in a form acceptable to the Funder, acknowledging the support of the Province.

15.2 Insignia and Logo. Neither party may use any insignia or logo of the other party without the prior written permission of the other party. For the Hospital, this includes the insignia and logo of Her Majesty the Queen in right of Ontario.

Article 16. ADDITIONAL PROVISIONS

16.1 Interpretation. In the event of a conflict or inconsistency in any provision of this Agreement, the main body of this Agreement will prevail over the Schedules.

16.2 Amendment of Agreement. This Agreement may only be amended by a written agreement duly executed by the parties.

16.3 Invalidity or Unenforceability of Any Provision. The invalidity or unenforceability of any provision of this Agreement will not affect the validity or enforceability of any other provision of this Agreement and any invalid or unenforceable provision will be deemed to be severed.

16.4 No Assignment. The Hospital will not assign this Agreement or the Funding in whole or in part, directly or indirectly, without the prior written consent of the Funder. The Funder may assign this Agreement or any of its rights and obligations under this Agreement to any one or more agencies or ministries of Her Majesty the Queen in right of Ontario and as otherwise directed by the Ministry.


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16.5 Funder is an Agent of the Crown. The parties acknowledge that the Funder is an agent of the Crown and may only act as an agent of the Crown in accordance with the provisions of the Enabling Legislation. Notwithstanding anything else in this Agreement, any express or implied reference to the Funder providing an indemnity or any other form of indebtedness or contingent liability that would directly or indirectly increase the indebtedness or contingent liabilities of the Funder or Ontario, whether at the time of execution of this Agreement or at any time during the term of this Agreement, will be void and of no legal effect.

16.6 Parties Independent. The parties are and will at all times remain independent of each other and are not and will not represent themselves to be the agent, joint venturer, partner or employee of the other. No representations will be made or acts taken by either party which could establish or imply any apparent relationship of agency, joint venture, partnership or employment and neither party will be bound in any manner whatsoever by any agreements, warranties or representations made by the other party to any other person or entity, nor with respect to any other action of the other party.

16.7 Survival. The provisions in Articles 1 (Definitions and Interpretation) and 5 (Repayment and Recovery of Funding), sections 8.7 (Confidential Information), 8.8 (Required Disclosure), 8.9 (Document Retention and Record Maintenance), 8.10 (Final Reports), and Articles 12 (Insurance and Indemnity), 14 (Notices) and 16 (Additional Provisions) will continue in full force and effect for a period of seven years from the date this Agreement ceases to be in effect, whether due to expiry or otherwise.

16.8 Waiver. A party may only rely on a waiver of the party’s failure to comply with any term of this Agreement if the other party has provided a written and signed Notice of waiver. Any waiver must refer to a specific failure to comply and will not have the effect of waiving any subsequent failures to comply.

16.9 Counterparts. This Agreement may be executed in any number of counterparts, each of which will be deemed an original, but all of which together will constitute one and the same instrument.

16.10 Further Assurances. The parties agree to do or cause to be done all acts or things necessary to implement and carry into effect this Agreement to its full extent.

16.11 Governing Law. This Agreement and the rights, obligations and relations of the parties hereto will be governed by and construed in accordance with the laws of the Province of Ontario and the federal laws of Canada applicable therein. Any litigation or arbitration arising in connection with this Agreement will be conducted in Ontario unless the parties agree in writing otherwise.


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16.12 Entire Agreement. This Agreement forms the entire Agreement between the parties and supersedes all prior oral or written representations and agreements, except that where the Funder has provided Funding to the Hospital pursuant to an amendment to the 2008-18 H-SAA or to this Agreement, whether by funding letter or otherwise, and an amount of Funding for the same purpose is set out in Schedule A, that Funding is subject to all of the terms and conditions on which funding for that purpose was initially provided, unless those terms and conditions have been superseded by any terms or conditions of this Agreement or by the HSAA Indicator Technical Specifications, or unless they conflict with Applicable Law or Applicable Policy.

-SIGNATURE PAGE FOLLOWS -


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IN WITNESS WHEREOF the parties have executed this Agreement made effective as of

Date: ____________________

Bluewater Health

By:

Name Date

Board Chair

I sign as a representative of the Hospital, not in my personal capacity, and I represent

that I have authority to bind the Hospital.

And By:

Mr. Mike Lapaine Date

CEO

I sign as a representative of the Hospital, not in my personal capacity, and I represent

that I have authority to bind the Hospital.


By:

Nicole Robinson Date

VP-Integrated Delivery Systems

And By:

Bruce Lauckner Date

CEO


Via Email

February 12, 2020

Mike Lapaine President & Chief Executive Officer Bluewater Health 89 Norman Street Sarnia, ON N7T 6S3

Dear Mr. Lapaine,

As the Interim Chief Executive Officer of Ontario Health indicated on November 14, 2019, it is expected that your 2020/21 Multi-Service Accountability Agreement (MSAA) will be with Ontario Health. This letter provides further information on the process, timeline and plan going forward.

Attached please find a Notice of Amendment and an Amending Agreement with respect to your MSAA to extend it to June 30, 2020 with minimal amendments to reflect legislative changes and to simplify the anticipated transition of the MSAA to Ontario Health from your LHIN. You are asked to have the Amending Agreement duly signed on behalf of your organization and returned to Huy Vu, Performance Analyst, at [email protected] no later than March 15, 2020. While the MSAA will remain with the LHIN, as of March 31, 2020, it is our expectation that your MSAA will be transferred to Ontario Health by Minister’s transfer order. The three-month extension will help to enable changes to the MSAA that will address the Ministry of Health and Ontario Health priorities.

Ontario Health and the LHINs are working closely to effect a smooth transition process. Until you are notified otherwise, the Erie St. Clair Local Health Integration Network and your usual LHIN contact will be responsible for the administration of your MSAA. Please continue to direct all communications to that person.

Yours sincerely,


cc. Matthew Anderson, Ontario Health

Attach: (1) Notice of Amendment and (2) MSAA Amending Agreement

Appendix B



Delivered by email February 12, 2020 Dear Health Service Provider,

LHSIA S.20 NOTICE The Local Health System Integration Act, 2006 requires the Erie St. Clair Local Health Integration Network (ESC LHIN) to notify a health service provider when the LHIN proposes to enter into, or amend, a service accountability agreement with that health service provider. The LHIN hereby gives notice that it proposes to amend one or more existing service accountability agreements currently in effect between the LHIN and your organization, on or before March 31, 2020. Should you have any questions, please contact Erin Link, Director, Performance & Accountability, at [email protected]. Sincerely yours, Bruce Lauckner, Transitional Regional Lead (West and CEO of Erie St. Clair, South West, Hamilton Niagara Haldimand Brant and Waterloo Wellington LHINs) Ontario Health Cc: Health Service Provider Board Chair Nicole Robinson, Vice President, Performance and Accountability


MSAA Amending Agreement–Amendments and Extending Schedules to June 30, 2020 Page 1

MSAA AMENDING AGREEMENT

THIS AMENDING AGREEMENT (the “Agreement”) is made as of the 31st day of March, 2020 B E T W E E N:

ERIE ST. CLAIR LOCAL HEALTH INTEGRATION NETWORK (the “LHIN”) AND

BLUEWATER HEALTH (the “HSP”) WHEREAS the LHIN and the HSP (together the “Parties”) entered into a multi-sector service accountability agreement that took effect April 1, 2019 (the “MSAA”); AND WHEREAS the Parties wish to amend the MSAA in the manner set out in this Agreement; NOW THEREFORE in consideration of mutual promises and agreements contained in this Agreement and other good and valuable consideration, the Parties agree as follows:

1.0 Definitions. Except as otherwise defined in this Agreement, all terms shall have the meaning ascribed to them in the MSAA. References in this Agreement to the MSAA mean the MSAA as amended.

2.0 Amendments. 2.1 Agreed Amendments. The MSAA is amended as follows.

a) All references to “LHIN” are deleted and replaced with “Funder”, with the exceptions of the defined term “LHIN” as a party to the agreement, and section 6.1(b) only in reference to the integrated health service plan which remain unamended.

b) The first four paragraphs of the part of the MSAA entitled “Background” are deleted and replaced with the following.

“This service accountability agreement is entered into pursuant to the Local Health System Integration Act, 2006, with the expectation that it will be transferred by means of a transfer order issued by the Minister of Health under the Connecting Care Act, 2019 (the “CCA”), from the LHIN as funder to Ontario Health, which is a Crown agency which, pursuant to the CCA, has the power to provide funding to health service providers and integrated care delivery systems in respect of health services .

The HSP and the Funder are committed to working together, and with others, to achieve evolving provincial priorities including building a connected and sustainable health care system centred around the needs of patients, their families and their caregivers.


In this context, the HSP and the Funder agree that the Funder will provide funding to the HSP on the terms and conditions set out in this Agreement to enable the provision of services to the health system by the HSP.”

c) All references to “LHSIA” are deleted and replaced with “the Enabling Legislation”, with the exceptions of the defined term “LHSIA” in section 1.1, and section 6.1(b) and section 8.1(b) in reference to LHSIA sections 5(m.1) and (m.2)” which remain unamended.

d) The defined term “MOHLTC” and its definition are deleted and replaced with the following.

““Ministry” means, as the context requires, the Minister or the Ministry of Health and Long-Term Care or such other ministry as may be designated in accordance with Applicable Law as the ministry responsible in relation to the relevant matter or the Minister of that ministry, as the context requires;”.

e) All references to “MOHLTC” are deleted and replaced with “Ministry”.

In addition to the foregoing, the MSAA is further amended as follows.

f) In section 1.1, the definition of “Accountability Agreement” is amended by deleting “, currently referred to as the Ministry LHIN Accountability Agreement”.

g) In section 1.1, the definition of “Confidential Information” is amended by deleting: “: (1)”, and by deleting “; and (2) eligible for exclusion from disclosure at a public board meeting in accordance with section 9 of LHSIA”.

h) In section 1.1, the definition of “Digital Health” is amended by deleting “has the meaning ascribed to it in the Accountability Agreement and”.

i) In section 1.1, the definition of “LHIN Cluster” is deleted.

j) In section 1.1, the definition of “Mandate Letter” is amended by adding “the” before “Ministry” three times.

k) In section 1.1, the definition of “Minister” is deleted and replaced with:

““Minister” means such minister of the Crown as may be designated as the responsible minister in relation to this Agreement or in relation to any subject matter under this Agreement, as the case may be, in accordance with the Executive Council Act, as amended;”.

l) The following definitions are added to section 1.1:

““CCA” means the Connecting Care Act, 2019, and the regulations under it, as it and they may be amended from time to time;”


““Enabling Legislation” before the date a Transfer Order takes

effect means LHSIA, and after the date a Transfer Order takes effect

means the CCA;”

““Funder” before the date a Transfer Order takes effect means the LHIN, and after the date a Transfer Order takes effect means Ontario Health;”

““Ontario Health” means the corporation without share capital under the name Ontario Health as continued under the CCA;”

““Transfer Order” means a transfer order issued pursuant to subsection 40(1) of the CCA transferring this Agreement from the LHIN to Ontario Health;”.

m) In section 2.2, “section 20(1) of” is deleted.

n) Section 3.4(a) is deleted and replaced with “assist the Funder to implement Digital Health priorities of the Funder;”.

o) In section 3.4(b). “the” is added after “providers by” and again after “set by”.

p) In section 3.4(c), “in the LHIN Digital Health plan” is deleted and replaced with “by the Funder”.

q) In section 3.4(d), “the LHIN Cluster Digital Health plan” is deleted and replaced with “the Funder’s Digital Health priorities”.

r) In section 3.5.1, “Guide to Requirements and Obligations of LHIN French Language Services” is deleted and replaced with “Guide to Requirements and Obligations Relating to French Language Services”.

s) The first sentence of the last paragraph of section 6.1(b) is deleted and replaced with:

“If applicable, it will be aligned with the LHIN’s then current integrated

health service plan required by LHSIA and will reflect the Funder’s

priorities and initiatives.”

t) In section 6.2(a), “its local” is deleted and replaced with “the”.

u) Section 6.2(b) is deleted and replaced with:

“Integration. The HSP will, separately and in conjunction with the

Funder, other health service providers, if applicable, and

integrated care delivery systems, if applicable, identify

opportunities to integrate the services of the local health system

to provide appropriate, coordinated, effective and efficient

services.”


v) In section 6.3(a)(2), “whether within or outside of the LHIN” is deleted twice and replaced both times with “anywhere”.

w) In section 6.3(b), “section 27 of” and “sections 25 or 27 of” are deleted.

x) Section 6.5 is deleted.

y) In section 8.1(a), “its local” is deleted and replaced with “the”.

z) In section 8.1(a), “as contemplated by LHSIA,” is deleted.

aa) In the last paragraph of section 8.1(b), “, if applicable,” is added before the words “to provide certain services” and “of LHSIA” is added after the words “with section 5(m.2)”.

bb) In section 14.7 “of the LHINs or to the MOHLTC” is deleted and replaced with “agencies or ministries of Her Majesty the Queen in right of Ontario and as otherwise directed by the Ministry.”

cc) The titles LHIN “Chair” and LHIN “CEO” are deleted on the signature page. 2.2 Schedules. The Schedules in effect on March 31, 2020 shall remain in effect until

June 30, 2020, or until such other time as may be agreed to by the Parties. 3.0 Effective Date. The amendments set out in Article 2 shall take effect on March

31, 2020. All other terms of the MSAA shall remain in full force and effect. 4.0 Appendix 1. Appendix 1 is the MSAA, incorporating all of the amendments set

out in section 2.1 above, that is effective March 31, 2020. 5.0 Entire Agreement. This Agreement constitutes the entire agreement between the

Parties with respect to the subject matter contained in this Agreement and supersedes all prior oral or written representations and agreements.

-SIGNATURE PAGE FOLLOWS-


IN WITNESS WHEREOF the Parties have executed this Agreement on the dates set out below. ERIE ST. CLAIR LOCAL HEALTH INTEGRATION NETWORK By: ________________________________ ________________________________ Nicole Robinson, VP- Integrated Delivery Systems Date And by: ________________________________ ________________________________ Bruce Lauckner, Chief Executive Officer Date BLUEWATER HEALTH By: ________________________________ ________________________________ Board Chair Date And by: ________________________________ ________________________________ Mr. Mike Lapaine, President Date & Chief Executive Officer I/We have authority to bind the HSP.

APPENDIX 1 Attached to and forming part of the Amending Agreement between the LHIN and the HSP effective as of March 31, 2020.

MULTI-SECTOR SERVICE ACCOUNTABILITY AGREEMENT

April 1, 2019 to March 31, 2022

SERVICE ACCOUNTABILITY AGREEMENT

with

BLUEWATER HEALTH

Effective Date: April 1, 2019

Index to Agreement

ARTICLE 1.0 - DEFINITIONS & INTERPRETATION ............................................................ 2

ARTICLE 2.0 - TERM AND NATURE OF THIS AGREEMENT ............................................. 9

ARTICLE 3.0 - PROVISION OF SERVICES ......................................................................... 9

ARTICLE 4.0 - FUNDING ................................................................................................... 12

ARTICLE 5.0 - REPAYMENT AND RECOVERY OF FUNDING ......................................... 14

ARTICLE 6.0 - PLANNING & INTEGRATION ..................................................................... 17

ARTICLE 7.0 - PERFORMANCE ........................................................................................ 19

ARTICLE 8.0 - REPORTING, ACCOUNTING AND REVIEW .............................................. 20

ARTICLE 9.0 - ACKNOWLEDGEMENT OF FUNDER SUPPORT ...................................... 23

ARTICLE 10.0 - REPRESENTATIONS, WARRANTIES AND COVENANTS ...................... 24

ARTICLE 11.0 - LIMITATION OF LIABILITY, INDEMNITY & INSURANCE ........................ 25

ARTICLE 12.0 - TERMINATION AND EXPIRY OF AGREEMENT ...................................... 27

ARTICLE 13.0 - NOTICE .................................................................................................... 30

ARTICLE 14.0 - ADDITIONAL PROVISIONS ..................................................................... 31

ARTICLE 15.0 - ENTIRE AGREEMENT ............................................................................. 32

Schedules

A - Total Funder Funding B - Reports C - Directives, Guidelines, and Policies D - Performance E - Project Funding Agreement Template F - Declaration of Compliance

Multi-Sector Service Accountability Agreement April 1, 2019 - March 31, 2022 Page 2 of 38

THIS AGREEMENT effective as of the 1st day of April, 2019

B E T W E E N :

ERIE ST. CLAIR LOCAL HEALTH INTEGRATION NETWORK (the “LHIN”)

- and -

BLUEWATER HEALTH (the “HSP”)

Background:

This service accountability agreement is entered into pursuant to the Local Health System Integration Act, 2006, with the expectation that it will be transferred by means of a transfer order issued by the Minister of Health under the Connecting Care Act, 2019 (the “CCA”), from the LHIN as funder to Ontario Health, which is a Crown agency which, pursuant to the CCA, has the power to provide funding to health service providers and integrated care delivery systems in respect of health services.

