AGENDA OPEN SESSION BOARD MEETING

Wednesday, September 25, 2019 Bluewater Health Board Room, R-4-810

5:00 pm Directors:

Marg Dragan Anthony Iafrate Bill Gillam Jenny Greensmith

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

Rachael Simon Fred Vanderheide, Treasurer 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

Recorder: Melissa Rondinelli *attached

NO. TOPIC ACTION TIME PRESENTER

1.0 CALL TO ORDER: WELCOME AND OPENING REMARKS 5:00 Paul Wiersma

1.1 Traditional Territory Acknowledgement Paul Wiersma

2.0 AGENDA APPROVAL

2.1 Approval of Agenda Decision 5:02 Paul Wiersma

2.2 Declaration of Conflict of Interest Reference: Corporate By-Law of Bluewater Health s. 5.10 – Conflict of Interest

Decision Paul Wiersma

3.0 CONSENT AGENDA

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 Board Evaluation Results* Information Anthony Iafrate

3.1.4 Analysis of Loans and Investments* Information Marg Dragan

3.1.5 Facilities Quarterly Report* Information Marg Dragan

NO. TOPIC ACTION TIME PRESENTER

3.1.6 Draft Board Education Plan* Information Anthony Iafrate

3.1.7 Auditor’s Annual Post Audit Management Letter* Marg Dragan

4.2 ITEMS FOR APPROVAL Paul Wiersma

4.2.1 Open Session Board Minutes • June 26, 2019* • June 26, 2019 – Post AGM Meeting*

Decision Paul Wiersma

5.0 PRESIDENT AND CEO REPORT* Information 5:05 Mike Lapaine

6.0 BOARD DECISIONS/OVERSIGHT

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

6.2 Quality Committee Highlights* Information 5:25 Brian Knott

6.3 Quality Committee Performance Scorecard* Discussion

6.4 Resource Utilization & Audit Committee Highlights* Information 5:35 Marg Dragan

6.5 Financial Statement* Decision

6.6 Resource Utilization and Audit Committee Performance Scorecard*

Discussion

6.7 Chief Financial Officer Certificate* Decision

6.8 Chief of Professional Staff Report* Information 5:45 Dr. M. Haddad

6.9 Bluewater Health Foundation Report* Information 5:55 Kathy Alexander

7.0 POLICY FORMATION – None

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

Paul Wiersma

9.0 REPORT ON IN-CAMERA AGENDA ITEMS Information 6:05 Paul Wiersma

10.0 ADJOURNMENT: Next Meeting - November 27, 2019 (Petrolia) 6:05 Paul Wiersma

Board Chair Report

I would like to highlight my activities as Chair for the period of June 21, 2019 to September 20, 2019: June 26, 2019 Prepared for and chaired the BWH Board meetings and

annual general meeting June 27, 2019 Attended BWH EC/MAC/Board summer social event July 25, 2019 Attended dream home lottery 25th anniversary announcement August 14, 2019 Participated in OHA webinar, “Good Governance Practice to

Support System Transformation” August 14-19, 2019 Meetings with individual Board members to discuss

contributions to the Board August 19, 2019 Met with the President and CEO to prepare to discuss hospital

and Board business August 22, 2019 Co-led BWH Orientation for New Board Members – Part 1 September 4-6, 2019 Attended OHA Health Care Leadership Summit September 9, 2019 Chaired the BWH Board Orientation Session – Part 2 September 11, 2019 Participated in Governance and Nominating Committee

Meeting September 17, 2019 Met with the President and CEO to prepare for the September

Board meeting and discuss hospital and Board business September 21, 2019 Attended the Addiction and Mental Health Open House September 25, 2019 Met with the Chief of Professional Staff for quarterly review 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

September 2019 I would like to highlight my activities as PSA President since June 2019: July 15, 2019 Attended the quarterly Hospital On-Call Committee meeting September 9, 2019 Attended the Board Orientation Session September 11, 2019 Attended the Governance & Nominating Committee meeting September 18, 2019 Prepared for and attended the Medical Advisory Committee

meeting September 2019 Prepared agenda for the quarterly PSA Meeting (September

30, 2019)

Dr. Andre Rudovics

1

Bluewater Health Briefing Note

Name of Committee: Board of Directors Date of Meeting: September 25, 2019 Submitted by: Paul Wiersma Subject: Board Evaluation Purpose of Report: Information x Input Approval

Situation In accordance with Policy E-19 - Board Evaluation, the Board follows an annual process to evaluate Board effectiveness as a whole, its membership, leadership and Committees (see Board Evaluation Tools and Timelines document attached). Background A number of evaluation tools were distributed to Board members over the period of May to July. The results have been analyzed and summarized below. Analysis Board Chair Evaluation There were 12 responses to the survey (Ex-Officio Directors included in group), which was typically completed within three minutes. Overall, the responses and comments were positive. On a 5 point scale, the following 4 out of 20 statements had higher ratings:

• 4.92 - ensures the integrity and effectiveness of the Board's governance role and processes.

• 4.92 - adheres to the Mission, Vision and Values of the organization. • 4.92 - reports to the Board on any issues relevant to its governance responsibilities. • 4.92 - maintains a constructive relationship with the CEO, Chief of Staff and members of

the executive team. On a 5 point scale, the following 3 out of 20 statements had lower ratings:

• 4.25 - serves as a mentor to other members to ensure each is supported and contributes his/her skills and expertise effectively.

• 4.33 - facilitates relationships with and between Board members. • 4.42 - provides constructive feedback to members as required to foster continuous

improvement. Exit Survey The Board received two responses to this survey. The results were positive overall. Recommendations shared by the outgoing members included the following:

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2

• Continue to encourage learning opportunities, attend open meetings of other boards • Encourage members to serve on each committee during tenure • Allocate specific discussion time for current topics • Consider longer term trends (e.g. indicators on score cards) and project further into the

future. • Providing feedback face-to-face or via phone rather than filling out an electronic survey

Individual and Peer Evaluation Results All Board Directors participated in these surveys. The typical time spent to complete the individual survey was 12 minutes, and 9 minutes for the peer survey. Again, the results were positive overall. The Board was recognized as high functioning, with strong relationships and trust.

Requests for education regarding Ontario Health Teams and financial training were made which will be included in this year’s education plan. There was also interest in Board leadership training which is being investigated.

In terms of the survey tools and process, there was confusion amongst Directors about rating themselves again in the peer survey, there was not a comment box for each question, and the process of combining the data was time-consuming. There is opportunity to simplify the survey tool and process pending feedback from G&N and the Board.

Recommendation

The Board continue use of the current evaluation tools and implement recommendations made.

Updated: September 20, 2019

BWH Board Evaluation Tools and Timelines

Type of Survey Frequency/month Last Completed

Sept Oct Nov Dec Jan Feb Mar Apr May June July Aug

Orientation/Retreat Process

Following the session

November 2018

x x x

Collective Board performance evaluation • OHA GCE Board Self

Assessment Tool

• Governance Self-Assessment Survey/ Governance Functioning Tool

• Director/NDCM Exit

Survey

Every two years

With Accreditation

cycle and when Standards are

updated

Annually

2018

2018

June 2019

x

x

Director/NDCM performance evaluation • Individual • Peer Evaluation

Annually

June 2019 June 2019

x x

Board Meeting effectiveness

Twice annually Fall/Spring

April 2019 x X

Committee Effectiveness Annually May 2019 x

Board leadership effectiveness

Annually

June 2019

x

Bluewater HealthBank Loan AnalysisFor the period ending June 30, 2019

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

Bank Loans - Long TermDemand loan, 2.39%, repayable in blended monthly Honeywell Energy Project 994,611 1,126,898 1,258,397 1,389,114 1,519,053 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, 1,694,035 1,842,616 1,990,317 2,137,142 2,283,097 4,500,000 matures March 2022TOTAL DEBT 2,688,646 2,969,514 3,248,714 3,526,256 3,802,150 8,300,000

Less: Current Portion of Long Term Debt (852,711) (1,133,579) (279,200) (556,742) (832,636) 1,835,935 1,835,935 2,969,514 2,969,514 2,969,514

TOTAL LONG TERM DEBT 1,835,935 1,835,935 2,969,514 2,969,514 2,969,514 TOTAL CURRENT PORTION OF LONG TERM DEBT (OTHER LIABILITIES) 852,711 1,133,579 279,200 556,742 832,636

2016/17 Capital Expenditures

Charlotte Eleanor Englehart Hospital of Bluewater HealthEnglehart Estate InvestmentsAs at June 30, 2019

Cash Accounts:Revenue Cash 8,331.83 Capital Cash 23,448.07

Total Endowment Cash per TD Waterhouse Stmnt 31,779.90

Original Cost FMV Held for Trading Investments

Money Market Funds 15,062.34 15,062.34 Bond Funds 394,316.46 403,944.00 Equity Funds 318,459.08 331,088.00

Total Held for Trading Investments 727,837.88 750,094.34

Total Investments and Cash Accounts 759,617.78 781,874.24

1

Bluewater Health Briefing Note

Name of Committee: Resource Utilization & Audit Committee Date of Meeting: September 12, 2019 Submitted by: Marlene Kerwin Subject: 2020-21 Budget Planning Purpose of Report: Information Input Approval

Situation Bluewater Health has begun the budget planning process for the 2020-21 fiscal year with the goal of presenting a budget for Board approval in February 2021. Background The Finance Department is in the process of preparing a preliminary budget and budget envelopes for each department. Envelopes will illustrate the inflationary pressures that each department will need to find for the 2020-21 fiscal year. The envelopes will also contain peer comparator data to help managers evaluate their operations. The budget envelopes and associated savings targets are set with the goal of absorbing all 2020-21 inflationary pressures. Analysis The hospital must make certain assumptions with the budget planning process. The following assumptions will be incorporated into the budget planning for 2020-2021: Ministry funding will remain the same as what was received for 2019-20 fiscal year

with the exception of one-time funding; One-time funding (and associated expense) will be removed from the 2020-21

operating plan; Other sources of revenue such as room differential will be adjusted to better align

with 2019-20 forecasted revenue; Salaries & Benefits will increase based on a review of current year actual expense

as well as by percentages outlined in current collective agreements; Inflation related to supplies will be absorbed by the departments; and, Costs associated with any new initiatives and services will be reviewed and

incorporated into the preliminary budget plan

X

X

X

X

X

X

X

DATE OF PRESENTATION

COMMITTEE TITLE TOUR/ PRESENTATION EXECUTIVE SPONSOR LEAD (S)

22-Aug-19 NA New Board Member Orientation BWH Overview - Mission Vision Values, Strategic Plan, etc. Board Overview - Committees, Responsiblities, Governance ModelProfessional Staff Overview Tour

Presentation Mike Lapaine Dr. Haddad

Mike Lapaine Dr. Haddad

9-Sep-19 Board BWH Board OrientationPortfolio OverviewStrategic Plan Committee OrientationPerformance Monitoring

Presentation All EC Mike Lapaine

25-Sep-19 Board /G&N OHT Update Presentation Mike Lapaine23-Oct-19 Board Hold

26-Oct-19 Board Board Retreat - TBDOntario Health Team Development Environmental Scan - Ministry/LHIN Strategic Plan Priorities and GoalsEthical Decision-Making

14-Nov-19 RUAC Financial Statements Presentation - work plan item Samer Abou-Sweid Marlene Kerwin Al S ll14-Nov-19 RUAC QBP Financial Exposure Presentation - work plan item Samer Abou-Sweid Marlene Kerwin

