Agenda Item Tab No. Time Presenter 1.0 MEETING CALLED TO ORDER 1:00 Mr. John Langs. 2.0 NOTICE/RECOGNITION OF A QUORUM 1 Mr.

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1 AGENDA BOARD OF DIRECTORS September 24, :00pm- 3:00pm Central LHIN 60 Renfrew Drive, Markham ON Agenda Item Tab No. Time Presenter 1.0 MEETING CALLED TO ORDER 1:00 Mr. John Langs 2.0 NOTICE/RECOGNITION OF A QUORUM 1 Mr. John Langs 3.0 APPROVAL OF AGENDA 2 Mr. John Langs 3.1 Welcome members of the public 4.0 DECLARATION OF CONFLICTS OF INTEREST Mr. John Langs 5.0 APPROVAL OF CONSENT AGENDA 3 1:10 Mr. John Langs 5.1 MINUTES OF THE PREVIOUS MEETING 3 Mr. John Langs June 25, OTHER ITEMS 3 Ms. Kim Baker Central LHIN Operations Fiscal 2013/14 Revised Budget Ministry LHIN Performance Agreement 2013/ REPORTS OF COMMITTEE Audit Committee Risk Management Framework Audit Committee Workplan 6.0 CHAIRMAN S REPORT 1:20 Mr. John Langs 6.1 Board Vacancies 6.2 Board Development Day 7.0 CEO REPORT ITEMS FOR APPROVAL 4 1:30 Ms. Kim Baker /14 Hospital Service Accountability Agreements- Extensions 7.2 North York General Hospital: Pre-Capital Submission Part A - Redevelopment of Emergency Department Triage - General Site 7.3 Mental Health & Addictions Crisis Services: Allocation Priorities 7.4 CCAC 2013/14 MSAA Amendment 8.0 CEO REPORT ITEMS FOR INFORMATION 4 2:00 Ms. Kim Baker 8.1 Provincial Physiotherapy Services Reform updatepresentation 1:55 Ms. Nathalie Beaulieu Ms. Nancy Lum- Wilson Ms. Carol Edward

2 Agenda Item Tab No. Time Presenter 9.0 OTHER BUSINESS (Additions to the Agenda) Mr. John Langs 10.0 FUTURE MEETINGS Mr. John Langs Tuesday October 29, :00pm 3:00pm Central LHIN 60 Renfrew Drive, Markham 11.0 BOARD DEVELOPMENT AND EDUCATION 5 Mr. John Langs ED Wait Times in Central LHIN- presentation 2:10 Dr. Rakesh Kumar 12.0 MOTION MOVING INTO A CLOSED SESSION 6 3:30 Mr. John Langs 12.1 Approval of Minutes of the Previous Meeting 7 3:30 June 25, Business Arising FOR APPROVAL RECESS/PUBLIC DIALOGUE 3:00-3:30 Mr. John Langs 14.0 CHAIRMAN S REPORT OF A CLOSED SESSION (IF REQUIRED) Mr. John Langs 15.0 MOTION OF TERMINATION 4:00 Mr. John Langs 2

3 Item 5.1 CENTRAL LOCAL HEALTH INTEGRATION NETWORK BOARD OF DIRECTORS June 25, :00pm- 3:00pm Central LHIN, 60 Renfrew Dr. Markham, ON Board Members Present: Mr. John Langs, Chairman Mr. Albert Liang, Board Member Mr. Stephen Quinlan, Board Member Mr. John Rogers, Board Member (Teleconference) Ms. Judy Cameron, Board Member Ms. Brenda Urbanski, Board Member Ms. Uzo Anucha, Board Member Regrets: None MINUTES OF MEETING Staff Participants: Ms. Kim Baker, Chief Executive Officer Ms. Karin Dschankilic, Senior Director, Performance, Contracts and Allocations & Chief Financial Officer Mr. Nathalie Beaulieu, Senior Director Planning Integration & Community Engagement Ms. Robin Gauzas, Executive Assistant, Recording Secretary Guests: Mr. Andrew Hussain Ms. Sophie Outar 1.0 MEETING CALLED TO ORDER The meeting was called to order at 1:00 p.m. 2.0 NOTICE/RECOGNITION OF A QUORUM This meeting was formally constituted with Board members receiving adequate notice in accordance with By-Law No. 2. The notice, agenda and materials were distributed to the Board and were posted on the Central LHIN website. Quorum of a Board comprising seven members is 5 directors. A quorum was present at the meeting. In accordance with the By-law, participants and guest speakers were introduced. There are no provisions for deputations.

4 3.0 APPROVAL OF AGENDA ON MOTION made by Ms. Judy Cameron and seconded by Mr. Albert Liang IT WAS RESOLVED THAT, The Agenda be approved as distributed. CARRIED June DECLARATION OF CONFLICT OF INTEREST No conflicts were declared. 5.0 APPROVAL OF CONSENT AGENDA ON MOTION made by Mr. Stephen Quinlan and seconded by Mr. Albert Liang IT WAS RESOLVED THAT, The Consent Agenda be approved as distributed and all resolutions contained therein be adopted as follows: CARRIED June APPROVAL OF MINUTES The Minutes of May 28, 2013 be approved as circulated. CARRIED June CEO s REPORT- ITEMS FOR APPROVAL West Park Hospital Service Accountability Agreement The Central LHIN Board of Directors: 1) Approves the proposed funding and volume targets to be included in the 2013/14 Hospital Service Accountability Agreement with West Park Healthcare Center: 2013/14 Base Funding $1,150,000 Complex Continuing Care (RUG Weighted Patient Days) 1,385 2) Delegates authority to the Chair and CEO to sign the 2013/14 Hospital Service Accountability Amending Agreement. CARRIED June

5 5.2.2 Diabetes Education Program Multi-Sector Service Accountability Agreements The Central LHIN Board of Directors approves the following allocation of funding and associated performance targets for Diabetes Education Programs in Central LHIN: Diabetes Education Program Annual # Clients # Visits Funding Black Creek CHC $1,833,075 4,149 10,240 Vaughan CHC $ 870,131 2,096 4,237 Mackenzie Health $1,324,262 3,182 9,567 Markham Stouffville Hospital $1,269,665 2,730 10,579 Southlake Regional Health Centre $2,650,902 5,058 13,735 Total $7,948,035 19,201 48, H-SAA Updates: Quality Indicators CARRIED June The Central LHIN Board of Directors approves the following targets for the quality indicators in the 2013/14 Hospital Service Accountability Amending Agreements for the following Central LHIN public hospitals as follows: Indicator Rate of Ventilator-Associated Pneumonia (VAP) Central Line Infection Rate (CIL) Rate of Hospital Acquired Cases of Clostridium Difficile Infections Rate of Hospital Acquired Cases of Vancomycin Resistant Enterococcus Bacteremia (VRE) North York General Hospital Mackenzie Health Southlake Regional Health Markham Stouffville Hospital Humber River Hospital Rate of Hospital Acquired Cases of Methicillin Resistant Staphylococcus Aureus Bacteremia Delegation of Authority CARRIED June The Central LHIN Board of Directors approves delegation of authority to the Chair in the absence of a July and August 2013 Board Meeting. CARRIED June

6 6.0 CHAIRMAN S REPORT Provincial Budget Mr. Langs gave a brief update on provincial budget and advised that in the 2012 Budget, the Province made a commitment to increasing investment in home and community care services by an average of four per cent per year. The government is building on this commitment by providing an additional one per cent per year to increase overall funding for home and community care services by an average of over five per cent annually over the next three years. The Provincial budget was passed on June 11 th. The Ontario legislature has risen and adjourned for the summer. Mr. Langs advised that Ontario Premier Wynne and Minister Mario Sergio visited the Better Living Centre in Don Mills on June 3 rd to launch Senior s Month and both he and Ms. Baker attended to support the kick-off of Seniors Month. Mr. Langs advised that Minister Deb Matthews of Health and Long-Term Care visited Central LHIN s Southlake Regional Health Centre on June 4 th to experience, first hand, innovations that have dramatically improved patient flow throughout the hospital. Both Mr. Langs and Ms. Baker were in attendance. Innovation through Collaboration Awards Mr. Langs and Ms. Baker presented awards for the collaborative work of various individuals who have made a meaningful difference to the health care system and for the residents of Central LHIN. Two awards that are being recognized: 1. Innovation Through Collaboration-Wait Time Strategic Planning Group The Wait Time Strategic Planning Group s work that has resulted in sustained positive wait time improvements- improving access to surgical and diagnostic procedures in Central LHIN 2. Innovation Through Collaboration-Cluster Care Model A group of individuals working cross ministries have supported the creation of an innovative cluster care model for young adults with complex medical needs in the community. 7.0 CEO REPORT ITEMS FOR APPROVAL There are no items for approval 8.0 CEO REPORT-ITEMS FOR INFORMATION 8.2 Ms. Baker provided a brief update on Provincial Physiotherapy Reforms underway. The changes being planned for will be in effect as of August 1, Physiotherapy services in community settings will continue to be funded and these changes will not affect physiotherapy services provided in hospitals. The changes to physiotherapy services are divided into five streams. Ms. Baker noted LHINs are working collaboratively across the province and are currently developing contingency plans should there be any unforeseen disruption to services. 4

7 8.3 Ms. Baker advised that on June 17 th The Ministry of Health and Long-Term Care held a Health Links day which Ms. Baker attended and sat on a panel with other LHIN CEO s. The objectives of the day were to understand what has been done to date to spread learnings and share progress. 8.4 Ms. Baker advised that in January 2013 LHIN staff facilitated discussions with clinicians and providers regarding, child/adolescent and adult inpatient beds in the Central LHIN. A working group was established with a mandate to develop a process for all hospitals in Central LHIN to enable equitable access for both children/adolescent and adults that requires an inpatient mental health and addictions bed. Next steps include the development of a project charter. 8.5 On June 6, 2013, Ontario s French Language Services Commissioner, Francois Boileau presented his Annual Report titled A new Approach. The Commissioner commended the government of Ontario for the initiatives it has undertaken to help improve the delivery of French Language Services in the last fiscal year and recognized government agencies whose actions have contributed to the expansion of the delivery of high-quality French language services across the province. One of the initiatives the Commissioner highlighted was the work at Bendale Acres Long- Term Care Home (Bendale Acres) in Scarborough. Central LHIN partnered with Central East LHIN to facilitate this work which included two streams. Ms. Baker also informed the Board of recently funded capacity to improve translation services in the community anticipated by October The Board inquired if Central LHIN understood the current capacity of HSPs to provide translation services. Do we understand what types of service are being provided now? ACTION: Staff will follow up and inform the Board 8.6 In a letter received June 7, 2013, the Ministry set out a Target Confirmation Template and timelines for the LHINs and Ministry to negotiate the targets for the MLPA indicators. Staff have a meeting with the Ministry of Health and Long Term Care set for July. ACTION: Staff will keep the Board informed as this process unfolds 8.7 On May 23, 2013, the Canadian Institute for Health Information released its annual health indicator report Health Indicators Jointly produced by Canadian Institute for Health Information and Statistics Canada. This annual report informs on a broad range of measures related to health system performance and the health status of Canadians. Ms. Baker noted that 24 of 33 indicator results are better than the Canadian average, six are below but within 10% of the average and of the three outside of that only one is statistically significant. Staff will follow up with health service providers regarding the 30-Day readmission rate for people 19 years old and younger 5

8 8.9 Mr. Hussain and Ms. Sophie Outar gave a presentation on the ehealth Strategic Plan 2013/2014. Topics covered in the presentation include: Electronic Medical Record Adoption (EMR) Hospital Report Manager (HRM) Ontario Laboratory Information System (OLIS) Integrated Assessment Record (IAR) Connecting GTA (cgta) Participate in ALC RM&R Business Transformation Initiative (BTI) Health Links & ehealth RM&R Reporting and Analytics Framework Standardized Discharge Summary Template Telehomecare (THC) Resource Matching & Referral (RM&R) and Hospital Integration Resource Matching & Referral (RM&R) and Family Health Team integration Alignment with the ehealth Ontario Blueprint? 8.10 Ms. Baker advised that the two-year Ministry-Local Health Integration Network Performance Agreement (MLPA) was extended until March 31, 2013 and a new agreement has been drafted. The new agreement will be effective April 1, 2013 March 31, 2015 and is intended to reflect the evolution of Local Health Integration Networks (LHINs) as critical to the transformative change currently underway in Ontario s healthcare system. Approval of the agreement is anticipated in September OTHER BUSINESS None at this time 10.0 FUTURE MEETINGS Tuesday September 24, :00pm 3:00pm 60 Renfrew Drive, Markham ON 11.0 BOARD DEVELOPMENT AND EDUCATION No presentations 12.0 MOTION MOVING INTO A CLOSED SESSION ON MOTION by Ms. Uzo Anucha and seconded by Mr. Stephen Quinlan. IT WAS RESOLVED THAT, The members attending this meeting move into a Closed Session pursuant to the following exceptions of LHINS set out in s.9(5) of the Local Health Systems Integration Act, 2006: Personal or public interest Public security Security of the LHIN and its directors Personal health information Prejudice to legal proceedings Safety Personnel matters Labour relations Matters subject to solicitor client privilege 6

9 Matters prescribed by regulation Deliberations on whether to move into a closed session and further that the following persons be permitted to attend: Ms. Kim Baker Ms. Karin Dschankilic Ms. Nathalie Beaulieu Ms. Robin Gauzas CARRIED June RECESS/PUBLIC DIALOGUE A recess was held from 2:32pm - 2:55pm to provide the Board with an opportunity to dialogue with the public 14.0 CLOSED SESSSION CALLED TO ORDER The session was called to order at 2:55 pm APPROVAL OF AGENDA ON MOTION by Ms. Judy Cameron and seconded by Ms. Uzo Anucha, IT WAS RESOLVED THAT, The Agenda of the Closed Session of May 28, 2013 be approved APPROVAL OF MINUTES CARRIED June ON MOTION by Mr. John Rogers and seconded by Ms. Judy Cameron, IT WAS RESOLVED THAT, The minutes of the Closed Session of May 28, 2013, be approved as distributed. CARRIED June MOTION MOVING OUT OF CLOSED MEETING ON MOTION by Ms. Brenda Urbanski and seconded by Ms. Judy Cameron, IT WAS RESOLVED THAT, The Closed Session is terminated (5:25 p.m.) and that closed session minutes are permitted to be shared with all board members and permitted attendees. CARRIED June

10 18.0 MOTION TO TERMINATE SESSION ON MOTION by Ms. Brenda Urbanski and seconded by Ms. Judy Cameron, IT WAS RESOLVED THAT, The session be terminated (5:25 p.m.). CARRIED June John Langs, Chairman Robin Gauzas, Recording Secretary 8

11 60 Renfrew Drive, Suite 300 Markham, ON L3R 0E1 Tel: Fax: Toll Free: CENTRAL LHIN BOARD OF DIRECTORS BRIEFING NOTE UPDATED OPERATIONS BUDGET AUGUST 22, 2013 ITEM PROPOSED RESOLUTION: WHEREAS the LHIN Board approved the LHIN Operating Budget at the May 28, 2013 meeting; and WHEREAS as a result of new funding and variances in spending in some line items both year-to-date and forecasted ; and WHEREAS spending for unbudgeted items over $25,000 require Board approval; and WHEREAS the Audit Committee has reviewed the updated forecast at the August 22, 2103 Audit Committee meeting and is recommending it for approval to the Board of Directors: BE IT RESOLVED THAT: The Central LHIN Board of Directors approves the updated balanced forecast for LHIN Operations Fiscal Year ANALYSIS: Highlights of Year-to-Date Results Revenue The Ministry of Health and Long-Term Care has announced that it will provide the LHIN with an additional $27,344 on a one-time basis for FY to support the implementation of Physiotherapy Reform. The LHIN has not yet received a funding letter for the Primary Care Physician Lead (expected to be $75,000) nor for the ehealth Project Management Office (budgeted for $510,000). Management is reasonably confident that the ministry remains committed to funding these initiatives this year. In the interim, the LHIN has incurred staffing and related expenses of $100,000 to date, and can cover these costs through committed Ministry funds if need be. Other funding remains at budgeted levels. Expenses The largest variation is due to staffing vacancies, primarily due to longer than anticipated time-to-fill for new positions. Many variances are related to timing and funding is expected to be spent by year end. Income/Loss from Operations The fiscal year-to-date results are a loss from operations of $100,072. This is a result of the expenses related to Primary Care Lead and ehealth Project Management Office. This loss will reverse once funds have been received from the ministry.

12 60 Renfrew Drive, Suite 300 Markham, ON L3R 0E1 Tel: Fax: Toll Free: Updated Forecast The LHIN Operating Budget for was approved at the May 28, 2103 Central Board of Directors meeting. As noted above, there have been some variances in the revenue and expense lines on a year-to-date basis. The LHIN needs to reallocate $176,626 to utilize the full year s revenue allocation in line with LHIN priorities. Management is proposing the following reallocation: Increased funds allocated for consulting for assistance with key projects ($30,000); Ergonomic assessments for staff work spaces, and purchase of related equipment recommended from the assessments (13,000); Contract positions to ensure successful implementation of Physiotherapy Reform ($27,344, included in the updated salary forecast); Software to assist with health services planning ($25,000); Increased budget for annual Quality Forum ($25,000); ehealth Cluster projects ($17,305); and LHIN Shared Services Office central projects: LSSO has not yet finalized its budget, however some recommended projects are on hold pending additional funding sources. This may include funds to implement the IT Disaster Recovery and Business Continuity Plan, and/or enhancements to business applications ($67,321). LHIN operating results to July 2013, with explanation of large variances, is attached as Appendix A: Consolidated LHIN Operating Results and Forecast. NEXT STEPS: Upon approval of the updated forecast, LHIN management will execute the forecast for LHIN Operations.

13 Appendix A Consolidated LHIN Operating Results and Forecast For the Four Months Ending July ITEM APPENDIX A Year to Date Annual Actual Budget Variance Budget Forecast Variance Explanation of Variances A B C= A-B D E F= E-D Revenue Revenue - Ministry $1,619,003 $2,026,686 ($407,683) $6,080,030 $6,080,030 $0 DCC Amortization 22,890 21,804 1,086 65,403 65,403 0 Revenue- LHIN transfer $27,344 $27,344 one-time to implement physio reform Total Revenue 1,641,893 2,048,490 (406,596) 6,145,433 6,172,777 27,344 Expenses Salaries 1,085,909 1,171,887 (85,978) 3,515,658 3,390,424 (125,234) longer than anticipated time-to-fill for new positions Total Benefits 207, ,381 (27,240) 703, ,097 (25,047) Staff Development 3,338 19,341 (16,004) 58,000 58,000 0 will re-evaluate at Q3 Recruitment 230 6,668 (6,438) 20,000 20,000 0 will re-evaluate at Q3 Travel Staff 3,500 5,256 (1,755) 15,780 15,780 0 Consulting Services 0 9,667 (9,667) 29,000 59,000 30,000 increased for transportation RFP Professional services 78, ,537 (41,667) 361, ,610 0 Accommodation Leases 117,646 98,716 18, , ,143 0 General Repairs & Maintenance 5,747 11,000 (5,253) 33,000 33,000 0 Insurance 2,022 2,232 (210) 6,700 6,700 0 one time and other expenses 21,868 44,160 (22,292) 132, ,468 25,000 software Meeting Expenses 10,174 25,360 (15,186) 76, ,080 25,000 increased for Quality forum Voice & Data 7,064 15,284 (8,220) 45,850 45,850 0 Equipment & Furniture 3,806 3, ,060 23,060 13,000 erogonomic assessment equipment Supplies 16,493 18,470 (1,977) 55,413 55,413 0 Printing and Translation 12,471 20,315 (7,844) 60,937 60,937 0 Board members Per Diems 9,200 12,800 (3,600) 38,400 38,400 0 timing; will re-evaluate at Q3 Board Chair per Diems 0 9,100 (9,100) 27,300 27,300 0 timing; will re-evaluate at Q3 Travel Board Members 544 1,667 (1,122) 5,000 5,000 0 Other Governance Costs 0 4,000 (4,000) 12,000 12,000 0 LSSO 117, ,827 (608) 353, ,803 67,321 project work TBD LHIN Collaborative (LHINC) 15,833 15, ,500 47,500 0 ehealth Central Cluster 0 58,835 (58,835) 176, ,810 17,305 final amount to be confirmed once funds received Amortization 22,890 21,804 1,086 65,403 65,403 0 Total Expenses 1,741,965 2,048,490 (306,524) 6,145,433 6,172,777 27,344 Income (Loss) from Operations (100,072) 0 (100,072) 0 (0) (0) Deficit due to Primary Care and ehealth

14 60 Renfrew Drive, Suite 300 Markham, ON L3R 0E1 Tel: Fax: Toll Free: ITEM CENTRAL LHIN BOARD OF DIRECTORS DELEGATION OF AUTHORITY TO CHAIR AND CEO FOR MINISTRY LHIN PERFORMANCE AGREEMENT (MLPA) SEPTEMBER 24, 2013 WHEREAS LHIN representatives and the Ministry- LHIN Joint Advisory Committee (JAC) have been working to draft the Ministry LHIN Performance Agreement ; WHEREAS the LHIN Leads and the Ministry have completed negotiating all but two schedules of the MLPA; WHEREAS the outstanding schedules; Schedule 4 (Funding and Allocation) and Schedule 5 (Local Health System Performance) are still to be confirmed; WHEREAS key changes have been highlighted for the board and discussed in detail at the June 25, 2013 Board of Directors Meeting; BE IT RESOLVED THAT: That the Central Local Health Integration Network Board of Directors authorize the Board Chair to execute the Ministry-LHIN Performance Agreement ( MLPA ) presented to this Board and attached to the minutes of this meeting provided that the execution version of the MLPA, including the performance requirements and funding allocations, are substantially the same as those presented. 1