The HSP and the Funder are committed to working together, and with others, to achieve evolving provincial priorities including building a connected and sustainable health care system centred around the needs of patients, their families and their caregivers.

In this context, the HSP and the Funder agree that the Funder will provide funding to the HSP on the terms and conditions set out in this Agreement to enable the provision of services to the health system by the HSP. In consideration of their respective agreements set out below, the Funder and the HSP covenant and agree as follows:

ARTICLE 1.0- DEFINITIONS & INTERPRETATION

1.1 Definitions. In this Agreement the following terms will have the following meanings:

“Accountability Agreement” means the accountability agreement, as that term is defined in the Enabling Legislation, in place between the Funder and the Ministry during a Funding Year;

“Active Offer” means the clear and proactive offer of service in French to individuals, from the first point of contact, without placing the responsibility of requesting services in French on the individual;

“Agreement” means this agreement and includes the Schedules and any instrument amending this agreement or the Schedules;


“Annual Balanced Budget” means that, in each Funding Year of the term of this Agreement, the total revenues of the HSP are greater than or equal to the total expenses, from all sources, of the HSP;

“Applicable Law” means all federal, provincial or municipal laws, regulations, common law, orders, rules or by-laws that are applicable to the HSP, the Services, this Agreement and the parties’ obligations under this Agreement during the term of this Agreement;

“Applicable Policy” means any rules, policies, directives, standards of practice or Program Parameters issued or adopted by the Funder, the Ministry or other ministries or agencies of the province of Ontario that are applicable to the HSP, the Services, this Agreement and the parties’ obligations under this Agreement during the term of this Agreement. Without limiting the generality of the foregoing, Applicable Policy includes the other documents identified in Schedule C;

“Board” means:

(a) in respect of an HSP that does not have a Long-Term Care Home Service Accountability Agreement with the Funder and is:

(1) a corporation, the board of directors;

(2) a First Nation, the band council; and

(3) a municipality, the municipal council;

and,

(b) in respect of an HSP that has a Long-Term Care Home Service Accountability Agreement with the Funder and may be:

(1) a corporation, the board of directors;

(2) a First Nation, the band council;

(3) a municipality, the committee of management;

(4) a board of management established by one or more municipalities or by one or more First Nations’ band councils, the members of the board of management;

“BPSAA” means the Broader Public Sector Accountability Act, 2010 and regulations made under it, as it and they may be amended from time to time;

“Budget” means the budget approved by the Funder and appended to this Agreement in Schedule A;

“CCA” means the Connecting Care Act, 2019, and the regulations under it, as it and they may be amended from time to time;

“CEO” means the individual accountable to the Board for the provision of the Services in accordance with the terms of this Agreement;


“Chair” means, if the HSP is:

(a) a corporation, the Chair of the Board;

(b) a First Nation, the Chief; and

(c) a municipality, the Mayor,

or such other person properly authorized by the Board or under Applicable Law;

“Compliance Declaration” means a compliance declaration substantially in the form set out in Schedule F;

“Confidential Information” means information that is marked or otherwise identified as confidential by the disclosing party at the time the information is provided to the receiving party. Confidential Information does not include information that: (a) was known to the receiving party prior to receiving the information from the disclosing party; (b) has become publicly known through no wrongful act of the receiving party; or (c) is required to be disclosed by law, provided that the receiving party provides Notice in a timely manner of such requirement to the disclosing party, consults with the disclosing party on the proposed form and nature of the disclosure, and ensures that any disclosure is made in strict accordance with Applicable Law;

“Conflict of Interest” in respect of an HSP, includes any situation or circumstance where: in relation to the performance of its obligations under this Agreement:

(a) the HSP;

(b) a member of the HSP’s Board; or

(c) any person employed by the HSP who has the capacity to influence the HSP’s decision,

has other commitments, relationships or financial interests that:

(a) could or could be seen to interfere with the HSP’s objective, unbiased and impartial exercise of its judgement; or

(b) could or could be seen to compromise, impair or be incompatible with the effective performance of its obligations under this Agreement;

“Controlling Shareholder” of a corporation means a shareholder who or which holds (or another person who or which holds for the benefit of such shareholder), other than by way of security only, voting securities of such corporation carrying more than 50% of the votes for the election of directors, provided that the votes carried by such securities are sufficient, if exercised, to elect a majority of the board of directors of such corporation;

“Days” means calendar days;

“Designated” means designated as a public service agency under the FLSA;


“Digital Health” means the coordinated and integrated use of electronic systems, information and communication technologies to facilitate the collection, exchange and management of personal health information in order to improve the quality, access, productivity and sustainability of the healthcare system;

“Effective Date” means April 1, 2019;

“Enabling Legislation” before the date a Transfer Order takes effect means LHSIA, and after the date a Transfer Order takes effect means the CCA;

“Explanatory Indicator” means a measure that is connected to and helps to explain performance in a Performance Indicator or a Monitoring Indicator. An Explanatory Indicator may or may not be a measure of the HSP’s performance. No Performance Target is set for an Explanatory Indicator;

“Factors Beyond the HSP’s Control” include occurrences that are, in whole or in part, caused by persons, entities or events beyond the HSP’s control. Examples may include, but are not limited to, the following:

(a) significant costs associated with complying with new or amended Government of Ontario technical standards, guidelines, policies or legislation;

(b) the availability of health care in the community (hospital care, long-term care, home care, and primary care);

(c) the availability of health human resources; arbitration decisions that affect HSP employee compensation packages, including wage, benefit and pension compensation, which exceed reasonable HSP planned compensation settlement increases and in certain cases non-monetary arbitration awards that significantly impact upon HSP operational flexibility; and

(d) catastrophic events, such as natural disasters and infectious disease outbreaks;

“FIPPA” means the Freedom of Information and Protection of Privacy Act (Ontario) and the regulations made under it as it and they may be amended from time to time;

“FLSA” means the French Language Services Act and the regulations made under it as it and they may be amended from time to time;

“Funder” before the date a Transfer Order takes effect means the LHIN, and after the date a Transfer Order takes effect means Ontario Health;

“Funding” means the amounts of money provided by the Funder to the HSP in each Funding Year of this Agreement;

“Funding Year” means in the case of the first Funding Year, the period commencing on the Effective Date and ending on the following March 31, and in the case of Funding Years subsequent to the first Funding Year, the period


commencing on the date that is April 1 following the end of the previous Funding Year and ending on the following March 31;

“Health System Funding Reform” has the meaning ascribed to it in the Accountability Agreement, and is a funding strategy that features quality-based funding to facilitate fiscal sustainability through high quality, evidence-based and patient-centred care;

“HSP’s Personnel and Volunteers” means the Controlling Shareholders (if any), directors, officers, employees, agents, volunteers and other representatives of the HSP. In addition to the foregoing, HSP’s Personnel and Volunteers shall include the contractors and subcontractors and their respective shareholders, directors, officers, employees, agents, volunteers or other representatives;

“Identified” means identified by the Funder or the Ministry to provide French language services;

“Indemnified Parties” means the Funder and its officers, employees, directors, independent contractors, subcontractors, agents, successors and assigns and Her Majesty the Queen in right of Ontario and Her Ministers, appointees and employees, independent contractors, subcontractors, agents and assigns. Indemnified Parties also includes any person participating on behalf of the Funder in a Review;

“Interest Income” means interest earned on the Funding;

“LHSIA” means the Local Health System Integration Act, 2006, and the regulations made under it, as it and they may be amended from time to time;

“Mandate Letter” has the meaning ascribed to it in the Memorandum of Understanding between the Ministry and the Funder, and means a letter from the Ministry to the Funder establishing priorities in accordance with the Premier’s mandate letter to the Ministry;

“Minister” means such minister of the Crown as may be designated as the responsible minister in relation to this Agreement or in relation to any subject matter under this Agreement, as the case may be, in accordance with the Executive Council Act, as amended;

“Ministry” means, as the context requires, the Minister or the Ministry of Health and Long-Term Care or such other ministry as may be designated in accordance with Applicable Law as the ministry responsible in relation to the relevant matter or the Minister of that ministry, as the context requires;

“Monitoring Indicator” means a measure of HSP performance that may be monitored against provincial results or provincial targets, but for which no Performance Target is set;


“MSAA Indicator Technical Specifications document” means, as the context requires, either or both of the document entitled “Multi-Sector Service Accountability Agreement (MSAA) 2019-20 Indicator Technical Specifications November 5, 2018 Version 1.3” and the document entitled “Multi-Sector Service Accountability Agreement (MSAA) 2019-20 Target and Corridor-Setting Guidelines” as they may be amended or replaced from time to time;

“Notice” means any notice or other communication required to be provided pursuant to this Agreement or the Enabling Legislation;

“Ontario Health” means the corporation without share capital under the name Ontario Health as continued under the CCA;

“Performance Agreement” means an agreement between an HSP and its CEO that requires the CEO to perform in a manner that enables the HSP to achieve the terms of this Agreement and any additional performance improvement targets set out in the HSP’s annual quality improvement plan under the Excellent Care for All Act, 2010;

“Performance Corridor” means the acceptable range of results around a Performance Target;

“Performance Factor” means any matter that could or will significantly affect a party’s ability to fulfill its obligations under this Agreement;

“Performance Indicator” means a measure of HSP performance for which a Performance Target is set; technical specifications of specific Performance Indicators can be found in the MSAA Indicator Technical Specifications document;

“Performance Standard” means the acceptable range of performance for a Performance Indicator or a Service Volume that results when a Performance Corridor is applied to a Performance Target;

“Performance Target” means the level of performance expected of the HSP in respect of a Performance Indicator or a Service Volume;

“person or entity” includes any individual and any corporation, partnership, firm, joint venture or other single or collective form of organization under which business may be conducted;

“Planning Submission” or “CAPS” or “Community Accountability Planning Submission” means the HSP Board approved planning document submitted by the HSP to the Funder. The form, content and scheduling of the Planning Submission will be identified by the Funder;

“Program Parameter” means, in respect of a program, the provincial standards (such as operational, financial or service standards and policies, operating


manuals and program eligibility), directives, guidelines and expectations and requirements for that program;

“Project Funding Agreement” means an agreement in the form of Schedule D that incorporates the terms of this Agreement and enables the Funder to provide one-time or short term funding for a specific project or service that is not already described in the Schedules;

“Reports” means the reports described in Schedule B as well as any other reports or information required to be provided under the Enabling Legislation or this Agreement;

“Review” means a financial or operational audit, investigation, inspection or other form of review requested or required by the Funder under the terms of the Enabling Legislation or this Agreement, but does not include the annual audit of the HSP’s financial statements;

“Schedule” means any one, and “Schedules” mean any two or more, as the context requires, of the schedules appended to this Agreement including the following:

Schedule A: Total Funder Funding;

Schedule B: Reports;

Schedule C: Directives, Guidelines and Policies;

Schedule D: Performance;

Schedule E: Project Funding Agreement Template; and

Schedule F: Declaration of Compliance.

“Service Plan” means the Operating Plan and Budget appended as Schedules A and D2a of Schedule D;

“Services” means the care, programs, goods and other services described by reference to the Ontario Healthcare Reporting Standards functional centres in Schedule D2a of Schedule D, and in any Project Funding Agreement executed pursuant to this Agreement, and includes the type, volume, frequency and availability of the care, programs, goods and other services;

“Service Volume” means a measure of Services for which a Performance Target is set;

“Transfer Order” means a transfer order issued pursuant to subsection 40(1) of the CCA transferring this Agreement from the LHIN to Ontario Health;

“Transition Plan” means a transition plan, acceptable to the Funder that indicates how the needs of the HSP’s clients will be met following the termination of this


Agreement and how the transition of the clients to new service providers will be effected in a timely manner; and

“2014-18 MSAA” means the Multi-Sector Service Accountability Agreement April 1, 2014 to March 31, 2018.

1.2 Interpretation. Words in the singular include the plural and vice-versa. Words in one gender include all genders. The words “including” and “includes” are not intended to be limiting and shall mean “including without limitation” or “includes without limitation”, as the case may be. The headings do not form part of this Agreement. They are for convenience of reference only and will not affect the interpretation of this Agreement. Terms used in the Schedules shall have the meanings set out in this Agreement unless separately and specifically defined in a Schedule in which case the definition in the Schedule shall govern for the purposes of that Schedule.

1.3 MSAA Indicator Technical Specification Document. This Agreement shall be interpreted with reference to the MSAA Indicator Technical Specifications document.

ARTICLE 2.0- TERM AND NATURE OF THIS AGREEMENT

2.1 Term. The term of this Agreement will commence on the Effective Date and will expire on March 31, 2022 unless terminated earlier or extended pursuant to its terms.

2.2 A Service Accountability Agreement. This Agreement is a service accountability agreement for the purposes of the Enabling Legislation.

ARTICLE 3.0 - PROVISION OF SERVICES

3.1 Provision of Services.

(a) The HSP will provide the Services in accordance with, and otherwise comply with:

the terms of this Agreement, including the Service Plan;

Applicable Law; and

Applicable Policy.

(b) When providing the Services, the HSP will meet the Performance Standards and conditions identified in Schedule D and any applicable Project Funding Agreements.

(c) Unless otherwise provided in this Agreement, the HSP will not reduce, stop, start, expand, cease to provide or transfer the provision of the Services or change its Service Plan except with Notice to the Funder, and if required by Applicable Law or Applicable Policy, the prior written consent of the Funder.


(d) The HSP will not restrict or refuse the provision of Services to an individual, directly or indirectly, based on the geographic area in which the person resides in Ontario.

(e) The HSP will not withdraw any Services from a patient with complex needs who continues to require those Services, unless prior to discharging that patient from the Services, the HSP has made alternate arrangements for equivalent services to be delivered to that patient.

3.2 Subcontracting for the Provision of Services.

(a) The parties acknowledge that, subject to the provisions of the Enabling Legislation, the HSP may subcontract the provision of some or all of the Services. For the purposes of this Agreement, actions taken or not taken by the subcontractor, and Services provided by the subcontractor, will be deemed actions taken or not taken by the HSP, and Services provided by the HSP.

(b) When entering into a subcontract the HSP agrees that the terms of the subcontract will enable the HSP to meet its obligations under this Agreement. Without limiting the foregoing, the HSP will include a provision that permits the Funder or its authorized representatives, to audit the subcontractor in respect of the subcontract if the Funder or its authorized representatives determines that such an audit would be necessary to confirm that the HSP has complied with the terms of this Agreement.

(c) Nothing contained in this Agreement or a subcontract will create a contractual relationship between any subcontractor or its directors, officers, employees, agents, partners, affiliates or volunteers and the Funder.

(d) When entering into a subcontract, the HSP agrees that the terms of the subcontract will enable the HSP to meet its obligations under the FLSA.

3.3 Conflict of Interest. The HSP will use the Funding, provide the Services and otherwise fulfil its obligations under this Agreement, without an actual, potential or perceived Conflict of Interest. The HSP will disclose to the Funder without delay any situation that a reasonable person would interpret as an actual, potential or perceived Conflict of Interest and comply with any requirements prescribed by the Funder to resolve any Conflict of Interest.

3.4 Digital Health. The HSP agrees to:

(a) assist the Funder to implement Digital Health priorities of the Funder;

(b) comply with any technical and information management standards, including those related to data, architecture, technology, privacy and security set for health service providers by the Ministry or the Funder within the timeframes set by the Ministry or the Funder as the case may be;

(c) implement and use the approved provincial Digital Health solutions identified by the Funder;

(d) implement technology solutions that are compatible or interoperable with the provincial blueprint and with the Funder’s Digital Health priorities; and


(e) include in its annual Planning Submissions, plans for achieving Digital Health priority initiatives.

3.5 French Language Services.

3.5.1 The Funder will provide the Ministry “Guide to Requirements and Obligations Relating to French Language Services” to the HSP and the HSP will fulfill its roles, responsibilities and other obligations set out therein.