14-Nov-19 RUAC Legislative Requirements Presentation - work plan item Samer Abou-Sweid Marlene Kerwin 18-Nov-19 Quality Infection Control Presentation - work plan item Shannon Landry Helen Shaw

18-Nov-19 Quality Stroke Vascular Rehab Program Presentation - work plan item Laurie Zimmer Paula Gilmore

27-Nov-19 Board CEEH Tour and Update on Project Tour and presentation? Laurie Zimmer Bob DeRaad

9-Jan-20 RUAC HR Report with focus on Absenteeism Rate

Presentation - work plan item - presented quarterly

Shannon Landry Colleen Cook

9-Jan-20 RUAC Cost per Weighted Case Presentation - work plan item Samer Abou-Sweid Marlene Kerwin 13-Jan-19 Quality Diagnositc Services Presentation - work plan item Samer Abou-Sweid Deb Croteau13-Jan-19 Quality Diagnostic Imaging Presentation - work plan item Samer Abou-Sweid Deirdre Shipley 13-Jan-19 Quality Best Practice Presentation - work plan item Shannon Landry Jane Mathews22-Jan-20 Board Addictions/Access Open Minds Presentation Paula Reaume-Zimmer

13-Feb-20 RUAC Draft Operating Plan Presentation - work plan item Samer Abou-Sweid Marlene Kerwin

18-Feb-20 Quality Pharmacy Presentation - work plan item Samer Abou-Sweid Andrea Wist

18-Feb-20 Quality Mental Health Presentation - work plan item Paula Reaume-Zimmer Andrea Wist

26-Feb-20 Board Tour - 2nd Floor Redesign?12-Mar-20 RUAC Cyber Security Presentation - work plan item Samer Abou-Sweid Mazen Joukhadar12-Mar-20 RUAC Capital Budget Presentation - work plan item Samer Abou-Sweid Marlene Kerwin

S12-Mar-20 RUAC Working Capital Presentation - work plan item Samer Abou-Sweid Marlene Kerwin 16-Mar-20 Quality Surgical Program Presentation - work plan item Samer Sally Jenkins

16-Mar-20 Quality MIC Presentation - work plan item Samer Sally Jenkins

25-Mar-20 Board OHT Update - Board to Board?CMHA, Primary Care, St. Joseph's Hospice

22-Apr-19 Board HOLD for Retreat #214-May-20 RUAC Insurance Presentation - work plan item Samer Abou-Sweid HIROC19-May-20 Quality ED, ICU, Respiratory, Pt Flow, P&TS Presentation - work plan item Laurie Zimmer Lisa Regan 27-May-20 Board TBD - Petrolia 15-Jun-20 Quality Rural Health

Medicine Presentation - work plan item Laurie Zimmer Bob DeRaad

24-Jun-20 Board AGM

Other ideasGovernance functioning - legal overview Leading Effective meetings for Board ChairsIndigenous training Board social events Conflit of interest

Tours -CEEH -MIC - 2nd Floor Redevelopment

Draft Board Education and Quality Reporting Plan 2019/20

MINUTES

OPEN SESSION BOARD MEETING Wednesday, June 26, 2019

Directors:

Marg Dragan √ Anthony Iafrate √ Bill Gillam √ Jenny Greensmith

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

Wayne Pease √ Rachael Simon √ Fred Vanderheide, Treasurer √ Paul Wiersma, Chair √

Ex-Officio Directors:

Mike Lapaine √ Dr. Michel Haddad - R

Shannon Landry √ Dr. Andre Rudovics - R

Participants: Samer Abou-Sweid √ Julia Oosterman √

Laurie Zimmer √ Kathy Alexander √

Paula Reaume-Zimmer √

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

1.0 CALL TO ORDER - Paul Wiersma called the meeting to order at 4:00 pm and welcomed the

Board and guests.

1.1 Traditional Territory Acknowledgement - Paul read the traditional territory acknowledgement.

2.0 AGENDA APPROVAL 2.1 Report on April In-Camera Board Meeting

Paul reported on the items discussed at the May and June In-Camera Board meeting, which included: May 22

o Approved the Nominating Committee report o Reports on:

CEO and COPS succession planning CEO and COPS performance evaluation Board correspondence Ontario Health Teams Annual Quality and Patient Safety Report Litigations Claims Report Risk Assessment Checklists and Integrated Risk Management Business and Financial Risk Assessment Annual Review of Insurance Coverage Pay Equity Executive and Director Expense Reporting 2019-20 Funding

• June 26 o Approved professional staff credentialing

Bluewater Health – Open Meeting June 26, 2019 Page 2 ____________________________________________________________________________

o Reports on: Ontario Health Teams Board Correspondence CEO and COPS Annual Performance Evaluations

2.2 Approval of Agenda*

Motion duly made, seconded and carried: to approve the agenda as presented. 2.3 Declaration of Conflict of Interest

Paul invited Directors to share any conflicts of interest. No conflicts were declared.

3.0 CONSENT AGENDA 3.1 ITEMS TO BE RECEIVED 3.1.1 Facilities Quarterly Report* 3.1.2 Legislative Updates*

• Amendments to Public Sector Labour Relations Transition Act, 1997* • Protecting a Sustainable Public Sector for Future Generations Act, 2019*

3.1.3 Board Chair Report* 3.2 ITEMS FOR APPROVAL 3.2.1 Open Session Board Minutes – May 22, 2019* 3.2.2 Broader Public Sector Accountability Act (BPSAA) Attestation* 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 – May 22, 2019 Authorize the Board Chair to sign the annual BPSAA Attestation.

4.0 BOARD DECISIONS/OVERSIGHT

4.1 Quality Committee Highlights*

Brian Knott presented the Quality Committee Highlights. He reported the Committee received updates from the Rural Health and Medicine departments and noted a recreational therapist has been added to the CC COG unit with good results. He also shared a patient experience story that highlighted a special bond between a patient and an environmental services worker.

Bluewater Health – Open Meeting June 26, 2019 Page 3 ____________________________________________________________________________ 4.2 Quality Committee Performance Scorecard*

Brian presented the scorecard and highlighted BWH’s Access to care indicators #s1-4 had improved compared to January, the Treated with Kindness Indicators results are positive, and BWH is awaiting a target for the Workplace Violence indicator to be determined by Health Quality Ontario. Next, he presented a new Scorecard, which was developed based on Board feedback, research, and other examples. Changes include baseline/last year’s performance data, preferred trending direction, and new definitions for the colour coding, which are expected to provide the Board with a better reflection of the hospital’s performance. Motion duly made, seconded and carried: to approve the revised performance monitoring framework for the Quality Committee Performance Scorecard as presented. Board members shared positive feedback regarding the changes and suggested the format will help the Board to focus on indicators not reaching the targets.

4.3 Quality Improvement Plan (QIP) Update* Brian presented the QIP update for information and noted the indicator results are included on the Scorecard. He explained this document provides details regarding the change initiatives taking place to drive the QIP indicators. There were no questions or comments.

4.4 Resource Utilization & Audit Committee (RUAC) Highlights* Fred Vanderheide presented the RUAC Committee Highlights. He reported the Committee

discussed the Erie St. Clair Security Maturity Dashboard outlining the work to be done for cyber security. In addition, the Committee discussed how it contributed to the Board’s Goals, and received a positive update on the No One Waits (NOW) initiative. There were no questions or comments.

4.5 Revised 2019-20 Operating Plan* Fred presented the briefing note outlining the revised operating plan based on funding

confirmation received from the Ministry of Health and Long-Term Care. He noted the Board previously approved a deficit of $2.6M and the revised operating plan deficit is $1.3 M.

Motion duly made, seconded and carried: to endorse the 2019-20 proposed Operating

Plan as presented with the revised plan to be used to update the Hospital Accountability Planning Submission.

Bluewater Health – Open Meeting June 26, 2019 Page 4 ____________________________________________________________________________ Louis Guimond commented he was supportive of the motion in the spirit the hospital will

aim to balance this year. 4.6 Resource Utilization and Audit Committee Performance Scorecard*

Fred presented the RUAC Scorecard and highlighted the following indicators updated this month: • Cost per patient day for Mental Health is off target • QBP Financial Exposure is positive • Surplus/deficit is positive • Working capital is $1M (positive) • Capital spending is at 62% (positive)

There were no questions or comments. Next, Fred presented a newly revised RUAC Performance Scorecard. He explained the Scorecard has new colour coding related to last year’s results/baseline and a trend line. Motion duly made, seconded and carried: to approve the revised performance monitoring framework for the RUAC Performance Scorecard as presented. Fred was thanked for his years of service on RUAC and more recently in his leadership role as Board Treasurer. It was noted he would be appointed to the Quality Committee next year.

4.7 Governance and Nominating Committee (G&N) Highlights* Anthony Iafrate presented the highlights and reminded the Board to complete any

outstanding surveys. He acknowledged and thanked members for their contributions to the Board Goals, and noted the Board is still looking for someone to act as the representative for the CEEH Foundation Board. If you are interested in this role, please reach out to Paul Wiersma. Lastly, Anthony thanked Wayne Pease for contributions and leadership of the G&N Committee. There were no questions or comments.

4.8 Board Work Plan 2018-19* Anthony presented the work plan. It was noted all but one item was complete - 4.18

Review/approve Broader Public Sector Executive Compensation Act Annual Attestation, as BWH is awaiting direction from the ESC LHIN on this item.

Bluewater Health – Open Meeting June 26, 2019 Page 5 ____________________________________________________________________________ 4.9 Strategic Plan Progress Report*

Mike Lapaine presented the Strategic Plan Progress Report for the 2018 calendar year. He noted the hospital worked to summarize the activities for each strategic goal to one page, and explained the challenges were grouped at the end, since many overlapped more than one goal. There were no questions. Paul commended BWH and the CEO for this work, and advised the Board the report is used to measure the CEO’s leadership. Mike credited the collective work of the teams across BWH for the progress made on the Strategic Plan.

4.10 Charlotte Eleanor Englehart Hospital Capital Improvement Project Update* Mike presented a letter from the ESC LHIN endorsing Stage 1A of the CEEH Capital Improvement Project Submission. He noted the hospital continues to await information about Hospital Infrastructure Renewal Funding and a special circumstances grant it applied for, which would help to inform the remainder of the plan. More information will be provided to the Board as it is received. If was questioned whether the project was at risk with the move to Ontario Health Teams. Mike suggested it was not, since CEEH has infrastructure issues that must be addressed. The current issue is that the previous Ministry representatives working with BWH are now in different positions, and the new staff are not familiar with this project. Therefore, BWH may have to use original planning grant funds to address infrastructure items.

5.0 CHIEF OF PROFESSIONAL STAFF REPORT* Dr. Haddad presented the report and highlighted the work of the Medical Advisory

Committee for the month, which included policy reviews, professional staff internet planning, and discussion about specialy shortage and recruitment needs. He also noted a new Professional Staff Association President had been elected, Dr. Andre Rudovics. Paul asked Dr. Haddad to share the Board’s appreciation with Dr. Rutledge for her past leadership in this role.

6.0 OPEN FORUM

Kathy Alexander reported the BWH Foundation recently held its Annual General Meeting and celebrated a very successful year. She noted they have great plans underway for next year, and highlighted the Do it for Sarnia Block Party was a great success. Kathy thanked the Mental Health and Addictions Services team for volunteering at the event.