15 MINISTRY-LHIN PERFORMANCE AGREEMENT APRIL 1, 2013 MARCH 31, 2015 BETWEEN: Her Majesty the Queen in right of Ontario, as represented by the Minister of Health and Long-Term Care ( MOHLTC ) - and - XXXX Local Health Integration Network ( LHIN ) Introduction The Local Health System Integration Act, 2006 (LHSIA), the Memorandum of Understanding (MOU) and the Ministry-LHIN Performance Agreement ( Agreement ) are the key elements of the accountability framework between the MOHLTC and the Local Health Integration Networks (LHINs). The Agreement identifies the MOHLTC s key operational and funding expectations of the LHIN that are not already addressed in the LHSIA or the MOU. It recognizes that the MOHLTC and the LHIN have a joint responsibility to serve the public interest and effectively oversee the use of public funds. The Agreement reflects the LHINs critical role in ensuring enhanced access and quality of healthcare in a fiscally sustainable manner while acknowledging the MOHLTC s responsibility to apply appropriate and legitimate scrutiny of fiscal management and health services delivery by the LHINs. The MOHLTC has communicated provincial strategic direction that provides a vision for system change and reinforces the principles articulated in the Excellent Care for All Act, The MOHLTC and the LHINs used this vision to develop a Performance Framework focused on better patient outcomes and value for healthcare dollars. The framework includes the following shared system goals: Enhanced Person-Centred Care Improved System Integration and Enhance Coordination and Transitions of Care Implementation of Evidence-Based Practices to Drive Quality, Value and Improved Health Outcomes Financial Sustainability A number of key initiatives have been introduced to transform the healthcare system and achieve the vision set forth by the MOHLTC. The LHINs will work with health services providers and other providers to enhance collaboration within and between sectors and ensure alignment with current provincial strategies, including: Patient-Based Funding: a new funding strategy to facilitate fiscal sustainability and person-centred care. This will impact hospital, Community Care Access Centre (CCAC), and Long-Term Care Homes (LTCH) budgets. Health Links: an innovative approach to enhancing coordinated care for people who DRAFT Ministry-LHIN Performance Agreement (2013/ /15) Page 1 of 39 May 15, 2013

16 access the system frequently and at multiple entry points. Seniors Strategy: a provincial initiative to keep seniors healthy and at home longer and reduce pressures on hospitals and LTCHs by increasing capacity in the community. Mental Health and Addictions Strategy: an inter-ministerial commitment to improve the well-being of all Ontarians and create healthy, resilient communities. To further support the transformation agenda and address the demographic and fiscal challenges facing Ontario, comprehensive service capacity planning that includes both the MOHLTC and the LHINs is required. Primary Purpose of the Agreement 1. This Agreement outlines the mutual understanding between the MOHLTC and the LHIN of their respective performance obligations in the period from April 1, 2013 to March 31, 2015 covering the and fiscal years. This is an accountability Agreement for the purposes of s. 18 of the LHSIA. Principles 2. Both parties will carry out the responsibilities and obligations based on principles that reflect: a) Alignment with provincial priorities and strategies; b) Sustainability of the healthcare system by maximizing the efficient and effective use of public funds; c) Performance improvement; d) High-quality, person-centred service delivery; e) Consistency; f) Consultation and collaboration among MOHLTC, LHINs, health service providers, other providers and the applicable communities; g) Openness and transparency; and h) Innovation, creativity and flexibility. Definitions 3. The following terms have the following meanings in all the Schedules: Agreement means this Agreement, including any schedules, and any instrument which amends this Agreement. Annual Business Plan means the plan for spending the funding received by the LHIN from the MOHLTC and included in this Agreement as required by s. 18(2) (d) of the LHSIA. DRAFT Ministry-LHIN Performance Agreement (2013/ /15) Page 2 of 39 May 15, 2013

17 "Community" has the meaning set out in s. 16(2) of the LHSIA. Consolidation Report means a report that includes the LHIN s revenues and expenditures for LHIN operations and transfer payments to health service providers, and balance sheet accounts for the LHIN. Dedicated Service Funding means, in respect of a specific service, the funding that must be used by the LHIN to fund the provision of the specific service. ehealth means the coordinated and integrated use of electronic systems, information and communication technologies to facilitate the collection, exchange and management of personal health information in order to improve the quality, access, productivity and sustainability of the healthcare system. Key application areas of ehealth in Ontario include, but are not limited to: Electronic health information systems (e.g., electronic medical records, hospital information systems, electronic referral and scheduling systems, digital imaging and archiving systems, chronic disease management systems, laboratory information systems, drug information and eprescribing systems) Electronic health information access systems (e.g., provider portals, consumer ehealth) Underlying enabling systems (e.g., client/provider/user registries, health information access layer) Remote healthcare delivery systems (e.g., telemedicine services) ehealth Ontario means the government agency responsible to the Minister of Health and Long-Term Care which is a corporation without share capital created and continued in Ontario Regulation 43/02 made under the Development Corporations Act. Fiscal year means April 1 to March 31. "Health service provider" has the meaning set out in s. 2(1) of the LHSIA. Regular Report means a report that includes a statement of the LHIN s revenues, actual expenditures, forecasted expenditures for LHIN operations, transfer payments, an explanation of variances as required between the forecasted expenditures and revenues, and the identification of any financial and performance risks. Schedule means any one of and Schedules means any two or more of the schedules appended to this Agreement, including the following: 1. General; 2. Local Health System Program Management; 3. Long-Term Care Homes Program Specific Management 4. Funding and Allocations; 5. Local Health System Performance; and 6. Integrated Reporting. Service accountability agreement means the service accountability agreement that the LHIN and a health service provider are required to enter into under s. 20 (1) of the LHSIA. DRAFT Ministry-LHIN Performance Agreement (2013/ /15) Page 3 of 39 May 15, 2013

18 Year-end means the end of a fiscal year. Accountability 4. Both parties will fulfill their performance obligations in accordance with the terms of this Agreement. 5. Both parties will collaborate and cooperate to: a) Facilitate the achievement of the requirements of the Agreement; b) Promote financial sustainability and efficient utilization of financial resources; c) Develop clear and achievable service and financial performance obligations and identify risks to performance; d) Establish clear lines of communication and responsibility; and e) Work diligently to resolve issues in a proactive and timely manner. 6. The LHIN is responsible for managing its performance, the performance of the local health system, and collaborating with other providers to support provincial goals, as set out in the Agreement and using its authority under law. The MOHLTC is responsible for collaborating with the LHIN to achieve those ends. The MOHLTC and the LHIN recognize that issues may arise in the local health system that will require joint MOHLTC-LHIN problem-solving, decision making and action. Performance Improvement 7. Both parties will follow a proactive and responsive approach to performance improvement based on the following principles: a) Prudent financial management of public healthcare resources; b) Better access to high quality, person-centred services; c) Strengthened transitions in care across the entire patient journey; d) Ongoing performance improvement; e) An orientation to problem-solving; and f) A focus on relative risk of non-performance. 8. Where matters arise that could significantly affect either the LHIN or MOHLTC s ability to perform their obligations under this Agreement, they shall provide written notice to the other party as soon as reasonably possible (a Performance Factor ). Notice shall include a description of any remedial action the party has taken or plans to take to remedy the issue. Receipt of notice will be acknowledged within five business days of the date of the notice. 9. Both parties agree to meet and discuss the Performance Factor within one calendar month of the date of the notice. During the meeting, using the principles set out in paragraph 7, the parties will discuss: a) The causes of the Performance Factor; b) The impact of the Performance Factor and whether it poses a low, moderate or high risk to achieving the obligations of the Agreement; DRAFT Ministry-LHIN Performance Agreement (2013/ /15) Page 4 of 39 May 15, 2013

19 c) The steps in the performance improvement process to be taken to mitigate the impact of the Performance Factor; and d) Whether revisions or amendments to a party s performance obligations are required. 10. Where a LHIN Performance Factor is not mutually resolved, the Minister will determine the remedies to improve performance, depending on the extent, exposure or level of risk. Next MOHLTC LHIN Agreement 11. Both Parties will enter into a new agreement under s. 18 of the LHSIA to be effective at the end of this Agreement. If the new agreement is not signed by the Parties by April 1, 2015 this Agreement will continue in force until the new agreement is signed. Both Parties will make their best efforts to sign a new agreement as soon as they are able. General 12. Any amendment to this Agreement will only be effective if it is in writing and executed by the authorized representative of each party. 13. The LHIN will not assign any duty, right or interest under this Agreement without the written consent of the MOHLTC. 14. If a due date for materials falls on a weekend or on a holiday recognized by the MOHLTC, the materials are due on the next business day. 15. Each Schedule applies to the fiscal years, unless stated otherwise in a Schedule. Some of the performance obligations in a Schedule may apply only to one fiscal year, as stated in that Schedule. 16. Each party will communicate with each other about matters pertaining to this Agreement through the following persons: DRAFT Ministry-LHIN Performance Agreement (2013/ /15) Page 5 of 39 May 15, 2013

20 To the MOHLTC: Ministry of Health and Long-Term Care, Health System Accountability and Performance Division Hepburn Block, 5 th Floor 80 Grosvenor Street, Toronto, ON M7A 1R3 Attention: Assistant Deputy Minister, Health System Accountability and Performance Fax: (416) Telephone: (416) With a copy to: Director, Local Health Integration Network (LHIN) Liaison Branch 80 Grosvenor St. 5 th Floor, Hepburn Block Toronto, ON M7A 1R3 To the LHIN: Attention: Chair Fax: () - Telephone: () - With a copy to: Attention: CEO Fax: () - Telephone: () - Fax: (416) Telephone: (416) Made effective this 1 st day of April, 2013 by: Her Majesty the Queen in right of Ontario, as represented by the Minister of Health and Long- Term Care: The Honourable Deb Matthews Minister of Health and Long-Term Care XXXX Local Health Integration Network By: Name Chair DRAFT Ministry-LHIN Performance Agreement (2013/ /15) Page 6 of 39 May 15, 2013

21 Provincial Priorities and Strategies SCHEDULE 1: GENERAL 1. The MOHLTC will establish provincial priorities and strategies for the health system and communicate these priorities to the LHINs. 2. The LHIN will: a) Work with the MOHLTC, health service providers and other providers in the local health system to achieve and accelerate provincial priorities and strategies. b) Work to align the Quality Improvement Plan (QIP) objectives and priorities of its health service providers to improve the quality of care across sectors and the healthcare system. 3. Both parties will work together to develop a collaborative process to support current and future service capacity planning so that decisions about local service provision will advance provincial priorities and strategies. Provincial Health Agencies 4. The MOHLTC will work with the following provincial health agencies to ensure they equally consider the role of the LHINs as local health system managers: a) Cancer Care Ontario; b) ehealth Ontario; c) Health Quality Ontario; and d) Ontario Agency for Health Protection and Promotion. 5. The LHIN will work with the aforementioned provincial health agencies to support the fulfillment of provincial priorities and strategies. Consistency 6. The MOHLTC will identify common issues and services for which a consistent approach across LHINs is required. 7. The LHIN will work collaboratively with other LHINs, and in accordance with the MOU, to ensure a consistent approach for common issues and services, including those identified by the MOHLTC in subparagraph 6(a). Local System Coordination and Integration 8. The LHIN will work with its health service providers and other LHINs to improve governance, coordination and integration of healthcare delivery across the continuum of care and both within and between LHINs. Community Engagement 9. The LHIN will fulfill its community engagement requirements in accordance with the DRAFT Ministry-LHIN Performance Agreement (2013/ /15) Page 7 of 39 May 15, 2013

22 community engagement guidelines to ensure greater clarity and transparency of process. Information Management 10. The MOHLTC will: a) Develop, maintain and support health data standards, communicate health data reporting requirements and standards to the LHIN and health service providers, advise/inform health service providers of reporting and data quality issues, and, inform the LHINsand health service providers of reporting timelines; b) Consult with the LHIN to identify LHIN data/information requirements that support data infrastructure for LHIN operational needs, and prepare data sharing agreements and / or amendments to existing agreements as required; and c) Receive data and information from health service providers on behalf of the LHIN and provide timely access to the appropriate data to support health system needs. 11. The LHIN will: a) Require health service providers to submit data and information as communicated by the MOHLTC under subparagraph 8(a) to the MOHLTC, Canadian Institute for Health Information, or other third party; b) Identify LHIN data/information requirements to support the LHIN analysis at the local level, and work collaboratively with the MOHLTC to develop appropriate methodology, consistent data analysis and reporting; and c) Work with health service providers to improve data quality and timeliness as necessary. 12. Both parties will avoid duplicating data and information management infrastructure and processes, determine and prioritize data and information products, and streamline reporting requirements and timelines for the LHIN and health service providers. Compliance Protocols 13. The MOHLTC will: a) Retain its compliance, inspection and enforcement authorities under legislation; and b) Inform the LHIN as soon as reasonably possible on matters related to compliance, inspection and enforcement in LTCHs and otherwise through a mutually agreeable reporting schedule. 14. The LHIN will: a) Exercise its legislative and contractual authorities as necessary or as required under law, including conducting or requiring audits and reviews of health service providers; and DRAFT Ministry-LHIN Performance Agreement (2013/ /15) Page 8 of 39 May 15, 2013

23 ehealth b) Inform the MOHLTC as soon as reasonably possible: i) Of non-compliance by a health service provider with an assigned agreement, a service accountability agreement, or legislation, that has not been resolved to the LHIN s satisfaction; or ii) Of a health service provider that is licenced or approved to operate a LTCH, 15. The MOHLTC will: a) That is experiencing financial issues; b) Where the LHIN is aware that there is risk to resident health and/or safety in a LTCH; or c) Where the results of an audit or review conducted or required by a LHIN identifies problems. a) Set technical and information management standards related to ehealth and implementation / compliance timeframes for the interoperability of the health system in Ontario, including standards related to content, architecture, technology, privacy and security; and b) Review annual LHIN Cluster ehealth plans as submitted by the LHINs. 16. The LHIN will: a) Assist their respective LHIN Clusters to prepare an annual LHIN Cluster ehealth plan that aligns with the provincial ehealth priorities for , to be submitted to the MOHLTC for review; b) Include ehealth commitments in service accountability agreements requiring health service providers to: i) Assist the LHIN to implement provincial ehealth priorities for ; ii) Comply with any technical and information management standards, including those related to data, architecture, technology, privacy and security, set for health service providers by the MOHLTC or the LHIN within the timeframes set by the MOHLTC or the LHIN as the case may be; iii) Implement and use the approved provincial ehealth solutions identified in the LHIN Cluster ehealth plan; iv) Implement technology solutions that are compatible or interoperable with the provincial blueprint and with the LHIN Cluster ehealth plan; and DRAFT Ministry-LHIN Performance Agreement (2013/ /15) Page 9 of 39 May 15, 2013

24 v) Include, in their annual planning submissions, plans for achieving ehealth priority initiatives, including full adoption by all hospitals of Ontario Laboratory Information System by March Both parties will work together, and in conjunction with ehealth Ontario and Ontario Telemedicine Network as appropriate, to: Capital a) Participate in forums for the discussion of ehealth issues at a provincial level to identify options to support the roll out of ehealth initiatives and related ehealth issues including local health system needs, challenges, and opportunities and ehealth standards, definitions, and architectural frameworks; and b) Inform one another of significant issues or initiatives that contribute to or have an impact on provincial or local ehealth issues, strategies or work plans. 18. Both parties will: a) Follow the November 2010 MOHLTC-LHIN Joint Review Framework for Early Capital Planning Stages; b) Work together during the term of this Agreement to develop a revised or updated capital planning and delivery model for the early capital planning stages informed by service capacity planning by the MOHLTC, the LHINs and other provincial health agencies; c) Follow the MOHLTC's current Health Infrastructure Renewal Fund Guidelines; and d) Work together to devolve the review and approval process for Own-Funds Capital Projects from the MOHLTC to the LHIN, as appropriate. Emergency Management 19. Both parties will work together to implement the approved policy: The LHIN Role in Emergency Management (August 2012). General Performance Obligations 20. The MOHLTC will provide the LHIN with, and develop as appropriate, those provincial standards (such as operational, financial or service standards and policies, operating manuals and program eligibility), directives and guidelines that apply to health service providers, including providing the LHIN with relevant program manuals. 21. The LHIN will: a) Require health service providers to provide services funded by the LHIN in accordance with provincial standards, directives and guidelines provided pursuant to paragraph 20 above; DRAFT Ministry-LHIN Performance Agreement (2013/ /15) Page 10 of 39 May 15, 2013

25 b) Provide a certificates of compliance, or attestations as the case may be, to the MOHLTC in form and substance as required by the MOHLTC; c) Maintain the 10% reduction in executive office costs that it achieved between April 1, 2011 and March 31, 2013 against its 2010/11 budget; d) Require its hospitals and CCAC to maintain the 10% reduction that they achieved between April 1, 2011 and March 31, 2013 against their respective 2010/11 budgets; e) Not use, nor permit its hospitals and CCAC to use, funding provided under this Agreement to increase executive office budgeted costs during the term of this Agreement; and f) Report on their executive costs in an attestation to the MOHLTC, and require its hospitals and its CCAC to report on their respective executive office costs in an attestation to the MOHLTC. 22. Both parties will work together to ensure that government priorities and implementation of provincial strategies are reflected in accountability planning submission templates, service accountability agreements and schedules with health service providers and other providers. Annual Review and Update 23. Both Parties agree that the Schedules will be reviewed and updated annually, as necessary to better reflect the Primary Purpose, within 120 days of a budget announcement of the Government of Ontario. DRAFT Ministry-LHIN Performance Agreement (2013/ /15) Page 11 of 39 May 15, 2013

26 SCHEDULE 2: LOCAL HEALTH SYSTEM PROGRAM SPECIFIC MANAGEMENT Provincial Programs 1. The MOHLTC and the LHIN will establish a coordinated and effective system for the management of provincial programs. 2. The MOHLTC will: a) Identify provincial programs, determine any terms and conditions, including dedicated service funding, related to these provincial programs and communicate these to the LHIN; and b) Establish: (i) Roles and responsibilities related to provincial program delivery; and (ii) Performance management, monitoring and evaluation processes. 3. The LHIN will fulfill requirements as may be identified under paragraph 2 above and work with other LHINs to coordinate provincial program service delivery. Other MOHLTC Programs 4. If the MOHLTC establishes expectations and requirements for other programs, it will advise the LHIN. 5. The LHIN will require health service providers that provide the specific program to provide program services in accordance with the expectations and requirements established by the MOHLTC. Devolution 6. The MOHLTC: a) Will determine the devolution of province-wide programs to the LHINs; b) Will consult with LHINs before identifying a Lead LHIN; and c) May specify the terms and conditions applicable to the funding and administration of the province-wide program after its devolution. 7. The LHIN will: a) Administer the devolved program in accordance with the Agreement Concerning the Devolution of Provincial Programs, also known as the Lead LHIN Model Agreement and any terms and conditions specified by the MOHLTC; and DRAFT Ministry-LHIN Performance Agreement (2013/ /15) Page 12 of 39 May 15, 2013

27 b) Confirm any proposed changes to the Lead LHIN Model Agreement with the MOHLTC prior to implementation. Community Health Centres ( CHCs ) 8. The MOHLTC will support development of QIPs by providing the required templates, guidance and accompanying supports. 9. The LHIN will require each CHC to submit a QIP to Health Quality Ontario that is aligned with and supports local health system priorities. Mental Health 10. The MOHLTC will: a) Determine and advise the LHIN of the number of housing units that receive rent supplements for persons with serious mental illness and the specific agencies that receive the rent supplements for these units from the MOHLTC; b) Determine and advise the LHIN of the required service levels for supports to housing services for persons with serious mental illness who occupy the housing units that receive rent supplements as described in subparagraph 10(a); c) For forensic mental health services, determine and advise the LHIN of: (i) the number and type of forensic mental health inpatient beds and the forensic case management initiatives, and the Transitional Rehabilitation Housing Programs numbers and models; (ii) the designated hospitals that provide forensic mental health services; and (iii) the required service levels for forensic mental health services; and d) Determine and advise the LHIN of the type (adult or paediatric, inpatient, residential, day treatment or outpatient) and quantity of specialty eating disorder services, where applicable. 11. The LHIN will: a) Fund the provision by health service providers of a combination of community mental health services for the local health system, including services for people who have been in conflict with the criminal justice system; b) Fund the provision by health service providers of the following services: (i) Supports to housing services for persons who occupy the housing units that receive rent supplements at the service levels as described in subparagraph 10(b); (ii) forensic mental health services that include forensic mental health inpatient beds, forensic case management initiatives, and the Transitional Rehabilitation DRAFT Ministry-LHIN Performance Agreement (2013/ /15) Page 13 of 39 May 15, 2013

28 Addictions Housing Programs; and (iii) specialty eating disorder services; at the service levels as specified under paragraph 10; c) Require health service providers, designated as psychiatric facilities under the Mental Health Act, to provide the essential mental health services in accordance with the specific designation for that site and discuss any material changes to the service delivery models or service levels with the MOHLTC; and d) Not make any changes to the types and/or levels of service as specified under paragraph 10 without MOHLTC approval. 12. The MOHLTC will: a) Determine and advise the LHIN of type and quantity of problem gambling treatment and prevention services; b) Determine and advise the LHIN of the number of housing units that receive rent supplements for persons with problematic substance use and the specific agencies who receive the rent supplements for these units from the MOHLTC; and c) Determine and advise the LHIN of the required service levels for supports to housing services for persons with problematic substance use who occupy the housing units that receive rent supplements as described in paragraph 12(b). 13. The LHIN will: a) Fund the provision by health service providers of the following services: (i) Problem gambling treatment and prevention services as described in subparagraph 12(a); (ii) Supports to housing services for persons who occupy the housing units that receive rent supplements as described in subparagraph 12(c); and (iii) A combination of substance abuse treatment services for the local health system; and b) Not make any proposed changes to types and/or levels of service as specified under paragraph 12 without MOHLTC approval. DRAFT Ministry-LHIN Performance Agreement (2013/ /15) Page 14 of 39 May 15, 2013

29 SCHEDULE 3: LONG-TERM CARE HOMES PROGRAM SPECIFIC MANAGEMENT Definitions 1. Definitions below apply to Schedule 3: Long-Term Care Homes and Schedule 4: Funding and Allocations: Acknowledgement and Consent Agreement means an agreement entered into between the MOHLTC, the operator of a LTCH, and one or more lenders or secured parties, by which the MOHLTC consented to, or agreed to request a consent to, any of the following: (a) a mortgage of real property associated with the LTCH, (b) an assignment of a Development Agreement with the MOHLTC, and/or (c) an assignment of a service agreement; Beds in Abeyance means LTCH beds licensed or approved by the MOHLTC, for which the LTC health service provider has obtained written permission from the Director, PICB, in accordance with the LTCHA for the beds not to be available for occupancy.; Construction Funding Subsidy per diem or CFS per diem means any per diem funding paid pursuant to a Development Agreement; Convalescent Care Beds means those short-stay beds, licensed or approved under the LTCHA, that are part of a short-stay convalescent care program for which residents may be eligible for admission in accordance with regulations under the LTCHA; Development Agreement means an agreement between the MOHLTC and a LTC health service provider, or a proposed LTC health service provider, to develop, upgrade, retrofit or redevelop LTCH beds; Funding Policies means the funding and financial management policies determined by the MOHLTC for LTCHs as the same may be amended from time to time. Funding Policies establish the rates, and amounts and envelopes of all funding provided to LTC health service providers by the MOHLTC or the LHIN, including Supplementary Funding. Funding Policies also establish the applicable conditions for funding, the funding reconciliation rules, and the form, manner and content and date for submission of reports; Interim Beds means those short-stay beds that are licensed or approved under the LTCHA and that fall within the definition of interim bed in accordance with regulations under the LTCHA; LTCH means long-term care home; LTCH Protocol means the document titled Long-Term Care Homes Protocol as prepared and amended by the MOHLTC; LTCHA means the Long-Term Care Homes Act, 2007 and regulations thereunder; LTC health service provider means a health service provider that is a licensee within DRAFT Ministry-LHIN Performance Agreement (2013/ /15) Page 15 of 39 May 15, 2013