3.5.2 If Not Identified or Designated. If the HSP has not been Designated or Identified it will:

(a) develop and implement a plan to address the needs of the local Francophone community, including the provision of information on services available in French;

(b) work towards applying the principles of Active Offer in the provision of services;

(c) provide a report to the Funder that outlines how the HSP addresses the needs of its local Francophone community; and

(d) collect and submit to the Funder as requested by the Funder from time to time, French language service data.

3.5.3 If Identified. If the HSP is Identified, it will:

(a) work towards applying the principles of Active Offer in the provision of services;

(b) provide services to the public in French in accordance with its existing French language services capacity;

(c) develop, and provide to the Funder upon request from time to time, a plan to become Designated by the date agreed to by the HSP and the Funder;

(d) continuously work towards improving its capacity to provide services in French and toward becoming Designated within the time frame agreed to by the parties;

(e) provide a report to the Funder that outlines progress in its capacity to provide services in French and toward becoming Designated;

(f) annually, provide a report to the Funder that outlines how it addresses the needs of its local Francophone community; and

(g) collect and submit to the Funder, as requested by the Funder from time to time, French language services data.

3.5.4 If Designated. If the HSP is Designated, it will:

(a) apply the principles of Active Offer in the provision of services; (b) continue to provide services to the public in French in accordance with the

provisions of the FLSA; (c) maintain its French language services capacity; (d) submit a French language implementation report to the Funder on the date

specified by the Funder, and thereafter, on each anniversary of that date, or on such other dates as the Funder may, by Notice, require; and


(e) collect and submit to the Funder as requested by the Funder from time to time, French language services data.

3.6 Mandate Letter language. The Funder will receive a Mandate Letter from the Ministry annually. Each Mandate Letter articulates areas of focus for the Funder, and the Ministry’s expectation that the Funder and health service providers it funds will collaborate to advance these areas of focus. To assist the HSP in its collaborative efforts with the Funder, the Funder will share each relevant Mandate Letter with the HSP. The Funder may also add local obligations to Schedule D as appropriate to further advance any priorities set put in a Mandate Letter.

3.7 Policies, Guidelines, Directives and Standards. Either the Funder or the Ministry will give the HSP Notice of any amendments to the manuals, guidelines or policies identified in Schedule C. An amendment will be effective in accordance with the terms of the amendment. By signing a copy of this Agreement the HSP acknowledges that it has a copy of the documents identified in Schedule C.

ARTICLE 4.0 - FUNDING

4.1 Funding. Subject to the terms of this Agreement, and in accordance with the applicable provisions of the Accountability Agreement, the Funder:

(a) will provide the funds identified in Schedule A to the HSP for the purpose of providing or ensuring the provision of the Services; and

(b) will deposit the funds in regular instalments, once or twice monthly, over the term of this Agreement, into an account designated by the HSP provided that the account resides at a Canadian financial institution and is in the name of the HSP.

4.2 Limitation on Payment of Funding. Despite section 4.1, the Funder:

(a) will not provide any funds to the HSP until this Agreement is fully executed;

(b) may pro-rate the funds identified in Schedule A to the date on which this Agreement is signed, if that date is after April 1;

(c) will not provide any funds to the HSP until the HSP meets the insurance requirements described in section 11.4;

(d) will not be required to continue to provide funds in the event the HSP breaches any of its obligations under this Agreement, until the breach is remedied to the Funder’s satisfaction; and

(e) upon Notice to the HSP, may adjust the amount of funds it provides to the HSP in any Funding Year based upon the Funder’s assessment of the information contained in the Reports.

4.3 Appropriation. Funding under this Agreement is conditional upon an appropriation of moneys by the Legislature of Ontario to the Ministry and funding of the Funder by the Ministry pursuant to the Enabling Legislation. If the Funder does not receive its


anticipated funding the Funder will not be obligated to make the payments required by this Agreement.

4.4 Additional Funding.

(a) Unless the Funder has agreed to do so in writing, the Funder is not required to provide additional funds to the HSP for providing additional Services or for exceeding the requirements of Schedule D.

(b) The HSP may request additional funding by submitting a proposal to amend its Service Plan. The HSP will abide by all decisions of the Funder with respect to a proposal to amend the Service Plan and will make whatever changes are requested or approved by the Funder. The Service Plan will be amended to include any approved additional funding.

(c) Funding Increases. Before the Funder can make an allocation of additional funds to the HSP, the parties will:

(1) agree on the amount of the increase;

(2) agree on any terms and conditions that will apply to the increase; and

(3) execute an amendment to this Agreement that reflects the agreement reached.

4.5 Conditions of Funding.

(a) The HSP will:

fulfill all obligations in this Agreement;

use the Funding only for the purpose of providing the Services in accordance with Applicable Law, Applicable Policy and the terms of this Agreement;

spend the Funding only in accordance with the Service Plan; and

plan for and achieve an Annual Balanced Budget.

(b) The Funder may add such additional terms or conditions on the use of the Funding which it considers appropriate for the proper expenditure and management of the Funding.

(c) All Funding is subject to all Applicable Law and Applicable Policy, including Health System Funding Reform, as it may evolve or be replaced over the term of this Agreement.

4.6 Interest.

(a) If the Funder provides the Funding to the HSP prior to the HSP’s immediate need for the Funding, the HSP shall place the Funding in an interest bearing account in the name of the HSP at a Canadian financial institution.

(b) Interest Income must be used, within the fiscal year in which it is received, to provide the Services.


(c) Interest Income will be reported to the Funder and is subject to year-end reconciliation. In the event that some or all of the Interest Income is not used to provide the Services, the Funder may take one or more of the following actions:

the Funder may deduct the amount equal to the unused Interest Income from any further Funding instalments under this or any other agreement with the HSP;

the Funder may require the HSP to pay an amount equal to the unused Interest Income to the Ministry of Finance.

4.7 Rebates, Credits and Refunds. The HSP:

(a) acknowledges that rebates, credits and refunds it anticipates receiving from the use of the Funding have been incorporated in its Budget;

(b) agrees that it will advise the Funder if it receives any unanticipated rebates, credits and refunds from the use of the Funding, or from the use of funding received from either the Funder or the Ministry in years prior to this Agreement that was not recorded in the year of the related expenditure; and

(c) agrees that all rebates, credits and refunds referred to in (b) will be considered Funding in the year that the rebates, credits and refunds are received, regardless of the year to which the rebates, credits and refunds relate.

4.8 Procurement of Goods and Services.

(a) If the HSP is subject to the procurement provisions of the BPSAA, the HSP will abide by all directives and guidelines issued by the Management Board of Cabinet that are applicable to the HSP pursuant to the BPSAA.

(b) If the HSP is not subject to the procurement provisions of the BPSAA, the HSP will have a procurement policy in place that requires the acquisition of supplies, equipment or services valued at over $25,000 through a competitive process that ensures the best value for funds expended. If the HSP acquires supplies, equipment or services with the Funding it will do so through a process that is consistent with this policy.

4.9 Disposition. The HSP will not, without the Funder’s prior written consent, sell, lease or otherwise dispose of any assets purchased with Funding, the cost of which exceeded $25,000 at the time of purchase.

ARTICLE 5.0 - REPAYMENT AND RECOVERY OF FUNDING

5.1 Repayment and Recovery.

(a) At the End of a Funding Year. If, in any Funding Year, the HSP has not spent all of the Funding the Funder will require the repayment of the unspent Funding.

(b) On Termination or Expiration of this Agreement. Upon termination or expiry of this Agreement and subject to section 12.4, the Funder will require the


repayment of any Funding remaining in the possession or under the control of the HSP and the payment of an amount equal to any Funding the HSP used for purposes not permitted by this Agreement. The Funder will act reasonably and will consider the impact, if any, that a recovery of Funding will have on the HSP’s ability to meet its obligations under this Agreement.

(c) On Reconciliation and Settlement. If the year-end reconciliation and settlement process demonstrates that the HSP received Funding in excess of its confirmed funds, the Funder will require the repayment of the excess Funding.

(d) As a Result of Performance Management or System Planning. If Services are adjusted, as a result of the performance management or system planning processes, the Funder may take one or more of the following actions:

adjust the Funding to be paid under Schedule A,

require the repayment of excess Funding;

adjust the amount of any future funding installments accordingly.

(e) In the Event of Forecasted Surpluses. If the HSP is forecasting a surplus, the Funder may take one or more of the following actions:

adjust the amount of Funding to be paid under Schedule A,

require the repayment of excess Funding;

adjust the amount of any future funding installments accordingly.

(f) On the Request of the Funder. The HSP will, at the request of the Funder, repay the whole or any part of the Funding, or an amount equal thereto if the HSP:

has provided false information to the Funder knowing it to be false;

breaches a term or condition of this Agreement and does not, within 30 Days after receiving Notice from the Funder take reasonable steps to remedy the breach; or

breaches any Applicable Law that directly relates to the provision of, or ensuring the provision of, the Services.

(g) Sections 5.1(c) and (d) do not apply to Funding already expended properly in accordance with this Agreement. The Funder will, at its sole discretion, and without liability or penalty, determine whether the Funding has been expended properly in accordance with this Agreement.

5.2 Provision for the Recovery of Funding. The HSP will make reasonable and prudent provision for the recovery by the Funder of any Funding for which the conditions of Funding set out in section 4.5 are not met and will hold this Funding in accordance with the provisions of section 4.6 until such time as reconciliation and settlement has


occurred with the Funder. Interest earned on Funding will be reported and recovered in accordance with section 4.6.

5.3 Process for Recovery of Funding. If the Funder, acting reasonably, determines that a recovery of Funding under section 5.1 is appropriate, then the Funder will give 30 Days’ Notice to the HSP.

The Notice will describe:

the amount of the proposed recovery;

the term of the recovery, if not permanent;

the proposed timing of the recovery;

the reasons for the recovery; and

the amendments, if any, that the Funder proposes be made to the HSP’s obligations under this Agreement.

Where the HSP disputes any matter set out in the Notice, the parties will discuss the circumstances that resulted in the Notice and the HSP may make representations to the Funder about the matters set out in the Notice within 14 Days of receiving the Notice.

The Funder will consider the representations made by the HSP and will advise the HSP of its decision. Funding recoveries, if any, will occur in accordance with the timing set out in the Funder’s decision. No recovery of Funding will be implemented earlier than 30 Days after the delivery of the Notice.

(a) Settlement and Recovery of Funding for Prior Years.

(a) The HSP acknowledges that settlement and recovery of Funding can occur up to 7 years after the provision of Funding.

(b) Recognizing the transition of responsibilities from the Ministry to the Funder, the HSP agrees that if the parties are directed in writing to do so by the Ministry, the Funder will settle and recover funding provided by the Ministry to the HSP prior to the transition of the Funding for the Services to the Funder, provided that such settlement and recovery occurs within 7 years of the provision of the funding by the Ministry. All such settlements and recoveries will be subject to the terms applicable to the original provision of Funding.

5.4 Debt Due.

(a) If the Funder requires the re-payment by the HSP of any Funding, the amount required will be deemed to be a debt owing to the Crown by the HSP. The Funder may adjust future funding instalments to recover the amounts owed or may, at its discretion direct the HSP to pay the amount owing to the Crown and the HSP shall comply immediately with any such direction.


(b) All amounts repayable to the Crown will be paid by cheque payable to the “Ontario Minister of Finance” and mailed or delivered to the Funder at the address provided in section 13.1.

5.5 Interest Rate. The Funder may charge the HSP interest on any amount owing by the HSP at the then current interest rate charged by the Province of Ontario on accounts receivable.

ARTICLE 6.0 - PLANNING & INTEGRATION

6.1 Planning for Future Years.

(a) Advance Notice. The Funder will give at least 60 Days’ Notice to the HSP of the date by which a CAPS must be submitted to the Funder.

(b) Multi-Year Planning. The CAPS will be in a form acceptable to the Funder and may be required to incorporate:

(1) prudent multi-year financial forecasts;

(2) plans for the achievement of Performance Targets; and

(3) realistic risk management strategies.

If applicable, it will be aligned with the LHIN’s then current integrated health service plan required by LHSIA and will reflect the Funder’s priorities and initiatives. If the Funder has provided multi-year planning targets for the HSP, the CAPS will reflect the planning targets.

(c) Multi-year Planning Targets. Schedule A may reflect an allocation for the first Funding Year of this Agreement as well as planning targets for up to two additional years, consistent with the term of this Agreement. In such an event,

the HSP acknowledges that if it is provided with planning targets, these targets:

a. are targets only,

b. are provided solely for the purposes of planning,

c. are subject to confirmation, and

d. may be changed at the discretion of the Funder in consultation with the HSP.

The HSP will proactively manage the risks associated with multi-year planning and the potential changes to the planning targets; and

the Funder agrees that it will communicate any changes to the planning targets as soon as reasonably possible.

(d) Service Accountability Agreements. The HSP acknowledges that if the Funder and the HSP enter into negotiations for a subsequent service accountability agreement, subsequent funding may be interrupted if the next service accountability agreement is not executed on or before the expiration date of this Agreement.


6.2 Community Engagement & Integration Activities.

(a) Community Engagement. The HSP will engage the community of diverse persons and entities in the area where it provides health services when setting priorities for the delivery of health services and when developing plans for submission to the Funder including but not limited to CAPS and integration proposals. As part of its community engagement activities, the HSPs will have in place and utilize effective mechanisms for engaging families, caregivers, clients, residents, patients and other individuals who use the services of the HSP, to help inform the HSP plans, including the HSP’s contribution to the establishment and implementation by the Funder of geographic sub-regions in the health system.

(b) Integration. The HSP will, separately and in conjunction with the Funder, other health service providers, if applicable, and integrated care delivery systems, if applicable, identify opportunities to integrate the services of the local health system to provide appropriate, coordinated, effective and efficient services.

(c) Reporting. The HSP will report on its community engagement and integration activities, using any templates provided by the Funder, as requested by the Funder and in any event, in its year-end report to the Funder.

6.3 Planning and Integration Activity Pre-proposals.

(a) General. A pre-proposal process has been developed to: (A) reduce the costs incurred by an HSP when proposing operational or service changes; (B) assist the HSP to carry out its statutory obligations; and (C) enable an effective and efficient response by the Funder. Subject to specific direction from the Funder, this pre-proposal process will be used in the following instances:

the HSP is considering an integration or an integration of services, as defined in the Enabling Legislation between the HSP and another person or entity;

the HSP is proposing to reduce, stop, start, expand or transfer the location of services, which for certainty includes: the transfer of services from the HSP to another person or entity anywhere; and the relocation or transfer of services from one of the HSP’s sites to another of the HSP’s sites anywhere;

to identify opportunities to integrate the services of the local health system, other than those identified in (A) or (B) above; or

if requested by the Funder.

(b) Funder Evaluation of the Pre-proposal. Use of the pre-proposal process is not formal Notice of a proposed integration under the Enabling Legislation. Funder consent to develop the project concept outlined in a pre-proposal does not constitute approval to proceed with the project. Nor does the Funder consent to develop a project concept presume the issuance of a favourable decision, should such a decision be required by the Enabling Legislation. Following the Funder’s review and evaluation, the HSP may be invited to submit a detailed proposal and a business plan for further analysis. Guidelines for the development of a detailed proposal and business case will be provided by the Funder.


6.4 Proposing Integration Activities in the Planning Submission. No integration activity described in section 6.3 may be proposed in a CAPS unless the Funder has consented, in writing, to its inclusion pursuant to the process set out in section 6.3(b).

ARTICLE 7.0- PERFORMANCE

7.1 Performance. The parties will strive to achieve on-going performance improvement. They will address performance improvement in a proactive, collaborative and responsive manner.

7.2 Performance Factors.

(a) Each party will notify the other party of the existence of a Performance Factor, as soon as reasonably possible after the party becomes aware of the Performance Factor. The Notice will:

describe the Performance Factor and its actual or anticipated impact;

include a description of any action the party is undertaking, or plans to undertake, to remedy or mitigate the Performance Factor;

indicate whether the party is requesting a meeting to discuss the Performance Factor; and

address any other issue or matter the party wishes to raise with the other party.

(b) The recipient party will provide a written acknowledgment of receipt of the Notice within 7 Days of the date on which the Notice was received (“Date of the Notice”).

(c) Where a meeting has been requested under paragraph 7.2(a)(3), the parties agree to meet and discuss the Performance Factors within 14 Days of the Date of the Notice, in accordance with the provisions of section 7.3.