7.0 ADJOURNMENT Motion duly made, seconded and carried: to adjourn the meeting at 4:32 pm.

Bluewater Health – Open Meeting June 26, 2019 Page 6 ____________________________________________________________________________ ________________________ ____________________________ Paul Wiersma Mike Lapaine Chair Secretary Board of Bluewater Health Board of Bluewater Health

_________________ Melissa Rondinelli Senior Executive Assistant, Recorder

MINUTES

OPEN SESSION BOARD MEETING Wednesday, June 26, 2019

Directors:

Marg Dragan √ Anthony Iafrate √ Bill Gillam √ Jenny Greensmith √

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

Rachael Simon √ Fred Vanderheide, Treasurer √ Paul Wiersma, Chair √ Kirk Wilson √

Ex-Officio Directors:

Mike Lapaine √ Dr. Michel Haddad

Shannon Landry √ Dr. Andre Rudovics - R

Participants: Samer Abou-Sweid - R Julia Oosterman √

Laurie Zimmer √ Kathy Alexander - R

Paula Reaume-Zimmer √

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

1.0 CALL TO ORDER

Paul Wiersma called the meeting to order at 6:56 pm and welcomed the Board and guests.

2.0 AGENDA APPROVAL 2.1 Approval of Agenda*

Motion duly made, seconded and carried: to approve the agenda as presented. 2.2 Declaration of Conflict of Interest

Paul invited Directors to share any conflicts of interest. No conflicts were declared.

3.0 BOARD DECISIONS

3.1 2019-20 Board Leadership and Committee Appointments* Paul presented the recommendations for Board Leadership appointments and the committee appointments for the 2019-20 Board meetings for approval. There were no questions or comments.

Motion duly made, seconded and carried: to approve the Board leadership appointments and Committee appointments as presented.

Bluewater Health – Open Meeting June 26, 2019 Page 2 ____________________________________________________________________________ 4.0 ADJOURNMENT Motion duly made, seconded and carried: to adjourn the meeting at 6:56 pm. ________________________ ____________________________ Paul Wiersma Mike Lapaine Chair Secretary Board of Bluewater Health Board of Bluewater Health

_________________ Melissa Rondinelli Senior Executive Assistant, Recorder

Stroke Care Leadership Following the recent successful Accreditation process, Bluewater Health has now committed to the process of achieving the first disease-specific accreditation program in Canada, Stroke Distinction (https://accreditation.ca/stroke-distinction/). Achieving distinction will allow the organization to showcase its excellence in stroke care and be recognized nationally as a high-performing centre. Over recent years Bluewater Health has been highlighted as a provincial top performer in a number of indicators (how quickly a patient accesses the stroke inpatient rehabilitation they need and the percentage of ischemic stroke patients receiving carotid imaging during their inpatient stay). This success is the perfect start to achieving Canadian Stroke Best Practice Standards for Acute and Rehabilitation Stroke services and in 15 months we will welcome the expert surveyors to showcase our quality improvement work and excellence in our patient-centred care. Bluewater Health is working in partnership with seven other District Stroke Centres within the Southwestern Ontario Stroke Network to complete the Stroke Distinction journey. Advancing Indigenous Care Bluewater Health is committed to improving the health of Indigenous people, and responding to The Truth and Reconciliation Commission’s Calls to Action related to healthcare. Everyone registering for patient care at Bluewater Health is now asked if they would like to voluntarily self-identify as First Nations, Métis or Inuit. Responses will be saved, allowing the hospital to provide extra support through the Indigenous Patient Navigator as needed, and the patient will not be asked when registering in the future. On September 30, Bluewater Health will mark Orange Shirt Day. PEP Rounding The Chief Nursing Executive, Patient Experience Specialist and Patient Experience Partners (PEPs) have been visiting inpatient clinical units over the past year to raise awareness of the PEP role at Bluewater Health and to hear from the units about their efforts to exemplify patient and staff experience. Using an Appreciative Inquiry approach, this rounding team asks staff about successes, barriers and improvement ideas for strengthening patient and family-centred care at Bluewater Health. An area of focus is asking staff and patients how to best support anxiety and fears across the continuum of care. This affirmative feedback, received from patients about their care experience, shines the light on positive actions across the hospital that can be reinforced and strengthened. The next visits are scheduled, from September to June. The next step is to track the feedback electronically and share it broadly throughout the organization.

Report to the Board from President & CEO Mike Lapaine

September 2019

No One Waits (NOW) Our teams have been working diligently toward our target of two-hour patient transitions by October 1, 2019. We have identified opportunities within work processes to achieve more timely patient transitions and we have been testing solutions throughout the organization. Progress towards our goal has been consistent. So far we have seen:

• A 34% decrease in Average Time to Inpatient Bed from 8 hours Year to Date (YTD) 2017/18 to 5.3 hours YTD 19/20.

• A 66% decrease in shifts not filled which means that units are not working short-staffed, more staff were granted vacation time, and beds stayed open as they were staffed.

• The number of Conservable Bed Days (days that extend beyond the Estimated Length of Stay) has decreased steadily. This means we are discharging patients in a timelier manner and the use of white boards to communicate Estimated Date of Discharge (EDD) to patients and families has been well received and gives everyone time to proactively plan for discharge.

• The activities to transfer a patient from the Emergency Department (ED) to an inpatient unit and between units have been identified and tested over the summer months. Teams have been encouraged to seek the support of their Managers and Directors when there is risk that the patient will not meet the two-hour time frame. This ensures all possible solutions are considered, barriers are tracked for trends and everyone is held accountable to the new culture.

• The policy and practices associated with physician consultation in the ED have been updated and implemented to expedite patient admissions from the ED.

As we continue with our efforts beyond October 2019 and establish our sustainability plan we are well positioned for continued success. Combined Heat and Power Plant A Request for Proposal (RFP) was issued for a project to fill a substantial portion of the Sarnia hospital’s ongoing energy needs through a combined heat and power plant. A feasibility study determined the future plant’s optimal capacity to be 800 KWH, which would supply approximately 60% of the Sarnia hospital’s power needs. The project is expected to deliver savings of over $500,000 annually based on a conservative estimate of utility costs over the next 15 years. Savings will be applied to financing daily operations of the hospital, or increasing its working capital, while maintaining a manageable debt load. An application for an incentive of $1.2 million toward the project was approved by Ontario’s Independent Electrical System Operator (IESO) and Bluewater Health has entered into a contract for the incentive with Bluewater Power. The location of the combined heat and power plant has not been decided, and will be determined during the engineering phase of the project. A second RFP for the build and installation portions of the project will be posted in the fall. The project is expected to be completed by December 1, 2020.

Executive Outreach As part of my commitment to increasing executive visibility and trust in leadership, in June, I rounded to most units and departments to discuss the organization’s progress against the goals set out in the No One Waits (NOW) initiative and provide an update on the hospital’s financial performance. The Executive Team, directors and managers staffed the appreciation barbecues hosted by the Healthy Living Team in Petrolia and Sarnia. Through these initiatives over 1,100 people were connected with leaders in the organization. Bluewater Health Featured in Caring Greatly Podcast Shannon Landry, Chief Nursing Executive, recently showcased Bluewater Health’s work in the third episode of the Vocera Communications Caring Greatly™ podcast, a platform designed to give healthcare leaders stories and resources that help them to grow, lead, innovate, and rejuvenate more effectively. The episode speaks to the importance of a culture of kindness in healthcare and the focus on Emily as the guiding factor in the work that is done at the hospital. Click here to listen to the podcast. Bluewater Health Published in Peer-reviewed Journal Paula Reaume-Zimmer has been published in Early Intervention in Psychiatry, a publication that promotes the importance of early intervention in psychiatric practice. The journal article aims to describe how mental health services for youth are being transformed within the context of a semi-urban and rural region of Canada (Chatham-Kent, Ontario) based on the framework of ACCESS Open Minds, a pan-Canadian youth mental health research and evaluation network. The work that Paula does is appreciated across the hospital and in our community. Click here to read the article. See below for a recent announcement by the Mike Weir Foundation to raise funds for ACCESS Open Minds locally. Sue Denomy Leadership Award Recipient Named The Sue Denomy Leadership Award was established in 2015 upon Sue’s retirement as President & CEO after a career spanning more than four decades. The award follows her mantra that ‘everyone is a leader if they choose to be’ and recognizes contributions made by engaged frontline employees who exemplify Bluewater Health’s Mission, Vision and Values in their daily demonstration of My Promise to Emily. Sue presented the fourth annual award to Angela MacDonald, Charge Nurse in the Emergency Department. The award comes with a financial bursary of $1,000 for continued professional development, made possible by a donation to Bluewater Health Foundation, and an engraved award.

Time Capsule Opening and Cornerstone Celebration Bluewater Health and the Sarnia community will pay homage to the hospital’s past with the opening of three time capsules found in Sarnia General Hospital’s cornerstones. Attendees will watch history be revealed as the Sarnia Historical Society opens the three capsules and displays their contents. The event will also feature a display with the original cornerstones from Sarnia General Hospital.

Mike Weir Foundation Launches Campaign for Mental Health Returning to his roots, Brights Grove golf star Mike Weir has launched a campaign to raise money for a youth mental health program supported by Bluewater Health in Sarnia-Lambton. The money raised will go towards the opening of an ACCESS Open Minds facility to help youth ages 11 to 25 cope with mental health. The Mike Weir Foundation is matching donations up to $200,000 for the youth program. Donations are being accepted at www.mikeweir.com. Huron Oaks hosted a fundraising event on September 19, the Mike Weir Par 3 Challenge for Mental Health, with all the money raised going towards the campaign. Chris Hadfield directed the $10,000 donation from his Walk of Fame induction to this worthwhile cause. Community Allies Create New Mobile Crisis Rapid Response Team During an event hosted by three provincial Cabinet ministers (Minister Christine Elliott, Minister Sylvia Jones, Associate Minister Michael Tibollo), the Canadian Mental Health Association Lambton Kent, Ontario Provincial Police, Sarnia Police Services and Bluewater Health announced the introduction of a new service in Sarnia/Lambton. MHEART (Mental Health Engagement and Response Team) aims to improve the experience of those who have mental health and addiction needs and come into contact with police services. Mobile crisis rapid response teams are made up of mental health workers who work with police to engage individuals in crisis, de-escalate the situation, and connect people with needed services. They are a proven model provincially and nationally and MHEART Sarnia Lambton is following in the footsteps of other successful models. The new protocol will improve the transition process between police and hospital staff to help patients in crisis access timely care. Mental Health and Addictions Community Outreach On September 11, the Mental Health & Addiction Services team hosted a Recovery Day Celebration in the Bluewater Health Auditorium. September is recovery month and addictions organizations across the province, including Bluewater Health, organized celebrations to recognize the clients’ journey in their recovery. This is the first time we have hosted such an event. The second annual community open house was held Saturday, September 21 in response to the community’s need for information about addiction and mental health services and programs available in Sarnia-Lambton. Professionals, friends, family and the community at large were all invited to attend. More than 20 community organizations were onsite to share information about support for people who are struggling or recovering from an addiction and/or have experience with mental health concerns. Critical Care Education Partnership Bluewater Health and Chatham Kent Health Alliance have issued a news release about their jointly-developed program. It meets criteria for critical care training funding that aligns with Critical Care Services Ontario (CCSO) Practice Standards for Critical Care nursing in Ontario. For details please refer to my May report. Petrolia Hospital Celebrates Partnership with Western University Charlotte Eleanor Englehart Hospital (CEEH) of Bluewater Health celebrated its longstanding partnership with Western University’s Schulich School of Medicine & Dentistry with the addition of prominent signage in the busy emergency department. The unveiling of the new partnership signage in Petrolia serves as a constant reminder to local residents, patients and families of the shared academic mission, commitment and alignment for both institutions. In 2010, the partnership began with the inclusion of two residents on rotation and since then, the hospital has trained a total of 18 resident doctors. In fact, upon graduation 50 per cent of the residents who intern at CEEH of Bluewater Health return to either work full-time or become actively involved with the hospital in some form; this is far higher than the program’s average retention rate of 33 per cent. Fundraising For the first time in history, proceeds of the Dream Home Lottery will support both Bluewater Health Foundation and Charlotte Eleanor Englehart Hospital Foundation. This historical partnership and 25th anniversary milestone is marked by the expansion of the Lottery prize board, estimated at over $1 million, which includes two houses up for grabs: one in Sarnia and one in Petrolia. The Sarnia home, built by Stelobrook Homes and decorated by Brush Strokes Interiors, is