30 Funding the meaning of s. 2(1) of the LTCHA; Supplementary Funding means funding for LTCH beds provided directly by the MOHLTC to LTC health service providers in accordance with applicable Funding Policies and pursuant to a funding agreement between MOHLTC and the LTC health service provider; service agreement means the agreement pursuant to which funding is provided to a LTC health service provider and includes a service accountability agreement; service accountability agreement means the service accountability agreement between a LHIN and a LTC health service provider required by s. 20 of the LHSIA; and Short-Stay Respite Beds means those short-stay beds, licensed or approved under the LTCHA, that are part of a short-stay respite care program for which residents may be eligible for admission in accordance with regulations under the LTCHA. 2. The MOHLTC will: a) Determine and provide to the LHIN, the amount of funding that a LHIN may provide to a LTC health service provider together with any applicable terms and conditions; b) Determine any net projected unused funding for all LHINs that, as of September 30 in each fiscal year, has not or is projected not to be used by LTC health service providers; c) Reallocate a share of the net projected unused funding to the LHIN if the LHIN is projected to be overspent on its funding for the LTCH per diem rate; d) If there is net projected unused funding remaining after the reallocation, allocate to the LHIN by December 31 of each year a share of the unused funding in proportion to the number of LTCH beds that are licensed or approved and in operation in the LHIN s geographic area, other than (i) Beds in Abeyance and (ii) beds funded by the LHIN pursuant to paragraphs 18 and 21 of this Schedule, compared to the provincial total number of LTCH beds that are licensed or approved and in operation in the Province, other than Beds in Abeyance and beds funded by all the LHINs pursuant to paragraphs 18 and 21 of Schedule 3 to their respective Ministry LHIN Performance Agreements; and e) At its discretion, provide Supplementary Funding. 3. The LHIN will distribute and reconcile the funding provided under paragraph 2, pursuant to the terms of a service accountability agreement that is consistent with and requires adherence to the Funding Policies and any additional terms and conditions. For greater certainty, the LHIN may not provide any more funding to LTC health service providers than is identified in paragraph 2 above, except as provided in the Funding Policies and this Schedule. 4. If a LTC health service provider s beds are closed or transferred to another LHIN, or if a DRAFT Ministry-LHIN Performance Agreement (2013/ /15) Page 16 of 39 May 15, 2013

31 LTC health service provider s licence expires, is surrendered or is revoked under the LTCHA, the residual funding for the beds provided under subparagraph 2 (a) reverts to the MOHLTC. Construction Funding Subsidy (CFS) 5. The MOHLTC will: a) Determine the CFS per diem and the LTC health service providers in the geographic area of the LHIN that will receive the per diem, including any conditions on the funding and the number of beds for which the LTC health service provider will receive the CFS per diem; and b) Provide the CFS per diem to the LHIN. 6. The LHIN will provide the CFS per diem to LTC health service providers for each approved or licensed bed that is identified in paragraph 5 and operated in accordance with the MOHLTC s conditions of funding, applicable legislation or Development Agreement. 7. Every service accountability agreement entered into between the LHIN and the LTC health service provider during the term of this Agreement and in the future will contain an obligation on the LHIN to provide the CFS per diem to the LTC health service provider for the length of time set out in the particular Development Agreement for the particular beds. Assignment of LTC Service Agreement 8. Where the MOHLTC has entered into an Acknowledgement and Consent Agreement with a LTC health service provider and one or more lenders of the LTC health service provider (Lender) prior to the proclamation of the LTCHA, the LHIN will treat the MOHLTC s consent to assign the service agreement under the Acknowledgement and Consent Agreement as if MOHLTC had provided the consent on behalf of the LHIN. 9. Where an Acknowledgement and Consent Agreement or a Development Agreement between the MOHLTC and the LTC health service provider provides that the MOHLTC will request the LHIN to consent to an assignment of the service agreement, to the Lender or person designated by the Lender, the LHIN will consent to the assignment of the service agreement to that person where the MOHLTC so requests, and the consent shall be subject to terms and conditions similar to those of the Acknowledgement and Consent Agreement or the Development Agreement as the case may be. 10. In addition, the LHIN will not unreasonably withhold consent requested from a Lender, or from a receiver or receiver and manager appointed by a Lender or by a court order, to assign its or the LTC health service provider s right, title and interest in the service agreement or any part thereof or interest therein to another party, subject to all applicable legislative requirements. 11. Where the MOHLTC DRAFT Ministry-LHIN Performance Agreement (2013/ /15) Page 17 of 39 May 15, 2013

32 a) has entered into a Development Agreement with a LTCH health service provider or a proposed LTCH health service provider (an Operator ); b) has consented to the grant of a security interest to a Lender under the Development Agreement; and c) has directed the LHIN to consent to the assignment of the Operator s rights under a service accountability agreement, then the LHIN, d) Shall deliver to the Lender a commitment, in the MOHLTC s standard form, to provide the LHIN s consent to the assignment of the Operator s rights under the service accountability agreement between the Operator and the LHIN; e) Upon the grant of a licence to the Operator in respect of the Home, and for so long as a CFS is to be paid in respect of the Home, shall consent to the grant of a security interest in the service accountability agreement between the LHIN and the Operator in respect of the Home, provided that: 1) The security interest in the service accountability agreement may only be exercised together with the exercise of a security interest in the licence for the beds; and 2) The security interest is subject to all applicable statutory requirements and restrictions, including s. 107 of the LTCHA and s. 2(2), 19 and 20 of the LHSIA; and f) Shall amend s of the service accountability agreement in respect of the Home to remove the following sentence: No assignment or subcontract shall relieve the HSP from its obligations under this Agreement or impose any liability upon the LHIN to any assignee or subcontractor. Beds in Abeyance 12. The MOHLTC will review and may approve Beds in Abeyance applications in accordance with the Beds in Abeyance policy and LTCH Protocol. 13. In the event that an application is approved, the LHIN may seek and the MOHLTC may grant permission to temporarily use the amount of funding available as a result of any approved Beds in Abeyance applications. If the MOHLTC approves the LHIN s request, the LHIN may use the funding in accordance with the approval, including any conditions that may attach to the approval. Short-Stay Program Beds 14. The MOHLTC will: a) Determine the minimum threshold for occupancy for Short-Stay Respite Beds to inform approval of these beds in accordance with the LTCH Protocol; DRAFT Ministry-LHIN Performance Agreement (2013/ /15) Page 18 of 39 May 15, 2013

33 b) Determine the minimum number of Convalescent Care Beds and Interim Beds in the Province; c) In consultation with the LHIN, determine the LTC health service providers that will provide the Convalescent Care Beds and the Interim Beds and the number of those beds from the minimum number of beds determined in subparagraph (b); and d) Set other conditions for the operation of Convalescent Care Beds and Interim Beds. 15. The LHIN will: a) Take action as appropriate to improve the utilization of Short-Stay Respite Beds; b) Have the ability to set, in its discretion, a threshold for occupancy of Short-Stay Respite Beds that is higher than the minimum set by the MOHLTC pursuant to subparagraph14 (a); c) Determine which LTC health service providers will provide Short-Stay Respite Beds within the existing licensed or approved beds of each home and the number of such beds; d) Advise and/or make a proposal to MOHLTC about matters referred to in subparagraph 14(c); e) Incorporate the conditions referred to in subparagraph 14(d) in service accountability agreements; f) At its discretion, request that the MOHLTC approve the conversion of existing licensed or approved beds into Convalescent Care Beds additional to those identified in subparagraph14(b) in accordance with the LTCH Protocol; and g) Provide from its allocation, all additional funding for the converted Convalescent Care Beds approved by the MOHLTC pursuant to subparagraph 15(f) to LTC health service providers in accordance with the Funding Policies, including the additional subsidy for Convalescent Care Beds and the resident co-payment portion of the base level-of-care per diem funding. LHIN-Requested LTCH Beds 16. In paragraphs 17 and 18 LHIN Requested LTCH Beds means, subject to a determination under subparagraph 18(b), a LTCH bed funded by the LHIN out of its allocation, other than its allocation for LTCHs: a) That would increase the bed capacity of an existing LTCH licence issued under s.99, or an approval granted under s. 130 of the LTCHA; or b) In the case of a development or redevelopment, that is over and above the number of LTCH beds that the MOHLTC has approved a LTC health service provider for development or redevelopment. 17. The LHIN will: DRAFT Ministry-LHIN Performance Agreement (2013/ /15) Page 19 of 39 May 15, 2013

34 a) At its discretion, request LHIN Requested LTCH Beds; b) In its request identify (i) the number of LHIN Requested LTCH Beds requested; (ii) the estimated amount of funding required to support the beds in accordance with the Funding Policies, including Supplementary Funding and funding that would be paid in accordance with paragraphs 3 and 6 in this Schedule; and (iii) where, subject to a determination under subparagraph 18(b), the funding will be found within the LHIN s allocation, other than its allocation for LTCHs; and c) Fund the LHIN Requested LTCH Beds in accordance with the Funding Policies and paragraphs 3 and 5 of this Schedule if the LHIN s request for LHIN Requested LTCH Beds is granted by the MOHLTC. 18. The MOHLTC will: a) Consider the LHIN s request for LHIN Requested LTCH Beds and decide whether to grant the request. b) Determine the amount of funding, if any, that the MOHLTC may contribute; c) Confirm the amount of the funding required to support the beds in accordance with the Funding Policies, including Supplementary Funding and funding that would be calculated pursuant to paragraphs 2 and 5 in this Schedule; and d) Reallocate the confirmed funding from the sources identified by the LHIN to (i) the LHIN s allocation for LTCH beds for all funding to be paid in accordance with paragraphs 3 and 6 of this Schedule; and (ii) the MOHLTC s allocation for Supplementary Funding when the LHIN Requested LTCH Beds are available for occupancy. LHIN-Requested Temporary LTCH Beds 19. In paragraphs 20 and 21, LHIN Requested Temporary LTCH Beds means a LTCH bed for which the MOHLTC would issue a temporary licence in accordance with s. 111 of the LTCHA or increase the bed capacity of a temporary licence in accordance with the LTCHA, on the condition that the LTCH bed will be funded by the LHIN out of the LHIN s allocation, which may include funding approved for temporary use under paragraph The LHIN will: a) At its discretion, make a request for LHIN Requested Temporary LTCH Beds for a term of no longer than 5 years; b) In its request identify (i) the number of LHIN Requested Temporary LTCH Beds requested; (ii) the estimated amount of funding required to support the beds in accordance with the Funding Policies, including Supplementary Funding and funding that would be paid in accordance with paragraph 3; and (iii) where the funding will be found within the LHIN s allocation; and DRAFT Ministry-LHIN Performance Agreement (2013/ /15) Page 20 of 39 May 15, 2013

35 c) If the request is approved pursuant to paragraph 21, provide the funding identified in subparagraph 21(b) for the LHIN Requested Temporary LTCH Beds in accordance with the Funding Policies for the term of the temporary licence issued by the MOHLTC, including any increases in this funding and Supplementary Funding after the date the temporary licence is issued by the MOHLTC for these beds. 21. The MOHLTC will: a) Consider the LHIN s request for LHIN Requested Temporary LTCH Beds and decide whether to grant the request; b) Confirm the amount of funding required to support the beds in accordance with the Funding Policies, including Supplementary Funding and the funding paid in accordance with paragraph 3 of this Schedule. DRAFT Ministry-LHIN Performance Agreement (2013/ /15) Page 21 of 39 May 15, 2013

36 SCHEDULE 4: FUNDING and ALLOCATIONS Definitions 1. In this Schedule, the following terms have the following meanings: Funding Annual Balanced Budget means that, in a fiscal year, the total revenues are greater than or equal to the total expenses. Further, for the LHIN, the meaning of annual balanced budget is also subject to Public Sector Accounting Board (PSAB) rules as well as any interpretations issued by the MOHLTC in financial policies, directives or guidelines under paragraph 8. Health Based Allocation Model (HBAM) is a population health-based funding methodology that uses population and clinical information to inform funding allocation. HBAM Funding means the portion of funding allocated to a health service provider based on the results of HBAM allocation methodology. Multi-year funding targets means the funding targets for remaining years of the Agreement. Operating Budget means the budget for the LHIN s corporate operations. Quality Based Procedures (QBP) means the evidence-based funding determination that uses a price times volume methodology to calculate the funding for a targeted set of specific patient groups. QBP Funding means the amount allocated to a health service providers as a result of QBP analyses using QBP allocation methodology. Transfer Payment Budget means the budget for the LHIN s funding of health service providers. 2. The government s overall provincial LHIN funding allocations that have been updated from the Printed Estimates to include any additional funding to July 31, 2013 and any reallocations initiated by the LHINs are set out in the following tables, in this Schedule: a) Table 1 Statement of Overall LHIN Provincial Funding Allocation b) Table 1a Statement of Overall LHIN Provincial Funding Allocation Health System Funding Reform Budget c) Table 3 Statement of Overall LHIN Provincial Dedicated Service Funding by Sector 3. The MOHLTC: a) Will provide to the LHIN on August 20, 2013 the funding allocation, such funding allocation having been updated from the Printed Estimates to DRAFT Ministry-LHIN Performance Agreement (2013/ /15) Page 22 of 39 May 15, 2013

37 include any additional funding to July 31, 2013 and any reallocations initiated by the LHIN, set out in the following tables in this Schedule: (i) Table 2 Statement of Individual LHIN Funding Allocation (ii) Table 2a Statement of Individual LHIN Funding Allocation Health System Funding Reform Budget (iii) Table 3a Statement of Individual LHIN Dedicated Service Funding by Sector b) As the LHIN makes funding allocation decisions at the sector level throughout the year, will revise the Health Service Provider Transfer Payment Budget by Sector Initiatives allocation in Table 2 in this Schedule to the appropriate sectors; c) May set terms and conditions for any of the funding set out in the tables in this Schedule, including the type of funding (e.g. base or one-time), whether the funding is subject to annual adjustment, and whether and in what circumstances the funding may be recoverable from the LHIN by the MOHLTC: d) Has determined that HBAM Funding set out in Tables 1a and 2a is subject to annual adjustment by the MOHLTC, and QBP funding set out in Tables 1a and 2a in this Schedule is subject to annual adjustment and is recoverable by the MOHLTC; e) Will reconcile all funding provided to the LHIN under this Agreement on an annual basis; f) Will recover funding from the LHIN if the MOHLTC has advised the LHIN that the particular funding is recoverable; and g) May require the LHIN to carry out certain initiatives. 4. The LHIN: a) Will allocate the funds provided by the MOHLTC for , in accordance with the LHSIA, this Agreement and any applicable terms and conditions of which the LHIN is advised by the MOHLTC, including those set out in paragraph 3; b) Will carry out MOHLTC-required initiatives that may include: (i) Aboriginal Community Engagement, French Language Health Services, French Language Health Planning Entities, LHIN Shared Services Office, Diabetes Regional Coordination Centre Program, Emergency/Alternative Level of Care Performance Leeds, Emergency Department LHIN Leads and Critical Care LHIN Leads, as set out in Table 2 in this Schedule under LHIN Operating Budget Initiatives; and (ii) Aging At Home, Urgent Priorities Fund, ALC Investment, Behavioural Supports Ontario Project and funding for Community Investment Initiatives ($XXXM), as set out in Table 2 in this Schedule under Health Service Provider Transfer Payment Budget Initiatives. c) May, at its discretion, provide additional funding for the services for which Dedicated DRAFT Ministry-LHIN Performance Agreement (2013/ /15) Page 23 of 39 May 15, 2013

38 Service Funding is identified; and d) May, only with prior approval from the MOHLTC, reallocate unused Dedicated Service Funding to another service. If the MOHLTC does not give approval, the LHIN shall return unused Dedicated Service Funding to the MOHLTC. Long-Term Care Homes 5. The funding allocations in Tables 1 and 2 for LTCHs are only estimates that are subject to adjustment in accordance with the Funding Policies, including adjustments for reconciliation, Beds in Abeyance, and Construction Funding Subsidy per diem. Annual Balanced Budget Requirements 6. The LHIN will: a) Plan for an Annual Balanced Budget for its operations and health service provider transfer payments; b) Achieve an Annual Balanced Budget for its operations; and c) Require health service providers who receive LHIN funding through transfer payments to achieve an Annual Balanced Budget. Multi-Year Funding Requirements 7. The LHIN will plan and manage LHIN forecasted expenses for the LHIN s Operating and Transfer Payment Budgets within the multi-year funding targets set out in this schedule and the Multi-Year Funding Framework. Multi-year funding targets are to be used for planning purposes only and may be revised upward or downward at the discretion of the MOHLTC. Financial Management Polices and Guidelines 8. The MOHLTC may develop and issue to the LHIN policies, directives and guidelines related to financial management. 9. The LHIN will comply with all applicable legislation; including the Financial Administration Act, any MOHLTC policies, directives and guidelines issued to the LHIN related to financial management; as well as government financial management policies; guidelines; and directives, including the following: a) Multi-Year Funding Framework; b) Parameters for Financial Health Framework; c) Fiscal Prudence through Contingency Planning Policy; and d) Parameters for In Year and Year End Reallocations Policy. Accounting Standards 10. The MOHLTC: DRAFT Ministry-LHIN Performance Agreement (2013/ /15) Page 24 of 39 May 15, 2013

39 a) Will issue interpretations and modifications relating to Public Sector Accounting Board (PSAB) standards, based on advice from the Office of the Provincial Controller; and b) May review the documentation described in paragraph 11 during regular business hours and upon twenty-four hours notice to the LHIN. 11. The LHIN will: a) Prepare its financial reports and statements on its Operating and health service provider Transfer Payment Budgets, including its Annual Business Plan, based on the Public Sector Accounting Board (PSAB) standards, subject to modifications and interpretations issued as per paragraph 10. b) Maintain documentation to support all financial statements and related payment instructions, including funding approval letters to health service providers and service accountability agreements signed between the LHIN and its health service providers. DRAFT Ministry-LHIN Performance Agreement (2013/ /15) Page 25 of 39 May 15, 2013

40 Table 1: Statement of Overall LHIN Provincial Funding Allocation Funding Allocation (000's) Funding Allocation (000's) Total LHIN Operating Budget XXXX TBD Total Health Service Provider Transfer Payments XXXX TBD Operation of LHIN XXX TBD Initiatives XXX TBD E-Health XXX TBD Total Health Service Provider Transfer Payment Budget by Sector: Operations of Hospitals XXXX TBD Grants to Compensate for Municipal Taxation - Public Hospitals XXXX Long Term Care Homes XXXX TBD Community Care Access Centres XXXX TBD Community Support Services XXXX TBD Acquired Brain Injury XXXX TBD Assisted Living Services in Supportive Housing XXXX TBD Community Health Centres XXXX TBD Community Mental Health XXXX TBD Addictions Program XXXX TBD TBD Specialty Psychiatric Hospitals Grants to Compensate for Municipal Taxation - Psychiatric Hospitals XXXX XXXX TBD TBD Initiatives XXXX TBD DRAFT Ministry-LHIN Performance Agreement (2013/ /15) Page 26 of 39 May 15, 2013

41 Table 1a: Statement of Overall LHIN Provincial Funding Allocation - Health System Funding Reform Budget Funding Allocation (000s) (1) Funding Allocation (000s) (1) Total Health System Funding Reform Budget Total Health Service Provider Transfer Payments XXX TBD Total Health Service Provider Transfer Payments XXX TBD Hospitals Health Based Allocation Model (HBAM) Funding (2) XX TBD Quality Based Procedures (QBP) Funding (3) XX TBD Community Care Acces Centre Health Based Allocation Model (HBAM) Funding (2) XX TBD Quality Based Procedures (QBP) Funding (3) XX TBD 1. The amounts in this table are included in Table 1 under the respective sectors. 2. HBAM funding will be processed as base funding subject to annual adjustment. 3. QBP funding will be processed as base funding subject to annual adjustment and recovery. DRAFT Ministry-LHIN Performance Agreement (2013/ /15) Page 27 of 39 May 15, 2013

42 Table 2: Statement of Individual LHIN Funding Allocation Funding Allocation (000s) Funding Allocation (000s) Total LHIN Operating Budget XXXX TBD Total Health Service Provider (HSP) Transfer Payments XXXX TBD Operation of LHIN XXX TBD Initiatives XXX TBD E-Health XXX TBD Total Health Service Provider Transfer Payment Budget by Sector: XXXX TBD Operations of Hospitals XXXX TBD Grants to compensate for Municipal Taxation - Public Hospitals XXXX Long Term Care Homes XXXX TBD Community Care Access Centres XXXX TBD Community Support Services XXXX TBD Acquired Brain Injury XXXX TBD Assisted Living Services in Supportive Housing XXXX TBD Community Health Centres XXXX TBD Community Mental Health XXXX TBD Addictions Program XXXX TBD Specialty Psychiatric Hospitals XXXX TBD TBD Grants to compensate for Municipal Taxation - Psychiatric Hospitals XXXX TBD Initiatives XXXX TBD DRAFT Ministry-LHIN Performance Agreement (2013/ /15) Page 28 of 39 May 15, 2013

43 Table 2a: Statement of Individual LHIN Funding Allocation - Health System Funding Reform Budget Funding Allocation (000s) (1) Funding Allocation (000s) (1) Total Health System Funding Reform Budget Total Health Service Provider Transfer Payments XXX TBD Total Health Service Provider Transfer Payments XXX TBD Hospitals Health Based Allocation Model (HBAM) Funding (2) XX TBD Quality Based Procedures (QBP) Funding (3) XX TBD Community Care Acces Centre Health Based Allocation Model (HBAM) Funding (2) XX TBD Quality Based Procedures (QBP) Funding (3) XX TBD 1. The amounts in this table are included in Table 2 under the respective sectors. 2. HBAM funding will be processed as base funding subject to annual adjustment. 3. QBP funding will be processed as base funding subject to annual adjustment and recovery. DRAFT Ministry-LHIN Performance Agreement (2013/ /15) Page 29 of 39 May 15, 2013