7.3 Performance Meetings. During a meeting on performance, the parties will:

(a) discuss the causes of a Performance Factor;

(b) discuss the impact of a Performance Factor on the local health system and the risk resulting from non-performance; and

(c) determine the steps to be taken to remedy or mitigate the impact of the Performance Factor (the “Performance Improvement Process”).

7.4 The Performance Improvement Process.

(a) The Performance Improvement Process will focus on the risks of non-performance and problem-solving. It may include one or more of the following actions:


a requirement that the HSP develop and implement an improvement plan that is acceptable to the Funder;

the conduct of a Review;

an amendment of the HSP’s obligations;

an in-year, or year-end, adjustment to the Funding,

among other possible means of responding to the Performance Factor or improving performance.

(b) Any performance improvement process begun under a prior service accountability agreement that was not completed under the prior agreement will continue under this Agreement. Any performance improvement required by a Funder under a prior service accountability agreement will be deemed to be a requirement of this Agreement until fulfilled or waived by the Funder.

7.5 Factors Beyond the HSP’s Control. Despite the foregoing, if the Funder, acting reasonably, determines that the Performance Factor is, in whole or in part, a Factor Beyond the HSP’s Control:

(a) the Funder will collaborate with the HSP to develop and implement a mutually agreed upon joint response plan which may include an amendment of the HSP’s obligations under this Agreement;

(b) the Funder will not require the HSP to prepare an Improvement Plan; and

(c) the failure to meet an obligation under this Agreement will not be considered a breach of this Agreement to the extent that failure is caused by a Factor Beyond the HSP’s Control.

ARTICLE 8.0 - REPORTING, ACCOUNTING AND REVIEW

8.1 Reporting.

(a) Generally. The Funder’s ability to enable the health system to provide appropriate, co-ordinated, effective and efficient health services, is heavily dependent on the timely collection and analysis of accurate information. The HSP acknowledges that the timely provision of accurate information related to the HSP, and its performance of its obligations under this Agreement, is under the HSP’s control.

(b) Specific Obligations. The HSP:

will provide to the Funder, or to such other entity as the Funder may direct, in the form and within the time specified by the Funder, the Reports, other than personal health information as defined in the Enabling Legislation, that the Funder requires for the purposes of exercising its powers and duties under this Agreement, the Accountability Agreement, the Enabling Legislation or for the purposes that are prescribed under any Applicable Law;

will fulfil the specific reporting requirements set out in Schedule B;


will ensure that every Report is complete, accurate, signed on behalf of the HSP by an authorized signing officer where required and provided in a timely manner and in a form satisfactory to the Funder; and

agrees that every Report submitted to the Funder by or on behalf of the HSP, will be deemed to have been authorized by the HSP for submission.

For certainty, nothing in this section 8.1 or in this Agreement restricts or otherwise limits the Funder’s right to access or to require access to personal health information as defined in the Enabling Legislation, in accordance with Applicable Law for purposes of carrying out the Funder’s statutory objects to achieve the purposes of the Enabling Legislation, including, if applicable, to provide certain services, supplies and equipment in accordance with section 5(m.1) of LHSIA and to manage placement of persons in accordance with section 5(m.2) of LHSIA.

(c) French Language Services. If the HSP is required to provide services to the public in French under the provisions of the FLSA, the HSP will be required to submit a French language services report to the Funder. If the HSP is not required to provide services to the public in French under the provisions of the FLSA, it will be required to provide a report to the Funder that outlines how the HSP addresses the needs of its local Francophone community.

(d) Declaration of Compliance. Within 90 Days of the HSP’s fiscal year-end, the Board will issue a Compliance Declaration declaring that the HSP has complied with the terms of this Agreement. The form of the declaration is set out in Schedule F and may be amended by the Funder from time to time through the term of this Agreement.

(e) Financial Reductions. Notwithstanding any other provision of this Agreement, and at the discretion of the Funder, the HSP may be subject to a financial reduction in any of the following circumstances:

its CAPS is received after the due date;

its CAPS is incomplete;

the quarterly performance reports are not provided when due; or

financial or clinical data requirements are late, incomplete or inaccurate,

where the errors or delay were not as a result of Funder actions or inaction or the actions or inactions of persons acting on behalf of the Funder. If assessed, the financial reduction will be as follows:

if received within 7 Days after the due date, incomplete or inaccurate, the financial penalty will be the greater of (1) a reduction of 0.02 percent (0.02%) of the Funding; or (2) two hundred and fifty dollars ($250.00); and

for every full or partial week of non-compliance thereafter, the rate will be one half of the initial reduction.


8.2 Reviews.

(a) During the term of this Agreement and for 7 years after the term of this Agreement, the HSP agrees that the Funder or its authorized representatives may conduct a Review of the HSP to confirm the HSP’s fulfillment of its obligations under this Agreement. For these purposes the Funder or its authorized representatives may, upon 24 hours’ Notice to the HSP and during normal business hours enter the HSP’s premises to:

inspect and copy any financial records, invoices and other finance-related documents, other than personal health information as defined in the Enabling Legislation, in the possession or under the control of the HSP which relate to the Funding or otherwise to the Services; and

inspect and copy non-financial records, other than personal health information as defined in the Enabling Legislation, in the possession or under the control of the HSP which relate to the Funding, the Services or otherwise to the performance of the HSP under this Agreement.

(b) The cost of any Review will be borne by the HSP if the Review: (1) was made necessary because the HSP did not comply with a requirement under the Enabling Legislation or this Agreement; or (2) indicates that the HSP has not fulfilled its obligations under this Agreement, including its obligations under Applicable Law and Applicable Policy.

(c) To assist in respect of the rights set out in (a) above, the HSP shall disclose any information requested by the Funder or its authorized representatives, and shall do so in a form requested by the Funder or its authorized representatives.

(d) The HSP may not commence a proceeding for damages or otherwise against any person with respect to any act done or omitted to be done, any conclusion reached or report submitted that is done in good faith in respect of a Review.

8.3 Document Retention and Record Maintenance. The HSP will

(a) retain all records (as that term is defined in FIPPA) related to the HSP’s performance of its obligations under this Agreement for 7 years after the termination or expiration of the term of this Agreement;

(b) keep all financial records, invoices and other finance-related documents relating to the Funding or otherwise to the Services in a manner consistent with either generally accepted accounting principles or international financial reporting standards as advised by the HSP’s auditor; and

(c) keep all non-financial documents and records relating to the Funding or otherwise to the Services in a manner consistent with all Applicable Law.

8.4 Disclosure of Information.

(a) FIPPA. The HSP acknowledges that the Funder is bound by FIPPA and that any information provided to the Funder in connection with this Agreement may be subject to disclosure in accordance with FIPPA.


(b) Confidential Information. The parties will treat Confidential Information as confidential and will not disclose Confidential Information except with the consent of the disclosing party or as permitted or required under FIPPA or the Personal Health Information Protection Act, 2004, the Enabling Legislation, court order, subpoena or other Applicable Law. Notwithstanding the foregoing, the Funder may disclose information that it collects under this Agreement in accordance with the Enabling Legislation.

8.5 Transparency. The HSP will post a copy of this Agreement and each Compliance Declaration submitted to the Funder during the term of this Agreement in a conspicuous and easily accessible public place at its sites of operations to which this Agreement applies and on its public website, if the HSP operates a public website.

8.6 Auditor General. For greater certainty the Funder’s rights under this article are in addition to any rights provided to the Auditor General under the Auditor General Act (Ontario).

ARTICLE 9.0 - ACKNOWLEDGEMENT OF FUNDER SUPPORT

9.1 Publication. For the purposes of this Article 9, the term “publication” means any material on or concerning the Services that the HSP makes available to the public, regardless of whether the material is provided electronically or in hard copy. Examples include a website, an advertisement, a brochure, promotional documents and a report. Materials that are prepared by the HSP in order to fulfil its reporting obligations under this Agreement are not included in the term “publication”.

9.2 Acknowledgment of Funding Support.

(a) The HSP agrees all publications will include

an acknowledgment of the Funding provided by the Funder and the Government of Ontario. Prior to including an acknowledgement in any publication, the HSP will obtain the Funder’s approval of the form of acknowledgement. The Funder may, at its discretion, decide that an acknowledgement is not necessary; and

a statement indicating that the views expressed in the publication are the views of the HSP and do not necessarily reflect those of the Funder or the Government of Ontario.

(b) The HSP shall not use any insignia or logo of Her Majesty the Queen in right of Ontario, including those of the Funder, unless it has received the prior written permission of the Funder to do so.


ARTICLE 10.0 - REPRESENTATIONS, WARRANTIES AND COVENANTS

10.1 General. The HSP represents, warrants and covenants that:

(a) it is, and will continue for the term of this Agreement to be, a validly existing legal entity with full power to fulfill its obligations under this Agreement;

(b) it has the experience and expertise necessary to carry out the Services;

(c) it holds all permits, licences, consents, intellectual property rights and authorities necessary to perform its obligations under this Agreement;

(d) all information (including information relating to any eligibility requirements for Funding) that the HSP provided to the Funder in support of its request for Funding was true and complete at the time the HSP provided it, and will, subject to the provision of Notice otherwise, continue to be true and complete for the term of this Agreement; and

(e) it does, and will continue for the term of this Agreement to, operate in compliance with all Applicable Law and Applicable Policy, including observing where applicable, the requirements of the Corporations Act or successor legislation and the HSP's by-laws in respect of, but not limited to, the holding of board meetings, the requirements of quorum for decision-making, the maintenance of minutes for all board and committee meetings and the holding of members’ meetings.

10.2 Execution of Agreement. The HSP represents and warrants that:

(a) it has the full power and authority to enter into this Agreement; and

(b) it has taken all necessary actions to authorize the execution of this Agreement.

10.3 Governance.

(a) The HSP represents, warrants and covenants that it has established, and will maintain for the period during which this Agreement is in effect, policies and procedures:

that set out a code of conduct for, and that identify the ethical responsibilities for all persons at all levels of the HSP’s organization;

to ensure the ongoing effective functioning of the HSP;

for effective and appropriate decision-making;

for effective and prudent risk-management, including the identification and management of potential, actual and perceived conflicts of interest;

for the prudent and effective management of the Funding;

to monitor and ensure the accurate and timely fulfillment of the HSP’s obligations under this Agreement and compliance with the Enabling Legislation;

to enable the preparation, approval and delivery of all Reports;


to address complaints about the provision of Services, the management or governance of the HSP; and

to deal with such other matters as the HSP considers necessary to ensure that the HSP carries out its obligations under this Agreement.

(b) The HSP represents and warrants that:

it has, or will have within 60 Days of the execution of this Agreement, a Performance Agreement with its CEO that ties a reasonable portion of the CEO’s compensation plan to the CEO’s performance;

it will take all reasonable care to ensure that its CEO complies with the Performance Agreement;

it will enforce the HSP’s rights under the Performance Agreement; and

a reasonable portion of any compensation award provided to the CEO during the term of this Agreement will be pursuant to an evaluation of the CEO’s performance under the Performance Agreement and the CEO’s achievement of performance goals and performance improvement targets and in compliance with Applicable Law.

“compensation award”, for the purposes of Section 10.3(b)(4) above, means all forms of payment, benefits and perquisites paid or provided, directly or indirectly, to or for the benefit of a CEO who performs duties and functions that entitle him or her to be paid.

10.4 Funding, Services and Reporting. The HSP represents warrants and covenants that

(a) the Funding is, and will continue to be, used only to provide the Services in accordance with the terms of this Agreement;

(b) the Services are and will continue to be provided:

by persons with the expertise, professional qualifications, licensing and skills necessary to complete their respective tasks; and

in compliance with Applicable Law and Applicable Policy; and

(c) every Report is accurate and in full compliance with the provisions of this Agreement, including any particular requirements applicable to the Report and any material change to a Report will be communicated to the Funder immediately.

10.5 Supporting Documentation. Upon request, the HSP will provide the Funder with proof of the matters referred to in this Article.

ARTICLE 11.0 - LIMITATION OF LIABILITY, INDEMNITY & INSURANCE

11.1 Limitation of Liability. The Indemnified Parties will not be liable to the HSP or any of the HSP’s Personnel and Volunteers for costs, losses, claims, liabilities and damages


howsoever caused arising out of or in any way related to the Services or otherwise in connection with this Agreement, unless caused by the negligence or willful act of any of the Indemnified Parties.

11.2 Ibid. For greater certainty and without limiting section 11.1, the Funder is not liable for how the HSP and the HSP’s Personnel and Volunteers carry out the Services and is therefore not responsible to the HSP for such Services. Moreover, the Funder is not contracting with or employing any HSP’s Personnel and Volunteers to carry out the terms of this Agreement. As such, it is not liable for contracting with, employing or terminating a contract with or the employment of any HSP’s Personnel and Volunteers required to carry out this Agreement, nor for the withholding, collection or payment of any taxes, premiums, contributions or any other remittances due to government for the HSP’s Personnel and Volunteers required by the HSP to carry out this Agreement.

11.3 Indemnification. The HSP hereby agrees to indemnify and hold harmless the Indemnified Parties from and against any and all liability, loss, costs, damages and expenses (including legal, expert and consultant costs), causes of action, actions, claims, demands, lawsuits or other proceedings (collectively, the “Claims”), by whomever made, sustained, brought or prosecuted (including for third party bodily injury (including death), personal injury and property damage), in any way based upon, occasioned by or attributable to anything done or omitted to be done by the HSP or the HSP’s Personnel and Volunteers, in the course of the performance of the HSP’s obligations under, or otherwise in connection with, this Agreement, unless caused by the negligence or willful misconduct of any Indemnified Parties.

11.4 Insurance.

(a) Generally. The HSP shall protect itself from and against all Claims that might arise from anything done or omitted to be done by the HSP and the HSP’s Personnel and Volunteers under this Agreement and more specifically all Claims that might arise from anything done or omitted to be done under this Agreement where bodily injury (including personal injury), death or property damage, including loss of use of property is caused.

(b) Required Insurance. The HSP will put into effect and maintain, with insurers having a secure A.M. Best rating of B+ or greater, or the equivalent, all necessary and appropriate insurance that a prudent person in the business of the HSP would maintain, including, but not limited to, the following at its own expense:

Commercial General Liability Insurance, for third party bodily injury, personal injury and property damage to an inclusive limit of not less than 2 million dollars per occurrence and not less than 2 million dollars products and completed operations aggregate. The policy will include the following clauses:

a. The Indemnified Parties as additional insureds; b. Contractual Liability; c. Cross-Liability; d. Products and Completed Operations Liability;


e. Employers Liability and Voluntary Compensation unless the HSP complies with the Section below entitled “Proof of WSIA Coverage”;

f. Tenants Legal Liability; (for premises/building leases only); g. Non-Owned automobile coverage with blanket contractual

coverage for hired automobiles; and h. A 30-Day written notice of cancellation, termination or material

change.

Proof of WSIA Coverage. Unless the HSP puts into effect and maintains Employers Liability and Voluntary Compensation as set out above, the HSP will provide the Funder with a valid Workplace Safety and Insurance Act, 1997 (“WSIA”) Clearance Certificate and any renewal replacements, and will pay all amounts required to be paid to maintain a valid WSIA Clearance Certificate throughout the term of this Agreement.

All Risk Property Insurance on property of every description, for the term, providing coverage to a limit of not less than the full replacement cost, including earthquake and flood. All reasonable deductibles and self-insured retentions are the responsibility of the HSP.

Comprehensive Crime insurance, Disappearance, Destruction and Dishonest coverage.

Errors and Omissions Liability Insurance insuring liability for errors and omissions in the provision of any professional services as part of the Services or failure to perform any such professional services, in the amount of not less than two million dollars per claim and in the annual aggregate.

(c) Certificates of Insurance. The HSP will provide the Funder with proof of the insurance required by this Agreement in the form of a valid certificate of insurance that references this Agreement and confirms the required coverage, on or before the commencement of this Agreement, and renewal replacements on or before the expiry of any such insurance. Upon the request of the Funder, a copy of each insurance policy shall be made available to it. The HSP shall ensure that each of its subcontractors obtains all the necessary and appropriate insurance that a prudent person in the business of the subcontractor would maintain and that the Indemnified Parties are named as additional insureds with respect to any liability arising in the course of performance of the subcontractor's obligations under the subcontract.

ARTICLE 12.0 - TERMINATION AND EXPIRY OF AGREEMENT

12.1 Termination by the Funder.

(a) Without Cause. The Funder may terminate this Agreement at any time, for any reason, upon giving at least 60 Days’ Notice to the HSP.