located at 564 Franco Ave. in the Rapids Parkway and is valued at over $668,000. The Petrolia home, built by Sepe Construction and decorated by D. Janzen Interiors, is located at 304 Sunset Court and is valued at over $540,000. Each home also has an increased alternate cash option. Both homes will once again be fully VisitAble. New this year is the addition of a third early bird prize, a 330i xDrive Black Sapphire Metallic Sedan BMW (or $30,000 cash option), provided by Sarnia BMW with a value of over $59,000. The remainder of the prize board includes additional cash prizes and more. Finally, a new website will allow for the addition of a 50/50 draw and the ability to purchase tickets online individually and in packs. The Dream Home Lottery has raised over $7 million dollars for Bluewater Health over the past 24 years. Tickets go on sale October 1, with full lottery details, including prize board and house information, to come at that time. Three upcoming events are planned by Bluewater Health Foundation: • October 5 – Dream Home open houses begin • October 17 – Gala with headliner Jessica Holmes, supporting the Mental Health & Addiction Services program at

Bluewater Health The CEEH Foundation Board’s membership has changed. Judy McCallum and John Turvey have joined, and after more than 30 years of service, Board member Roger Mailloux retired In June. Two upcoming events are planned by CEEH Foundation: • September 27 – Shop Like Charlotte (SOLD OUT) • December 13 to 15 – Victoria Playhouse Christmas Jamboree The Auxiliary is updating the product lines for Charlotte’s Boutique in the Petrolia hospital. A survey was created to obtain input from staff, patients, families, and community members. A Thanksgiving bake sale is being held on Friday. Oct 11 outside the boutique from 10:00 am until sold out. The CEEH Foundation and CEEH Auxiliary have joined forces to buy a vein illuminator for the CEEH Emergency Department valued at $19,690.00.

1

Governance and Nominating (G&N) Committee Highlights

September 11, 2019

Work Plan The draft work plan was reviewed by the Committee to consider any changes/additions. It was recommended each Committee receive updates regarding the development of a local Ontario Health Team (as required), versus the G&N Committee solely monitoring this item. The final draft work plan will be presented for Board approval in November. Board Evaluation The Committee discussed the Board’s Annual General Meeting in June, and had lengthy discussion about the results of the Committee Self-Assessment, Individual, Peer, Board Chair, and Exit Survey Results. The collective feedback from these various evaluation tools was positive, reflecting a high-functioning Board (see Consent Agenda). Work is underway to address opportunities identified by the survey results. Board Policy Review The Committee discussed the annual policy review process and made a few suggested revisions to policies, which will be brought forward to the Board in November. Consideration will be given to distributing the policies to be reviewed over the months of September to June, instead of reviewing the large volume of policies at the beginning of the Board year. Annual By-Law Review A recommendation regarding proposed amendments to the Corporate and Professional Staff By-Laws of Bluewater Health was shared with the Committee. The Committee requested further legal advice before making a recommendation to the Board, which is expected in November. Board Education/Orientation/Team Building The Committee received an overview of the draft education plan for the Board calendar year, which includes tours and various presentations. This plan is subject to change (see Consent Agenda). There was also discussion about the upcoming Board Retreat agenda. More planning will follow. Board members are encouraged to consider attending education sessions being offered by the OHA GCE. Please click here for details. In addition, the following items will be coming forward separately for Board approval/discussion:

• Ontario Health Team Update

Submitted by: Anthony Iafrate

Quality Committee of the Board Highlights

September 16, 2019

Accreditation Activities Update An update on Accreditation Activities was presented to the Committee. This report outlined the 10 missed standards from the Accreditation Survey final report, and action items that have been initiated to address the missed standards. Mock tracers are also being introduced on a monthly basis as a method of sustainability. No One Waits (N.O.W) Initiative Update The Committee was updated on the current status of the No One Waits (N.O.W) Initiative, as well as successes, opportunities, and next steps. Work Plan The draft work plan was reviewed by the Committee to consider any changes/additions. The final draft work plan will be presented for Board approval in November. Board Committee Evaluation The Committee discussed the Board’s Annual General Meeting in June, and had a discussion about the results of the Committee Self-Assessment survey. The results were largely positive, and opportunities for future improvements were identified. Board Policy Review The Committee discussed the annual policy review process with no revisions made. In addition, the following items will be coming forward separately for Board approval/discussion:

• Integrated Risk Management • Quality Committee Performance Scorecard

Submitted by: Brian Knott, Chair

FOI

Italics

*

ⱡ

APR

18

MAY

18

JUN

18

JUL

18

AUG

18

SEP

18

OCT

18

NOV

18

DEC

18

JAN

19

FEB

19

MAR

19

APR

19

MAY

19

JUN

19

JUL

19Report

PeriodYTD

1 SarniaQIP/

P4R

25.7

hrs

20.2

hrs

<=16

hrs16.8 16.6 18.9 23.4 20.2 29.3 19.4 19.0 6.3 12.9 18.2 17.2 11.3 13.3 15.9 17.9

Jan -

Dec15.6 t

Sarnia9.7

hrs

7.9

hrs6.5 6.3 7.8 9.5 8.2 11.7 6.8 6.4 3.3 5.1 6.5 6.2 4.1 4.6 5.1 6.3

Jan -

Dec5.4 t

SarniaHSAA/

P4R

10.8

hrs

9.2

hrs

<=8

hrs9.7 8.5 9.9 10.5 8.8 11.1 8.9 9.1 8.0 8.9 9.7 9.4 9.2 8.9 9.0 9.1

Jan -

Dec9.1 t

Petrolia 0 03.9

hrs

<=8

hrs4.0 3.9 3.7 3.5 4.0 3.6 3.8 4.3 3.6 4.0 3.6 4.1 4.3 4.6 4.3 4.4

Jan -

Dec4.1 t

Sarnia P4R33.3

hrs

26

hrs

<=20

hrs21.7 21.7 24.7 29.0 26.6 38.1 24.5 24.9 14.2 20.3 25.5 24.1 18.6 19.4 22.6 26.0

Jan-

Dec22.2 t

Petrolia 0 07.8

hrs* 7.8 7.4 6.0 9.6 12.2 10.9 6.3 6.8 7.9 5.0 6.1 7.3 10.3 5.4 8.1 9.3

Jan -

Dec7.0 t

5 0.0 n/a 4 0Jan-

Dec4 t

6 QIP 12.3% 12.1% 12.1% 0Jan-

Dec10.8% 0

7 QIP 19.2% 18.5% 16.4%Jan-

Dec9.3% t

ED n/a 51.1% 52.0% 60.0 49.3 47.4 49.3 52.2 41.1 50.0 56.4 50.8 47.0 49.2 52.3 53.1 52.7 46.2Jan-

Dec50.6% t

Inpatient

Med/Surg65.4% 65.9% 67.0% 67.9 80.4 58.2 62.7 64.8 54.2 65.5 69.8 63.8 64.1 62.8 71.4 81.4 66.7 69.8

Jan-

Dec69.7% t

ED SP 82.4% 83.5% 85.0% 88.9 81.4 77.6 89.2 76.6 81.5 82.8 91.2 87.9 78.5 75.4 86.4 80.4 90.9 90.0Jan-

Dec83.2% t

Inpatient

Med/SurgQIP 55.4% 56.7% 58.0% 67.9 80.0 55.8 55.1 50.0 51.0 63.5 61.8 61.7 47.6 54.8 56.1 65.2 61.7 63.6

Jan-

Dec56.5% t

ED n/a 71.7% 73.1% 74.5 76.7 74.6 75.7 68.2 70.2 64.4 72.2 72.7 66.2 68.9 56.8 67.3 69.1 69.2Jan-

Dec66.6% t

All Inpatient n/a 74.7% 76.0% 87.1 81.2 75.0 80.9 66.7 70.4 80.9 79.2 87.1 76.0 76.7 88.0 83.1 83.9 71.7Jan-

Dec80.1% t

11 QIP n/a 81 * 4 10 6 5 3 5 16 17 15 35 33 41 27 28 18 20Jan-

Dec202 t

2 0 1 2 2

SP

Strengthen Patient and Family-Centred Care

Readmission with 30 days for COPD

13.9 11.0 17.5 10.8

12.9 22.6 21.3 9.3

SP

Positive score = Yes, definitely

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

0Average Time to Inpatient Bed

SP/

NOW

Improve access to care

ⱡ 2 hrs

0

0

0

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

Total High Severity Patient Safety Incidents

(Level 4 - 5)

Focus on the experience of care and caring

Positive score = 9 - 10

Positive score = Yes

Positive score = Completely

8

9

10

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)

YTD

Performance

UP

DA

TED

#

Meets/Exceeds Target

Meeting baseline but not meeting target

Performance not meeting baseline

Data Unavailable

Q1 18/19 Q2 18/19 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

De

sire

d

Tre

nd

ingQ2

19/20TargetBaseline CommentsTrending

30-Day Mental Health Readmission

Was patient/family treated with kindness

Positive score = 9 - 10

Leaving hospital did patients receive

enough information

Overall Incidents of Workplace ViolenceThis indicator tracks the total number of incidents reported

organization wide. Collecting baseline

Overall Rating of Experience

Positive score = Yes, definitely

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

OMHRS assessments: 30 days or less since last discharge from

this facility; excluding short-stay assessments

This is preliminary data and subject to change

0

0

2

0

Performance Indicator Definitions and Graphs

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

Improve access to care

1 90th Percentile Time to Inpatient Bed

2 Average Time to Inpatient Bed

3 90th Percentile Emergency Department (ED) Length of Stay for Complex Patients Sarnia

Petrolia

4 90th Percentile Emergency Department (ED) Wait Times (Admitted Patients) Sarnia

Petrolia

Ingrain patient safety

5 Total High Severity Patient Safety Incidents

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

Build sustainable partnerships and collaborations

6 30-Day Mental Health Readmission

7 Readmission within 30 days for Chronic Obstructive Pulmonary Disease (COPD)

Strengthen Patient and Family – Centred Care

8 Overall Rating of Experience

9 Leaving Hospital did Patients Receive Enough Information

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

Focus on the experience of care and caring

10 Was Patient/Family Treated with Kindness

11 Overall Incidents of Workplace Violence

Updated: September 2019 Bluewater Health Page | 1

Indicator Name: 90th Percentile Time to Inpatient Bed

Alignment: Performance and Utilization Committee (PUC); Quality Committee of the Board (QCB); Resource Utilization and Audit Committee (RUAC)

Strategic Goal: Improve access to care

Definition: 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.