44 Table 3: Statement of Overall LHIN Provincial Dedicated Service Funding by Sector Hospitals Dedicated Service Funding Allocation (000s) Post Construction Operating Plan XXX Community Health Centres Uninsured Persons Services XXX Mental Health Consumer Survivor Initiatives XXX Addictions Problem Gambling Treatment Services Programs for Pregnant or Parenting Women with Problematic Substance Use XXX XXX Community Care Access Centres School Health Professional and Personal Support Services XXX Other Compensation Under Specified Initiatives / Agreements (1) XXX 1. Includes CHC physician salaries and psychiatric sessional fees for community and hospital-based agencies. Table 3a: Statement of Individual LHIN Dedicated Service Funding by Sector Hospitals Dedicated Service Funding Allocation (000s) Post Construction Operating Plan XXX Community Health Centres Uninsured Persons Services XXX Mental Health Consumer Survivor Initiatives XXX Addictions Problem Gambling Treatment Services Programs for Pregnant or Parenting Women with Problematic Substance Use XXX XXX Community Care Access Centres School Health Professional and Personal Support Services XXX Other Compensation Under Specified Initiatives / Agreements (1) XXX 1. Includes CHC physician salaries and psychiatric sessional fees for community and hospital-based agencies. DRAFT Ministry-LHIN Performance Agreement (2013/ /15) Page 30 of 39 May 15, 2013

45 Definitions SCHEDULE 5: LOCAL HEALTH SYSTEM PERFORMANCE 1. In this Schedule, the following terms have the following meanings: LHIN baseline means the result at a given time for a performance indicator that provides a starting point for measuring changes in local health system performance and for establishing LHIN targets for future local health system performance; LHIN target means a planned result for an indicator against which actual results can be compared; Performance indicator means a measure of local health system performance for which a LHIN target will be set, and the LHIN will be held accountable for achieving results under the terms of this Agreement for the local health system in connection with a performance indicator; Provincial target means an optimal performance result for an indicator, which may be based on expert consensus, performance achieved in other jurisdictions, or provincial expectations; CTAS means Canadian Emergency Department Triage and Acuity Scale; and CMG means Case Mix Group. General Obligations 2. Under the Act and the Commitment to the Future of Medicare Act, the LHIN will measure and plan to improve performance at the local level through service accountability agreements with health service providers. Specific Obligations 3. The MOHLTC will: a) Calculate the results for the performance indicators set out in Tables 1, 2 and 3: b) Provide the LHIN with calculated results for the performance indicators by the release dates set out in Schedule 6, and supporting performance information as requested, such as the performance of health service providers; and c) Provide the LHIN with technical documentation for the performance indicators set out in Tables 1, 2 and 3, including the methodology, inclusions and exclusions. 4. The LHIN will: a) Work to achieve the LHIN s performance targets for the performance indicators; b) Report quarterly on the performance of the local health system on all performance indicators; and DRAFT Ministry-LHIN Performance Agreement (2013/ /15) Page 31 of 39 May 15, 2013

46 c) Report on the performance of the local health system on all performance indicators in the LHIN Annual Report. Objective: To enhance person-centred care Table 1: Performance Indicators Expected Outcome: Persons will experience improved access to healthcare services identified below in alignment with best practices. INDICATOR Provincial target LHIN Baseline LHIN Target th Percentile Emergency Room (ER) Length 8 hours of Stay for Admitted Patients 90th Percentile ER Length of Stay for Non- 8 hours Admitted Complex (CTAS I-III) Patients 90th Percentile ER Length of Stay for Non- 4 hours Admitted Minor Uncomplicated (CTAS IV-V) Patients Percent of Priority IV Cases Completed Priority IV: 84 days Within Access Target for Cancer Surgery * Percent of Priority IV Cases Completed Priority IV: 90 days Within Access Target for Cardiac By-Pass Procedures * Percent of Priority IV Cased Completed Priority IV: 182 Within Access Target for Cataract Surgery * days Percent of Priority IV Cases Completed Priority IV: 182 Within Access Targets for Hip Replacement * days Percent of Priority IV Cases Completed Priority IV : 182 Within Access Target for Knee Replacement * days Percent of Priority IV Cases Completed Priority IV : 28 days Within Access Target for MRI Scan * Percent of Priority IV Cases Completed Priority IV : 28 days Within Access Target for Diagnostic CT Scan* * The reporting for these indicators has been revised starting 2013/14. Previous Agreements included the 90 th percentile wait time for these surgical and diagnostic imaging services DRAFT Ministry-LHIN Performance Agreement (2013/ /15) Page 32 of 39 May 15, 2013

47 Table 2: Performance Indicators Objective: To improve system integration and enhance coordination of care while ensuring better transitions to various care settings. Expected Outcome: Persons will be able to navigate the healthcare system and receive the care they need, when and where they need it. INDICATOR Provincial target LHIN Baseline LHIN Target Percentage of Alternate Level of Care (ALC) 9.46% Days 90th Percentile Wait Time from Community To be determined for CCAC In-Home Services Application (TBD) from Community Setting to first CCAC Service (excluding case management) Wait Time from When CCAC Receives (TBD) Application to Long Term Care Home to When Assessment for Eligibility is Completed * * New indicator for 2013/14. The MOHLTC and the LHINs will monitor performance in 2013/14 and work together to refine quality and consistency of data. Targets will be established starting 2014/15. Table 3: Performance Indicators Objective: To implement evidence based practice to drive quality and value and improve health outcomes Expected Outcome: Persons will receive quality inpatient care and coordinated post-discharge care, leading to reduced readmission rates that may improve survival, quality of life and other outcomes without increasing cost. INDICATOR Provincial target LHIN Baseline Readmissions within 30 days for Selected TBD CMGs Repeat Unscheduled Emergency Visits within TBD 30 days for Mental Health Conditions ** Repeat Unscheduled Emergency Visits within TBD 30 days for Substance Abuse Conditions ** ** The methodology for these indicators has been revised starting 2013/14. Results may not be comparable to the previous Agreement. LHIN Target DRAFT Ministry-LHIN Performance Agreement (2013/ /15) Page 33 of 39 May 15, 2013

48 General Obligations 1. The MOHLTC will: SCHEDULE 6: INTEGRATED REPORTING a) Provide any necessary training, instructions, materials, data, templates, forms, and guidelines to the LHIN to assist with the completion of the reports listed in Table 1; and b) As required, develop reporting requirements relating to government priorities and notify the LHIN of the requirements; 2. Both parties will: a) Work together to ensure a timely flow of information, including financial records, to fulfill the reporting requirements of both parties; b) Finalize the Annual Business Plan within 120 days of a budget announcement by the Government of Ontario as part of the annual review set out in Schedule 1: General. DRAFT Ministry-LHIN Performance Agreement (2013/ /15) Page 34 of 39 May 15, 2013

49 Table 1: MOHLTC and LHIN Reporting Obligations (2013/14) Due Date April 16, 2013 April 30, 2013 April 30, 2013 April 30, 2013 May 13, 2013 May 14, 2013 May 17, 2013 May 31, 2013 June 3, 2013 On or about the 7 th working day (date may depending on the IFIS GL close) June 28, 2013 June 28, 2013 June 28, 2013 July 31,2013 July 31,2013 August 12, 2013 August 15, 2013 Description of Item 2013/2014 APRIL MOHLTC will provide to the LHIN a Year End Report confirming the expenditures and revenue related to its transfer payments as of March 31 of the preceding fiscal year MOHLTC will provide to the LHIN the forms for the Year-end Consolidation Report The LHIN will submit to the MOHLTC a Quarterly Expense Report using the forms provided by the MOHLTC The LHIN will submit to the MOHLTC an Attestation as required under the Broader Public Sector Accountability Act (BPSAA) MAY MOHLTC will provide the LHIN with the most recent quarter of data for indicators in Schedule 5: Local Health System Performance MOHLTC will provide to the LHIN a Year End Report with updated expenditures and revenue related to its transfer payments as of March 31 of the preceding fiscal year The MOHLTC will provide to the LHIN for planning and reporting purposes the initial preliminary allocation for The LHIN will submit to the MOHLTC the year-end consolidation report using forms provided by the MOHLTC and the draft Audited Financial Statement if the signed statements are not ready by May 31 of each fiscal year to which this agreement applies JUNE The LHIN will submit to the MOHLTC a report on performance indicators using the forms provided by the MOHLTC MOHLTC will make the expenditure and revenue report available to the LHIN in APTS for the LHIN s review The LHIN will submit to the MOHLTC Q1 Regular and Consolidation Report using the forms provided by the MOHLTC The LHIN will submit to the MOHLTC an Annual Report for the previous fiscal year in accordance with MOHLTC requirements The LHIN will submit to the MOHLTC a Board approved report on consultant use for the previous fiscal year using the template provided in the Minister s Directive under the BPSAA JULY The LHINs will submit to the MOHLTC a Quarterly Expense Report using the forms provided by the MOHLTC The LHIN will submit to the MOHLTC an Attestation as required under the BPSAA AUGUST The MOHLTC will provide to the LHIN the most recent quarter of performance data for indicators in Schedule 5: Local Health System Management The MOHLTC will provide the preliminary approved allocation for the current fiscal year, as of July 31, 2013 DRAFT Ministry-LHIN Performance Agreement (2013/ /15) Page 35 of 39 May 15, 2013

50 Due Date August 30, 2013 September 3, 2013 On or about the 7 th working day (date may vary on IFIS GL close) September 30, 2013 September 30, 2013 October 31, 2013 (or date necessary to meet central agency reporting requirements) By October 31, 2013 October 31, 2013 November 12, 2013 December 2, 2013 On or about the 7 th working day (date may vary depending on the IFIS GL close) December 31, 2013 January 31, 2014 By January 31, 2014 January 31, 2014 February 10, 2014 February 14, 2014 March 3, 2014 Description of Item MOHLTC will provide to the LHIN the forms and information requirements for the Multi-year Consolidation Report SEPTEMBER The LHIN will submit to the MOHLTC a report on performance indicators using the forms provided by the MOHLTC The MOHLTC will make the expenditure and revenue report available to the LHIN in APTS for the LHIN s review The LHIN will submit to the MOHLTC Q2 Regular and Consolidation Report using the forms provided by the MOHLTC The MOHLTC will provide to the LHIN the forms and information requirements for the 2014/15 Annual Business Plan OCTOBER The LHIN will submit to the MOHLTC a Multi-year Consolidation Report using the form provided by the MOHLTC The LHIN will submit to the MOHLTC an Attestation as required under the BPSAA The LHINs will submit to the MOHLTC a Quarterly Expense Report using the forms provided by the MOHLTC NOVEMBER MOHLTC will provide to the LHIN the most recent quarter of performance data for indicators in Schedule 5: Local Health System Management DECEMBER The LHIN will submit to the MOHLTC a report on performance indicators using the forms provided by the MOHLTC The MOHLTC will make the expenditure and revenue report available to the LHIN in APTS for the LHIN s review LHIN will submit to the MOHLTC Q3 Regular and Consolidation Report including final year-end forecast using the forms provided by the MOHLTC JANUARY MOHLTC will provide the LHIN with year-end instructions (including templates) The LHIN will submit to the MOHLTC an Attestation required under the BPSAA The LHINs will submit to the MOHLTC a Quarterly Expense Report using the forms provided by the MOHLTC FEBRUARY MOHLTC will provide the LHIN with most recent quarter of performance data for indicators in Schedule 5: Local Health System Performance MOHLTC will provide to the LHIN the forms and requirements for the Annual Report (non-financial content) MARCH The LHIN will submit to the MOHLTC a report on performance indicators using the forms provided by the MOHLTC DRAFT Ministry-LHIN Performance Agreement (2013/ /15) Page 36 of 39 May 15, 2013

51 Due Date March 28, 2014 March 31, 2014 April 15, 2014 April 15, 2014 April 30, 2014 By April 30, 2014 April 30, 2014 May 12, 2014 May 13, 2014 May 16, 2014 May 30, 2014 June 2, 2014 On or about the 7 th working day (date may vary depending on the IFIS GL close) June 30, 2014 June 30, 2014 June 30, 2014 July 31,2014 July 31,2014 Description of Item MOHLTC will provide to the LHIN the forms for the Annual Report (financial content) The LHIN will submit to the MOHLTC a Draft 2014/15 Annual Business Plan using the forms provided by the MOHLTC 2014/2015 APRIL MOHLTC will provide to the LHIN a Year End Report confirming the expenditures and revenue related to its transfer payments as of March 31 of the preceding fiscal year The LHIN will submit to the MOHLTC Year End Reallocation Report on actual expenditures related to in-year reallocations as of March 31 of the preceding fiscal year MOHLTC will provide to the LHIN the forms for the Year-end Consolidation Report The LHIN will submit to the MOHLTC an Attestation as required under the BPSAA The LHINs will submit to the MOHLTC a Expense Report using the forms provided by the MOHLTC MAY The MOHLTC will provide to the LHIN the most recent quarter of performance data for indicators in Schedule 5: Local Health System Performance MOHLTC will provide to the LHIN a Year End Report with updated expenditures and revenue related to its transfer payments as of March 31, of the preceding fiscal year The MOHLTC will provide to the LHIN for planning and reporting purposes the initial preliminary allocation for The LHIN will submit to the MOHLTC the year-end consolidation report using forms provided by the MOHLTC and the draft Audited Financial Statement if the signed statements are not ready by May 31 of each fiscal year to which this agreement applies JUNE The LHIN will submit to the MOHLTC a report on performance indicators using the forms provided by the MOHLTC The MOHLTC will make the expenditure and revenue report available to the LHIN is APTS for the LHIN s review The LHIN will submit to the MOHLTC Q1 Regular and Consolidation Report using the forms provided by the MOHLTC The LHIN will submit to the MOHLTC an Annual Report for the previous fiscal year in accordance with MOHLTC requirements The LHIN will submit to the MOHLTC a Board approved report on consultant use for the previous fiscal year using the template provided in the Minister s Directive under the BPSAA JULY The LHINs will submit to the MOHLTC a Quarterly Expense Report using the forms provided by the MOHLTC The LHIN will submit to the MOHLTC an Attestation as required under the BPSAA DRAFT Ministry-LHIN Performance Agreement (2013/ /15) Page 37 of 39 May 15, 2013

52 Due Date August 12, 2014 August 15, 2014 August 29, 2014 September 2, 2014 On or about the 7 th working day (date may vary on IFIS GL close) September 30, 2014 September 30, 2014 October 31, 2014 (or date necessary to meet central agency reporting requirements) By October 31, 2014 October 31, 2014 November 12, 2014 December 2, 2014 On or about the 7 th working day (date may vary depending on the IFIS GL close) December 31, 2014 January 30, 2015 By January 30, 2015 January 30, 2015 February 10, 2015 Description of Item AUGUST The MOHLTC will provide to the LHIN the most recent quarter of performance data for indicators in Schedule 5: Local Health System Management The MOHLTC will provide the preliminary approved allocation for the current fiscal year, as of July 31, 2014 MOHLTC will provide to the LHIN the forms and information requirements for the Multi-year Consolidation Report SEPTEMBER The LHIN will submit to the MOHLTC a report on performance indicators using the forms provided by the MOHLTC The MOHLTC will make the expenditure and revenue report available to the LHIN in APTS for the LHIN s review The LHIN will submit to the MOHLTC Q2 Regular and Consolidation Report using the forms provided by the MOHLTC The MOHLTC will provide to the LHIN the forms and information requirements for the 2014/15 Annual Business Plan OCTOBER The LHIN will submit to the MOHLTC a Multi-year Consolidation Report using the form provided by the MOHLTC The LHIN will submit to the MOHLTC an Attestation as required under the BPSAA The LHINs will submit to the MOHLTC a Quarterly Expense Report using the forms provided by the MOHLTC NOVEMBER MOHLTC will provide to the LHIN the most recent quarter of performance data for indicators in Schedule 5: Local Health System Management DECEMBER The LHIN will submit to the MOHLTC a report on performance indicators using the forms provided by the MOHLTC The MOHLTC will make the expenditure and revenue report available to the LHIN in APTS for the LHIN s review LHIN will submit to the MOHLTC Q3 Regular and Consolidation Report including final year-end forecast using the forms provided by the MOHLTC JANUARY MOHLTC will provide the LHIN with year-end instructions (including templates) The LHIN will submit to the MOHLTC an Attestation required under the BPSAA The LHINs will submit to the MOHLTC a Quarterly Expense Report using the forms provided by the MOHLTC FEBRUARY MOHLTC will provide the LHIN with most recent quarter of performance data for indicators in Schedule 5: Local Health System Performance DRAFT Ministry-LHIN Performance Agreement (2013/ /15) Page 38 of 39 May 15, 2013

53 Due Date February 13, 2015 March 3, 2015 March 27, 2015 March 31, 2015 Description of Item MOHLTC will provide to the LHIN the forms and requirements for the Annual Report (non-financial content) MARCH The LHIN will submit to the MOHLTC a report on performance indicators using the forms provided by the MOHLTC MOHLTC will provide to the LHIN the forms for the Annual Report (financial content) The LHIN will submit to the MOHLTC a Draft 2015/16 Annual Business Plan using the forms provided by the MOHLTC DRAFT Ministry-LHIN Performance Agreement (2013/ /15) Page 39 of 39 May 15, 2013

54 1 60 Renfrew Drive, Suite 300 Markham, ON L3R 0E1 Tel: Fax: Toll Free: Date: September From: Judy Cameron, Chair, Audit Committee Audit Committee Summary Report to Board of Directors ITEM Report of the Audit Committee, which met on Thursday, August 22, ITEMS FOR APPROVAL Forecast for LHIN Operations K. Dschankilic presented the updated forecast for LHIN Operations. The budget has been updated to reflect new monies the LHIN will receive on a one-time basis this fiscal year in support of the implementation of Physiotherapy Reform ($27,344), as well as some changes in expense line items for staffing, consulting, software, meeting expenses, and LSSO. A copy of the Audit Committee briefing note is attached in the consent agenda under items for approval. ITEMS FOR INFORMATION New Statutory or Regulatory Updates K. Dschankilic informed the committee that Management Board of Cabinet has updated the Realty Directive and two companion policies relating to realty and space accommodation. At the request of LHIN CEOs, a LHIN working group, led by Central LHIN, has been formed to determine the impact of this Directive and any actions that the LHINs must take to ensure compliance with the Directive. The Audit Committee will be kept apprised of any issues that may arise from the working group. K. Dschankilic also informed the committee that LHINs are now designated a public body under the Archives and Record Keeping Act, and have two years to become fully compliant. The CEOs have requested a report on impact of the Act and a work plan for LHINs to be in compliance by the required timeline. The committee will be updated with any issues as the LHINs work through the implementation of the Act. Audit Committee Work Plan The Committee approved its work plan at the August meeting. A copy is attached to this report for your information. Page 1

55 2 60 Renfrew Drive, Suite 300 Markham, ON L3R 0E1 Tel: Fax: Toll Free: Risk Management A Risk Management Framework was also presented for discussion purposes and is attached for your review and comment. The framework will be discussed further at the October Board Retreat and will be presented to the Board for approval at the October Board meeting. K. Dschankilic presented the Q1 Risk Report (quarterly ministry submission). A copy of the report is attached in closed session materials. STANDING ITEMS Board Chair s expenses were approved as presented. The Q1 Compliance Declaration that was sent to the Ministry in July was presented for information. There is one issue with non-compliance amongst all LHINs relating to our insurance provider. The Ministry is aware and TC LHIN, on behalf of all the LHINs, is working with the ministry to bring this item to resolution. The Q1 Report on the Use of Consultants was received with no issues noted. Page 2

56 ITEM RISK MANAGEMENT FRAMEWORK 1

57 Executive Summary Enterprise risk management (ERM) is a strategic risk management framework across an organization that includes exercising effective risk governance, establishing risk management roles and responsibilities and implementing t risk management processes. It encompasses the methods and processes used by organizations to manage risks related to the achievement of their objectives. ERM may also be described as a risk-based approach to managing an organization that integrates strategic planning, operations management, and internal control. Effective risk management should not be premised on risk avoidance. Every organization is exposed to and takes risks daily. What is important is to manage the balance of risk and reward and to identify and minimize the consequences of a negative occurrence to the extent possible. A typical ERM framework guides management on how to: identify particular adverse events or circumstances relevant to the organization's objectives assess the likelihood and magnitude of impact determine a response or mitigation strategy monitor progress. The primary objective of enterprise risk management at Central LHIN is to improve performance and increase stakeholder value. Board Approach to Organization Risk Management Traditional governance models support the notion that boards should not be involved in day-to-day risk management. Rather, through their risk oversight role, directors should be able to satisfy themselves that effective risk management processes are in place and functioning effectively. The risk management system should allow management to bring to the board s attention the organization s material risks and assist the board to understand and evaluate how these risks interrelate, how they may affect the organization, and how these risks are being managed. The board's role is similar in some ways to the role of the audit committee. The audit committee does not prepare financial statements or maintain the system of internal control. Rather, the audit committee bears responsibility for overseeing the financial reporting and related internal control processes. Successful board oversight processes requires board confidence in management, access to relevant and reliable information and effective functioning of a board overall. Boards of directors provide oversight on identifying, assessing and to the extent possible mitigating organization risk. Boards are thus expected to provide an oversight role of the risk management systems and processes as well as reviewing both the planning and outcomes of such processes; however, there are certain circumstances in which boards must take a leadership role in assessing risk. Risks associated with leadership and strategy are examples of areas where a board must be involved more directly since management cannot be expected to objectively assess its own performance, capabilities and strategy from a risk perspective. For example, a primary risk might be an ill-advised strategy or a failure to execute strategy. Management may not be able to critically evaluate the very strategy it developed or objectively assess its ability to execute. 2

58 Enterprise Risk Management at Central LHIN will be a board agenda item twice a year. The Central LHIN board as a whole has taken on the responsibility for addressing risk; however overseeing financial risk has been included in the Audit Committee Terms of Reference as a specific mandate. Questions for directors to ask: Does the board clearly understand its oversight mandate and role? Is the board sufficiently active in fulfilling this part of its mandate? Do the directors share a common, practical understanding of their responsibility and objectives for risk oversight? Do board members understand that the most likely outcome of ineffective risk management is underperformance and the deterioration of stakeholder value? Does the board have the necessary blend of business and industry knowledge and experience to assess risk? Management Approach to Organization Risk Management The chief executive officer bears overall accountability for setting LHIN strategy and managing organization risk. Within this context, management develops and the Board approves the LHIN s Integrated Health Service Plan (IHSP). The IHSP maps future direction, and sets out specific plans to achieve the objectives. Since strategy ultimately involves choices, risks are inherent in the IHSP. It is management s responsibility to evaluate and adequately balance risk with reward. Questions for directors to ask: Does the board assess the IHSP in terms of its potential failure and the resulting consequences? Does the board understand and discuss the linkages between strategy and risk? Do board members have an appreciation of the nature, types and sources of risks faced by the organization? Does the board periodically consider the organization's capability to take on and manage risk? Does the board understand the differences between risk capacity, risk tolerance and risk appetite and are they documented? Does the board consciously assess risk and reward when making decisions? Does the board have a framework and tools to assist it to understand the consequences of strategic risk? Risk reporting Management provides the board of directors and the Audit Committee with regular performance reports, Ministry reporting submissions, the IHSP and the annual business plan. The Ministry reports include an annual comprehensive organizational risk assessment and specified risk reports twice a year. Questions for directors to ask: Does the board receive comprehensive reports on risk? Is this information sufficient to make well-reasoned judgments about risk and risk management? 3