(b) Where No Appropriation. If, as provided for in section 4.3, the Funder does not receive the necessary funding from the Ministry, the Funder may terminate this Agreement immediately by giving Notice to the HSP.


(c) For Cause. The Funder may terminate all or part of this Agreement immediately upon giving Notice to the HSP if:

in the opinion of the Funder:

a. the HSP has knowingly provided false or misleading information regarding its funding request or in any other communication with the Funder;

b. the HSP breaches any material provision of this Agreement; c. the HSP is unable to provide or has discontinued all or part of the

Services; or d. it is not reasonable for the HSP to continue to provide all or part of

the Services;

the nature of the HSP’s business, or its corporate status, changes so that it no longer meets the applicable eligibility requirements of the program under which the Funder provides the Funding;

the HSP makes an assignment, proposal, compromise, or arrangement for the benefit of creditors, or is petitioned into bankruptcy, or files for the appointment of a receiver; or

the HSP ceases to carry on business.

(d) Material Breach. A breach of a material provision of this Agreement includes, but is not limited to:

misuse of Funding;

a failure or inability to provide the Services as set out in the Service Plan;

a failure to provide the Compliance Declaration;

a failure to implement, or follow, a Performance Agreement, one or more material requirements of a Performance Improvement Process or of a Transition Plan;

a failure to respond to Funder requests in a timely manner;

a failure to: A) advise the Funder of actual, potential or perceived Conflict of Interest; or B) comply with any requirements prescribed by the Funder to resolve a Conflict of Interest; and

a Conflict of Interest that cannot be resolved.

(e) Transition Plan. In the event of termination by the Funder pursuant to this section, the Funder and the HSP will develop a Transition Plan. The HSP agrees that it will take all actions, and provide all information, required by the Funder to facilitate the transition of the HSP’s clients.

12.2 Termination by the HSP.

(a) The HSP may terminate this Agreement at any time, for any reason, upon giving 6 months’ Notice (or such shorter period as may be agreed by the HSP and the Funder) to the Funder provided that the Notice is accompanied by:


satisfactory evidence that the HSP has taken all necessary actions to authorize the termination of this Agreement; and

a Transition Plan, acceptable to the Funder, that indicates how the needs of the HSP’s clients will be met following the termination and how the transition of the clients to new service providers will be effected within the six-month Notice period.

(b) In the event that the HSP fails to provide an acceptable Transition Plan, the Funder may reduce Funding payable to the HSP prior to termination of this Agreement to compensate the Funder for transition costs.

12.3 Opportunity to Remedy.

(a) Opportunity to Remedy. If the Funder considers that it is appropriate to allow the HSP an opportunity to remedy a breach of this Agreement, the Funder may give the HSP an opportunity to remedy the breach by giving the HSP Notice of the particulars of the breach and of the period of time within which the HSP is required to remedy the breach. The Notice will also advise the HSP that the Funder may terminate this Agreement:

at the end of the Notice period provided for in the Notice if the HSP fails to remedy the breach within the time specified in the Notice; or

prior to the end of the Notice period provided for in the Notice if it becomes apparent to the Funder that the HSP cannot completely remedy the breach within that time or such further period of time as the Funder considers reasonable, or the HSP is not proceeding to remedy the breach in a way that is satisfactory to the Funder.

(b) Failure to Remedy. If the Funder has provided the HSP with an opportunity to remedy the breach, and:

the HSP does not remedy the breach within the time period specified in the Notice;

it becomes apparent to the Funder that the HSP cannot completely remedy the breach within the time specified in the Notice or such further period of time as the Funder considers reasonable; or

the HSP is not proceeding to remedy the breach in a way that is satisfactory to the Funder,

then the Funder may immediately terminate this Agreement by giving Notice of termination to the HSP.

12.4 Consequences of Termination. If this Agreement is terminated pursuant to this Article, the Funder may:

(a) cancel all further Funding instalments;

(b) demand the repayment of any Funding remaining in the possession or under the control of the HSP;

(c) through consultation with the HSP, determine the HSP’s reasonable costs to wind down the Services; and


(d) permit the HSP to offset the costs determined pursuant to section (c), against the amount owing pursuant to section (b).

12.5 Effective Date. Termination under this Article will take effect as set out in the Notice.

12.6 Corrective Action. Despite its right to terminate this Agreement pursuant to this Article, the Funder may choose not to terminate this Agreement and may take whatever corrective action it considers necessary and appropriate, including suspending Funding for such period as the Funder determines, to ensure the successful completion of the Services in accordance with the terms of this Agreement.

12.7 Expiry of Agreement. If the HSP intends to allow this Agreement to expire at the end of its term, the HSP will provide 6 months’ Notice (or such shorter period as may be agreed by the HSP and the Funder) to the Funder, along with a Transition Plan, acceptable to the Funder, that indicates how the needs of the HSP’s clients will be met following the expiry and how the transition of the clients to new service providers will be effected within the 6-month Notice period.

12.8 Failure to Provide Notice of Expiry. If the HSP fails to provide the required 6 months’ Notice that it intends to allow this Agreement to expire, or fails to provide a Transition Plan along with any such Notice, this Agreement shall automatically be extended and the HSP will continue to provide the Services under this Agreement for so long as the Funder may reasonably require to enable all clients of the HSP to transition to new service providers.

ARTICLE 13.0 - NOTICE

13.1 Notice. A Notice will be in writing; delivered personally, by pre-paid courier, by any form of mail where evidence of receipt is provided by the post office, or by facsimile with confirmation of receipt, or by email where no delivery failure notification has been received. For certainty, delivery failure notification includes an automated ‘out of office’ notification. A Notice will be addressed to the other party as provided below or as either party will later designate to the other in writing:

To the Funder:

Erie St. Clair Local Health Integration Network 712 Richmond Street, Chatham, ON N7M 5J5

Attn: Bruce Lauckner, Chief Executive Officer Fax: 519-351-5842 Email: [email protected]

To the HSP:

Bluewater Health 89 Norman Street Sarnia, ON N7T 6S3



Attn: Mr. Mike Lapaine Fax: 519-336-8780 Email: [email protected]

13.2 Notices Effective From. A Notice will be deemed to have been duly given 1 business day after delivery if the Notice is delivered personally, by pre-paid courier or by mail. A Notice that is delivered by facsimile with confirmation of receipt or by email where no delivery failure notification has been received will be deemed to have been duly given 1 business day after the facsimile or email was sent.

ARTICLE 14.0 - ADDITIONAL PROVISIONS

14.1 Interpretation. In the event of a conflict or inconsistency in any provision of this Agreement, the main body of this Agreement will prevail over the Schedules.

14.2 Invalidity or Unenforceability of Any Provision. The invalidity or unenforceability of any provision of this Agreement will not affect the validity or enforceability of any other provision of this Agreement and any invalid or unenforceable provision will be deemed to be severed.

14.3 Waiver. A party may only rely on a waiver of the party’s failure to comply with any term of this Agreement if the other party has provided a written and signed Notice of waiver. Any waiver must refer to a specific failure to comply and will not have the effect of waiving any subsequent failures to comply.

14.4 Parties Independent. The parties are and will at all times remain independent of each other and are not and will not represent themselves to be the agent, joint venturer, partner or employee of the other. No representations will be made or acts taken by either party which could establish or imply any apparent relationship of agency, joint venture, partnership or employment and neither party will be bound in any manner whatsoever by any agreements, warranties or representations made by the other party to any other person or entity, nor with respect to any other action of the other party.

14.5 Funder is an Agent of the Crown. The parties acknowledge that the Funder is an agent of the Crown and may only act as an agent of the Crown in accordance with the provisions of the Enabling Legislation. Notwithstanding anything else in this Agreement, any express or implied reference to the Funder providing an indemnity or any other form of indebtedness or contingent liability that would directly or indirectly increase the indebtedness or contingent liabilities of the Funder or of Ontario, whether at the time of execution of this Agreement or at any time during the term of this Agreement, will be void and of no legal effect.

14.6 Express Rights and Remedies Not Limited. The express rights and remedies of the Funder are in addition to and will not limit any other rights and remedies available to the Funder at law or in equity. For further certainty, the Funder has not waived any provision


of any applicable statute, including the Enabling Legislation, nor the right to exercise its rights under these statutes at any time.

14.7 No Assignment. The HSP will not assign this Agreement or the Funding in whole or in part, directly or indirectly, without the prior written consent of the Funder. No assignment or subcontract shall relieve the HSP from its obligations under this Agreement or impose any liability upon the Funder to any assignee or subcontractor. The Funder may assign this Agreement or any of its rights and obligations under this Agreement to any one or more agencies or ministries of Her Majesty the Queen in right of Ontario and as otherwise directed by the Ministry.

14.8 Governing Law. This Agreement and the rights, obligations and relations of the parties hereto will be governed by and construed in accordance with the laws of the Province of Ontario and the federal laws of Canada applicable therein. Any litigation arising in connection with this Agreement will be conducted in Ontario unless the parties agree in writing otherwise.

14.9 Survival. The provisions in Articles 1.0, 5.0, 8.0, 10.5, 11.0, 13.0, 14.0 and 15.0 will continue in full force and effect for a period of seven years from the date of expiry or termination of this Agreement.

14.10 Further Assurances. The parties agree to do or cause to be done all acts or things necessary to implement and carry into effect this Agreement to its full extent.

14.11 Amendment of Agreement. This Agreement may only be amended by a written agreement duly executed by the parties.

14.12 Counterparts. This Agreement may be executed in any number of counterparts, each of which will be deemed an original, but all of which together will constitute one and the same instrument.

ARTICLE 15.0- ENTIRE AGREEMENT

15.1 Entire Agreement. This Agreement forms the entire Agreement between the parties and supersedes all prior oral or written representations and agreements, except that where the Funder has provided Funding to the HSP pursuant to an amendment to the 2014-2018 MSAA, the 2018 Multi-Sector Accountability Agreement, or to this Agreement, whether by Project Funding Agreement or otherwise, and an amount of Funding for the same purpose is set out in the Schedules, that Funding is subject to all of the terms and conditions on which funding for that purpose was initially provided, unless those terms and conditions have been superseded by any terms or conditions of this Agreement or by the MSAA Indicator Technical Specifications document, or unless they conflict with Applicable Law or Applicable Policy.

-SIGNATURE PAGE FOLLOWS-


The parties have executed this Agreement on the dates set out below.


By: _____________________________ _______________________________ Nicole Robinson Date VP-Integrated Delivery Systems

And by: _____________________________ _______________________________ Bruce Lauckner, Chief Executive Officer Date

BLUEWATER HEALTH

By: _____________________________ _______________________________ Board Chair Date I have authority to bind the HSP

And by: _____________________________ _______________________________ Mr. Mike Lapaine,President Date & Chief Executive Officer I have authority to bind the HSP

Statement of Revenue and ExpenseForecast surplus/(deficit) as at March 31, 2020Based upon the nine (9) months ended December 31, 2019(000's)

19/20 19/20 19/20 19/20 19/20 19/20 Projected 19/20 NotesYTD YTD YTD YTD % Annual Forecast Variance to Forecast %

Budget Actual Variance Variance Budget Amount Budget Variance

Revenue $

LHIN Revenue 112,718 112,466 (252) 0% 149,861 149,870 9 0% 1Cancer Care Ontario Revenue 5,929 6,160 231 4% 7,891 8,180 289 4% 2Paymaster Funding 972 980 8 1% 1,293 1,302 8 1%OHIP Revenue 10,313 10,711 398 4% 13,775 14,298 523 4% 3Patient Revenue - Other 1,060 1,327 266 25% 1,411 1,769 358 25% 4Room differential 1,855 2,261 406 22% 2,469 3,064 595 24% 5Co-payment 326 380 54 16% 434 506 72 17%External Recoveries 1,776 1,849 72 4% 2,617 4,521 1,903 73% 6Parking Revenue 760 770 10 1% 997 1,007 10 1%Other Revenue 227 240 13 6% 236 249 13 5%Deferred Equipment Grants 2,002 1,766 (236) -12% 2,664 2,664 - 0%Interest and Donations 75 132 57 76% 100 135 35 35%

Total Revenue $ 138,013 139,041 1,027 1% 183,750 187,564 3,815 2%

Expenses $

Salaries and Wages 68,847 68,927 (80) 0% 92,067 92,247 (180) 0%Medical Staff Remuneration 16,443 17,105 (662) -4% 21,917 22,789 (872) -4% 3Employee Benefits 18,400 18,970 (570) -3% 24,911 25,631 (720) -3% 7Employee Future Benefits 225 331 (105) -47% 300 435 (135) -45%Utilities, Buildings & Grounds 3,154 2,742 412 13% 4,194 3,566 628 15% 8Equipment Expense 5,077 5,266 (188) -4% 6,694 6,947 (254) -4% 9Supplies and Expenses 7,925 8,505 (580) -7% 10,548 11,235 (687) -7% 10Contracted Out Services 2,816 3,050 (234) -8% 3,748 3,823 (75) -2%Medical/Surgical Supplies 6,528 6,809 (282) -4% 8,688 9,019 (332) -4% 11Drug Expense 4,680 5,202 (523) -11% 6,228 6,897 (669) -11% 2Interest Expense 234 197 37 16% 312 270 42 13%Amortization 4,390 3,610 780 18% 5,842 5,342 500 9% 12

Total Expenses $ 138,720 140,713 (1,994) -1% 185,449 188,203 (2,754) -1%

Hospital Operating Surplus/(Deficit) $ (706) (1,673) (966) n/a (1,699) (639) 1,061 n/a

Net Marketed Service Surplus/(Deficit) 268 343 75 28% 390 360 (30) -8%

Net Other Vote Surplus/(Deficit) 18 (0) (18) n/a 0 0 - n/a

LHIN Operating Surplus/(Deficit) $ (421) (1,330) (909) (1,309) (279) 1,030

Deferred Building Grants 6,670 6,714 43 1% 8,878 8,878 - 0%Building Amortization (7,776) (7,843) (67) 1% (10,349) (10,349) - 0%Interest on L/T Liabilities (64) (46) 17 -27% (85) (85) - 0%

Operating Surplus/(Deficit) $ (1,590) (2,506) (916) (2,865) (1,835) 1,030

Notes to Financial StatementsDecember 31, 2019 Actual and Full Year Forecast

Note 1

Note 2

YTD Actual Annual Budget Year-End Forecast

$ 2,785,429 $ 2,800,000 $ 3,707,153 $ 3,160,229 $ 4,886,408 $ 4,205,977 $ 152,066 $ 204,258 $ 204,258 $ 62,236 $ - $ 62,236 $ 6,159,960 $ 7,890,666 $ 8,179,624

Note 3

Note 4

Note 5

Note 6

Note 7

Note 8

Note 9

Note 10

Note 11

Note 12

Supplies and Expenses are over budget $580K at the end of December. This negative variance is mainly due to patient transporation costs, and professional fees. The forecasted negative variance is expected to grow to $687K due partly to some unbudgeted community integration work.

Room Differential revenue is better than budget by $406K at the end of December. The majority of this positive variance is from Inpatient Mental Health, Telemetry, & Acute Medicine. The year-end forecast anticipates further improvements to this positive variance.

Utilities are under budget $412K at the end of December. The hospital is forecasting a continual improvement to this postive variance over the course of the year. At year-end, the hospital is forecasting a positive variance of $628K.

Med/Surg supplies are over budget by $282K at the end of December. This negative variance is primarily attributed to the Operating Room which performed higher volumes of hip & knee replacements. This negative variance is forecasted to grow to $332K at year-end.

Equipment expense is over budget by $188K at the end of December. It is forecasted to be over budget by $254K at year-end. The negative variance is comprised of equipment maintenance contracts and other minor equipment purchases.

External Recoveries are forecasted to be better than budget by $1.9M at year-end. The majority of this positive variance is attributed to a utility rebate dating back to January 2017.

Total Funding

Amortization expense is expected to be under budget by $500K at year-end. Delays in the purchase of approved capital items that require a competitive procurement process contribute to this forecasted variance.

Ontario Breast Screening Program Funding

Employee Benefits are over budget by $570K at the end of December. The hospital is forecasting a negative variance of $720K at year-end. The variance consists of a one-time WSIB charge as well as the hospital portion of benefits for employees who are off on an approved leave (ie. maternity leave). Employees have the option of contributing to certain benefits and pension while off on leave. If they choose to contribute, the hospital will incur the expense of the employer portion of the benefits.