Peer Comparator: Ontario High Volume Community Hospital Results, Sarnia only – Calendar year 2018

Updated: September 2019 Bluewater Health Page | 2

Indicator Name: Average Time to Inpatient Bed

Alignment: Performance and Utilization Committee (PUC); Quality Committee of the Board (QCB); Quality and Patient Experience Committee (QPEC); Resource Utilization and Audit Committee (RUAC)

Strategic Goal: Improve access to care

Definition: 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).

Additional Specifications: Average: Total time to inpatient bed hours

Total number of admitted ED visits

Peer Comparator: Ontario High-Volume Community Hospital Results, Sarnia only – Calendar year 2018

Updated: September 2019 Bluewater Health Page | 3

Indicator Name: 90th Percentile Emergency Department (ED) Length of Stay (LOS) for Complex Patients

Alignment: Quality Committee of the Board (QCB); Resource Utilization and Audit Committee (RUAC)

Strategic Goal: Improve access to care

Definition: The total ED length of stay where nine out of 10 complex patients completed their visits. ED Length of Stay is defined as the time from triage or registration, whichever comes first, to the time the patient leaves the ED.

Additional Specifications: Patients are determined complex based on visit disposition and the Canadian Triage and Acuity Scales (CTAS) level.

Peer Comparator: Ontario High-Volume Community Hospital Results, Sarnia only – Calendar year 2018

Updated: September 2019 Bluewater Health Page | 4

Indicator Name: 90th Percentile Emergency Department (ED) Length of Stay (LOS) for Admitted Patients

Alignment: Performance and Utilization Committee (PUC); Quality Committee of the Board (QCB); Quality and Patient Experience Committee (QPEC); Resource Utilization and Audit Committee (RUAC)

Strategic Goal: Improve access to care

Definition: Measurement of ED length of stay for admitted visits is in hours. ED length of stay is the time from triage or registration, whichever comes first, to the time the patient leaves the ED to an inpatient bed. The 90th percentile is the maximum length of time in which nine of 10 of admitted patients have completed their ED visit and have moved to an inpatient unit. A smaller number is desirable.

Rationale: Time is crucial to the effectiveness and outcome of patient care, especially for emergency patients. In conjunction with other indicators, this can be used to monitor the total length of time admitted patients spend in the ED to improve the efficiency and, ultimately, the outcome of patient care. This measure remains one of Bluewater Health’s top priorities in our Quality Improvement Plan (QIP) and Strategic Plan.

Peer Comparator: Ontario High-Volume Community Hospitals, Sarnia only – Calendar year 2018

Updated: September 2019 Bluewater Health Page | 5

Indicator Name: Total High Severity Patient Safety Incidents

Alignment: Quality Committee of the Board (QCB); Quality and Patient Experience Committee (QPEC)

Strategic Goal: Ingrain patient safety

Definition: This measure tracks the total number of patient safety incidents categorized as Level 4 or Level 5.

Rationale: A patient safety incident is an event or circumstance that could have resulted, or did result, in unnecessary harm to a patient. Bluewater Health’s fiscal year 18/19 target for Total High Severity Patient Safety Incidents is set as 0, “as zero patient harm is a certain goal that must be a priority for all stakeholders. It is the right thing to do for patients and families.” (Cochrane et al. 2017, p.66) In compliance with the Public Hospital’s Act and Excellent Care for All Act (ECFAA), 2010. There is an obligation of hospitals to report critical incidents to the Quality Committee of the Board.

Additional Specifications: Bluewater Health’s incident severity levels reflect the updated guidelines set by the Ontario Hospital Association (OHA).

Level 4 - Patient outcome is symptomatic, requiring life-saving intervention or major surgical/medical intervention, shortening life expectancy or causing major permanent or long-term harm or loss of function. (Example: A patient falls and sustains a fractured hip requiring surgical intervention, causing long-term rehabilitation).

Level 5 - On balance of probabilities, death was caused or brought forward in the short term by the incident.

Peer Comparator: No peer comparator data available

Updated: September 2019 Bluewater Health Page | 6

Indicator Name: 30 Day Mental Health Readmission

Alignment: Quality Committee of the Board (QCB); Quality and Patient Experience Committee (QPEC)

Strategic Goal: Build sustainable partnerships and collaborations

Definition: The percentage of Ontario Mental Health Reporting System (OMHRS) full admissions that were discharged 30 days ago or less from this facility.

Rationale: Hospitalization for people diagnosed with a mental illness aims to stabilize acute symptoms. Once the individual is stabilized, they can be discharged and receive subsequent care through primary care, outpatient and community programs to prevent relapse and complications. Not all readmissions can be avoided and measuring how often patients discharged from hospital return to hospital can assist in the appropriateness of discharge and follow-up care.

Peer Comparator: Ontario Hospitals: General >= 25 Mental Health Beds Fiscal year 2018/2019

Updated: September 2019 Bluewater Health Page | 7

Indicator Name: Readmission within 30 days for Chronic Obstructive Pulmonary Disease (COPD)

Alignment: Quality Committee of the Board (QCB); Quality and Patient Experience Committee

(QPEC)

Strategic Goal: Build sustainable partnerships and collaborations

Definition: The measuring unit of this indicator is admission for COPD, as defined for the quality

based procedure (QBP). Results are expressed as crude all cause 30-day non-elective

readmission rate among patients admitted to Ontario acute care facilities.

Rationale: Measuring how often patients discharged from hospital actually return to hospital reveals how well we have prepared them for discharge, including how well we have set up linkages with community providers to help meet patients’ needs while at home. Not all readmissions are avoidable and this indicator does not capture which readmissions were avoidable and the underlying reasons (e.g. condition aggravation, poor transition, lack of community support/care).

Peer Comparator: Crude calculation of 30 day readmission for COPD in the Erie St Clair LHIN (ESC LHIN)

Hospitals fiscal year 2018/2019

Updated: September 2019 Bluewater Health Page | 8

Indicator Name: Overall Rating of Experience

Alignment: Quality Committee of the Board (QCB); Quality and Patient Experience Committee (QPEC)

Strategic Goal: Strengthen Patient and Family-Centered Care

Definition: This question asks patients to rate their hospital experience on a scale from 0 to 10, with 0 being I had a very poor experience and 10 being I had a very good experience. Results are calculated using the number of respondents who responded 9 or 10 and dividing by the number of respondents who registered any response to this question.

Rationale: Patient experience measurement is a healthcare system best practice and hospitals are required to survey patients at least once every fiscal year, according to Ontario’s Excellent Care for All Act (ECFAA), 2010. “We create exemplary healthcare experiences with patients and families every time,” is the mission of Bluewater Health. These questions reflect how well the hospital is achieving its overall mission. Measurement of patient experience is essential because it provides an opportunity to improve care, enhance strategic decision making, meet patients’ expectations, effectively manage and monitor healthcare performance, and document benchmarks for the organization.

Peer Comparator: The Ontario Inpatient (IP) Community Hospital (Hosp) Average compares hospitals of the same size within the province. Peer comparators are updated quarterly.

Inpatient

Ontario IP Community Hosp Average

Emergency Department (ED) No peer comparator data available

Updated: September 2019 Bluewater Health Page | 9

Indicator Name: Leaving hospital did patients receive enough information

Alignment: Quality Committee of the Board (QCB); Quality and Patient Experience Committee (QPEC)

Strategic Goal: Strengthen Patient and Family-Centered Care

Definition: As Emily leaves the hospital, this question asks whether Emily perceives that she received the information she needed from Bluewater Health staff and physicians before leaving our care. This question is asked of both inpatients and emergency department patients.

Inpatient Medical/Surgical Question:

This question asks patients to respond to the statement ‘Did you receive enough information from hospital staff about what to do if you were worried about your condition or treatment after you left the hospital?’ Response options to this question include Not at all, Partly, Quite a bit, and Completely. Of these choices “Completely” is the positive response counted.

Emergency Question: This question asks patients to respond to the statement ‘Before you left the emergency

department, did you understand what symptoms or health problems to look out for when you left the emergency department?’ Response options to this question include Yes or No. Of these choices “Yes” is the positive response.

Rationale: Patient experience measurement is a healthcare best practice and hospitals are required to survey patients at least once every fiscal year, according to Ontario’s Excellent Care for All Act (ECFAA), 2010.

Peer Comparator: The Ontario Inpatient (IP) Community Hospital (Hosp) Average and the Ontario ED

Community Hosp Average is a comparator of hospitals of the same size. Peer

comparators are updated quarterly.

Inpatient

Ontario IP Community Hosp Average

ED

Ontario ED Community Hosp Average

Updated: September 2019 Bluewater Health Page | 10

Indicator Name: Was Patient/Family Treated with Kindness

Alignment: Quality Committee of the Board (QCB); Quality and Patient Experience Committee (QPEC)

Strategic Goal: Focus on the experience of care and caring

Definition: This is a custom question for Bluewater Health’s patient experience surveys which are mailed to a random selection of patients after they are discharged. Our aim is that the culture of kindness at Bluewater Health will be increasingly felt by our patients and families over time. This question asks Emily to reflect and respond to the statement “Were you and your family treated with kindness by employees, volunteers and physicians at Bluewater Health?” Response options to this question include Yes, Definitely, Yes, mostly, Yes, somewhat, and No. Of these choices "Yes, Definitely" is the positive response counted.

Rationale: Exemplary healthcare experiences begin with kindness. We understand that patients expect courtesy, respect, and dignity, starting with expressing an attitude of kindness and caring. We realize that having highly skilled and competent staff isn’t enough. Ensuring that you and your family are treated with kindness is a crucial focus of Bluewater Health’s commitment to Patient & Family-Centred Care. Patient experience measurement is an industry best practice and hospitals are required to survey patients at least once every fiscal year, according to Ontario’s Excellent Care for All Act (ECFAA), 2010.

Peer Comparator: This is a Bluewater Health custom question and no peer comparator data is available.

Updated: September 2019 Bluewater Health Page | 11

Indicator Name: Overall Incidents of Workplace Violence

Alignment: Quality Committee of the Board (QCB), Quality and Patient Experience Committee (QPEC)

Strategic Goal: Focus on the experience of care and caring

Definition: This indicator measures the number of reported workplace violence incidents by hospital employees. Bluewater Health is focused on building a reporting culture.

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 the worker; and a

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

Rationale: At Bluewater Health violence and harassment in the workplace is not tolerated. The development and implementation of many workplace violence prevention programs, over the past few years, has not only raised the awareness of these negative behaviours but has provided a framework to support a safe and healthy workplace.