59 Management has recommended to the Audit Committee that the Central LHIN implement an ERM framework which will incorporate the Ministry risk tools and augment these when they are not sufficient for management and board purposes. Questions for directors to ask: Does management have a robust framework and comprehensive process to assess risk? Are risk management processes or systems well designed such that risk is managed holistically and not in silos? Does the organization have adequate systems and processes in place to monitor the effectiveness of risk management? Do the board and management learn from and act on instances where risk management strategies and systems have been ineffective? Interrelationships and compounding effect of risks Organization under performance may result from many factors occurring simultaneously. Questions for directors to ask: Does management understand the interconnectivity and interdependencies of risks? Does the board recognize that the organization may have several embedded exposures so that even relatively minor risks can produce unfavourable consequences? Are risk interrelationships ignored because the likelihood of a negative occurrence is deemed remote? Does the board have an adequate framework to understand the interrelationships, interdependencies and compounding effect of risks? Does the board understand the interdependencies and how events or conditions occurring simultaneously may cause organizational stress? Are seemingly unthinkable business risks ignored because their occurrence is thought to be unlikely? 4

60 Risk Management Framework Overview The following eight-step process to be deployed at Central LHIN identifies and addresses critical risks, analyzes the interconnectivity of risks and the potential compounding effect of unfavourable events occurring simultaneously. It serves to document the LHIN s tolerance and appetite for risk in planned and unplanned activities and events and guides development of their response or mitigation strategy. I. Establish context - Understand current conditions in which the Central LHIN operates from an internal, external and risk management perspective II. Identify risks - Document material threats to the Central LHIN s achievement of its objectives Ill. Analyze consequences - Quantify the impact of the risk and likelihood of occurrence IV. Analyze interconnectivities and compounding effects - Aggregate risks and understand relationships, interdependencies, and the compounding effect of simultaneous occurrences V. Prioritize Rank risks in order of importance, blending severity with likelihood of occurrence and potential for mitigation VI. Assess Risk Capacity, Tolerance and Risk Appetite - Determine the entity's capability, tolerance and appetite for potential consequences of risk VII. Choose Response Strategy - Develop plans to avoid, reduce or control, share or insure, accept, or, in certain cases, potentially exploit risks VIII. Monitor - Continually measure and monitor the risk environment and the performance of the risk management strategies 5

61 Definitions of key terms and concepts 1. Risk severity or impact It is important to separate the analysis of the severity of the exposure from the likelihood of occurrence. The severity of risks should first be ranked in order of impact without regard to possible occurrence, thus capturing material risks before probability discounting. This helps ensure that potential major risks are not prematurely dismissed. Impacts are as follows: a. Low or Minor Risks - No material effect on the organization. Slightly impairs the achievement of objectives. Low risks include customary operational risks, such as health, safety and environment and facility or system disruption, and other risks where the potential adverse effect on the organization is moderate or has been offloaded such as through an insurance program or other means. b. Medium or Moderate Risks - Could affect results and performance but not severely. Partially prevents the achievement of objectives. c. High Risks - Results in a significant degradation in performance. Prevents achievement of objectives. Medium and high risks fall into two categories: 1. high-impact risks that cannot be adequately mitigated 2. risks involving the presence of management bias. For medium and high risks, the board would work closely with management to understand, quantify, prioritize, mitigate and monitor such risks. For medium and high risks involving potential management bias, board involvement would expand to fully understanding the underlying facts and assumptions and how the risk might be quantified, validated and monitored. For example, strategic risk would fall into this category since management developed and was committed to execute the strategy and would have difficulty objectively assessing its viability and associated risks. Assessing the CEO's performance, capability and suitability would also fall in this category. 2. Likelihood of occurrence Risks should be classified by the probability that the event of condition will materialize. a. Low Likelihood A slight likelihood of occurrence (0-39%) b. Medium Likelihood Occurrence is a real possibility. May have occurred in the past. (40-79%) c. High Likelihood - It is very likely that this event will occur within the time horizon (80-99%) 3. Risk Tolerance a. Low tolerance no variance from objective is acceptable. b. Medium tolerance some variance from objective is acceptable c. High tolerance variance from objective will be tolerated 6

62 4. Risk Management Capability a. High capability people, processes and systems are in place to manage the risk b. Medium capability some of the elements are in place to manage the risk c. Low capability the ability to manage the risk does not currently exist 5. Risk parameters The risk parameters are any event or condition that could materially affect short-term or long-term performance or cause material destruction of asset or stakeholder value. A robust risk management process and establishing appropriate risk parameters to include potential occurrences that could affect long term performance or the decline of stakeholder value has the benefit of improved organization performance. 7

63 I. Central LHIN Context LHINs are designed to plan, integrate and fund local health services including hospitals, community care access centres, home care, long-term care, mental health, community health centres and addiction and community support services. The geographically based networks allow local communities and health care providers to work together to identify local priorities and plan and deliver local health services in a coordinated fashion. Politico-Legal LHINs are not providers of direct services. LHINs are Crown Agencies and non-profit organizations. The LHIN environment is such that in the minds of taxpayers the actions of health service providers may be directly attributable to the LHIN. Outcomes of public policy objectives are difficult to measure yet LHINs may be criticized for health service delivery by opposing political opposition parties in public. Local MPPs may try to exert influence or demand actions from the LHIN. The LHIN operates in an environment of high transparency. Board meetings are open to the public. This may inhibit full and frank discussion at the public board meetings. In addition, LHIN documents are subject to the Freedom of Information Act so the LHIN must act with care to protect its reputational risk. Processes such as the sunshine list and public posting of expenses have been developed to inform the public how the government spends taxpayer dollars. Business or other issues regarding the LHIN and its health service providers may be found in the front pages of a newspaper. Since LHINs were first announced in September 2004 by George Smitherman, Minister of Health and Long Term Care, the health care sector has become increasingly regulated. The Ministry of Health which has ultimate responsibility for providing Ontarians with high quality health care services issues many Directives for both LHIN and health service provider compliance. The LHIN s must comply with these Directives, and monitor and deal with health service provider compliance or non-compliance. Without a direct line of accountability between health services providers and LHINs, this sometimes proves to be a difficult task. Economic The Central LHIN s audited Financial Statements include transfer payments to health service providers for approximately $1.8 billion. The LHIN approves health service provider funding and spending and is expected to ensure that value for money is received. The LHINs are subject to audits on the management of transfer payments by both the Health Services Audit Team and the Provincial Auditor. The LHIN must demonstrate appropriate procedures, evidence of monitoring and appropriate receipt of services. When spending taxpayer dollars providers must balance fiscal efficiency with public policy objectives. This involves ethical decision making as demand for healthcare services is almost unlimited while financial sustainability is an ongoing challenge in the current fiscal environment. While there are a plethora of indicators and activity reports published for the hospital sector which assist the LHIN in provider performance evaluation, the community sector is only emergent in its sophistication. Traditional measures such as return on investment or market share do not apply. The LHIN s operational funding is relatively low at approximately $5 million. 8

64 II. Identify and Categorize Risks Central LHIN Category Ministry Equivalent How Reported 1. Strategic risk: selection of ineffective strategies MLPA commitments Stocktake Strategic/Policy/Performance Annual Risk Report 2. Financial risk: liquidity Balanced Budget Quarterly Risk Summary 3. Organizational risk: leadership depth and quality management and labour availability and cost, cultural alignment 4. Operational risk: stakeholder dissatisfaction LHIN service failure LHIN service quality capacity constraints dependency on health service providers dependency on government funding 5. External risk: Provincial deficit Government party changes 6. Hazardous risk: liability torts property damage natural catastrophe environmental Workforce Compensation Accountability/Governance Accounting/Controllership Strategic/Policy/Performance I/T and Infrastrucure Capital projects Utilization / Workload Strategic / Policy Information technology Capital project delays Political commitment No equivalent for government party changes Other Accountability/Governance Annual Risk Report Quarterly Risk Summary Annual Risk Report Quarterly Risk Report Annual Risk Report Annual Risk Report Annual Risk Report Quarterly Risk Summary Quarterly Risk Summary Quarterly Risk Summary Quarterly Risk Summary LSSO report (future) Quarterly Risk Summary Quarterly Risk Summary Annual Risk Report Annual Risk Report 7. Compliance risk: compliance with applicable laws and regulations 8. Reputational risk: consequences of acts, events and perceptions Legal / Contractual Quarterly Risk Summary Quarterly Compliance Declarations Strategic Annual Risk Report 9

65 1. Strategic Risk The primary risks associated with strategy stem from the selection of strategies that are inappropriate in the circumstances, the organization's inability to execute its strategy, and the timeliness of implementation. Poor strategy formulation or execution can cause underperformance. Strategic risk at Central LHIN may be defined as the risk of not having an accurate strategic perspective on the healthcare problems at hand. This translates to the risk of failing to achieve impact given the investment made. The Central LHIN follows the guidelines for strategy development set out by the Ministry of Health through the IHSP process. The facts that form the basis for the Central LHIN strategy were largely pulled from the environmental scan that was prepared by the Ministry of Health on behalf of all LHINs. The LHIN also prepares an Annual Business Plan which lays out the execution strategy to achieve the goals in the IHSP, over a three year period. The Ministry and the Board approve the LHIN s IHSP and ABP. Analysis and benchmarking to set strategy Effective analysis should adhere to the following three principles: 1. The analysis should measure performance against the critical factors that make LHINs successful in healthcare (the "organization drivers"). 2. The analysis should be data-driven and fact-based. 3. The interpretation should be as objective and unbiased as possible. Benchmarking against other LHINs is useful to understand why differences arise. For example, why does another LHIN produce consistently better ALC results? Factors could include superior health service providers, breadth of programs, health service provider cost structure, and funding strategy. Board feedback opportunity Central LHIN management provides the board with an outline of the proposed final IHSP, its sources and the approach to data gathering and analysis, and key assumption requirements, as required by the Ministry. This ensures there are no surprises for management or the board on the day of presentation. The board is given the opportunity to provide feedback to management in advance of the final IHSP being submitted to the Ministry. Through this process, board members can identify areas where further analysis or clarification is required, where strategies may be misaligned with goals, or underlying assumptions appear to be too optimistic, pessimistic or invalid. Management incorporates the boards feedback and modifies the IHSP accordingly before submission to the Ministry. Post-strategy presentation risk assessment It may be helpful to schedule a risk review session following the strategy presentation so the Board and management can reflect on strategy solely from a risk perspective and set aside sufficient time for discussion. 2. Financial Risk Financial risk at Central LHIN has been defined as insufficient cash flow to finance operations. The LHIN has no ability to generate cash flow independent from the Ministry and must therefore finance all expenses and expenditures within the Ministry funding allocation. It is not acceptable to the Ministry for the LHIN to not balance the budget and the Ministry will not entertain requests for additional funding. 10

66 3. Organizational Risk Organizational risk spans leadership quality and depth, management and staff performance, retention and availability, organizational cost and cultural alignment. Ineffective leadership may pose the greatest organizational risk to the organization. Leadership has been defined to encompass the board, chief executive officer (CEO) and senior directors of the LHIN. In addressing this risk, the board has direct responsibility for selecting and assessing the performance and capability of the CEO and, to a certain degree, the senior directors. Assessing the capability of management to develop and execute the IHSP and operate the daily organization goes beyond financial performance and operational metrics. The Board must assess executive performance on qualitative measures and competencies including strategic capability, talent acquisition and retention, the ability to motivate and align staff with a positive culture, and exercise of good judgment, particularly in risk/reward situations. The depth and breadth of talent can be a major source of organizational advantage, but it also poses risks if there is cultural misalignment or high voluntary turnover rates among top performers. Leadership assessment The chief executive officer's capability and performance is critical to the success of the LHIN and also pose significant risk. The board will undertake an annual review of the CEO's performance, focusing on and assessing periodic results of the LHIN and the CEO's performance against specific annual objectives. In addition, the board will periodically review the CEO against other measures including capability and suitability. In evaluating these qualities, it is important to establish appropriate criteria, including the criteria that the board would use to hire for that position at that point in time. This would involve first understanding the critical requirements and challenges of the position. In that context, the board would then assess relevant skills and capabilities such as leadership, talent attraction, team building, strategy, internal and external communications, track record, judgment, foresight and risk management. The review of a CEO's suitability will assess his or her strengths in terms of the organization's future and related leadership requirements. Given that the board's exposure to the CEO through the year is limited primarily to a boardroom environment, an important source of input will be from the chair of the board, who typically has more interaction with the CEO between meetings. Tone at the top The term "tone at the top" is often used in connection with the internal control environment. It equally can be applied to assess the leadership team's tolerance and prudence in managing risk. A board may ask itself if the organization's executives are appropriately balancing risk with reward and acting prudently in higher-risk situations. Capability of risk management staff and ERM system The board should periodically assess the strengths, depth and independence of staff involved in managing dayto-day risks and the maturity and robustness of the risk management system and processes. Resource limitations, ad hoc risk management systems, and absence of defined accountabilities should heighten board concern. 11

67 Talent review versus succession planning The board will conduct periodic succession planning reviews to assess management continuity issues at the senior level. The succession planning analysis will identify potential successors in terms of capability. The timeline for readiness to move into more senior positions is restricted by the Ministry s policy on the cost of the executive office and the LHIN s budget. Succession planning at the LHIN is regarded as a useful tool to map and prepare for future organizational changes. 4. Operational Risk Operational risks are typically broad and often unique to each organization. Operational risks at Central LHIN include: stakeholder dissatisfaction LHIN service quality LHIN capacity constraints potential prolonged disruption at the LHIN offices or with computer systems and networks shared services dependencies Determining which operational risks are critical requires mapping the strategic drivers of the organization. Operational risk often involves failure to execute rather than selection of a flawed strategy. The board will focus risk assessment on those operational elements that represent strategic and operational concerns that are critical to the success of the LHIN. Stakeholder satisfaction Stakeholder interviews can provide excellent insight into the effectiveness of an organization's strategy and pinpoint operational issues, including LHIN service quality and perceived value for money. Capacity constraint analysis Central LHIN may face capacity limitations that could create a performance risk. It is helpful to review capacity utilization and constraint analyses to identify capacity limitations, the reason for capacity constraints (such as buildings, equipment and labour) and the requirements and timeline for alleviating such constraints. 5. External Risk Structural or cyclical changes within the healthcare sector can create high-risk situations. The LHIN must be vigilant in early identification of changes in the external environment including transformative macroeconomic or healthcare-specific forces that could significantly alter the LHIN's performance, trajectory, or peer position. Industry changes Many industries are subject to cyclicality that arises from macroeconomic factors or industry specific behaviours. The LHIN is influenced by provincial elections and the fiscal policy. In times of fiscal restraint, the LHIN should understand the dynamics of contraction (such as capacity management) and maintain clarity on the LHIN's strategy to sustain itself through tough periods. This strategy should address management's capability and ability to foresee a fiscal downturn, its proactive plan to reduce capacity and costs without impairing its performance. 12

68 As healthcare undergoes macroeconomic shocks or industry-specific transformational events, the LHIN should be cognizant that the strategic drivers and dynamics may require a significant change in fundamental strategy. 6. Hazardous risk Hazardous risks pose threats to property, environment or health. Hazardous risk by its nature is difficult to predict and may never occur. However, a hazardous incident can create an emergency situation with far-reaching financial impact and other implications. These risks have been grouped into three categories: 1. Natural disasters - largely unpredictable hazards that can pose risks to property, the environment and health. 2. Environmental risk - adverse effects on the environment arising from emissions, effluents, wastes and resource depletion which unlike natural disasters may be preventable 3. Occupational health and safety - equipment operation and transportation accidents, workplace violence, communicable diseases, slips and falls, toxic exposure, particularly to chemical and gas, electrocution or explosion, repetitive motion and ergonomic injuries, and hearing loss The consequences of hazardous occurrences generally involve property loss or tangible asset value destruction, third party damages often involving litigation, regulator-imposed sanctions or penalties, and reputational damage. The LHIN shared Services Organization (LSSO) has developed an information technology disaster recovery plan for all LHINs, which will be reviewed by management. Central LHIN is underway in developing a business continuity plan. 7. Compliance risk Compliance risk covers all of the LHIN s exposure to breach of laws, regulations and ethics/codes of conduct. At Central LHIN the Board retains oversight and the Audit Committee reviews and obtains reasonable assurance with respect to compliance risk. This includes reporting, employment, compensation, and related matters. Code of conduct breaches or acts of fraud, particularly those involving senior executives, can expose the LHIN and individuals to well-publicized legal liability. The consequences of a compliance failure may fall into three categories. 1. specific penalties and other sanctions for violating specific laws and secondary regulations 2. claims from affected parties such as stakeholders or other claimants seeking damage claims and potentially leading to costly litigation 3. damage or loss of reputation that can significantly affect stakeholder value and create adverse consequences for residents, employees and/or other stakeholders. 8. Reputational risk An organization's reputation is a valuable intangible asset that falls within the board's broader responsibility for safeguarding the organization's assets. Reputational risk can be defined as a separate risk or, as the negative consequence of the occurrence of other risks. Loss of reputation can greatly affect stakeholder value. Reputation refers to the perception of the LHIN by various stakeholders such as residents, employees, health service providers, and government officials. Perceptions may differ among stakeholders and could be at odds with how the LHIN views itself. For example, the LHIN may have a positive reputation with government officials but may be perceived negatively by its employees because of its high performance culture and demanding work environment. 13

69 Reputation is also dynamic and stakeholder perceptions may shift for various reasons including specific adverse occurrences, unfavourable media coverage, and changes or actions of the organization's leadership. Factors that can adversely affect the LHIN s reputation include: health service quality relationship with health service providers employee opinion relationship with government officials compliance (including breach of ethics) The loss of reputation arising from a specific occurrence may have a much greater impact on stakeholder value and long-lasting collateral damage than the occurrence itself. Additionally, depending on the nature and size of the adverse occurrence, the level of effort to rebuild a tainted reputation can be enormous. From a reputational risk oversight perspective, boards may focus on three broad areas: a. identifying potential occurrences that could materially impact the organization's reputation b. oversight of response strategy, including crisis and related communication planning c. ongoing monitoring of potential triggering events and preventive measures and processes to address root causes. Ill Analyze Consequences Consequential analysis of risks may involve three dimensions: 1. Quantifying the severity of the impact on the organization 2. Assessing the likelihood or probability of occurrence 3. Determining the extent such risks can be mitigated through various response strategies Heat mapping Central LHIN uses heat mapping to pictorially prioritize risk along the lines of severity, likelihood and residual risk. This colour-coded model enables focus on critical areas of risk. Categorizing and ranking risks requires subjectivity and judgment. Ranking the top five or six risks in a particular order of importance is not as critical as ensuring they are identified and addressed. IV Analyze lnterconnectivities and Compounding Effects Interrelationships and compounding effect of risks Significant under performance may be due to the compounding effect of multiple simultaneous occurrences that fall into three broad scenarios: 14

70 1. The compounding effect of interconnected risks 2. The compounding effect of unrelated occurrences that arise at the same time 3. The effect of a single event combined with several higher-risk conditions that have been present for a considerable period. A difficult element in managing risk is evaluating the interconnectivity of risks and the compounding exposure when two or more occurrences take place simultaneously. Risk interconnectivity relates to the effect of one negative event that could trigger one or more other adverse consequences because of the interrelationships. For example, consider the BP offshore oil rig explosion. The occurrence of the spill triggered other consequential events. BP's debt was downgraded, it was forced to swiftly divest of certain strategic assets to provide additional liquidity, and the organization changed its leadership. It likely will take decades for BP to recover from the reputational damage. There are many permutations of potential risk interrelationships; however the LHIN will focus on the combined effect of individual risks already identified as High or Very High. To illustrate the interconnectivity analysis and the domino effect that can result from interconnectivities, consider the example depicted below. An organization fails to meet customer expectations caused by consistently poor production quality. This triggers the loss of a major customer-and significantly reduced revenues. The organization is unable to respond quickly enough to adjust its cost structure to the reduced revenue level. Now in a loss position, the organization violates its bank covenants under the loan agreement. Given the poor financial performance, the banks decline to extend the credit facility. Finally, with the organization in severe distress, the key senior leadership members seek opportunities elsewhere. The ultimate outcome for organization is extreme distress or even insolvency. 15

71 V Prioritize Risks will be assessed and prioritized based on the following rating scale: Risk Analysis: Risk Rating: Value Likelihood Value Impact Likelihood X s 1 Rare 1 Insignificant Rating Impact Score 2 Unlikely 2 Minor LOW Possible 3 Moderate MEDIUM Likely 4 Major HIGH Almost Certain 5 Extreme EXTREME > 20 Colour Code Risk Matrix: LIKELIHOOD IMPACT Rare Unlikely Possible Likely Almost Certain Extreme Low Medium High Extreme Extreme Major Low Medium High High Extreme Moderate Low Medium Medium High High Minor Low Low Medium Medium High Insignificant Low Low Low Low Low Risk Matrix: (Likelihood of value x Likelihood of impact) VI Risk Capacity, Risk Tolerance and Risk Appetite Every organization faces risk. Appropriately balancing risk and reward to generate satisfactory returns to stakeholders is fundamental to any organization. It is important to understand what is meant by the terms "risk capacity," "risk tolerance" and "risk appetite." Perhaps the simplest way is to think about these concepts as a hierarchy. Risk capacity defines the outer limit of risk that an organization could undertake. This limit is often expressed in financial terms but could also be expressed in resource or capability terms. For example, the maximum amount resources (human, capital, infrastructure) that an organization could deploy may be limited by the size of its human capital or infrastructure. Risk tolerance reflects the limit of risk set by the organization that it would not willingly exceed. This limit can be expressed in quantifiable terms, such as level of invested capital, amount of allocated resources- both human and infrastructure. It may also include other subjective limits related to reputational risk. Risk appetite is the level of risk that the organization is willing to accept in pursuit of its longer-term goals, provided there is a commensurate return. Risk tolerance Board members and management must align their determination of the maximum risk the organization is prepared to absorb. This determination will ultimately influence strategy development and implementation. Risk tolerance should be determined in the context of the strength and stability of the organization and the industry in which it participates, the organization's maturity, and its positioning within its industry. Risk tolerance should also be considered in relation to strategy and related risks as well as other critical, identified risks. The robustness of mitigation alternatives, the availability of viable response strategies, and stakeholder expectations concerning risk must be considered. 16