Bluewater Health is forecasting a deficit of $279K for the 19/20 fiscal year which is $1M better than the budgeted deficit of $1.3M. At the end of December, the hospital had a deficit of $1.33M. The largest contributing factor to the YTD and forecasted variances from budget are employee benefits, other supplies & expenses, and med/surg supplies. Drug expenses and medical staff remuneration are also forecasting to be over budget for the year (there is offsetting revenue for much of these variances).

LHIN Revenue is under budget by $252K at the end of December. This negative variance is attributed to pacemaker volumes compared to budgeted pacemaker funding and a LHIN recovery for psychiatric stipend funding from prior years. The year-end forecast is in-line with budget.

Bluewater Health does OHIP billings for various physician groups. There is an offsetting Med Staff Remuneration expense for these billings. The December YTD variance for OHIP Revenue and Med Staff remuneration is primarily CT, Radiography & MRI .

Patient Revenue - Other is a combination of WSIB Revenue, Revenue from Other Provinces, Revenue from Non-Residents, and Revenue paid directly by Patients. As of the end of December, these revenues were better than budget by $266K. The majority of this positive variance is revenue from other provinces and non-residents. The hospital anticipates further improvements to this positive variance to year-end.

Bluewater Health receives CCO funding for Oncology Drugs, QBPs, and the Ontario Breast Screening Program. Bluewater Health is forecasting achieving all QBP funding for Endoscopy and the Oncology program. The forecast anticipates a potential shortfall of QBP funding related to Cancer Surgeries. The hospital recorded additional QBP funding from 18/19 of $62K from year-end reconciliation in excess of what had been accrued. CCO funded Oncology drugs are contributing to the positive variance. The Oncology program has a corresponding overage in drug expense.

Description

Oncology Drug FundingQBP Funding (Cancer Surgeries, Endoscopy, Systemic Therapy)

2018/19 QBP Reconciliation

Balance SheetAs at December 31, 2019Comparison to December 31, 2018(000's)

% Change

Assets

Current AssetsOperating Cash $ 6,761 7,924 -15%Investments - CEE Site 1,011 1,264 -20%Accounts Receivable 5,452 5,118 7%Accounts Receivable - MOHLTC 0 0 #DIV/0! Inventories 1,156 1,119 3%Prepaid Expenses 2,261 1,483 52%

Total Current Assets 16,639 16,909 -2%

Fixed AssetsLand and Land Improvements 7,446 7,446Building/Building services Equipment 335,569 333,743Furniture and Equipment 80,896 84,726Less: Accumulated Amortization (189,058) 234,853 (180,726) 245,190 -4%Construction in Progress 1,489 1,616 -8%Other Non Current Assets 413 399 3%

Total Fixed Assets 236,754 247,205 -4%

Total Assets $ 253,394 264,115 -4%

Current LiabilitiesAccounts Payable 2,801 2,279 23% Accounts Payable - MOHLTC 2,809 970 190%Accrued Salaries & Vacation Pay 7,692 11,298 -32%Current Portion - Long Term Debt 286 279 2%Other Liabilities 7,781 5,687 37%

Total Current Liabilities 21,368 20,513 4%

Long Term LiabilitiesLong Term Bank Loans Payable 1,836 2,970 -38%Deferred Revenue 204,439 213,493 -4%Post Employment Benefits 15,315 15,474 -1%Other L/T Liabilities 2,522 1,574 60%

Total Long Term Liabilities $ 224,111 233,511 -4%

EquityOpening Equity 10,421 11,868R&E Surplus/(Deficit) (2,506) (1,777)

Total equity 7,914 10,091 -22%

Total Liabilities and Equity $ 253,394 264,115 -4%

Hospital Accountability Agreement Indicators: Negotiated Target

Current Ratio 0.73 0.76 0.60

Adjusted Working Capital 481$ 2,239$ -$

Note: Current ratio excludes CEEH Site Investments

Adjusted Working Capital is calculated using the definition of the Working Capital Funding Initiative

2019/20 2018/19Actual ActualDec-19 Dec-18

1


Name of Committee: Board of Directors Date of Meeting: February 26, 2020 Submitted by: Colleen Cook, Director Human Resources &

Occupational Health Subject: Annual Human Resources Plan Purpose of Report: Information Input Approval

Situation Each year, an annual Human Resources Plan is created which contains comprehensive information about our people, our current and future needs, and our workforce planning strategies. Background The Human Resources Plan aligns with and ensures that we will achieve our strategic goals. In aligning with the strategic goals, the objectives of the Human Resources Plan is to:

• Be proactive in planning and anticipating staffing needs through analysis of our current workforce demographics, historical staffing needs, and current operational efficiencies;

• Ensure a safe and healthy workplace where individuals take pride in where they work, and assuring that the needs of staff are met through proper orientation, safety training, quality of work life and workplace wellness initiatives;

• Foster a culture of learning where individuals can focus on and be supported in their development.

Analysis

• 38% of our employees have less than four years’ experience. Therefore, it is critical that we concentrate efforts on providing the necessary supports for new staff. It is also imperative to ensure a balanced staffing complement between those of varying degrees of experience.

• The average age of employee has decreased from previous years. 52% of our workforce are Millennials. Strategies are in place to understand different generational needs, values and priorities and promote respect for and amongst each generational group.

• Our turnover rate has increased and is above the provincial average. We are reviewing information from exit interviews to understand the reasons why individuals are leaving. We need to focus additional attention on retention strategies.

• Our retirement numbers remain steady and we expect this to continue. • We have experienced an increase in the number of maternity leaves and based on the

demographics of our workforce, we anticipate this will continue.

x

2

• We anticipate an increase in the number of retirements in our management positions and our front-line leadership roles such as charge nurses and senior technologists. A succession plan is being developed for the senior leadership positions and we have expanded our leadership development offerings in order to prepare individuals who will be interested in moving to first level supervisory roles.

• Continuous work occurs at the program level to ensure proper staffing levels are in place, and each vacancy is reviewed to determine optimization of that role, i.e. converting to full-time or part time, or filling with the same or different classification, for instance.

Current and anticipated human resources needs have been identified and are being planned for. Strategies are in place to prepare for future opportunities and requirements. Focus will continue on leadership development and enhanced retention strategies. Bluewater Health is well prepared for the human resources needs as outlined in the annual plan. Recommendation The Board approve the 2020-21 Human Resources Plan as presented.

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Human Resources Workforce Planning – February 2020 Executive Summary The Bluewater Health Human Resources Plan contains comprehensive information about our organization, our people, our direction and our workforce planning strategies. This plan outlines the direction for Bluewater Health in order foster a workplace that encompasses respect, compassion, excellence, development, engagement, quality and safety. In order to ensure appropriate staffing, we must be cognizant not only of the demographics within our hospital and community but also the changing health care workforce needs. We recognize that we must be forward thinking, innovative, and responsive to employees’ needs in order to be an employer of choice. Bluewater Health is going to continue to face additional recruitment pressures in the years to come. We have a number of employees who are at and/or approaching retirement age. We also have a number of individuals who are having families and, as a result, we are experiencing a high number of parental leaves. We anticipate both of these trends will continue for the coming years. Recruitment activities need to be ongoing and proactive to ensure timeliness in our filling of vacancies that occur throughout the year, both permanent and temporary. We also need to ensure we have the processes and programs in place that will assist in retention as well as support the different needs and development aspirations of our employees throughout their career at BWH. We have recruited a large number of employees who are in the early stages of their careers. We must ensure our orientation programs and ongoing supports are adequate to meet their continuous development needs.

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Human Resources Plan Setting the Context Human Resources workforce planning is essential for ensuring the provision of comprehensive health care to the patients, families and communities service by Bluewater Health. The most valuable asset of the hospital is its human resources. Hospital Staff, Professional Staff and Volunteers provide exemplary Patient-Family Centred Care. Recruitment and retention of knowledgeable, dedicated staff and volunteers is essential to the ongoing success of Bluewater Health. This is reflected in our strategic goal Inspired People which states that we will Advance our culture of kindness with an intention to learn, lead, collaborate and celebrate. We will focus on the experience of care and caring and we will Promote individual, team, and professional development. Having an appropriate Human Resources Workforce Plan aligns with and ensures that Bluewater Health will achieve its strategic goals of Quality Care, Exceptional Relationships, Inspired People and Outstanding Performance. In aligning with these strategic goals, the objectives of the Human Resources Plan is to:

1. Be proactive in planning and anticipating staffing needs through analysis of our current workforce demographics, projected staffing needs, and current operational efficiencies;

2. Ensure a safe and healthy workplace where individuals take pride in where they work, and assuring that the needs of staff are met through proper orientation, safety training, quality of work life and workplace wellness initiatives;

3. Foster a culture of learning where individuals can focus on and be supported in their development.

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Workforce Demographics To assess our future staffing needs, a profile of who we are is important. Length of Service A large number of our employees are in the 0-4 and 5-9 years of service categories. Thus, it is critical for the Hospital to concentrate efforts on supporting new staff and retention initiatives. As well, in planning the staffing mix in our clinical areas, it will be imperative to ensure that the staffing complement is balanced between those with varying degrees of experience in their profession. Employees who have been with the organization for many years have considerable knowledge of our culture and services, have experienced many changes within the workplace and it is important that they be able to share their knowledge with the less senior staff. New employees must be provided with a robust orientation and onboarding program, as well as continuous ongoing development to ensure they can be successful.

The average length of service at BWH is 11 years.

9.8%

28.2%

20.6%

11.5%

10.5%

4.8%

6.2%

5.3%2.5%

0.6%Length of Service<1 year

1-4 years

5-9 years

10-14 years

15-19 years

20-24 years

25-29 years

30-34 years

35-39 years

40+ years

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Gender The healthcare industry is predominantly female, and that is reflective within Bluewater Health. A predominantly female workforce will experience a high number of maternity leaves and therefore, an increased demand for temporary employees to cover these absences.

At BWH, 88% of our employee population is female.

88.4%

11.6%Gender

Female

Male

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Employee Age Breakdown The chart below outlines the percentage of total employees in each ten-year age group. Over half of our employees are between the ages of 25-44, representing 55% of our workforce. On the other hand, 20.0% of our employees are eligible for retirement now and this increases to 34.6% in the next 5 years. In management specifically, 32% of our management group are eligible to retire now and that increases to 51% within the next 5 years. As a result, BWH will have to focus on recruitment of staff, in all categories and professions across the organization, over the next several years.

The average age of our employees is 41.

8%

32%

23%

25%

12%

Age Breakdown

<25

25-34

35-44

45-54

>55

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52% of our current workforce consists of Millennials. We currently have 4 different generations within the workplace. Each generational group is defined by their own unique characteristics and values. It is important that we promote understanding and respect for and amongst each of the groups. As well, it is important to recognize that our future leaders will generally be individuals who are moving into leadership roles quicker and at earlier stages in their careers than their predecessors. This supports the emphasis on leadership development and preparation.

4%

52%25%

19%

Generational Breakdown

Centennials: 1996-present

Millennials: 1977-1995

Generation X: 1965-1976

Baby Boomers: 1946-1964

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Human Resources Indicators Turnover Rate The turnover rate speaks to how constant a workforce is. Over the past 2 years, our workforce has changed primarily as a result of retirements and maternity leaves. Our recruitment activity has increased significantly, not only to hire those employees leaving through retirements, but also to temporarily replace those individuals going on maternity leave. We expect this trend to continue for the foreseeable future. We have noted an increase in the number of our resignations, particularly amongst employees with shorter length of service. We have been working to determine associated factors, including making changes to our exit interview process, with the intent to address this through increased attention to retention efforts. The chart below represents the number of separations from the Hospital.

The turnover rate at BWH has averaged 10.3% which exceeds the provincial average of 8.9% *the turnover rate represents the total headcount/all separations

175

60

103

120

20

40

60

80

100

120

140

160

180

200

Total Retirements Resign/Term Contract End

Turnover Rate

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Retirements We have experienced a steady number of retirements over the past number of years. Based on the age of our workforce, we expect this number to remain steady or slightly increase in the coming years. We closely monitor the workforce demographic and are preparing ourselves for the impact of retirements in a number of areas, and specific positions.

Our current average age at retirement is 59.8 years of age

5347

50

60

0

10

20

30

40

50

60

70

2016 2017 2018 2019

Retirements

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Leaves of Absence and Parental Leaves In addition to retirements and separations, there is the need to replace employees for leave of absences including longer term illness and parental leaves. To address these absences, it is common to have part time employees assume additional hours or to hire temporary staff to fill these vacancies. The chart below represents the number of maternity leaves over the past 4 years. We have seen an increase in the number of maternity leaves, and as stated earlier, due to the age of a large group of our employees, we expect the number of maternity leaves to increase for the foreseeable future. Additionally, individuals now have the opportunity to extend their maternity leave to 18 months and we are noting that many of our employees are choosing this longer leave. This will also impact our re-orientation requirements for those individuals returning to the workforce after a lengthy absence.

111

139131

144

0

20

40

60

80

100

120

140

160

2016 2017 2018 2019

Pregnancy/Parental Leaves

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How are we positioning ourselves to meet our future needs? HR Objective #1

Deliverables:

Action Progress Timeline Role assessment of each vacancy

For each vacancy managers explore need to fill and/or opportunity to fill in a different manner. The intent is to ensure care and service is offered by the right provider, according to scope of practice, and to maximize efficiency.

established part of recruitment process going forward

For each vacancy managers review the staffing needs pertaining to available hours of work to determine if it is most appropriate to replace as a FT or PT employee

established part of recruitment process

Timely recruitment for vacancies

Programs are encouraged to start the recruitment process as soon as possible upon awareness of exit; allocate appropriate time to post, interview, complete background checks and onboarding/orientation to avoid gaps in staffing. On average, the recruitment process for external hires takes approximately 6 weeks.

Immediate

Workforce planning

Review workplace demographics to identify potential areas and positions expected to be affected by retirement. Assess ease of recruitment for each role and plan accordingly, i.e. through increasing student placements, attending job fairs, promoting potential vacancies throughout the organization.

Annual as part of HR planning/demographic review with each program

Recruitment planning

Work with programs to anticipate orientation needs and associated costs due to anticipated high turnover in particular classifications

Annual as part of HR planning/demographic review with each program

Plan for knowledge transfer

Managers have identified those positions for which there is one incumbent; working with managers and individuals to ensure appropriate coverage for these roles to minimize risk to the organization.

reviewed annually with programs; Organizational Development has developed a “Replacement Plan” document currently being piloted in a number of areas

Talent management for leadership positions

Leading in the Middle: 4 programs, 60 participants Innovative Management: 6 programs, 77 participants Board of Governors: 4 programs, 32 BWH participants

Annual; Applications being received for next wave beginning in spring 2020

Be proactive in planning and anticipating staffing needs through analysis of our current workforce demographics, historical staffing needs, and current operational efficiencies.

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Succession Planning

Foundation, guiding principles and action plan have been established and endorsed by Executive Council.

March 2020 Work currently underway with Executive Council

Future Opportunities

We introduced a "future opportunities" resource on our website that identifies roles that may be available, the qualifications required for the role, and how those qualifications can be obtained.

Update annually

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HR Objective #2

Deliverables:

Action Progress Timeline Ensure best practice in recruitment activities

Completed full recruitment review, implemented 6 quality improvements; continue to review and follow best pracatice

Review annually

Maximize recruitment effectiveness

Expand use of social media in recruitment Ongoing; specific to position

Increase presence at job fairs – managers and Human Resources participate; working in collaboration with Sarnia Lambton Economic Partnership

February & March 2020

Orientation and onboarding initiatives

Developing a standard onboarding template for all new employees which will include standard practices and legislative requirements to be covered across all departments

Being piloted now; will continue to enhance and expand based on feedback

Leadership onboarding has been enhanced to include an (up to) one year peer-mentor program, bootcamp as required to introduce management to key in house people/resources; standard documents available for all leaders

In place

Charge nurse onboarding Developing specific tool for new charge nurses incorporating standard work Spring 2020

Wellness and resilience initiatives

The Healthy Living Team has been established with an aim to instill a culture of wellness within BWH and develop initiatives to support and promote care for the people who care for Emily. Initiatives include: lunch and learn sessions on nutrition; recipe sharing; fitness challenges; mindfulness sessions; food recognition events

Goals established annually

Embed Culture of Kindness

Civility in the Workplace education sessions offered on units and established as part of corporate orientation

Highlight Culture of Kindness on recruitment section of our website

Ensure a safe and healthy workplace where individuals take pride in where they work, and assuring the needs of staff are met through proper orientation, training, quality of work life and workplace wellness initiatives.