Peer Comparator: No peer comparator data available

Resource Utilization and Audit Committee (RUAC)

September 12, 2019 Highlights

No One Waits (NOW) Quarterly Update The Committee received a presentation on the NOW initiative highlighting the Quarter 2 (July data only) results for the Time to Inpatient Bed Change Management Target Setting. The Committee received an overview of the work underway to reach the goal of two hours; the standard work that has been taken for transferring a patient from the ED; the work underway by the admission and transfer working group; stakeholder engagement; and, the accountability framework escalation and testing the process. Human Resources Quarterly Report The Committee received an update on the status of labour relations; pay equity; and, recruitment. An overview of Green Shield Canada’s Fraud Protection Program (FPP) was provided. 2019 RUAC Self-Assessment Survey Results The results of the 2019 RUAC Self-Assessment survey were shared with the Committee. The results overall were positive. Auditor’s Annual Post-Audit Management Letter & Management Responses The Committee received the Auditor’s post-audit management letter no concerns were raised. Analysis of the Loans and Investments The Committee received an update on the status of the bank loans and the Englehart estate investments. In addition, the following items will be coming forward separately for Board approval/discussion:

- Facilities Quarterly Report - Chief Financial Officer Certificate - Monthly Financial Statement - Balanced Scorecard

The following items were discussed and will proceed to the Governance and Nominating Committee for review/consideration prior to being forwarded to the Board for approval/discussion:

- RUAC Policies - 2019-20 Draft Work Plan

Submitted by: Marg Dragan Chair, Resource Utilization and Audit Committee

Statement of Revenue and ExpenseForecast surplus/(deficit) as at March 31, 2020Based upon the four (4) months ended July 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 50,006 49,721 (286) -1% 149,861 149,562 (299) 0% 1Cancer Care Ontario Revenue 2,630 2,905 275 10% 7,891 8,578 687 9% 2Paymaster Funding 431 413 (18) -4% 1,293 1,293 - 0%OHIP Revenue 4,492 4,794 302 7% 13,775 14,300 525 4% 3Patient Revenue - Other 470 661 190 40% 1,411 1,981 570 40% 4Room differential 823 909 86 10% 2,469 2,725 256 10% 5Co-payment 145 164 20 14% 434 492 58 13%External Recoveries 788 817 29 4% 2,617 4,421 1,803 69% 6Parking Revenue 361 372 11 3% 997 1,008 11 1%Other Revenue 12 25 13 107% 236 249 13 5%Deferred Equipment Grants 888 766 (122) -14% 2,664 2,664 - 0%Interest and Donations 33 71 38 114% 100 138 38 38%

Total Revenue $ 61,080 61,618 538 1% 183,750 187,412 3,662 2%

Expenses $

Salaries and Wages 30,695 30,722 (27) 0% 92,067 92,293 (227) 0% 7Medical Staff Remuneration 6,873 7,261 (388) -6% 20,820 21,330 (510) -2% 3Employee Benefits 8,600 8,882 (282) -3% 24,911 25,337 (425) -2% 8Employee Future Benefits 100 122 (22) -22% 300 322 (22) -7%Utilities, Buildings & Grounds 1,401 1,282 119 8% 4,194 4,075 119 3%Equipment Expense 2,316 2,355 (39) -2% 6,694 6,694 - 0%Supplies and Expenses 3,882 4,128 (246) -6% 11,645 12,141 (496) -4% 9Contracted Out Services 1,249 1,266 (16) -1% 3,748 3,748 - 0%Medical/Surgical Supplies 2,896 3,150 (254) -9% 8,688 9,142 (454) -5% 10Drug Expense 2,076 2,361 (284) -14% 6,228 6,911 (682) -11% 2Interest Expense 104 78 26 25% 312 286 26 8%Amortization 1,947 1,585 362 19% 5,842 5,842 (0) 0%

Total Expenses $ 62,141 63,191 (1,051) -2% 185,449 188,119 (2,671) -1%

Hospital Operating Surplus/(Deficit) $ (1,061) (1,573) (513) n/a (1,699) (708) 991 n/a

Net Marketed Service Surplus/(Deficit) 113 85 (28) -25% 390 362 (28) -7%

Net Other Vote Surplus/(Deficit) (10) - 10 n/a 0 0 - n/a

LHIN Operating Surplus/(Deficit) $ (958) (1,488) (530) (1,309) (346) 963

Deferred Building Grants 2,959 2,984 25 1% 8,878 8,878 - 0%Building Amortization (3,450) (3,480) (31) 1% (10,349) (10,349) - 0%Interest on L/T Liabilities (28) (22) 6 -20% (85) (85) - 0%

Operating Surplus/(Deficit) $ (1,477) (2,007) (531) (2,865) (1,902) 963

Notes to Financial StatementsJuly 31, 2019 Actual and Full Year Forecast

Note 1

Note 2

YTD Actual Annual Budget Year-End Forecast

$ 1,311,033 $ 2,800,000 $ 3,783,099 $ 1,528,804 $ 4,886,408 $ 4,590,693 $ 65,487 $ 204,258 $ 204,258

$ 2,905,324 $ 7,890,666 $ 8,578,050

Note 3

Note 4

Note 5

Note 6

Note 7

Note 8

Note 9

Note 10

Supplies and Expenses are over budget $246K at the end of July. This negative variance is mainly due to patient transporation costs, and professional fees. The forecasted negative variance is expected to grow to $496K.

Room Differential revenue is better than budget by $86K at the end of July. The majority of this positive variance is from Inpatient Mental Health, Rehab, & Obstetrics. The year-end forecast anticipates further improvements to this positive variance.

Salaries are over budget by $27K at the end of July. The hospital is forecasting a negative variance of $227K for year-end. The hospital anticipates an increase in staffing costs during the second half of the year when our patient census tends to be higher.

Med/Surg supplies are over budget by $254K at the end of July. 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 $454K at year-end.

External Recoveries are forecasted to be better than budget by $1.8M at year-end. This positive variance is attributed to a utility rebate dating back to January 2017.

Total Funding

Ontario Breast Screening Program Funding

Employee Benefits are over budget by $282K at the end of July. The hospital is forecasting a negative variance of $425K at year-end. The majority of the variance is a result of 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 $346K for the 19/20 fiscal year which is $963K better than the budgeted deficit of $1.3M. At the end of July, the hospital had a deficit of $1.49M. The largest contributing factor to the YTD variance from budget is employee benefits & med/surg supplies. For the year-end forecast, benefits, med/surg supplies and salaries are the largest contributing factors to the negative variance. 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 $286K at the end of July. This negative variance is attributed to pacemaker volume achievevement compared to budget and a LHIN recovery for psychiatric stipend funding from prior years. The year-end forecat is under budget by $299K which includes the above mentioned items as well as some other anticipated recoveries for under achievement of wait time funding.

Bluewater Health does OHIP billings for various physician groups. There is an offsetting Med Staff Remuneration expense for these billings. The July YTD variance for OHIP Revenue and Med Staff remuneration is primarily CT, Radiography and 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 July, these revenues were better than budget by $190K. The majority of this positive variance is revenue paid directly by patients. 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. 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)

Balance SheetAs at July 31, 2019Comparison to July 31, 2018(000's)

% Change

Assets

Current AssetsOperating Cash $ 2,109 8,884 -76%Investments - CEE Site 997 1,317 -24%Accounts Receivable 4,962 4,681 6%Accounts Receivable - MOHLTC 544 0 #DIV/0! Inventories 1,051 864 22%Prepaid Expenses 4,182 2,494 68%

Total Current Assets 13,845 18,240 -24%

Fixed AssetsLand and Land Improvements 7,446 7,446Building/Building services Equipment 335,147 333,447Furniture and Equipment 79,467 88,156Less: Accumulated Amortization (182,655) 239,405 (178,975) 250,074 -4%Construction in Progress 1,455 1,431 2%Other Non Current Assets 413 399 3%

Total Fixed Assets 241,272 251,904 -4%

Total Assets $ 255,117 270,145 -6%

Current LiabilitiesAccounts Payable 2,716 2,494 9% Accounts Payable - MOHLTC 441 1,687 -74%Accrued Salaries & Vacation Pay 8,059 11,682 -31%Current Portion - Long Term Debt 759 741 2%Other Liabilities 7,020 5,173 36%

Total Current Liabilities 18,995 21,777 -13%

Long Term LiabilitiesLong Term Bank Loans Payable 1,836 2,970 -38%Deferred Revenue 208,005 217,195 -4%Post Employment Benefits 15,392 15,580 -1%Other L/T Liabilities 2,476 1,530 62%

Total Long Term Liabilities $ 227,709 237,274 -4%

EquityOpening Equity 10,421 11,868R&E Surplus/(Deficit) (2,007) (775)

Total equity 8,413 11,093 -24%

Total Liabilities and Equity $ 255,117 270,145 -6%

Hospital Accountability Agreement Indicators: Negotiated Target

Current Ratio 0.68 0.78 0.60

Adjusted Working Capital 951$ 2,333$ -$

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 ActualJul-19 Jul-18

FOI

Italics

*

ⱡ

APR

18

MAY

18

JUN

18

JUL

18

AUG

18

SEP

18

OCT

18

NOV

18

DEC

18

JAN

19

FEB

19

MAR

19

APR

19

MAY

19

JUN

19

JUL

19Report

PeriodYTD

1 SarniaQIP/

P4R

25.7

hrs

20.2

hrs.

<=16

hrs16.8 16.6 18.9 23.4 20.2 29.3 19.4 19.0 6.3 12.9 18.2 17.2 11.3 13.3 15.9 17.9

Jan -

Dec15.6 t

Sarnia9.7

hrs

7.9

hrs.6.5 6.3 7.8 9.5 8.2 11.7 6.8 6.4 3.3 5.1 6.5 6.2 4.1 4.6 5.1 6.3

Jan -

Dec5.4 t

SarniaHSAA/

P4R

10.8

hrs

9.2

hrs.

<=8

hrs9.7 8.5 9.9 10.5 8.8 11.1 8.9 9.1 8.0 8.9 9.7 9.4 9.2 8.9 9.0 9.1

Jan -

Dec9.1 t

Petrolia 0 03.9

hrs.

<=8

hrs4.0 3.9 3.7 3.5 4.0 3.6 3.8 4.3 3.6 4.0 3.6 4.1 4.3 4.6 4.3 4.4

Jan -

Dec4.1 t

Sarnia P4R33.3

hrs

26

hrs.

<=20

hrs.21.7 21.7 24.7 29.0 26.6 38.1 24.5 24.9 14.2 20.3 25.5 24.1 18.6 19.4 22.6 26.0

Jan-

Dec22.2 t

Petrolia 0 0 0 * 7.8 7.4 6.0 9.6 12.2 10.9 6.3 6.8 7.9 5.0 6.1 7.3 10.3 5.4 8.1 9.3Jan -

Dec7.0 t

5 HSAA 12.7% 16.2% 16.2% 14.1 14.2 11.7 16.6 17.4 17.0 18.2 16.3 18.7 17.0 14.5 13.4 16.5 14.1 12.4Jan-

Dec15.1% t

6 SP 2.8 3.40 2.80Jan-

Dec0 t

7 SP $5,431 $5,988 $5,800Apr-

Mar$5,911 t

8 0.0 $5,814 $6,237 $5,849Apr-

Mar$6,257 t

9 0.0 $14,121 $14,404 $12,961Apr-

Mar$14,134 t

10 0 $637 $663 $620 0 0Apr-

Mar$635 t

11 0 $330 $317 $314 $338 $313 $310 $313 $313 $319 $322 $319 $317 $321 $321 $326 $402 $400 $375 $370Apr-

Mar$370 t

12 0.0 n/a $187 $0 -$44 -$90 -$131 -$188 -$245 $57 $29 $89 $187 $78 $476 $847 $175 -$33 -$104 -$100Apr-

Mar-$100 t

13 0.0 0.0 -$597 -$2,627 -$80 -$172 -$334 -$243 -$122 -$122 -$562 -$715 -$597 -$654 -$663 $127 -$642 -$1,038 -$1,579 -$1,452Apr-

Mar-$1,452 t

14 HSAA n/a $2,239 $0 $2,887 $2,523 $2,687 $2,333 $2,025 $2,117 $1,726 $1,268 $2,239 $2,490 $2,982 $1,048 $783 $349 -$305 $951Apr-

Mar$951 t

15 0.0 n/a 47% 100% 0 0 0 2 2 3 30 45 47 54 56 62 1 1 2 9Apr-

Mar9% t

2

FY 18/19 results 15.8%

0

3

40

0

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.