72 MOHLTC risk tolerance The Ministry s risk tolerance is defined by approved service plans, the minimum level of performance articulated in the accountability agreements and Memorandums of Understanding. The Ministry has identified a list of objectives it considers important and has a low tolerance for risks to the achievement of these objectives. Culture, mitigation alternatives, and response strategies A culture that identifies and balances risk is an important factor in counterbalancing potential exposures. An organization with well-developed, mature systems and processes adds protection to the organization and provides boards with added comfort in setting tolerances for risk. In addition, understanding how risks may be effectively mitigated or addressed are also factors in quantifying risk tolerance. Risk appetite While determining risk tolerance is a passive exercise in setting limits, determining risk appetite is actionable and can be a driving force for an organization. While risk tolerance is akin to limiting exposures, risk appetite is about optimizing the organization's risk/return profile. Risk appetite parameters are similar to risk tolerance but with two clear distinctions. First, the risk appetite threshold should be lower than risk tolerance. Second, risk appetite should also include a desired or expected outcome. In setting risk appetite, the same factors that were used to determine risk tolerance should be considered while overlaying expectations around returns. Some argue that the degree of risk appetite should vary depending on the nature of the decision-whether strategic or tactical. Others believe that risk appetite should be scaled against minimum returns. That is, the organization should set minimum acceptable outcomes but, for better outcomes risk appetite may increase. There is no right or wrong answer, but the question is worthy of board-level discussion. Underpinning risk appetite is the board's confidence in the organization's capability to manage risks at this level and to produce the minimum expected return. EXAMPLE: Parameter Risk Capacity Risk Tolerance Risk Appetite Capital invested in a project or acquisition Central LHIN Organizational change $500 million $300 million Loss of 75% of the management team Loss of 50% of the management team $200 million with a minimum internal rate of return of 17% Loss of 25% of the management team Marketing spending on new product introduction $50 million $20 million $15 million 17

73 VII Choose Response Strategy Response strategy must be specific to each organization's circumstances and include both proactive and reactive components. The proactive components should be designed to minimize residual consequences following mitigation, while reactive strategies should limit damage to the organization following an adverse occurrence. There are various ways to avoid risk or to mitigate risk by reducing, controlling or sharing it. The response strategy should be balanced by both economics and recognition that not all risks may be mitigated. Risk mitigation and risk avoidance can take many forms. Examples of risk avoidance might include limiting the size of acquisitions or major capital expenditure projects, and not entering highly competitive markets. Examples of risk mitigation include obtaining insurance against an "act of God" and accelerating a normal succession or external recruitment process to mitigate against a key executive's unexpected resignation. For each material risk, plans should be considered, in varying detail depending on the circumstances, to cope after the occurrence. This often involves crisis management planning, including identifying resource requirements and establishing specific accountabilities. RISK RESPONSE STRATEGIES: Ineffective strategy development or execution Ongoing formal assessment of success using key performance indicators, external benchmarking, and other early warning tools Focus on rapid corrective actions when objectives are not being met Development of alternate strategies and formal contingency planning Unplanned leadership loss Continuous updating of unplanned executive succession plan Accelerated executive development programs Talent upgrade through selective recruitment (potentially displacing competent but limited potential executives and senior level managers) Unforeseen services disruption Services capacity planning Organization interruption insurance programs Heightened attention to labour matters Reciprocal LHIN capacity arrangements in the event of certain occurrences (such as acts of God) VIII Monitor As part of the board's annual agenda, formal risk monitoring and review sessions are scheduled. Such sessions might include, updated peer analyses, and reviews of key performance indicators related to risk. 18

74 Activity Details Source of Data 1. Establishing Context Review of macroeconomic and geopolitical environment, size, characteristics of the industry, and other LHINs 2. Risk Identification Description of the current macroeconomic and geo-political environment Industry characteristics -size (spending), resident characteristics, resident concentration Relative size of other LHINs IHSP Broad understanding of external and healthcare environment Strategic Review of resident dynamics Organization positioning Trends, emerging areas for growth, maturing sub-sectors Description of key drivers for success Current relative size (share of Ontario), underlying reasons for current trajectory Resident value proposition Summary of most recent independent resident or MPP survey results IHSP Key resident risks and drivers IHSP Peer benchmarking and analysis Review of comparative LHIN models Comparative peer advantages and disadvantages against key drivers for success Comparative peer breadth of capabilities Comparative financial analysis Summary results of recent resident surveys Summarize key strategies and major initiatives IHSP HQO Reports Assess strength of peer position Description and analysis of key strategies Summary of key assumptions Outline of critical overall and functional strategies Analysis of key strategic initiatives IHSP ABP Assess validity of strategies including timeliness and capability to execute Financial Modelling Test strategies by varying amount of funds invested by initiative or sector TBD Impact on outcomes 19

75 Financial Cash flow forecast Organizational Leadership, labour, culture Resident satisfaction Service quality Capacity constraints In-year cash forecasts Analysis of human resource metrics Operations Analysis of recent Central LHIN community interviews and surveys Service quality analysis and trending In-field service failure analysis Capacity constraint analysis of multiple scenarios Annual Business Plan Annual Operating Plan Understand cash flow vulnerability Staff satisfaction survey Assess staff organizational loyalty / engagement Measure peer position in meeting current and future key resident requirements HSP QIPs SAA quality targets Assess quality performance Understand capacity limits, time and cost to expand Health service provider dependencies Hazardous Vulnerability to acts of external parties or nature Compliance Necessity of operating in a highly regulated environment External Risk Macroeconomic and geopolitical vulnerability Industry structural change Regulatory change or potential intervention Analysis of critical health service provider dependencies Focus on mitigation strategies Analysis of operating as a Crown Agency Analysis of critical exposures to changes in regional economy. Assessment of vulnerability to current and potential changes to the geopolitical environment Broad examination of industry changes and trends that signal fundamental change in end market dynamics, including demographic effects Examination of potential threats from changes in government- imposed regulations or intervention 20 HSP Accountability Planning Submissions Understand vulnerability in reliance on critical third-party dependencies Insurance coverage List of Applicable Acts Provincial Budget Assess degree of exposure to significant change in the economy or geopolitical environment. TBD Understand exposure of failing to act on potential major structural change TBD Assess regulatory or other government- initiated exposures

76 3. Initial Consequential Heat Map Analysis Rank ordering of risks Ordering of identified risks in terms of potential severity, regardless of the probability of occurrence Annual and Quarterly Risk Assessments Risks that materially affect asset or stakeholder value and those that may adversely impact longer-term performance Assess likelihood of occurrence Application of judgment Be conservative and use care before dismissing seemingly unlikely potential threats Mitigation capability Overview heat map Identification and understanding of capability and tools available to fully or partially mitigate risks Assessment of residual risk after mitigation Visual review of heat map to clarify focus on areas requiring board attention Focus on higher residual risk areas Re-rank identified risks in accordance with three dimensional analysis 4. Interconnectivity, Compounding effect, and Vulnerability Analysis Assess potential interrelationship of risks Compounding risk analysis Examination of each risk to determine if there was an occurrence would this trigger other identified risks to follow in a domino effect. This might involve high risks areas that cause lower severity or likelihood risks to follow. Separate examination of identified risks from the standpoint of one or more occurring simultaneously ("perfect storm") to understand potential compounding effect of severity Look for increased exposure though simultaneous adverse consequences due to linkages among risks or serendipitous multiple occurrences Assess imbedded vulnerabilities Development of list of vulnerabilities, with focus on critical areas such as areas of weak competitiveness, declining funding, margin pressures, organizational gaps or retention exposure, and health service provider dependencies In light of vulnerabilities, consider the other identified risks that could be a tipping point for potentially serious adverse consequences. 5. Prioritize Rank risk 6. Assess Risk Capacity, Risk Tolerance, and Risk Appetite Risk capacity Amount and type of risk supportable in pursuit of outcomes. May take into account financial, human resource and technology capacity. 21

77 Risk tolerance Risk appetite Development of quantifiable and qualitative analysis to determine limits that organization would never exceed in light of prioritized risks, risk capacity, organization performance, industry dynamics, stakeholder expectations, and risk mitigation alternatives Development of model and matrix, based on risk tolerance, to determine limit of exposure organization is willing to accept in pursuit of long-term goals; analysis must be related to expected outcomes Rigorous discussion of limits and willingness to accept risk in pursuit of defined outcomes 7. Response Strategy Prioritized, proactive risk mitigation strategies Development for each risk proactive responses to avoid or lessen, limit and avoid each exposure before occurrence Minimization of exposure at an acceptable cost Quantify residual exposure Compare residual exposure against risk tolerance Reactive post- occurrence strategies 8. Monitoring Determination for each risk residual exposure after considerations of all response strategies Analysis of residual risk exposure against risk tolerance. Development of sensitivity analysis for multiple simultaneous occurrences Development of crisis management plans(including resource requirements and defined accountabilities) for each major exposure on assumption that risk materializes Understanding unmitigated, residual exposure Test exposure against predetermined limits; consider necessary actions if residual risk exposure nears or exceeds risk tolerance Business Continuity Plan Advance preparedness Key indicators including operational and financial metrics Regular community satisfaction assessment Development of indicators for each prioritized risk in order to create early warning of a potential adverse occurrence (indicators can take many different forms, including quantitative and subjective) Tracking of trends in community to assess the effectiveness of successful community-facing strategies Scheduled board agenda items LHIN benchmarking and industry analyst reports Comprehensive competitive analysis and tracking industry trends Current executive talent management and succession planning Succession planning for unanticipated executive departures 22

78 ACKNOWLEDGEMENT Reproduced (or adapted) with permission from A Framework for Board Oversight of Enterprise Risk, published by the Chartered Professional Accountants of Canada. Any changes to the original material are the sole responsibility of the author (and/or publisher) and have not been reviewed or endorsed by the CPA Canada. 23

79 1 60 Renfrew Drive, Suite 300 Markham, ON L3R 0E1 Tel: Fax: Toll Free: CENTRAL LHIN AUDIT COMMITTEE AUDIT WORKPLAN AUGUST 22, 2013 ITEM Topic/Item Feb May Jul/Aug Oct Annual Items Annual Review of Terms of Reference Appointment of Auditor Review Audit Plan Report from Auditor and Recommend Audited Financial Statements for Approval Annual Review of Policies Review and Recommend Preliminary Operating Budget for Annual Business Plan Submission Review and Recommend Final Operating Budget Review of Agency Establishment and Accountability Directive Risk Report Standing Items Quarterly Compliance Certificate Operating Results Consulting Report Review Board Chair Expenses Report on whistleblowing Updates to accounting practices As Needed Updates to legislation, directives, etc. Page 1

80 60 Renfrew Drive, Suite 300 Markham, ON L3R 0E1 Tel: Fax: Toll Free: ITEM 7.1 CENTRAL LHIN BOARD OF DIRECTORS BRIEFING NOTE 2013/2014 HOSPITAL SERVICE ACCOUNTABILITY AMENDING AGREEMENTS SEPTEMBER 24, 2013 PROPOSED RESOLUTION: WHEREAS the current Hospital Service Accountability Amending Agreements expire on September 30, 2013; and WHEREAS the LHIN has been provided with an Amending Agreement template which has been approved provincially by the LHIN Boards; and WHEREAS the LHIN has received additional information related to 2013/14 hospital funding allocations including Health System Funding Reform and Surgical and Diagnostic Wait Times funding; and WHEREAS the LHIN and Ministry have finalized Ministry-LHIN Performance Agreement targets for 2013/14; and WHEREAS individual hospital performance targets have been set in a manner that will enable achievement of the Ministry-LHIN Performance Agreement targets; and WHEREAS the Hospital Service Accountability Agreement between St. Joseph s Infirmary and Central LHIN is set to expire on September 30, 2013 and, in February 2013, the Central LHIN Board approved the transfer of funds related to the hospital s physical relocation; BE IT RESOLVED THAT: The Central LHIN Board of Directors: a) Approves the amended 2013/14 Hospital Service Accountability Agreements for each of the following public hospitals: Stevenson Memorial Hospital North York General Hospital Mackenzie Health Southlake Regional Health Centre Markham Stouffville Hospital Humber River Hospital Page 1

81 60 Renfrew Drive, Suite 300 Markham, ON L3R 0E1 Tel: Fax: Toll Free: b) Approves the 2013/2014 funding, volume and performance targets for each of the public hospitals, as follows, to be included in the 2013/14 Hospital Service Accountability Amending Agreements: Stevenson Memorial Hospital North York General Hospital Mackenzie Health Southlake Regional Health Centre Markham Stouffville Hospital Humber River Hospital Total LHIN Funding $19,651,375 $246,217,767 $194,251,969 $280,349,675 $151,854,866 $264,802,480 Global Volumes: ED Weighted Cases 1,257 5,265 4,048 4,740 3,933 5,225 Total Acute Inpatient Weighted Cases 2,350 31,250 20,500 30,637 14,732 32,550 Day Surgery Weighted Cases 660 5,455 2,500 6,668 2,386 5,896 Complex Continuing Care RUG Weighted Patient Days na na 29,081 6,795 4,139 na Mental Health Weighted Inpatient Days na 19,050 9,055 11,394 13,658 16,809 Inpatient Rehabilitation Weighted Cases na na Ambulatory Care Visits 26, , , ,172 82, ,340 Wait Times Strategy Volumes: General Surgery Paediatric Surgery Hip & Knee Replacement Revisions MRI Scans - 3,110 2,395 2,690 2,975 2,830 OBSP MRI Scans CT Scans Bilateral Cataracts Quality Based Procedures: Unilateral Primary Hip Replacements Unilateral Primary Knee Replacements Inpatient Rehabilitation Unilateral Primary Hip Replacement Inpatient Rehabilitation Unilateral Primary Knee Replacement Unilateral Cataracts 300 7,382-4, Chronic Obstructive Pulmonary Disease Non-Cardiac Vascular Aortic Aneurysm Non-Cardiac Lower Extremity Occlusive Disease Congestive Heart Failure Stroke - Hemorrhage Stroke Ischemic or Unspecified Stroke Transient Ischemic Attack Financial Indicators: Current Ratio Page 2

82 60 Renfrew Drive, Suite 300 Markham, ON L3R 0E1 Tel: Fax: Toll Free: Year End Total Margin 0.00% 0.98% 0.00% 0.01% 0.00% 0.00% Person Experience Indicators: Stevenson Memorial Hospital North York General Hospital Mackenzie Health Southlake Regional Health Centre Markham Stouffville Hospital Humber River Hospital Cases of Ventilator-Associated Pneumonia (Cases/Days) na Central Line Infection Rate (Cases/Days) na Hospital-Acquired Cases of Clostridium Difficile Infections (Cases/Days) Hospital-Acquired Cases of Vancomycin Resistant Enterococcus (Cases/Days) Hospital-Acquired Cases of Methicillin Resistant Staphylococcus Aureus (Cases/Days) P ER LOS Admitted TBD TBD TBD TBD TBD TBD 90P ER LOS Non-Admitted Complex TBD TBD TBD TBD TBD TBD 90P ER LOS Non-Admitted Minor- Uncomplicated TBD TBD TBD TBD TBD TBD % Priority IV Cases Completed within Access Target for Cancer Surgery na 95% 95% 95% 95% 95% % Priority IV Cases Completed within Access Target for Cardiac By-Pass Surgery na na na 95% na na % Priority IV Cases Completed within Access Target for Cataract Surgery 95% 95% na 95% na 95% % Priority IV Cases Completed within Access Target for Hip Replacement Surgery TBD TBD TBD TBD TBD TBD % Priority IV Cases Completed within Access Target for Knee Replacement Surgery TBD TBD TBD TBD TBD TBD % Priority IV Cases Completed within Access Target for MRI Scan TBD TBD TBD TBD TBD TBD % Priority IV Cases Completed within Access Target for CT Scan TBD TBD TBD TBD TBD TBD % ALC Days TBD TBD TBD TBD TBD TBD c) Approves the amended 2013/14 Hospital Service Accountability Agreements for the fiscal year April 1, 2013 to March 31, 2014 for West Park Healthcare, with no changes to previously approved funding and volume targets; d) Approves the amended 2013/14 Private Hospital Service Accountability Agreements for the fiscal year April 1, 2013 to March 31, 2014 with no changes to previously approved funding and volume targets for each of the following private hospitals: Don Mills Surgical Unit Ltd Shouldice Hospital Ltd e) Delegates authority to the Chair and CEO to sign the 2013/14 Hospital Service Accountability Amending Agreements effective October 1, 2013, for Central LHIN hospitals; and Page 3

83 60 Renfrew Drive, Suite 300 Markham, ON L3R 0E1 Tel: Fax: Toll Free: f) Delegates authority to the CEO to approve hospital-specific targets for performance indicators that remain set as TBD, provided that they are set in a manner that will enable achievement of the Ministry-LHIN Performance Agreement targets; and g) Approves the termination of the St. Joseph s Infirmary Hospital Service Accountability Agreement and delegates authority to the CEO to sign the termination letter. ANALYSIS: Hospital Service Accountability Amending Agreement Process for Public Hospitals In March 2013, the Central LHIN Board of Directors approved amendments to five of the LHIN s six public Hospital Service Accountability Agreements (H-SAAs) and three private Hospital Service Accountability Agreements which extended the term of the existing Agreements to September 30, The amended agreements include funding, volumes and performance targets based on the approach and principles approved by the Central LHIN Board in January Several volume and performance targets were set to TBD as the information to set these targets was not yet available from the Ministry. The Board also approved the extension of the 2012/13 H-SAA for Stevenson Memorial Hospital to September 30, 2013 without amending the funding assumptions or performance measurements. On August 1, 2013, the Central LHIN received the funding letter detailing 2013/14 hospital funding related to Health System Funding Reform (HSFR). The Central LHIN s public hospitals, with the exception of Markham Stouffville and Stevenson Memorial Hospitals, received actual HSFR funding in excess of planned funding. The total funding variance to hospital budgets was $7.8 million. The planned funding provided the basis for the H-SAAs approved by both LHIN and hospital boards in March The hospitals current H-SAA volume targets are aligned with HBAM expected volumes, and all hospitals submitted a balanced budget. In addition, H-SAA performance targets include an acceptable range of performance within a corridor. As such, Central LHIN generally will not require additional volumes or performance adjustments in the H-SAA related to the additional funding. However, Central LHIN and the hospitals worked together to recommend the use of the additional funding as follows: Hospital North York General Mackenzie Health Funding Variance $1.6 million $1.7 million Intended Use of Funds Provision of services in the higher range of H-SAA performance corridors for ED, inpatient and day surgery weighted cases. Supplement funding for Emergency Department Express Admission Unit. Increased ED weighted cases by 201 to HBAM expected of 4,249. Increase CCC RUG Weighted Patient Days by 500 and increase Inpatient Rehab weighted cases by 5. Page 4

84 60 Renfrew Drive, Suite 300 Markham, ON L3R 0E1 Tel: Fax: Toll Free: Southlake Regional Health Center Humber River Hospital $2.7 million $1.8 million Improvement of working capital position with working capital in the higher range of the performance corridor. Improvement of working capital position and/or initiatives which will yield future cost savings. Actual HSFR revenue for Markham Stouffville Hospital is approximately $127,000 less than planned funding. As a result, it is expected that, while the hospital will achieve H-SAA performance requirements, actual volumes may be in the lower range of the performance corridor. In addition, the Hospital has not received its PCOP funding allocation from the Ministry. The Ministry is in the process of preparing the sign-off package for Ministry approval. In June 2013, Central LHIN made a formal request to the Ministry that Stevenson Memorial Hospital be included in the HBAM funding formula since the hospital now meets the criteria for inclusion. It is expected that the Ministry will accept this request and that Stevenson will receive additional funding for HBAM for 2013/14. During the summer, Central LHIN and the Ministry negotiated 2013/14 performance targets for the Ministry- LHIN Performance Agreement (MLPA). Subsequently, targets for several indicators were set for individual hospitals in a manner that will enable achievement of the MLPA targets while also considering historical performance. Given the timing of information received from the Ministry and the need for further analysis and discussion to set meaningful performance targets, certain indicators remain set as TBD. These indicators include those related to Emergency Department lengths of stay, wait times for hip and knee replacement surgeries, wait times for MRI and CT scans, and Percentage Alternate Level of Care Days. The 2013/14 H-SAA targets for these indicators will be based on the following: MLPA targets Historical performance Ministry funding levels LHIN-funded volumes Hospitals Needs and Capacity Survey A summary of hospital-specific historical performance for both volumes and performance indicators is included in Appendix A. LHIN-Specific Obligations Changes have been made to the LHIN-specific obligations included in Schedule C-3 for the 2013/14 H-SAA Amending Agreement. The changes are as follows: Clarification of the wording of the ehealth obligation Update of the submission date for the Health Equity Plan Inclusion of new provincial indicators for surgical and diagnostic wait times Page 5

85 60 Renfrew Drive, Suite 300 Markham, ON L3R 0E1 Tel: Fax: Toll Free: Addition of obligation related to participation in the Central LHIN Health System Funding Reform Local Partnership Inclusion of hospital-specific volume targets for Diabetes Education Programs, for applicable hospitals Addition of Telehomecare reporting obligation for Southlake Regional Health Centre These obligations have been discussed with the hospitals and there are no concerns noted. West Park Healthcare Center In June 2013, the Central LHIN Board of Directors approved funding and volume targets for the Transitional Home Ventilation Program at West Park; no changes have been made to these targets. Minor updates have been made to local indicators to better align performance objectives for the program. This agreement is being amended to cover the full fiscal year April 1, 2013 to March 31, Hospital Service Accountability Amending Agreement Process for Private Hospitals No changes have been made to funding or performance targets previously approved by the Central LHIN Board in March The agreements are being amended to cover the full fiscal year April 1, 2013 to March 31, The PH-SAA between St. Joseph s Infirmary and Central LHIN expires on September 30, Central LHIN will issue a termination letter which notifies the private hospital of the status of its obligations to date and any further obligations to the LHIN, if applicable. CURRENT STATUS: Draft H-SAA Amending Agreements have been sent to the Central LHIN s six public and two private hospitals. It is expected that all hospitals will approve the H-SAA Amending Agreements effective October 1, The H-SAA Steering Committee continues to make progress in its discussions with the Ministry and the Ontario Hospital Association to finalize an updated H-SAA legal agreement which is expected to be in effect from April 1, 2014 through March 31, Funding letters for HSFR, provincial programs, and wait times funding have been to the hospitals as disbursement of these funds was approved by the Central LHIN Board Chair and CEO during the summer, per the Board delegation approved at the June Board meeting. NEXT STEPS: Upon Board approval of the resolutions, the Board Chair and CEO will execute the Hospital Board approved Agreements. The LHIN CEO will also send a termination letter to St. Joseph s Infirmary confirming the termination of the Hospital Service Accountability Agreement and outlining any continuing obligations. Page 6

86 60 Renfrew Drive, Suite 300 Markham, ON L3R 0E1 Tel: Fax: Toll Free: Central LHIN staff will continue working to establish hospital-specific targets for those indicators currently set to TBD. These targets will be approved by the LHIN CEO. Page 7