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Culture of Kindness questions embedded as part of interview tool for all positions

Retention Actively work to increase number of exit interviews completed; and analyze information received to outline and develop retention strategies

In addition to online survey, have offered in person exit interviews; Revised tool to get information more specific to classifications

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HR Objective #3

Deliverables:

Action Progress Timeline Student Placements Continue to collaborate with local high schools,

colleges and universities to encourage student preceptorships, placements and experiences within Bluewater Health

Reviewed each semester

Explore the opportunity to increase the numbers and/or classifications for which placements are available

Part of annual HR planning

Collaboration/Partnership with Lambton College

Continued dialogue with Lambton College to explore opportunities related to education/skills sets and workforce demographics future needs

ongoing, specific programs and qualifications being reviewed

Continue with diversity understanding and education opportunities

Continue to offer educational opportunities based on interest and feedback; expand on diversity programs such as faith; Indigenous sensitivity and understanding and generational differences. Continue to work towards a “positive space” for the LGBTQ2IA community

Feedback gathered through surveys, reviewed twice annually Process and policy review ongoing, exploring education opportunities to be offered spring 2020

Establish a culture of consistent feedback and coaching/mentoring

Employee feedback is delivered through our Employee Development Program. Completion increased to

Introduce 360 feedback tool through LEADS for all management and supervisory positions.

Will be introduced in 4 groups over 18 months; 2 groups completed, 1 group beginning their education and

Foster a culture of learning where individuals can focus on and be supported in their development.

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the final group anticipate to be completed in Fall 2020

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Projected Staffing Needs Assumptions: Staffing levels fluctuate throughout the course of the year and increased slightly over last

year. It is anticipated that the headcount going forward will remain at or near the current 1715.

The number of employees who have left the organization (employee separations) has

averaged 139 per year (based on 3 years). Based on our employee demographics, it is assumed that the retirement levels will

continue at the same pace for the next few years. Based on previous years’ experience, it is assumed that the need for temporary

replacements due to illness will not change or decrease significantly. As the number of maternity leaves have significantly increased, it is assumed that the

need for replacements due to maternity leaves will continue to increase. With all of the assumptions above, it is anticipated that we will have a need to replace approximately 19 staff per month. Summary

It is recognized that many hospitals are challenged with regards to recruitment and retention of qualified staff as well as the need for succession planning. A thorough review of our demographics, understanding our current and future needs, and understanding best practice in terms of recruitment and retention has positioned us well as we proceed with our human resource planning. We recognize that we will be faced with recruitment pressures throughout the organization. We will be continue to be proactive, creative and strategic as we meet the challenges that will be presented to us in the years to come.

FOI

Italics

*

ⱡ

OCT

18

NOV

18

DEC

18

JAN

19

FEB

19

MAR

19

APR

19

MAY

19

JUN

19

JUL

19

AUG

19

SEP

19

OCT

19

NOV

19

DEC

19Report

PeriodYTD

1 SarniaQIP/

P4R

25.7

hrs

20.3

hrs

<=16

hrs19.4 19.0 6.3 12.9 18.2 17.2 11.3 13.6 15.9 19.0 15.4 7.8 11.4 15.0 8.1

Jan -

Dec14.2 t

2 SarniaSP/

NOW

9.7

hrs

7.9

hrs ⱡ 2 hrs 6.8 6.4 3.3 5.1 6.5 6.2 4.1 4.6 5.3 6.5 4.8 3.5 4.2 4.7 3.5

Jan -

Dec4.9 t

SarniaHSAA/

P4R

10.8

hrs

9.3

hrs

<=8

hrs8.9 9.1 8.0 8.9 9.7 9.4 9.2 8.9 9.2 9.1 8.7 7.6 8.1 8.4 8.1

Jan -

Dec8.7 t

Petrolia 0 04.0

hrs* 3.8 4.3 3.6 4.0 3.6 4.1 4.3 4.6 4.3 4.4 4.7 3.8 3.7 4.2 3.8

Jan -

Dec4.1 t

Sarnia P4R33.3

hrs

26.0

hrs

<=20

hrs24.5 24.9 14.2 20.3 25.5 24.1 18.6 19.5 22.6 26.3 21.2 15.8 17.9 21.4 16.2

Jan-

Dec20.8 t

Petrolia 0 07.9

hrs* 6.3 6.8 7.9 5.0 6.1 7.3 10.3 6.1 7.9 11.6 7.5 5.1 8.6 8.9 10.9

Jan -

Dec7.6 t

5 HSAA 12.7% 16.2% 16.2% 18.2 16.3 18.7 17.0 14.5 13.4 16.5 14.1 12.4 11.9 13.1 12.3 15.2 14.0Jan-

Dec14.1% 0

6 SP 2.8 3.40 2.80Jan-

Dec0 t

7 SP $5,431 $5,988 $5,800Apr-

Mar$6,052 t

8 0.0 $5,814 $6,237 $5,849Apr-

Mar$6,224 t

9 0.0 $14,121 $14,404 $12,961Apr-

Mar$14,493 t

10 0 $637 $663 $620Apr-

Mar$552 t

11 0 $327 $317 $314 $322 $319 $317 $321 $321 $326 $402 $400 $375 $370 $367 $378 $373 $366 $367Apr-

Mar$367 t

12 0.0 n/a $187 $0 $29 $89 $187 $78 $476 $847 $175 -$33 -$104 -$100 -$419 -$359 -$611 -$391 -$449Apr-

Mar-$449 t

13 0.0 n/a -$597 -$1,309 -$562 -$715 -$597 -$654 -$663 $127 -$642 -$1,038 -$1,579 -$1,452 -$1,028 -$791 -$1,277 -$1,536 -$1,347Apr-

Mar-$1,347 t

14 HSAA n/a $2,239 $0 $1,726 $1,268 $2,239 $2,490 $2,982 $1,048 $783 $349 -$305 $951 $844 $1,512 $1,219 $844 $481Apr-

Mar$481 t

15 0.0 n/a 47% 100% 30 45 47 54 56 62 1 1 2 9 13 17 18 24 26Apr-

Mar26% t

$14,493

$552

Ensure continuous investment in strategic infrastructure

0

0

Rehab Inpatient

(4% of overall activity)$14,404

Our overall expenses for this indicator have increased by $206K

compared to Q2 18/19 and our weighted cases have increased by

11 cases for the same period. The expected CPWC for Rehab for

19/20 is $13,595.

$14,134

Our overall expenses for this indicator have increased by $354K

compared to Q2 18/19 and our weighted cases have increased by

34 cases for the same period.

Exceptional Relationships - Expand innovative partnerships and collaborations to improve experiences, services, transitions and community health

0

Our overall expenses for this indicator have decreased by $374K

compared to Q2 18/19. The weighted patient days have increased

by 862 weighted days for the same period.

0

$653 $635

% of Capital Budget Spent Actual YTD 0%

QBP Financial Exposure (Potential lost revenue related to

QBP achievement) Actual YTD in 000s

ALC Rate - All Inpatient Services

(Sarnia and Petrolia)

Continuing Care Cost per Weighted Patient Day

$5,988

Mental Health Inpatient Cost per Patient Day

Surplus/(Deficit) Actual YTD in 000s

Inspired People - Advance our culture of kindness with an intention to learn, lead, collaborate and celebrate

Adjusted Working Capital Actual YTS in 000s


#

Build sustainable partnerships and collaborations

90th Percentile Time to Inpatient Bed

90th Percentile ED Length of Stay for

Complex Patients

90th Percentile ED Wait Times

(Admitted Patients)

Q3 19/20YTD

Performance

UP

DA

TED


0Average Time to Inpatient Bed

Improve access to care

0

0

Meets/Exceeds Target

Meeting baseline but not meeting target

Performance not meeting baseline

Data Unavailable

Q3 18/19 Q4 18/19

Resource Utilization & Audit Committee Performance Scorecard

REF

. Q1 19/20

Masked due to n size <5

n size between 5 - 29

no established target

corporate target

Key Performance Indicators

Pee

r

Co

mp

arat

or

Des

ired

Tren

din

gQ2 19/20

TargetBaseline CommentsTrending

$6,257

$6,052

$6,224

$5,911

3.343.12

Outstanding Performance - Optimize roles, resources, revenues, technology and innovation

2.97

Our overall expenses for this indicator have increased by $1M

compared to Q2 18/19 and our weighted cases have decreased by

67 cases for the same period.

3.05

ED Outpatient

(12% of overall activity)$6,237

Acute Inpatient & Day Surgery (53%

of overall activity)

Cost per

Weighted Case

(Actual YTD)

Demonstrate accountability and efficiency

Absenteeism Rate - (avg # 7.5 hr. sick days) All StaffPrevious target 3.10. Target 2019 CY - 2.80.

3.40

0

0

0

0

3

4

1


Name of Committee: Board of Directors Date of Meeting: February 26, 2020 Submitted by: Dr. Haddad, Chief of Professional Staff Subject: 2020-2021 Physician Resources Plan Purpose of Report: Information Input Approval

Situation The Medical Advisory Committee (MAC) is required to “develop, maintain and recommend to the Board a Clinical Human Resources Plan that takes into account the services provided by all Professional Staff members”, per section 11.02 of the Professional Staff By-laws. Background The Professional Staff By-law, Article 3.01 indicates that “in making an appointment or re-appointment to the Professional Staff, the Board shall consider the Hospital’s resources and whether there is a need for the services in the community.” Section 3.02 (g) also states that the Board may refuse to appoint any applicant to the Professional Staff if (iii) the Clinical Human Resources Plan and/or Program does not demonstrate sufficient resources to accommodate the applicant.” In developing the Physician Resource Plan, Medical Directors considered the following:

• Retirement, changes in practice patterns of existing Professional Staff • How their program has served Bluewater Health’s patient populations • Workload, on-call requirements, expertise/subspecialty requirements • Service gaps and discrepancies in skill proficiencies for care provision

If any new positions are identified in the Physician Resource Plan, an impact analysis is required. Analysis For the 2020-2021 year, the outstanding needs are: • 2 anaesthesiologists • 1 obstetrician/gynaecologist (replacement) • 1 otolaryngologist • 1 general surgeon • 1 orthopaedic surgeon (replacement) • 1 plastic surgeon • 1 radiologist

X

2

• 1 pathologist (replacement) • 2 Rural Health Emergency physicians (1 is a replacement) • 2 hospitalists (1 is a replacement) • 5 Emergency physicians • 2 paediatricians (1 is a replacement) • 1 cardiologist (replacement) • .5 infectious disease specialist • 1 rheumatologist • 2 geriatricians (business case submitted to the Ministry of Health) • 1 physiatrist • 1 neurologist • 2 psychiatrists A number of the positions identified in the plan are required to provide basic services to the residents of Sarnia-Lambton. An inability to meet the needs may impact the availability of surgery, emergency department wait times, implementing some components of the NOW strategy, including supporting timely discharge and transitions of care. Last year, the hospital budgeted $380,000 in the 2019-20 expenditure plan to reflect an anticipated increase in recruitment costs this fiscal year. For the 2020-2021 year, it is recommended that the recruitment costs increase to $812,750 due to the increased recruitment needs. The 2020-2021 Physician Resource Plan addresses recruitment for 28.5 physicians, compared to the 2019-2020 plan, which addressed 17.5 positions. Recommendation The Board approve the 2020-21 Physician Human Resources Plan as presented.

DRAFT

Medical Advisory Committee

2020/21

Physician Resources Plan

February 2020

Bluewater Health Physician Human Resources Plan 2020/21 February 2020

Page 2 of 14

Predicting Need for Physicians Predicting the required number of physicians to meet the current and future needs of the population is very difficult. It is recognized that counting the number of physicians per population is not adequate. A number of factors come into play when determining need:

• An aging population placing more demand on health services • The increasing sophistication of consumers, who have more access to information and therefore

changing expectations of the health system • Medical and technological advances, new drugs and treatments which may either increase or

decrease the need for care • Survivorship with diseases such as AIDS and cancer is increasing, therefore the individuals are

now considered to be living with a “chronic” condition, which leads to ongoing health care requirements

Physician supply is also influenced by the practice patterns and demographics of physicians. Key factors are the increasing average age of the health care professional, an increase in the number of women entering medicine, and the differing practice patterns. The Ontario Ministry of Health and Long-Term Care and the Ontario Medical Association engaged the Conference Board of Canada to develop a population needs-based physician simulation model in 2010. The model compares various health needs of the population to the supply of physician services, quantifies the variance, and converts the variance into a physician requirement. It is recognized that the modeling is not an exact science; however, it does provide some insight into potential future circumstances. The modeling suggests that the distribution and mix of physicians will be a higher priority in the future than the overall physician supply. The simulation estimated that the shortage of specialists would end by 2014. In the Erie St. Clair LHIN, it was estimated that there would still be a shortage in the specialties of cardiology, diagnostic imaging, and psychiatry. The simulation also estimated that for most of the province, the shortage of family physicians would end by 2017, with the trend beginning to plateau in 2025. In the Erie St. Clair LHIN area, it was estimated that the shortage of family physicians would continue into 2022. The Royal College of Physicians and Surgeons of Canada (RCPSC) conducted an in-depth study of medical specialist underemployment and unemployment. In 2010, the RCPSC conducted a mini-study which identified that specialists in neurosurgery, cardiac surgery, plastic surgery, public health and preventive medicine, otolaryngology, nephrology and radiation oncology were experiencing difficulties in finding employment in Canada. Since then, additional specialists were added to the list: cardiology, gastroenterology, palliative medicine, urology, orthopaedic surgery and thoracic surgery. The RCPSC conducted an in-depth two year study based on evidence from 50 in-depth interviews with physicians, hospital leaders, health system experts, residents and others, as well as an online survey of specialists newly-certified in 2011 and 2012. The study results indicated that:


Page 3 of 14

• Of the 32 per cent of survey respondents, 16 per cent indicated that they were unable to secure employment.

• Thirty-one per cent reported pursuing additional training rather than enter the job market in an attempt to make themselves more employable.

• Locum & part time positions are often a default option to unemployment (almost 22% of new graduates reported they are staying employed by combining multiple locum positions)

Three key drivers were identified as contributing to the employment issues:

1. Economy is main factor driving new medical & surgical specialists under and unemployment in Canada

a. more physicians competing for fewer resources b. weak stock markets delay retirements

2. The way in which the health care system is organized contributes to under and unemployment of new medical & surgical specialists

a. The role of interprofessional models i. Interprofessional models reduce reliance on physicians, slow job growth

ii. Interprofessional models are reducing reliance on residents for service, enabling the potential to better align supply of new physicians with longer term patient needs

b. Workforce planning i. Determining & allocating the number of residency positions is complex & may

not always take into account societal health needs & available resources ii. Increasing reliance on residents can lead to overproduction

c. Culture of practice influences physicians’ willingness to share resources 3. Personal & context-specific factors drive employment challenges among new graduates

a. Residents report a lack of adequate career counseling and information about jobs b. Personal preferences influence choices

The RCPSC report also noted that the employment challenges are creating a new type of specialist who is tailoring his/her practice to work within the resources available. The new practice may not encompass the full scope of the specialists’ abilities, resulting in skill loss or “brain waste”. “Brain drain” is also possible, since just under 20% of the recently certified specialists who had not found positions reported that they would be looking for work outside Canada. (Royal College of Physicians and Surgeons of Canada, “What’s really behind Canada’s unemployed specialists? Too many, too few doctors? Findings from the Royal College’s employment study – 2013)

In 2015, the Royal College hosted a National Physician Employment Summit. The participants supported the creation of a time-limited commission to study the nature and shape of the current health workforce, to better understand current gaps and shortfalls in meeting patients’ need, and to take steps to learn from comparative jurisdictions.