2.83 3.40 3.12

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

Meets/Exceeds Target

Meeting baseline but not meeting target

Performance not meeting baseline

Data Unavailable

Q1 18/19 Q2 18/19 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

De

sire

d

Tre

nd

ingQ2

19/20TargetBaseline CommentsTrending#

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)

YTD

Performance

UP

DA

TED

Focus on the experience of care and caring

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

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

0Average Time to Inpatient Bed

SP/

NOW

Improve access to care

ⱡ 2 hrs

0

0

% 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 Patient Day

$5,988$5,881

Mental Health Inpatient Cost per Patient Day

Surplus/(Deficit) Actual YTD in 000s

Acute Inpatient & Day Surgery (53% of

overall activity)

ED Outpatient

(12% of overall activity)

Rehab Inpatient

(4% of overall activity)

Outstanding Performance - Optimize roles, resources, revenues, technology and innovation

Adjusted Working Capital Actual YTS in 000s

Our overall expenses for this indicator have increased by

$4.2M compared to 17/18 YE and our weighted cases are up

by 427 for the same period

$6,257

$14,134

$6,154 $6,237

$14,335 $14,404

$5,911

Our overall expenses for this indicator have increased by

$180K compared to 17/18 YE and our weighted cases have

decreased by 172 cases for the same period

Our overall expenses for this indicator have increased by

$236K compared to 17/18 YE and our weighted cases have

increased by 28 cases for the same period

0

Our overall expenses for this indicator have decreased by $72K

compared to 17/18 YE. The weighted patient days have

decreased by 570 weighted days for the same period

0

$653 $635

Ensure continuous investment in strategic infrastructure

$663

0

0

3.052.85

Performance Indicator Definitions and Graphs

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

Improve access to care

1 90th Percentile Time to Inpatient Bed

2 Average Time to Inpatient Bed

3 90th Percentile Emergency Department (ED) Length of Stay for Complex Patients Sarnia

Petrolia

4 90th Percentile Emergency Department (ED) Wait Times (Admitted Patients) Sarnia

Petrolia

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

Build sustainable partnerships and collaborations

12 Alternate Level of Care (ALC) Rate - All Inpatient Services (Sarnia and Petrolia)

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

Focus on the experience of care and caring

16 Absenteeism Rate- (avg. # 7.5hr sick days)-All Staff

Outstanding Performance – Optimize roles, resources, revenues, technology and innovation

Demonstrate accountability and efficiency

17 Cost per weighted case: Acute Inpatient & Day Surgery (53% of overall activity)

18 Cost per weighted case: ED Outpatient (12% of overall activity)

19 Cost per weighted case: Rehab Inpatient (4% of overall activity)

24 Continuing Care Cost per Weighted Patient Day

25 Mental Health Inpatient Cost per Patient Day

26 Quality Based Procedure (QBP) Financial Exposure (Potential lost revenue related to QBP achievement) Actual YTD in 000s

27 Surplus/(Deficit) Actual YTD in 000s

Ensure continuous investment in strategic infrastructure

28 Adjusted Working Capital Actual YTD in 000s

29 Percent Capital Budget Spent Actual YTD

Updated: September 2019 Bluewater Health Page | 1

Indicator Name: 90th Percentile Time to Inpatient Bed

Alignment: Performance and Utilization Committee (PUC); Quality Committee of the Board (QCB); Resource Utilization and Audit Committee (RUAC)

Strategic Goal: Improve access to care

Definition: 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.

Peer Comparator: Ontario High Volume Community Hospital Results, Sarnia only – Calendar year 2018

Updated: September 2019 Bluewater Health Page | 2

Indicator Name: Average Time to Inpatient Bed

Alignment: Performance and Utilization Committee (PUC); Quality Committee of the Board (QCB); Quality and Patient Experience Committee (QPEC); Resource Utilization and Audit Committee (RUAC)

Strategic Goal: Improve access to care

Definition: 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).

Additional Specifications: Average: Total time to inpatient bed hours

Total number of admitted ED visits

Peer Comparator: Ontario High-Volume Community Hospital Results, Sarnia only – Calendar year 2018

Updated: September 2019 Bluewater Health Page | 3

Indicator Name: 90th Percentile Emergency Department (ED) Length of Stay (LOS) for Complex Patients

Alignment: Quality Committee of the Board (QCB); Resource Utilization and Audit Committee (RUAC)

Strategic Goal: Improve access to care

Definition: The total ED length of stay where nine out of 10 complex patients completed their visits. ED Length of Stay is defined as the time from triage or registration, whichever comes first, to the time the patient leaves the ED.

Additional Specifications: Patients are determined complex based on visit disposition and the Canadian Triage and Acuity Scales (CTAS) level.

Peer Comparator: Ontario High-Volume Community Hospital Results, Sarnia only – Calendar year 2018

Updated: September 2019 Bluewater Health Page | 4

Indicator Name: 90th Percentile Emergency Department (ED) Length of Stay (LOS) for Admitted Patients

Alignment: Performance and Utilization Committee (PUC); Quality Committee of the Board (QCB); Quality and Patient Experience Committee (QPEC); Resource Utilization and Audit Committee (RUAC)

Strategic Goal: Improve access to care

Definition: Measurement of ED length of stay for admitted visits is in hours. ED length of stay is the time from triage or registration, whichever comes first, to the time the patient leaves the ED to an inpatient bed. The 90th percentile is the maximum length of time in which nine of 10 of admitted patients have completed their ED visit and have moved to an inpatient unit. A smaller number is desirable.

Rationale: Time is crucial to the effectiveness and outcome of patient care, especially for emergency patients. In conjunction with other indicators, this can be used to monitor the total length of time admitted patients spend in the ED to improve the efficiency and, ultimately, the outcome of patient care. This measure remains one of Bluewater Health’s top priorities in our Quality Improvement Plan (QIP) and Strategic Plan.

Peer Comparator: Ontario High-Volume Community Hospitals, Sarnia only – Calendar year 2018

Updated: September 2019 Bluewater Health Page | 5

Indicator Name: Alternate Level of Care (ALC) Rate – All Inpatient Services

Alignment: Performance and Utilization Committee (PUC); Resource Utilization and Audit

Committee (RUAC)

Strategic Goal: Build sustainable partnerships and collaborations

Definition: The proportion of inpatient days in acute and post-acute care settings that are spent

designated ALC in a specific period.

Rationale: Ensuring that each patient receives the appropriate level of care at all times during their

healthcare journey is a priority at Bluewater Health. Our goal is for Emily to receive the

right care, given at the right time, in the right place, always. The ALC rate represents an

opportunity for inpatients to transition to the next level of care, where their care needs

and the services provided are better matched. Multiple factors can influence ALC rate,

including overall hospital occupancy, and availability of resources both internal and

external the hospital.

Additional Specifications: ALC Rate = Total number of ALC days in a given period

Total number of inpatient days in the same period X 100%

Peer Comparator: Provincial ALC target 12.7%

Updated: September 2019 Bluewater Health Page | 6

Indicator Name: Absenteeism Rate – (Avg. # 7.5 hr. Sick Days) All Staff

Alignment: Performance and Utilization Committee (PUC); Resource Utilization and Audit Committee (RUAC)

Strategic Goal: Focus on the experience of care and caring

Definition: Paid sick hours divided by 7.5 hrs. (for a normal shift), divided by the number of full-time and permanent part time eligible employees.

Rationale: A lower absenteeism rate is preferred. Lower absenteeism is aligned with overall employee wellness.

Peer Comparator: Ontario Hospital Association Average fiscal year 2018/2019

Updated: September 2019 Bluewater Health Page | 7

Indicator Name: Acute Cost per Weighted Case

Alignment: Performance and Utilization Committee (PUC); Resource Utilization and Audit Committee (RUAC)

Strategic Goal: Demonstrate accountability and efficiency

Definition: Acute Cost per Weighted Case is an indicator that measures the cost associated with caring for a standard acute patient. It is calculated as total acute inpatient and newborn expenses (both direct and indirect) divided by acute inpatient weighted cases. The direct costs are the expenses incurred in the departments providing service to our acute patients (e.g., Medicine, Surgery, and Obstetrics). The indirect costs are an allocation of Administration and Support expenses (e.g., Housekeeping, Lab, Pharmacy, etc.). A weighted case is a case with an assigned Resource Intensity Weight (RIW).

Rationale: This indicator is important as it tracks how an organization is utilizing its resources. It combines financial spending with the activity that drives the spending. By focusing on weighted cases, comparability is enhanced as differences in acuity, severity, and complexity of cases are taken into consideration.

Peer Comparator: Peer comparator is determined based on similar volume of weighted activity.

Updated: September 2019 Bluewater Health Page | 8

Indicator Name: Emergency Department (ED) Outpatient Cost per Weighted Case

Alignment: Performance and Utilization Committee (PUC); Resource Utilization and Audit Committee (RUAC)

Strategic Goal: Demonstrate accountability and efficiency

Definition: ED Outpatient Cost per Weighted Case is an indicator that measures the cost associated with caring for a standard ED patient. It is calculated as total ED expenses (both direct and indirect) divided by ED outpatient weighted cases. The direct costs are the expenses incurred in the departments providing service to our ED patients (both Sarnia & Petrolia hospitals). The indirect costs are an allocation of Administration and Support expenses (e.g., Housekeeping, Lab, Pharmacy, etc.). A weighted case is a case with an assigned Resource Intensity Weight (RIW).

Rationale: This indicator is important as it tracks how an organization is utilizing its resources. It combines financial spending with the activity that drives the spending. By focusing on weighted cases, comparability is enhanced as differences in acuity, severity, and complexity of cases are taken into consideration.

Peer Comparator: Peer comparator is determined based on similar volume of weighted activity.

Updated: September 2019 Bluewater Health Page | 9

Indicator Name: Rehab-Inpatient Cost per Weighted Case

Alignment: Performance and Utilization Committee (PUC); Resource Utilization and Audit Committee (RUAC)

Strategic Goal: Demonstrate accountability and efficiency

Definition: Rehab-Inpatient Cost per Weighted Case is an indicator that measures the costs associated with caring for a standard rehabilitation patient. It is calculated as total inpatient rehabilitation expenses (both direct and indirect) divided by rehabilitation weighted cases. The direct costs are the expenses incurred in the departments providing service to our rehabilitation inpatients. The indirect costs are an allocation of Administration and Support expenses (e.g., Housekeeping, Lab, Pharmacy, etc.). A rehabilitation weighted case is a case assigned a relative weight using the rehabilitation patient grouper (RPG).

Rationale: This indicator is important as it tracks how an organization is utilizing its resources. It combines financial spending with the activity that drives the spending. By focusing on weighted patient days, comparability is enhanced as differences in acuity, severity, and complexity of cases are taken into consideration.