87 Appendix A - Central LHIN Public Hospital Performance Summary /12 & 2012/13 ITEM 7.1 APPENDIX A FUNDING VOLUMES TORONTO North York General 2011/ / /14 Proposed 2011/ / /14 Proposed 2011/ / /14 Proposed 2011/ / /14 Proposed 2011/ / /14 Proposed 2011/ / /14 Proposed LHIN Funding ($million) $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ 19.5 $ 19.8 $ / / /13 Proposed 2011/ / / / /14 Proposed 2011/ /13 Proposed 2011/ /13 Proposed 2011/ / /14 Proposed 2011/ /13 Current Ratio (Provincial Target = 0.8) Year End Total Margin 0.03% 0.03% 0.00% 4.09% 0.91% 0.98% 2.60% 0.31% 0.01% 2.16% 3.80% 0.00% -0.64% 0.83% 0.00% 0.00% 0.37% 0.00% 2011/ / /14 Proposed 2011/ / /14 Proposed 2011/ / /14 Proposed 2011/ / /14 Proposed 2011/ / /14 Proposed 2011/ / /14 Proposed Cataract Surgery (Provincial Target = 90%) 100% 100% 95% 100% 100% 95% 100% 100% 95% % 100% 95% Cancer Surgery (Provincial Target = 90%) 100% 100% 95% 100% 100% 95% 95% 99% 95% 98% 99% 95% 100% 100% 95% 100% - - Cardiac By-Pass Surgery (Provincial Target = 90%) % 100% 95% (1) Includes PCOP funding and volumes (2) Set equal to HBAM expected (3) Southlake may receive funding through the provincial Working Funds Deficit Initiative to improve its current ratio position. (4) It is anticipated that Stevenson's current ratio position will improve once expected HBAM funding is received. NEWMARKET Southlake Regional RICHMOND HILL Mackenzie Health MARKHAM Stouffville (1) ALLISTON Stevenson Memorial TORONTO TORONTO NEWMARKET RICHMOND HILL MARKHAM ALLISTON GLOBAL VOLUMES Humber River Regional North York General Southlake Regional Mackenzie Health Stouffville Stevenson Memorial 2011/ / /14 Proposed 2011/ / /14 Proposed 2011/ / /14 Proposed 2011/ / /14 Proposed 2011/ / /14 Proposed 2011/ / /14 Proposed 2 2 Emergency Department - Weighted Cases 5,470 5,466 5,225 4,904 5,498 5,265 4,337 4,643 4,740 4,231 4,474 4,249 3,376 3,537 3,933 na Complex Continuing Care - RUG Weighted Patient Days ,930 9,150 6,795 32,226 29,941 29,581 3,238 4,304 4, Total Inpatient Acute Activity - Weighted Cases 33,921 32,223 32,550 29,531 30,530 31,250 27,921 30,371 30,637 20,069 21,685 20,500 15,487 14,471 14,732 1,983 2,371 2,350 Day Surgery - Weighted Cases 5,677 5,836 5,896 5,214 5,776 5,455 6,020 6,543 6,668 2,599 3,091 2,500 2,163 2,139 2, Inpatient Mental Health - Weighted Patient days 17,793 18,358 16,809 18,805 18,728 19,050 11,484 11,752 11,394 9,051 8,708 9,055 9,990 10,098 13, Inpatient Rehabilitation - Weighted Cases na Ambulatory Care - Visits 223, , , , , , , , , , , ,524 72,568 78,690 82,890 24,688 26,899 26,600 ORGANIZATIONAL HEALTH PERCENT OF PRIORITY IV CASES COMPLETED WITHIN PROVINCIAL TARGET TORONTO Humber River Regional TORONTO Humber River Regional TORONTO Humber River Regional TORONTO North York General TORONTO North York General NEWMARKET Southlake Regional NEWMARKET Southlake Regional RICHMOND HILL Mackenzie Health RICHMOND HILL Mackenzie Health MARKHAM Stouffville MARKHAM Stouffville ALLISTON Stevenson Memorial 2013/14 Proposed ALLISTON Stevenson Memorial

88 60 Renfrew Drive, Suite 300 Markham, ON L3R 0E1 Tel: Fax: Toll Free: CENTRAL LHIN BOARD OF DIRECTORS BRIEFING NOTE NORTH YORK GENERAL HOSPITAL PRE-CAPITAL SUBMISSION PART A REDEVELOPMENT OF EMERGENCY DEPARTMENT TRIAGE GENERAL SITE SEPTEMBER 24, 2013 PROPOSED RESOLUTION: WHEREAS on May 23, 2013, the North York General Hospital submitted a Pre-Capital Submission Form Part A in respect of the redevelopment of the Emergency Department Triage at the General Site with own funds to the Central LHIN for review; WHEREAS the Ministry of Health and Long-Term Care-LHIN Performance Agreement (MLPA) sets out the roles and responsibilities of LHINs with respect to capital initiatives proposed by a health service provider related to the construction, renewal or renovation of a facility or a site, including requiring that the LHIN review Part A of a health service provider s Pre-Capital submission and provide advice and/or endorsement to the Ministry; WHEREAS in October, 2010 the Ministry of Health and Long-Term Care provided LHINs and health service providers with a MOHLTC-LHIN Joint Review Framework for Early Capital Planning Stages Toolkit that included submission templates and LHIN review guidelines; WHEREAS Central LHIN staff have reviewed the Hospital s submission and determined that it addresses the requirements outlined in the Joint Review Framework ; BE IT RESOLVED THAT: ITEM 7.2 The Central LHIN Board of Directors endorses the North York General Hospital Pre-Capital Submission Part A, in respect of the redevelopment of the Emergency Department Triage at the General Site with own funds. PURPOSE: To seek Board endorsement of the North York General Hospital Pre-Capital Submission Part A to redevelop the Emergency Department Triage at the General Site with their own funds. ANALYSIS: The Joint Planning Framework requires a health service provider to address a number of key criteria in the development of a Pre-Capital Submission Part A. These criteria include: Page 1

89 60 Renfrew Drive, Suite 300 Markham, ON L3R 0E1 Tel: Fax: Toll Free: A narrative description of the program/service need to be addressed by the project; A statistical description of the program/service need to be addressed by the project; A description of how the program/service need supports local health system integration and a unified system of care; Support from other stakeholders with respect to the project; Any significant operational implications of the project; Alternative program/service solutions. North York General Hospital is a community teaching hospital located in a densely populated sub-lhin area with the highest per cent of population over 65 (17%) in Central LHIN. The hospital has seen a 25% growth in their Emergency Department over the past 5 years and is having significant challenges supporting the volume that it is currently experiencing, resulting in negative impact to effective and efficient patient flow and Emergency wait times that are suboptimal. In addition, although the North York General Hospital Emergency Department meets current infection control standards, they have experienced challenges in adapting their Emergency Department to do so. As a result, patient satisfaction survey scores for the Emergency Department are consistently below the scores for the inpatient units. North York General Hospital is proposing redevelopment of their Emergency Department triage area and configuration of the entrance with their own funds to better accommodate flow and improve the quality of patient care. There is no expansion of the program proposed and no impact on market share or volumes. As a result, North York General Hospital is not seeking any ongoing operating funds. However, long range forecasting provided by the hospital has projected a 32% increase in Emergency Department visits by the year 2030 and it is expected that the redevelopment will result in better capacity to meet the projected population needs in future. The Ministry of Health and Long-Term Care s ( the Ministry ) review of Part B of the Hospital s submission will address any facilities-related issues. There is no capital funding request to the Ministry. Central LHIN staff s review of the Hospital s submission confirms that it has met the threshold for LHIN support outlined in the Joint Review Framework, including alignment between the proposed services and local health system priorities. BACKGROUND: The MOHLTC-LHIN Joint Review Framework confirms that the role of the LHIN in the review of capital submissions is to focus on the alignment between the programs and services outlined in the proposed project and the needs of the local health system (the role of the Ministry is to review and approve the project, including to review all physical and cost elements as well as program and service elements from a provincial perspective). There are several points of alignment required between the LHIN and the Ministry in this process. A schematic summarizing the various stage of the capital planning process is as follows: Page 2

90 60 Renfrew Drive, Suite 300 Markham, ON L3R 0E1 Tel: Fax: Toll Free: Overview of Capital Planning Process Planning Grants: 3 possible approval milestones: proposal development, functional program, design development Construction Grant Pre-Capital (Part A & B) Stage 1 Proposal (Part A & B) Stage 2 Functional Program (Part A & B) Stage 3 Preliminary Design Or Output Specifications Stage 4 Working Drawings Or Output Specifications Stage 5 Implementation Review and support of Pre-Capital Submission. Proposal Development grant Review and approval Review and approval of Stage 1 Submission. of Stage 2 Functional Program Functional Program. grant. Design Development grant Requires Government approval to plan Review and approval of blocks and sketch plans; approval to proceed to working drawings OR blocks/output specifications Requires Government approval to construct Review and approval to tender & implement/issue RFP OR approval to award construction contract/ Project Agreement. LHIN review and advice to the Ministry is required in each of the first three stages. At Pre-Capital, the LHIN review is focused on whether the submission clearly describes and identifies the program/service need to be supported by the capital initiative; the alignment with local and provincial health system priorities; options for program/service delivery, including integration opportunities, collaboration and alternative service delivery models; and the demographic profile and projected utilization profile over a 20-year period. Further detail is provided at each of the subsequent stages of planning. According to the Joint Review Framework, at each stage LHIN staff are expected to review the submission and provide a recommendation to their Board to: endorse the program and service elements of the proposal; endorse the program and service elements of the proposal, with conditions, or; reject the program and service elements of the proposal; and provide written rationale and advice to the Ministry. NEXT STEPS: Upon Board endorsement of the Pre-Capital Submission Part A, notification will be given to the Ministry which will initiate the Ministry s review of the Pre-Capital Submission Part B (the Development Concept ). Page 3

91 60 Renfrew Drive, Suite 300 Markham, ON L3R 0E1 Tel: Fax: Toll Free: CENTRAL LHIN BOARD OF DIRECTORS BRIEFING NOTE 2013/14 ALLOCATION PRIORITES REVISION: MENTAL HEALTH AND ADDICTIONS CRISIS SERVICES FISCAL YEAR SEPTEMBER 24, 2013 ITEM 7.3 PROPOSED RESOLUTION: WHEREAS LHIN Board of Directors approved the in-year allocation priorities and process on May 28, 2013; and WHEREAS staff propose a revision to the approved allocation priorities; BE IT RESOLVED THAT: a. The Central LHIN Board of Directors approves the revised description under the High Users and Other priorities to include mental health/addictions crisis services up to $850,000 and Health Service Provider pressures when allocating funds for fiscal year for Central LHIN: Priority HIGH USERS Description Funding to support targeted interventions to improve the coordination of care for high users of health services. Initiatives may include: congregate care for transitional aged youth living with complex medical needs, telemedicine, Mental Health & Addictions funding for: supportive housing, abuse services, case management/care navigation, expanded centralized access and crisis services. Expected impact: reduce repeat ED visits, avoidable admissions and readmissions to hospital, ALC. OTHER Additional MoHLTC priorities that are aligned with the IHSP and to address specific PRIORITIES Health Service Provider Pressures Description b. Delegates signing authority to the CEO and Chair should a funding allocation exceed the CEO s financial authority as set out in Financial Signing Authority policy CFIN-3. PURPOSE: To seek Board approval for a revision to the High Users and Other priorities to include mental health/addictions crisis services and to address health service provider pressures for in-year funding allocations. Page 1

92 60 Renfrew Drive, Suite 300 Markham, ON L3R 0E1 Tel: Fax: Toll Free: BACKGROUND: In May 2013 the Central LHIN Board of Directors approved the priorities, principles and process for health service provider 2013/14 in-year funding allocations and delegated signing authority to the CEO. The following high level approved priorities have been updated with status of funding: Approved Amount Priority: High Users Up to $ 4,700,000 Integration Up to $ 1,100,000 Quality Based Procedures (QBPs) Up to $ 400,000 Seniors Strategy Up to $ 7,400,000 MLPA Targets Up to $ 8,800,000 Previously Committed Funds Up to $ 6,500,000 Other Priorities Up to $ 2,200,000 TOTAL Up to $ 31,100,000 In response to the identified geographic gaps in mobile crisis intervention teams (MCIT) coverage across the City of Toronto, the Toronto Central LHIN initiated a planning process focused on mobile crisis intervention teams (hospital-based mental health registered nurse and police response teams). The process was led by a hospital and the Toronto Police Services and included engagement of Central LHIN staff. In April 2013 the Toronto Central LHIN brought forward the resulting report from the Steering Committee, entitled MCIT Program Coordination in the City of Toronto which recommended that a new Mobile Crisis Intervention Team be created at North York General Hospital serving the Toronto Police Service division 32 (North York), which falls within the Central LHIN geography. Central LHIN staff have reviewed the report in the context of existing mental health crisis services, including mobile crisis teams, in the Central LHIN (see Appendix A) as they align with the Ministry of Health report (May 2005) entitled Ministry Framework, Crisis Response Service Standards for Mental Health Services and Supports. The framework describes a comprehensive pre-discharge mental health and addictions crisis service composed of a crisis warm line, mobile response, safe beds and case management/assertive community treatment teams programs, where Mobile Crisis Teams are just one component of a continuum of supports. Staff propose to undertake a process whereby emergency management services, police services, health service providers and consumers will be engaged to conduct focused planning on the full continuum of mental health/addictions crisis services in alignment with work done at the Toronto Central LHIN with the objectives to: a. better understand the continuum of services available and models of care in the LHIN; b. identify any potential opportunities to improve access to services. Page 2

93 60 Renfrew Drive, Suite 300 Markham, ON L3R 0E1 Tel: Fax: Toll Free: Expansion of mental health and addictions crisis services that is focused on providing the right supports at the right time is anticipated to reduce emergency department visits and admissions and readmissions to hospital. Adding crisis services as a targeted intervention under the High Users priority will expand the type of interventions identified for people living with mental health or addictions conditions without changing the total funding allocated. The additional inclusion of health service provider pressures will enable the LHIN to address pressures health service providers are facing given there is not an identified source of funds for the LHIN to use to address these pressures and/or risk areas. ALIGNMENT TO IHSP This model is aligned with the Central LHIN s Integrated Health Service Plan and Annual Business Plan. The initiatives will be targeted towards enhancing community services, increasing access to community services for vulnerable populations, including those living with mental health and addictions and at reducing repeat emergency department visits. NEXT STEPS 1. Central LHIN will host a series of engagements with the providers of crisis services and consumers in the LHIN to discuss current and future needs for mental health crisis services, specifically focused on pre-charge diversion. Opportunities to improve access through models that are evidence-informed will be identified for the Central LHIN. 2. Central LHIN will use the findings to release an RFP to health service providers to augment capacity through the allocation of in-year funding. Page 3

94 60 Renfrew Drive, Suite 300 Markham, ON L3R 0E1 Tel: Fax: Toll Free: Appendix A: Central LHIN Mental Health and Addictions Crisis Services Several elements of pre-charge diversion mental health and addictions crisis services currently exist across the Central LHIN: Service Type Mobile Crisis Team (with or without Police Office) Emergency Department Diversion Program Home+ Care Initiative Mental Health and Addictions Crisis Line Warm Line Peer Support Drop-in Centre Safe Beds Short-Term Residential Bed Program Acute Care Emergency Department Crisis Services Health Service Provider Humber River Hospital York Support Services Network Saint Elizabeth Health Care North York General Hospital Humber River Hospital CMHA York region Saint Elizabeth Health Care York Support Services Network Krasman Centre Krasman Centre CMHA Toronto York Support Services Network Markham Stouffville Hospital North York General Hospital Southlake Regional Health Centre Mackenzie Health Mobile Crisis Teams Mobile crisis teams (MCTs) consist of both police officers and mental health workers (a nurse, social worker or other mental health professional) that co-respond to crisis situations. The core components are: - Not a rapid response service such as 911, but once the MCT arrives on the scene; the mental health worker conducts a brief assessment of the individual in crisis. - The mental health worker can make a decision at the scene about whether the individual needs to undergo a psychiatric assessment at a hospital, or if the individual needs to be directed to community mental health services. - The police officers assist in the situation by securing the scene and ensuring everyone s safety and, if needed, apprehending the individual under the Mental Health Act and escorting them to the nearest hospital. i i Behavioral Sciences & the Law. Behav. Sci. Law 24: (2006) Pre-arrest Diversion of People with Mental Illness: Literature Review and International Survey. Kathleen Hartford R.N., Ph.D.,* Robert Carey. Ph.D. and James Mendonca Ph.D., C.Psych. Page 4

95 60 Renfrew Drive, Suite 300 Markham, ON L3R 0E1 Tel: Fax: Toll Free: CENTRAL LHIN BOARD OF DIRECTORS BRIEFING NOTE 2013/14 CENTRAL COMMUNITY CARE ACCESS CENTER MULTI-SECTOR ACCOUNTABILITY AGREEMENT AMENDMENT SEPTEMBER 24, 2013 ITEM 7.4 PROPOSED RESOLUTION: WHEREAS in a letter received August 1, 2013, the Ministry provided the details of 2013/14 funding allocations related to Health System Funding Reform; and WHEREAS in a letter received August 1, 2013, the Ministry provided the details of community sector base funding increase for fiscal 2013/14; and WHEREAS in a letter received August 9, 2013, the Ministry provided the details of 2013/14 funding related to Surgical and Diagnostic Wait Times; and WHEREAS Central LHIN and the Ministry have finalized Ministry-LHIN Performance Agreement targets for 2013/14 which includes a target related to wait times for CCAC services; and WHEREAS Central LHIN anticipates the availability of one-time funds later in fiscal 2013/14; and WHEREAS Central LHIN and Central CCAC have identified performance objectives which align with provincial and LHIN priorities and will inform the allocation of funds among Central CCAC services; BE IT RESOLVED THAT: The Central LHIN Board of Directors: a) Approves a 2013/14 base funding increase of $20,921,000 for Central CCAC to achieve the following goals: i. Eliminate waitlists for in-home clients with high and very high needs; ii. Meet Ministry-LHIN performance target related to wait times for CCAC services; iii. Meet provincial target for wait times for personal support services for complex clients; iv. Coordinate care of all physiotherapy clients under the provincial physiotherapy reform; v. Reduce wait time from assessment to first service for Home First clients; vi. Fully implement the expanded role for assisted living and adult day programs; and b) Approves the disbursement of $800,000 for HSFR-QBP funding assumed in the current Central CCAC MSAA and confirmed by the Ministry in the August 1, 2013 funding letter; and c) Approves $2,500,000 one-time funding in 2013/14 upon confirmation of the funds by the LHIN, for Central CCAC to achieve the following goals: Page 1

96 i. Reduce wait lists for services for school children; ii. Purchase increased medical supplies; iii. Provide additional in-home therapy services; and c) Delegates authority to the CEO and Board Chair to execute the CCAC M-SAA amendment; and d) Delegates authority to the CEO to disburse the base funding upon signing the amendment; and e) Delegates authority to the CEO to disburse the one-time funds when they become available. ANALYSIS: Incremental Funding and Services Summary: Funding Source Current 2013/14 M-SAA Assumptions Increase to M-SAA Amount Additional Cash Flow HSFR HBAM and 2013/14 QBP $0 $1,888,901 $1,888,901 HSFR 2012/13 QBP Add Back $800,000 $205,943 $1,005,943 Wait Times $0 $221,000 $221,000 PSW Wait Time Funding $0 $6,738,500 $6,738,500 Community Sector Base Increase $0 $11,866,656 $11,866,656 Total Base Funding Increase $800,000 $20,921,000 $21,721,000 Service Type Exiting 2013/14 M-SAA Targets 2013/14 Client Services Activity Incremental Volumes Amended 2013/14 M-SAA Targets Units Clients Units Clients Units Clients IN-HOME SERVICES Nursing 780,412 25, ,185 1, ,597 26,986 Therapies (1) 56,970 18,700 15,462 5,844 72,432 24,544 Personal Support 2,709,463 20, ,052 1,959 2,972,515 22,140 Other 35,431 24,351 1, ,315 24,926 Total 3,582,276 88, ,583 10,293 3,973,859 98,596 HOME FIRST Average Active Customers per Month Note 1: The following incremental volumes related to one-time funding will be added, once funding is approved: In-Home Therapies: 8,696 units, 2,131 clients; and In-School Therapies: 3,567 visits, 446 clients Page 2

97 Health System Funding (HSFR) Funding In a letter dated August 1, 2013, the Ministry provided additional 2013/14 base funding through Health System Funding Reform (HSFR) of $1,888,901 for HBAM and 2013/14 Quality Based Procedures (QBPs). The letter also included an additional $1,005,943 in QBP funding representing a reconfirmation of 2012/13 funding levels. It represents incremental funding of only $205,943 as the CCAC had already assumed $800,000 in the current MSAA. Community Sector Base Funding Increase In a letter dated August 1, 2013, the Ministry provided the details of the community sector base funding increase for 2013/14 which totals $27,515,700 for Central LHIN. The LHIN is allocating $18,805,156 of this amount to the Central CCAC to meet the following targeted priorities: $6,738,500 to Central CCAC to work toward a maximum five day wait time target for personal support services for clients with complex needs who are referred from community or hospital; and $11,866,656 to reduce ALC rates, support provision of in-home care, reduce avoidable hospital readmissions or emergency room visits within 30 days of hospital discharge, and support partners of Health Links to deliver care to the target/high needs populations including seniors and people with complex health conditions; Surgical and Diagnostic Wait Times Funding In a letter dated August 9, 2013, the Ministry communicated additional 2013/14 base funding of $221,000 for community rehabilitation volumes to be performed by Central CCAC. This funding and related volumes are incremental to those communicated in the August 1 st HSFR funding letter. One-Time Funds The Central LHIN anticipates the availability of $2,500,000 in discretionary one-time funds to be available later in the year. In addition to the above priorities, the funds will be utilized to reduce wait lists for services for school children, purchase increased medical supplies and provide additional in-home therapy services. Performance Targets and Deliverables A portion of the funding is being provided for the CCAC is to work towards a maximum five-day wait time target for personal support services, starting with clients with complex needs who require personal support services (referred from community or hospital). The intended target population is clients with complex and long-term medical, physical, cognitive and social conditions that place the client at risk of avoidable hospital utilization, ALC or premature institutionalization, or other issues if not appropriately supported. Page 3

98 The LHIN will be monitoring the impact of these investments through achievements on the percentage ALC days and unnecessary hospital readmissions and emergency room visits. Definitions and standards pertaining to wait times, wait lists and 5-day targets as well as standards for data collection and reporting are currently being developed in partnership with the Ministry and Health Quality Ontario. The CCAC will be expected to support and participate in the development of these standards and will be required to implement the standards once finalized. Until this work is complete, the CCAC will move forward with the deliverables as outlined above. CURRENT STATUS: There is increasing demand for CCAC services from both the hospitals and the community sector which has resulted in increased waitlists for personal support services and therapies. As of June 2013, waitlists for clients with high and very high needs were 157 for personal support services and 17 for therapies and other services. The incremental funding is anticipated to address these needs. Central CCAC is currently forecasting a balanced budget at fiscal year-end. NEXT STEPS: Central LHIN staff will communicate the incremental base funding to Central CCAC upon Board approval. The M-SAA will be amended to reflect the funding and service delivery targets. The incremental one-time funding will be confirmed with the CCAC upon availability of the funds, and the M- SAA will be amended at that point in time for funding and related deliverables. Central LHIN will continue to monitor Central CCAC performance, including waitlists for services. Page 4