Page 4 of 14

The most impacted disciplines reporting unemployment in the Royal College’s 2015-2016 Employment Survey, are neonatal-perinatal medicine, nephrology, neurosurgery, orthopedic surgery, pediatric emergency medicine, plastic surgery, radiation oncology, and vascular surgery. Supply of Physicians International Medical Graduates (IMGs)

The College of Physicians and Surgeons of Ontario (CPSO) established four pathways to registration for International Medical Graduates in 2008. The pathways address:

• Physicians with a Canadian Medical Degree and Postgraduate training without Royal College of Physicians and Surgeons of Canada (RCPSC) or College of Family Physicians of Canada (CFPC) Certification

• IMGs with Canadian Postgraduate Training without RCPSC or CFPC Certification and practicing independently in Canada

• Physicians with a Canadian or US Medical Degree with US Postgraduate Training and Certification

• IMGs with US Postgraduate Training and Certification

The College of Physicians and Surgeons of Ontario reported that in 2018, 5281 newly registered physicians, which represents a 5.4% increase over the previous year. The issuance by source of medical degree is: 40% Ontario, 20% other Canada, 3% USA, and 37% International. The CPSO reported that physicians from the following top 10 locations received the highest number of certificates: Saudi Arabia 266, Ireland 241, United Kingdom 141, India 130, Australia 93, Grenada 73, Netherlands Antilles 70, Egypt 68, Iran 62, and St. Kitts and Nevis 57. Unrestricted Mobility between Provinces The provincial licencing bodies for physicians have had varying standards for licensure across Canada. Ontario is considered to have more stringent criteria than some of the other provinces. For example, International Medical Graduates often apply for licensure in other provinces prior to coming to Ontario.

In December 2009 with the passage of Bill 175, Ontario was required to licence physicians coming from anywhere else in Canada, and apply the same restrictions on their certificate as were present in their prior jurisdiction, if any. This resulted from the labour mobility provisions in the Agreement on Internal Trade which enabled unrestricted mobility between provinces for anyone licenced to practice medicine in Canada.

To address the labour mobility provisions, the Federation of Medical Regulatory Authorities of Canada (FMRAC) developed a national standard for licensure in all jurisdictions. In February 2010, the College of Physicians and Surgeons of Ontario Council agreed to implement immediately the FMRAC requirements for full licensure.


Page 5 of 14

The Ontario Ministry of Health and Long-Term Care’s strategies to increase the supply of physicians over the past few years were:

• Increased medical school seats by 38% between 2005 and 2012 • Expanded Family Medicine training by 128% between 2004 and 2014 • Increased training and assessment positions for internationally trained doctors • Created the HealthForceOntario Marketing & Recruitment Agency • Established Family Health Teams

HealthForceOntario (now part of Ontario Health) was created “to ensure that Ontarians have access to the right number and mix of qualified health care providers, now and in the future. The HealthForceOntario Marketing and Recruitment Agency is focused on building and maintaining the province’s health human resources capacity through two categories of activity:

• Retention and distribution of Ontario’s health professionals • Recruitment and outreach to internationally educated health professionals living in Ontario,

Ontario’s recruitment community and practice-ready physicians living outside Ontario who are practicing in high-need specialties”

(former HealthForceOntario website) Areas of High Physician Need To improve access to physicians in communities where there is a high need for their services, the Ministry of Health and Long Term Care uses the Rurality Index for Ontario (RIO) score. If a community has a score of 40 or greater, different incentives or programs may be available.

Under the Managed Entry process for family physicians, twenty new family physicians per month are eligible to join the Family Health Organization and Family Health Network compensation models in an area of high physician need only (based on RIO scores). If a physician is interested in entering family practice in other parts of the province, there are different practice and compensation models available. The Ministry also noted that the Managed Entry process does not apply to replacement physicians. Within Sarnia-Lambton, the following communities have an RIO score of 40 or greater:

• Brooke-Alvinston • Dawn-Euphemia • Enniskillen • Kettle Point 44 (Indian Reserve) • Lambton Shores • Oil Springs • Plympton-Wyoming • Sarnia 45 (Indian Reserve) • St. Clair • Walpole Island (Indian Reserve)


Page 6 of 14

• Warwick

Importance of Family Physicians on Health of the Population The College of Family Physicians of Canada reports that evidence strongly supports better health outcomes for those in communities with better access to family physicians and primary health care professionals. Care from primary care physicians has been shown to have beneficial impacts on hospitalization rates and subsequent mortality, morbidity and costs. A study from the United States estimates than an enhanced primary care system in which every person had a family physician would improve the quality of care substantially and was estimated to be able to save 5.6% of the total US healthcare expenditures. Public surveys indicate that:

• 80% of Canadians reported that they preferred to access care through their family physicians, • about 88% agree that having a family physician allows them to feel more confident about access

to other services, • more than 80% of Canadians rate the quality of care from their family physicians as good to

excellent, and • more than 66% identified their family physician as the most important caregiver for them and

their families.

An ICES Investigative Report (July 2008), on the “Impact of Not Having a Primary Care Physician among Patients with Chronic Conditions,” identified that patients:

1) who did not have a regular medical doctor; 2) whose records showed relatively few physician visits in the previous two years; 3) whose pattern of health system usage suggested low continuity of care;

often had excess emergency department visits and excess medical non-elective hospital admissions. The 2018 Health Quality Ontario report, “Measuring Up – A Yearly report on how Ontario’s health system is performing,” identified that over 90% of Ontarians have a primary care provider however when they are sick, their wait to see the family doctor or nurse practitioner varies. In Ontario, 67.6% of people aged 16 and older indicated that the amount of time they waited for an appointment with their health care provider when sick was “about right” compared to 65.6% in the Erie St. Clair LHIN. 14.1% of the same Ontario population indicated that they waited much too long to see their provider when sick, compared to 15.3% in the Erie St. Clair LHIN. Current Supply of Physicians in Lambton County The Ontario Physician Human Resources Data Centre maintains a registry of all licensed physicians practicing in Ontario. It should also be noted that according to the Active physicians practicing in Lambton County in 2018, 28 family physicians were aged 65+, indicating that family physician retirements are expected in the immediate future.


Page 7 of 14

The active physicians in Lambton County by specialty (2018) are:

2018 PIO Specialty Total Family Medicine/Emergency Medicine 14 Family Medicine 92 Family Medicine Total 106 Anesthesiology 9 Critical Care Medicine 3 Diagnostic Radiology 6 Emergency Medicine 2 Psychiatry 12 Public Health & Preventive Medicine 3 Other Specialty Total 35 Cardiology 3 Dermatology 1 Internal Medicine 11 Medical Oncology 2 Nephrology 1 Neurology 1 Internal Medicine Total 19 Pediatrics 5 Pediatrics Total 5 Cardiac Surgery 1 General Surgery 8 Obstetrics & Gynecology 8 Ophthalmology 3 Orthopedic Surgery 6 Otolaryngology - Head & Neck Surgery 1 Urology 3 Surgery Total 30 Anatomical Pathology 4 General Pathology 1 Laboratory Medicine Total 5 Specialist Total 94 Grand Total 200 Ontario Physician Human Resources Data Centre Active Physician Registry December 31, 2018 report prepared January 2020


Page 8 of 14

Current Situation at Bluewater Health At Bluewater Health, each Department reviews the current physician complement in conjunction with the needs of the community, trends in care, and population health status to determine the Physician Health Human Resources Plan. Over the past year, Bluewater Health has successfully recruited:

• 1 otolaryngologist (to start July 2021) • 1 emergency physician • 1 medical oncologist • 1 neurologist (to start summer 2020)

For the 2020-2021 year, the outstanding needs are:

• 2 anaesthesiologists • 1 obstetrician/gynaecologist (replacement) • 1 otolaryngologist • 1 general surgeon • 1 orthopaedic surgeon (replacement) • 1 plastic surgeon • 1 radiologist • 1 pathologist (replacement) • 2 Rural Health Emergency physicians (1 is a replacement) • 2 hospitalists (1 is a replacement) • 5 Emergency physicians • 2 paediatricians (1 is a replacement) • 1 cardiologist (replacement) • .5 infectious disease specialist • 1 rheumatologist • 2 geriatricians * • 1 physiatrist • 1 neurologist • 2 psychiatrists

* Business Case for a Geriatrician


Page 9 of 14

A business case was submitted to the Ministry of Health and Long-Term Care for funding for a geriatrician. The Ministry proposed that Bluewater Health work with the London Regional Geriatric Program, and that there be two geriatricians located in Sarnia. Approval from the Ministry is required. The rationale for the positions is: A geriatrician would support Bluewater Health in enhancing the continuum of care that is provided for older adults. Forty seven percent of all of Bluewater Health discharges are for persons aged sixty five plus. Its catchment area is an aging population, with 21.6 percent aged 65+ compared to 16.7 percent for the province of Ontario. To support the aging population and assist them in maintaining their independence and quality of life, a geriatrician is required.

Older adults often have multiple health conditions which may cause physical and/or cognitive impairment, they are on multiple medications, and require more time for consultations and needs assessment. Geriatricians have expertise in the normal aging process and can understand how much of the patient’s problem is related to normal aging as opposed to disease conditions or the side effects of drugs used to treat diseases. The assessment and treatment plan developed can often lead to improved quality of life and promote independence for the older adult. Avoidance of hospitalization is also a secondary benefit of enhanced access to geriatrics care. Hospitalization may cause harm to older, frail adults, therefore an emphasis on supporting them in the community as much as possible, reducing emergency department visits and hospitalizations is very important.


Page 10 of 14

Immediate and Projected Need for Physicians at Bluewater Health

Discipline Ratio (physician to population)

2019-2020 identified need

2019 Recruited 2020-2021 identified need

Future Needs (2-3 yrs)

Anaesthesia 11,500 2 2

Surgery OB/Gyn 15,500 1 (replace) Ophthalmology 29,650 Otolaryngology 45,700 2 1 to start Jul 2021 1 General Surgery 13,850 1 Orthopaedics 27,500 1 (replace) Urology 51,950 Plastic 85,550 1 Plastic surgeon

has OR & AC time locally, still need 1

1

C.V. & Thoracic Surgery 158,400 Diagnostic Radiology

16,000 1

Pathology 25,400 (General, Lab Medicine) 79,400 (Microbiology Clinic Biochemistry)

1 (replace)

Family Medicine /Rural Health

1,380 1 -Rural Health Emerg

2 - Rural Health Emerg

Palliative Care

Hospitalist 1 (replace) 1 2

Emergency Medicine 55,846 2 2 5 (1 recruited)

Paediatrics 26,950 2

Medicine

General Internal & Sub-Specialties

19,300

Cardiology 32,100 1 (replacement)

Infectious Disease 617,000 .5 .5 Endocrinology 76,600 Rheumatology 94,100 1 1 MedicalOncology 114,350 1 recruited (rp) Geriatrician 2 (if AFP

funding) 2 awaiting

funding

Gastroenterology 62,800 Physiatry 1 1 Respiratory 81,450 Dermatology 62,650 Neurology 59,300 2 1 starting 2020 1 Critical Care (Intensivist)

Psychiatry 8,650 1 2


Page 14 of 14

References

Frechette, Danielle, MPA. “Specialist physician employment in Canada: unpeeling the onion to stimulate change.” Presentation @ Royal College Physician Employment Summit, November 2015.

Health Quality Ontario, Measuring Up 2018: A yearly report on how Ontario’s health system is performing. Ontario Ministry of Health and Long-Term Care website, Areas of High Physician Need dated last modified 2019-07-26. Ontario Ministry of Health and Long-Term Care and Ontario Medical Association. Final Report. Ontario Population Needs –Based Physician Simulation Model, October 2010. Ontario Physician Human Resources Data Centre, 2018

Active Physicians in Lambton County by Specialty of Practice & Age Range in 2018 Royal College of Physicians and Surgeons of Canada. “Health care leaders call for a pan-Canadian commission to study medical workforce issues, Media Release.” November 10, 2015 Royal College of Physicians and Surgeons of Canada, “What’s really behind Canada’s unemployed specialists? Too many, too few doctors? Findings from the Royal College’s employment study – 2013. Royal College of Physicians and Surgeons 2015-2016 Employment Survey. Snelgrove, Natasha, MD. Resident Doctors of Canada and Royal College Physicians and Surgeons of Canada. “Physician Employment Perspectives and Challenges for the New-in-Practice Physician.” Presentation @ Royal College Physician Employment Summit, November 5, 2015. The College of Physicians and Surgeons of Ontario. Annual Report, 2018.

Chief of Professional Staff Report to the Board

February 2020

At the Medical Advisory Committee meeting held on February 19, 2020, the following items were discussed: Quality Improvement Initiatives

• Approved recommendations from the Infection Prevention and Control Committee, Quality and Patient Experience Committee and Patient Order Sets Committee

• Reviewed and approved the following policies/revisions: o Medicine Telemetry Admission, Transfer, Discharge Guidelines Policy o Pediatric Noninvasive Ventilation Policy (revisions) o Code Pink – Cardiac Arrest/Medical Emergency – Infant/Child Policy

(revisions) • Received updates on:

o Physician Resource Plan for 2020-2021, Approved at RUAC o Emergency Department coverage and recruitment updates o Ambulatory Care Clinic Services review o Corporate vs medical items – what needs to come to MAC o No One Waits (N.O.W.) Initiative updates o Resuscitation Policy revision discussions o MAC sub-committee attendance and membership o Locums and on-call responsibilities, reviewed existing policy o Lead Hospitalist position vs elevate to Chief level o Reappointment process for 2020-2021 o Iron infusion changes, charging patients by AC o CPSO Audit process o Coronavirus local update o New Code Trauma Draft Policy updates o MAC scorecard, quarterly o QCR recommendations o Ontario Health Team updates

Physician Representation on Committees

• Appointed a new representative to the Health Information Committee Physician Education, Development and Engagement

• Discussed upcoming events: o Mini Medical School upcoming sessions:

− Resuscitation – Drs. Cuccarolo and Crombeen – February 24, 2020 − Genetics Revolution – Dr. Lacroix – March 5, 2020 − Osteoporosis and Osteoarthritis – Drs. Matlovich and A. Rahalkar –

April 16, 2020 o 9th Annual Medical Education Symposium – April 4, 2020 o PLI course – Building and Leading Teams – rescheduled to May 1&2 o Dream Home Lottery tickets are on sale

Recruitment/Succession Planning Two new Emergency physicians have accepted offers for the mentorship program, pending the credentialing process. We matched 2 new ER residents to start this July. A new radiologist has accepted an offer. Interviews are in progress for Medical Director, Laboratory Medicine, Rural Health Emergency physician, orthopaedic surgeon and psychiatrist. Recruitment efforts continue for many needed specialists: ENTs, anaesthesiologists, neurologists, Emergency physicians and psychiatrists (adult and child). Linkages with Western University Western’s Distributed Education Regional Academic Directors Retreat is being held in Sarnia this year on February 26, 2020. Submitted by: Michel Haddad, MD, MSc, FRCSC Chief of Staff, Bluewater Health

Executive Director’s Report February 2020

We were saddened to hear of the passing of long time Bluewater Health Foundation board member, committee member and friend Marty Raaymakers. Marty was not only actively involved with the hospital but so many other causes in the community. We send our condolences to his wife Pam and their family.

Tickets continue to sell well for the 25th anniversary of Dream Home lottery. The response to the new online format and partnership with CEEH Foundation has been great. The new 50/50 option has been very well received! We are aware that many changes have taken place with Dream Home and are thankful to the community who are continuing to support the lottery. Congratulations to the winners of the early bird draws that took place in January and February. We draw for a beautiful BMW (or $30,000 cash option) February 28th. The final draws take place March 25th in the atrium of Bluewater Health. I hope you can join us as we celebrate all of the winners! A reminder that tickets can be purchased online at bwhfdreamhome.com

The community is continuing to respond to the ACCESS Open Minds initiative. Imperial Oil made a generous $50,000 contribution in December and several third party events have been hosted where ACCESS has been the beneficiary. On February 1st, local musicians Emm Gryner and Preetam Sengupta hosted a concert at the Sarnia Library where donations will be raised and accepted for ACCESS. Corunna United Church hosted a soup luncheon and allocated donations to ACCESS. The Mike Weir Foundation matching campaign continues to accept donations and they are close to achieving their $200,000 goal!

Mike Lapaine, Mark Braet (CEEHF) and myself presented our request for funding to the County of Lambton on February 5th. This request has been in the works for quite sometime with a lot of work being done behind the scenes over the past couple of years. We requested a $10 million dollar investment over a 10 year period. While we are aware this is a large amount, we strongly believe this gift will have a tremendous impact on the patients and families we are honoured to provide care to. Thank you to all of the board members who attended the meeting to show their support of the request. Council will review all funding requests in details at their March 4th meeting.

Respectfully submitted,

Kathy Alexander

Documents

AGENDA...AGENDA OPEN SESSION BOARD MEETING Wednesday, February 26, 2020 Bluewater Health Board Room – R-4-810 5:05 pm Directors: Marg Dragan, Treasurer Anthony Iafrate Bill …