Peer Comparator: Peer comparator is determined based on similar volume of weighted activity.

Updated: September 2019 Bluewater Health Page | 10

Indicator Name: Continuing Care Cost per Weighted Patient Day

Alignment: Performance and Utilization Committee (PUC); Resource Utilization and Audit Committee (RUAC)

Strategic Goal: Demonstrate accountability and efficiency

Definition: Continuing Care Inpatient Cost per Weighted Patient Day is an indicator that measures

the costs of providing inpatient care to complex continuing care patients, and is stated

on a weighted patient day basis. It is calculated as total inpatient continuing care

expenses (both direct and indirect) divided by total resource utilization group weighted

patient days (RWPDs). The direct costs are the expenses incurred in the departments

providing service to our continuing care inpatients. The indirect costs are an allocation

of Administration and Support expenses (e.g., Housekeeping, Lab, Pharmacy, etc.).

RWPDs are patient days weighted using an appropriate cost weight (CMI). The CMI is a

cost weight reflecting the relative resource use of an individual within a specific RUG

group compared with the overall average resource use for all Ontario complex

continuing care residents.

Rationale: This indicator is essential as it tracks how an organization is utilizing its resources. It combines financial spending with the activity that drives the spending. By focusing on weighted patient days, comparability is enhanced as differences in acuity, severity, and complexity of cases are taken into consideration.

Additional Specifications: This indicator is also referred to as Cost per RUG weighted patient day (RWPD) where RUG stands for Resource Utilization Group.

Peer Comparator: Peer comparator is determined based on similar volume of weighted activity

Updated: September 2019 Bluewater Health Page | 11

Indicator Name: Mental Health Inpatient Cost per Patient Day

Alignment: Performance and Utilization Committee (PUC); Resource Utilization and Audit Committee (RUAC)

Strategic Goal: Demonstrate accountability and efficiency

Definition: Mental Health Inpatient Cost per Patient Day is an indicator that measures the cost associated with caring for a Mental Health inpatient. It is calculated as total inpatient mental health departmental expenses divided by total inpatient mental health patient days.

Peer Comparator: HIT Tool HSIMI year-end 25th percentile fiscal year 2017/2018

Updated: September 2019 Bluewater Health Page | 12

Indicator Name: Quality Based Procedure (QBP) Financial Exposure (Potential lost revenue related to QBP achievement) Actual YTD in 000s

Alignment: Performance and Utilization Committee (PUC); Resource Utilization and Audit

Committee (RUAC)

Strategic Goal: Demonstrate accountability and efficiency

Definition: This indicator represents the potential lost revenue associated with under achievement

of QBP-funded volumes for both Ministry-funded and Cancer Care Ontario (CCO)-funded

quality based procedures.

Rationale: The intent is that the hospital will achieve all anticipated volumes and not have to

return any QBP funding to the Ministry and/or CCO.

Peer Comparator: No established peer comparator data

Updated: September 2019 Bluewater Health Page | 13

Indicator Name: Surplus/ (Deficit) in 000s

Alignment: Performance and Utilization Committee (PUC); Resource Utilization and Audit

Committee (RUAC)

Strategic Goal: Demonstrate accountability and efficiency

Definition: The amount of operating revenue in excess of operating expense from regular hospital

operations. This amount excludes building amortization, building deferred

grants/donations and interest on long-term liabilities.

Rationale: The hospital compares its actual results to the Board approved budget. The hospital

plans for a surplus each year.

Peer Comparator: No peer comparator data available

Updated: September 2019 Bluewater Health Page | 14

Indicator Name: Adjusted Working Capital (in 000s)

Alignment: Performance and Utilization Committee (PUC); Resource Utilization and Audit Committee (RUAC)

Strategic Goal: Ensure continuous investment in strategic infrastructure

Definition: Adjusted Working Capital is calculated as the hospital’s total current assets less current liabilities from its balance sheet. This definition is then adjusted per Ministry direction to exclude current liabilities such as vacation accrual, etc. and to exclude any externally restricted current assets/liabilities.

Rationale: Adjusted working capital is a critical indicator to evaluate the hospital’s financial outlook. A strong working capital position indicates a readiness for potential capital investment.

Peer Comparator: No peer comparator data available

Updated: September 2019 Bluewater Health Page | 15

Indicator Name: Percentage of Capital Budget Spent

Alignment: Performance and Utilization Committee (PUC); Resource Utilization and Audit Committee (RUAC)

Strategic Goal: Ensure continuous investment in strategic infrastructure

Definition: Capital purchases made during the time period as a percentage of the overall capital budget for that period. The overall budget includes a budget for contingency items. If capital items are carried over from a previous year, the capital budget associated with those carry over items will also be included in the denominator for this indicator.

Peer Comparator: No established peer comparator data

Chief of Professional Staff Report to the Board

September 2019

At the Medical Advisory Committee meeting held on September 18, 2019, the following items were discussed: Quality Improvement Initiatives

• Received MAC on-boarding presentation • Approved recommendations from the Pharmacy & Therapeutics Committee,

Infection Prevention & Control Committee, Ethics & Research Committee and Quality and Patient Experience Committee

• Approved revisions to the Critical Care Results proposed by the Lab • Discussed concept of palliative assessments on floors • Reviewed the results of the MAC self-assessment survey • Approved MAC Terms of Reference (annual review – no changes made) • Reviewed MAC meeting attendance for 2018-2019 meeting season • Discussed Chief of Staff goals for 2019-2020 • Received updates on:

o No One Waits (N.O.W.) Initiative o Patient Order Sets Committee o On-call rooms o Chiropody o Physician Resource Plan, planning for 2020-2021 o Nurse Practitioners ordering CTs/MRIs o High sensitivity Troponin I test o Consolidation of Medical Affairs department o Ontario Health Teams o OHA physician well-being, organizational culture & engagement survey

Physician Representation on Committees

• Appointed a new representative to the By-laws Committee Physician Education, Development and Engagement

• Newly appointed interim Medical Director of Emergency Medicine and interim Chief of Anaesthesia were introduced

• New PSA Executive members were introduced • Received update on next PLI course ‘Managing people effectively’ • Quarterly Chief of Staff Hospital-wide M&M Rounds will begin soon • Starting in October, Hospital-wide M&M Rounds will be held on the fourth

Thursday of each month at 5pm (changing from the fourth Friday of each month at noon)

• Physicians were encouraged to nominate colleagues for Physician Recognition Awards for Peer Recognition, Outstanding Contribution to the Hospital, Outstanding Physician of the Year

• Discussed recent and upcoming events: o Strategic Leadership Council – Tuesday, September 24, 2019 o Mini Medical School – planning a session in October on Breast Health and

November 18, 2019 on Prostate Health o Professional Staff Halloween Breakfast – Thursday, October 31, 2019 o Physician Appreciation Evening – date change to Thursday, November 7,

2019 at Huron Oaks o Bluewater Health Foundation Gala - Thursday, October 17, 2019 o Dream Home Lottery tickets go on sale Tuesday, October 1, 2019

Professional Staff By-Laws

• Accepted the By-Laws Committee’s recommendation regarding revised wording to the Professional Staff By-laws to allow for PSA Executive nominations from the floor at the PSA annual meeting, if there are no nominations prior to the annual meeting

• As per the Professional Staff By-Laws, the Board will post for a period of at least 30 days to allow for comment before a recommendation to the Board

Recruitment/Succession Planning • Recruitment efforts continue for many needed specialists: ENTs, Plastic Surgery,

Anaesthesiologists, Neurologists, Emergency physicians and Psychiatrists (adult and child)

Emergency Coverage Due to extenuating circumstances, there is a shortage of Emergency Physicians for the Sarnia site. Bluewater Health has received the support of HealthForceOntario to support coverage of emergency shifts. An aggressive recruitment strategy is in place as well as advertising for physicians interested in being mentored to practice full scope in Emergency. Submitted by: Michel Haddad, MD, MSc, FRCSC Chief of Professional Staff, Bluewater Health

Executive Director Report September 2019

The Foundation office had a busy summer! Much work has been done in anticipation for the launching of the new format of Dream Home Lottery, in partnership with CEEH Foundation. Tickets will officially go on sale Oct. 1st via our brand new website www.bwhfdreamhome.com We have an incredible team of staff and volunteers working on this new format and we are excited to showcase, for the first time in our 25 year history, two beautiful homes up for grabs all in support of Bluewater Health.

The summer kicked off with the LiUNA Do it for Sarnia Block Party featuring Canadian rock band the Trews! The concert was a great success and proceeds raised enabled Dan Edwards to complete his $150,000 fundraising goal in support of Mental Health and Addictions. We are beyond grateful to Dan for ALL that he has done for our hospital and community. There are several identified capital priorities for the Mental Health program and we are working closely with Dan and the Mental Health team on the allocation of the proceeds raised.

Many of you are aware that Bluewater Health Foundation, together with lead partner agencies, Bluewater Health, St. Clair Child and Youth Services and the Canadian Mental Health Association, are working to bring an ACCESS Open Minds Centre to the Sarnia-Lambton community. The Mike Weir Foundation has made an incredible and generous commitment to the ACCESS Open Minds project. A “Chip in Challenge” campaign is ongoing where donations up to $200,000 will be matched by the Weir Foundation! A sold out golf event with Mike Weir was held on Sept. 19th and a special luncheon featuring Michelle Money was hosted Sept. 20th. Proceeds raised at the tournament and luncheon were allocated to the ACCESS project. Thank you to all the sponsors, golfers and guests who supported the events.

Bluewater Health Foundation is thrilled to be part of the planning and fundraising needed to open the ACCESS Open Minds Centre for youth in our community. This is an identified priority and project of the Foundation. As such, we are allocating the proceeds from this year’s gala to support this amazing project! Jessica Holmes, Canadian comedian will be joining us this year as the keynote speaker for the annual Foundation gala, sponsored by NGL Supply. The gala will be held October 17th at Huron Oaks. New this year we are selling tickets online at https://www.bwhf.ca/purchase-gala-tickets

In addition to Foundation planned events, Bluewater Health Foundation is often the fortunate beneficiary of several third party events that raise both funds and awareness for the hospital. We are extremely grateful to the organizers of these events for the commitment and support of Bluewater Health.

Foundation staff member Danielle Catton hosted a “Curvy Beach Party” at Canatara Park promoting body positivity. Proceeds supported the Eating Disorders program. Thank you Danielle!

On August 23rd, the annual “Fore the Cure” Golf Tournament, honoring the memory of Pam Kohlmeier took place. Proceeds from this tournament are shared between Bluewater Health’s Mammography Department and breast cancer research at London Health Sciences Centre. Congratulations and thank you to the Fore the Cure committee on another incredible year!

The generosity of the Sarnia-Lambton community never ceases to amaze me and we are truly honoured that these events have chosen to support Bluewater Health.

On August 4th, over 1000 riders, including many members of the Bluewater Health family, took part in the Bluewater International Granfondo that started and finished along the shores of Lake Huron in Sarnia’s beautiful Mike Weir Park. Funds raised support educational opportunities for the Palliative Care department and St. Joseph’s Hospice. Thank you to the organizers and volunteers of this event for all of their efforts in planning the ride!

I would like to highlight a few of the events held over the summer:

Respectfully submitted,

Kathy AlexanderExecutive Director