99 Central LHIN CEO Report- Items for Information Table of Contents 8. CEO HIGHLIGHTS Interpretation Services Provincial Physiotherapy Services Reform Presentation Appendix A Minister s Medal to Honor Health System Partners/Providers Appendix B Common Quality Agenda- Health Quality Ontario Transitional Aged Youth with Medical Complexity Advisory A Cross LHIN and Cross Ministry Initiative Citizen s Health Advisory Panel Engagement Session Update Aboriginal Strategy Update French Language Services Update Health Links ehealth Update MOHLTC/LHIN Capital Planning Process Planning Submission Appendix C Ministry-LHIN Performance Agreement (MLPA) Targets Appendix D Quarterly Stocktake Report to Ministry of Health and Long-Term Care - Appendix E Community based specialty clinics Notice of Proposed Local Health System Integration Act (LHSIA) and Independent Health Facilities Act (IHFA) Regulatory Changes Leisureworld Senior Care Corporation and Speciality Care Inc Life or Limb Policy Summary of Hospital Compliance Reports Q4 Community Sector Performance Appendix F Q4 Hospital Sector Performance Appendix G Funding Allocations Delegated Authority Appendix H Central LHIN Board of Directors Page 1 CEO Report September 24, 2013

100 Central LHIN CEO Report- Items for Information 8. CEO HIGHLIGHTS Business Arising 8.1 Interpretation Services In 2011, Central LHIN commissioned The Regional Municipality of York and Social Enterprise for Canada to conduct the Improved Integration of Newcomers Project. The project examined, among other issues, organizational communication challenges and capacity within Central LHIN. In March 2012, a report was provided to the Central LHIN, which included the following key findings: Most community agencies engage staff, family members and friends of clients, to provide interpretation services. Occasionally, professional interpretation services are purchased; LHIN-funded agencies responded to the needs of their clients with who had limited English proficiency. However, they have no dedicated resources, plan to assess and/or address challenges, or any measures to assess performance and effectiveness. As a follow-up to the report, the Central LHIN conducted a survey with community support agencies from November to December 2012 to determine their capacity and need for interpretation services. The findings of the survey reinforced the March 2012 report from The Regional Municipality of York and Social Enterprise for Canada. As a result of the findings, Central LHIN awarded annualized funding of $99,999 through an RFP process to Vaughan Community Health Centre to coordinate the provision of interpretation services for CSS and MHA agencies in the Central LHIN. The initiative will roll out in October It is expected to serve approximately 2800 to 3200 clients per year, offering a range of interpretation services, including face to face, telephone, and video-conferencing. 8.2 Provincial Physiotherapy Services Reform Presentation Appendix A In light of the announcement regarding changes in OHIP funded physiotherapy services and as promised at the June 2013, Board meeting, please see the presentation (Appendix A). Provincial physiotherapy reform: Helping Seniors Stay Healy, Physically Active and Independent. Quality/Stakeholder Engagement 8.3 Minister s Medal to Honor Health System Partners/Providers Appendix B The Minister s Medal is a highly competitive and rigorous recognition program that will be awarded annually by the Minister of Health and Long-Term Care, ( the Ministry ). This recognition program is open to all health care partners across the system and is to recognize individuals and organizations, whom demonstrate exceptional work in collaboration, sustainable results, measurable outcomes, and promote system value, and quality within health care. The winners will serve as a resource for other teams in driving quality efforts across the system and their success will be profiled through various communications. Central LHIN Board of Directors Page 2 CEO Report September 24, 2013

101 Central LHIN CEO Report- Items for Information LHINs will take a lead in coordinating and promoting this program and will review all applications submitted to their offices to provide input regarding overall completeness, quality of the application, and capacity of the success being nominated to be spread to other regions/ settings. The LHINs will then forward all applications received to an external representative selection committee via the Ministry to review and score all applications and make recommendations on successful recipients. The successful applicants will be awarded their medal at Health Quality Transformation 2013, an annual event hosted by Health Quality Ontario, on November 21, Common Quality Agenda- Health Quality Ontario On September 10, Health Quality Ontario (HQO) shared a preview of their Common Quality Agenda Initiative. HQO s objective is to focus the system on quality improvement by identifying a priority set of performance indicators and associated targets and linking the system to the tools and resources that can support change. The common quality agenda is intended to focus efforts to move the needle on approximately 40 performance indicators. System integration indicators have also been developed which will require that health service providers work together. All indicators are already in use by our system and areas of focus include chronic disease, mental health and end of life care to name a few. Health Quality Ontario will be accountable through this agenda to provide evidence on: Which topic areas have the greatest potential for impact and will therefore be a priority; Benchmarks for targets to be used in QIPs; Relationship of indicators to Quality Based Procedures; Effective strategies and ideas for improvement and QI tools. 8.5 Transitional Aged Youth with Medical Complexity Advisory A Cross LHIN and Cross Ministry Initiative Central LHIN has shared its newly created congregate model for complex care in the community for children transitioning into adulthood with the GTA/NSM LHINs. With support of the CEOs of the GTA/NSM LHINs, Central LHIN is leading the cross-lhin engagement to support assessing this model for further roll out across LHINs more broadly. As part of the expansion, across LHINs, an advisory group was created. The membership includes stakeholders from Community Care Access Centres, community providers, physicians and representatives from the Ministry of Community and Social Services. The group is leveraging the cross- ministerial relationships developed by Central LHIN and expands the understanding of local needs of youth and young adults with medical complexities or in combination with developmental complexities. Within the group, it was recommended the current focus be on individuals between the age of 14-29, who are medically complex with or without a developmental/ intellectual disability. As a priority, the work will focus on clients who are living in the community or are designated alternate level of care (ALC) in hospitals. The Advisory Group will be preparing recommendations on how to build further capacity and expand services throughout the GTA and North Simcoe Muskoka. Recommendations are currently anticipated for Spring of Central LHIN Board of Directors Page 3 CEO Report September 24, 2013

102 Central LHIN CEO Report- Items for Information Central LHIN continues to identify this capacity need as a priority and intends to invest in expanding this model further through in-year reallocation. Support for the model has been well received by stakeholders and the LHIN is keeping the Ministry of Health and Long-Term Care apprised of developments. 8.6 Citizen s Health Advisory Panel Engagement Session Update The Central LHIN hosted eight community engagement sessions during the month of July, The sessions, titled Join the Conversation about Health Services in your Community, were hosted in Alliston, Georgina, Aurora, Vaughan, Markham and North York. Sessions were offered on both weekdays and on the weekend. In total, there were 287 participants a combination of both residents and health service providers. Participants ranged in age from youth to seniors. The objectives of the sessions included: discussing with the community with respect to their recent health care experiences; their recommendations for health system improvements and enhancements; and to explore interest to volunteer on the new Citizens Health Advisory Panel. The community engagement sessions began with an introduction to the Central LHIN, an overview of our Integrated Health Services Plan and Health Links. The majority of the session time focused on a conversation with residents around their experiences with the health care system and recommendations for improvement. The sessions concluded with an introduction to the Citizens Health Advisory Panel. The sessions were evaluated by the participants and feedback received through survey was positive. Analysis of the results is underway and a final report will be posted on the Central LHIN website and will be circulated to Health Service Providers and interested session participants. The information gathered will inform Central LHIN health system planning activities, including the establishment of the new Citizens Health Advisory Panel. The panel will host its inaugural meeting in the fall of The objective of the Panel will be to hear from residents on system challenges related to their experience in the health care system. 8.7 Aboriginal Strategy Update The Central LHIN is home to over 7,000 Aboriginal people, representing 0.4 per cent of the population living within the boundaries of the Central LHIN. The Chippewas of Georgina Island, comprising of approximately 200 residents, is Central LHIN s only First Nations and on-reserve community. In alignment with the Central LHIN Integrated Health Service Plan (IHSP) , the LHIN re-affirmed its commitment to collaborate and engage with the local Aboriginal population. The Central LHIN has engaged the on-reserve Aboriginal population in various initiatives related to Diabetes care over the past few years. There has, however, been no engagement to date, focused on the off-reserve Aboriginal population. As such, the Aboriginal Engagement Strategy is focused on the off-reserve population (approximately 7,100 people). Census data indicates that the majority of the off-reserve Aboriginal population lives in North York, Northern York Region and South Simcoe, with small pockets within other sub-lhin areas. Central LHIN Board of Directors Page 4 CEO Report September 24, 2013

103 Central LHIN CEO Report- Items for Information The initial consultations will begin with Aboriginal Health Service Professionals. This will allow the Central LHIN to understand the issues raised by the health professionals and help to frame the off-reserve Aboriginal population engagement. Eight community engagement sessions will take place between December 2013-March Goals of the engagement include discussing health care experiences of the off-reserve Aboriginal people and soliciting their feedback and recommendations for health system improvements. 8.8 Understanding Community Mental Health and Additions Needs, and Capacity within the Central LHIN School of Health Policy and Management, York University As part of a summer course at York University for Bachelor of Health Studies students, a group of students worked with Central LHIN staff to complete their project which focused on Understanding Mental Health and Substance Abuse Needs and Capacity in CLHIN. At the end of July students reported out their findings from their four month project. The focus of the project was to understand community mental health and addictions needs and capacity within the Central LHIN through conducting a needs and capacity assessment of community mental health and substance abuse programs within the Central LHIN planning areas. In the summer, recommendations resulting from the project were presented to the Central LHIN. The recommendations focused on: Prevention and health promotion programs; Implementing plans to increase access to community psychogeriatric health care services; Increasing access to translation services especially in the area of substance abuse. 8.9 French Language Services Update On September 10, 2013, the French Language Health Planning Entity #4 (Entité 4) held its third annual general meeting in Aurora. Entité 4 made a presentation, which featured partner collaborations during The highlighted collaborations focused on improved access and health outcomes for the francophone communities of the Central, Central-East and North Simcoe Muskoka LHINs. Two key achievements included the French peer leader training on chronic disease self-management that took place in September 2012 and the planning activities which resulted into the prioritization of the 37 francophone beds at the Pavillon Omer Deslauriers of Bendale Acres Long-Term Care Home in Scarborough by the Central East Community Care Access Centre (CCAC) in collaboration with the Central CCAC on June 3, In recognition of their leadership role and the fulfillment of the achievements, both the Central CCAC and Southlake Regional Health Centre (Southlake) were presented with awards by Entité 4. Up-coming collaborations include the French chronic disease self-management workshop series, which will be hosted in Richmond Hill from September 28 to November 2, 2013.The workshops aim to help francophone individuals with a chronic condition, their family members or caregivers manage their condition. Central LHIN Board of Directors Page 5 CEO Report September 24, 2013

104 Central LHIN CEO Report- Items for Information Capacity Planning 8.10 Health Links In a letter dated July 15, 2013, the Ministry allocated $600,000 in one-time funding for the fiscal year to each of The North York Central Health Link, and The South Simcoe Northern York Region Health Link to implement the initiatives outlined in the Health Link s Business Plan, including the Resource Plan. Key deliverables include: Coordinated care plans for complex patients; Regular and timely access to a primary care provider for seniors and complex patients; Patient and family engagement. On July 9, 2013, Central LHIN submitted the readiness assessment to The Ministry of Health and Long-Term Care ( the Ministry ) for the South West York Region Health Link. This link will soon be up and operational with our two existing Health LINKs- South East York Region and North York West. There are five Health Links planned for Central LHIN in total. Engaging Community Providers In June 2013, Central LHIN held two Planning Days, one for the Community Support Service providers and the other for the Mental Health and Addictions providers. Follow up sessions have been planned for fall 2013 to continue to define opportunities to integrate care to better support complex clients across the LHIN and within the Health Links. Predicting High Users On September 16, 2013, Central LHIN held a special meeting of the Health Links System Planning Committee. The first part of the session was interactive dialogue with Dr. Walter Wodchis, Associate Professor at the Institute of Health Policy Management and Evaluation at the University of Toronto, on predictive tools. The tools explored identifying patients with complex needs and garnered the support of the committee ehealth Update Resource Matching and Referral Improvements Following on the implementation of RMR across the Central LHIN Hospital/CCAC, Humber River Regional Hospital is taking an operational lead role to work with the key stakeholders as they streamline the process even further to improve the solutions by reducing the amount of duplication of data entry that is currently required by clinicians. This effort will enable the hospital systems currently in place to better align with the solution to reduce the time to make an electronic referral further Telehomecare Telehomecare is a program that allows clients to remotely input and transmit their vital health information electronically from their home to a remote monitoring care team. In July 2013, Central LHIN provided funding to Southlake Regional Health to implement a Telehomecare program as part of the South Simcoe Northern York Region Health Links. Plans to enroll the first client in the Telehomecare program in November 2013 are proceeding on schedule. ConnectingGTA View-Only Expansion ConnectingGTA integrates data collected in clinical information systems (e.g., Hospital Information Systems and local, regional and provincial registries and repositories) and acts as a Central LHIN Board of Directors Page 6 CEO Report September 24, 2013

105 Central LHIN CEO Report- Items for Information central point of access to provincial data (e.g., Ontario Laboratory Information System) and other clinical prioritized data (e.g., Discharge Summaries). An exciting new project is the ConnectingGTA view-only expansion project where 9000 health care providers, spread over 70 sites (other than acute care), across our Cluster will be given view-only access to the ConnectingGTA clinical data repository. Access to the repository is anticipated to support clinical decision making. The Central LHIN is currently working with our Cluster partners to identify and select the 70 sites that will be given access. The goal is to have the sites selected by Mid-October Electronic Medical Record Adoption One of our ehealth Strategic Plan goals is to significantly increase our Primary Care Electronic Medical Record adoption from its initial 63% to at least 67%. Working closely with OntarioMD, we held an Electronic Medical Record adoption Physician Engagement session on September 10, Both OntarioMD and CLHIN were very excited as this is the very first OntarioMD/LHIN co-hosted session in the province. The event was well attended with over 100 Primary Care Providers present, many of which have signed up for Electronic Medical Record offered through OntarioMD. As a result, Central LHIN is looking forward to the outcome of improved patient care through increased EMR adoption and strengthened relationships with our Primary Care Provider. Hospital Report Manager Hospital Report Manager is a critical enabler for our Health Links project. Hospital Report Manager will greatly reduce the amount of time it takes to deliver Hospital Diagnostic Imaging and Medical Reports to Primary Care Providers from days to 30 minutes of being released. Our Hospital Report Manager project is on track and progressing very well. 5 of our 6 hospitals are engaged and at various stages of implementation: Markham Stouffville Hospital Early adopter live; North York General Hospital Implementing, going live November 2013; Stevenson Memorial Hospital, Southlake Regional Health Center, and Mackenzie Health Planning with a tentative go live of February 2014; Humber River Hospital- currently developing their business case MOHLTC/LHIN Capital Planning Process Planning Submission Appendix C There are several capital redevelopment planning initiatives underway at Central LHIN hospitals. These initiatives are at various stages of approval, details shown at Appendix C. System Accountability and Performance Ministry-LHIN Performance Agreement (MLPA) Targets Appendix D In July 2013, Central LHIN Management negotiated with the Ministry to arrive at the targets included in the appendices. LHINs currently report on 15 MLPA indicators covering Alternate Level of Care/Emergency Room, surgical and diagnostic wait times, quality, mental health and substance abuse, and access to community care. The eleven ALC/ED and wait time indicators have both provincial and local LHIN targets, while the remaining indicators do not have provincial targets. Central LHIN Board of Directors Page 7 CEO Report September 24, 2013

106 Central LHIN CEO Report- Items for Information The negotiations utilized the target setting approach proposed by the ministry to the LHIN CEOs in June The principles of the approach presented include: Continuing to demonstrate progress on the indicators in the MLPA; Maintaining gains that have been achieved on specific indicators provincially or in specific LHINs; Reducing the variation or gap in performance across the province, and Establish performance corridor for monitoring risk. The indicators and targets for surgical and diagnostic wait times have been changed from 90P wait times to percent of Priority IV cases completed within access time targets. Priority IV cases represent the lowest level of priority. There is no direct correlation between achieving 90P wait times and percent of Priority IV cases completed. LHIN staff is further analyzing the new targets and past performance. Specific targets in the Appendix have been colour-coded orange to indicate that these are stretch targets which require improvement over the LHIN performance in 2012/13 or the most recent quarter to achieve the fiscal 2013/14 targets. The LHIN is currently in discussion with health service providers to communicate the LHIN targets and to align the accountability agreements and LHIN funding investments with these targets Quarterly Stocktake Report to Ministry of Health and Long-Term Care - Appendix E Central LHIN received its Quarter One 13/14 performance report from the Ministry of Health and Long-Term Care, on August 12, There are two reporting changes in the new release: The seven Surgical and Diagnostic Imaging indicators previously reported as 90th percentile are replaced with Percent of cases completed within access target ; The color coding has changed; in the previous reports, green color indicated results within acceptable performance range (within 10% of target), whereas in this quarterly report, green color is attained when performance meets target and thus there is no performance corridor. Central LHIN is ranked #1 in the province for the 90th percentile ER Length of stay for nonadmitted minor uncomplicated patients and for Percent of priority 4 cases completed within access target for cataract surgery. Central LHIN performed slightly below its target and is in yellow for two indicators, Percentage of ALC days and 30-day readmission rate for selected CMGs. Although the 30- day readmission rate for selected CMGs is slightly below its target, Central LHIN has exceeded the provincial performance. Plans are in progress to decrease ALC days within the Central LHIN for the year 13/14 to meet or exceed performance. There are five indicators which continue to be a challenge within the Central LHIN: Percent of priority 4 cases completed within access target (28days) for MRI Scans; Percent of priority 4 cases completed within access target (28days) for CT Scans; 90th Percentile Wait Time for CCAC In-Home Services; Repeat Unscheduled Emergency Visits within 30 Days for Mental Health Conditions; Repeat Unscheduled Emergency Visits within 30 Days for Substance Abuse Conditions. Central LHIN Board of Directors Page 8 CEO Report September 24, 2013

107 Central LHIN CEO Report- Items for Information Plans are in progress to explore strategies to meet targets for these indicators. A summary report is attached as Appendix E Community based specialty clinics Notice of Proposed Local Health System Integration Act (LHSIA) and Independent Health Facilities Act (IHFA) Regulatory Changes On August 12, 2013, the Ministry of Health and Long-Term Care (the Ministry ) posted two proposals to the regulatory registry to amend Regulation 264/07 made under the Local Health System Integration Act ( LHSIA ) and to create a new Regulation under the Independent Health Facilities Act ( IHFA ). The amendments are designed to allow LHINs and Cancer Care Ontario (CCO) to directly fund specialty clinics licensed as independent health facilities (IHFs). Current Legislation Under LHSIA, LHINs are able to fund health service providers that provide services in the LHINs geographic region. Health service providers must sign accountability agreements with the LHIN and are subject to the auditing and reporting requirements of the Act. Currently, LHINs may only fund the entities enumerated in subsection 2(2) of Local Health System Integration Act which sets out 11 categories of "health service provider" including, additional persons or entities (or classes of persons or entities) to be prescribed as health service providers by regulation. Under the Independent Health Facilities Act, independent health facilities are prohibited from charging or accepting payment of facility fees unless those fees are charged to or payment is received from the Minister or a prescribed person. Proposed Changes These changes will allow the Ministry s proposed community-based specialty clinics to be set up as Independent Health Facilities that may be funded directly from the LHIN or from Cancer Care Ontario if providing cancer related services. The amendments to Regulation 264/07 aim to prescribe all Independent Health Facilities as health service providers under the Independent Health Facilities Act. Effectively, this would expand the list of entities that LHINs would be able to fund and sign accountability agreements with. The new regulation under the Independent Health Facilities Act aims to prescribe all LHINs and Cancer Care Ontario as persons able to charge fees to and accept payment from Independent Health Facilities under the Independent Health Facilities Act. This would allow LHINs and Cancer Care Ontario to provide funds in support of the medical procedures that the independent health facilities provide. Both proposals state explicitly that services will not be shifted from hospitals if changes to capacity will impact their stability and the establishment of community-based specialty clinics will be guided by clinical evidence and stakeholder consultations. Comments on the proposals may be submitted on the Regulatory Registry website until October 11, No draft regulations will be released as part of the consultation process. Based on this timing, it seems likely that the earliest the Ministry will begin the process to transfer procedures from hospitals to Community-Based Specialty Clinics would be late 2013 or early Central LHIN Board of Directors Page 9 CEO Report September 24, 2013

108 Central LHIN CEO Report- Items for Information 8.16 Leisureworld Senior Care Corporation and Speciality Care Inc. In April 2013, Central LHIN was made aware by the Ministry of Health and Long-Term Care ( the Ministry ) that the following Long-Term Care facilities: Bloomington Cove (Stouffville), Bradford Valley (Bradford), and Cedarvale Lodge (Keswick), whose licences are held by Specialty Care Inc., were the subject of a joint proposal involving the transfer of licences to, The Royale Development GP Corporation (Leisureworld Senior Care Corporation). It is anticipated that the licence transaction will close in September The Ministry has the sole authority, through the Minister of Health and Long-Term Care, under the Long-Term Care Homes Act, 2007 (LTCHA), to make decisions about who holds a licence or approval to operate a Long-Term Care home. On the basis of the Long-Term Care Licence Transaction Policy and Local Health System Integration Act, (LHSIA), 2006, Central LHIN staff view that the transaction proposed is a voluntary integration. On July 26, 2013, Central LHIN apprised Specialty Care Inc. and The Royale Development GP Corporation (Leisureworld Senior Care Corporation), that the transaction is in accordance with the provisions outlined in Section 27 of the Local Health System Integration Act, (LHSIA) 2006 and will not issue a decision to stop the proposed integration. Further notice was received from the Ministry on August 28, 2013 that public consultation on the proposed licence transfer of the LTC homes will be conducted in October Life or Limb Policy In response to recommendations from the Office of the Chief Coroner, a Life or Limb Policy ( the policy ) has been developed province wide to assist with care for the sickest, most vulnerable and critically ill patients and promotes the patient s clinical condition as a priority. The development of the policy was led by the Critical Care Services Ontario (CCSO) and was supported by the Provincial Program Branch of the Ministry of Health and Long-Term Care ( the Ministry ) as well as the LHINs. Critical Care Services Ontario in partnership with the LHINs, is holding provincial tours for an inclusive and collaborative dialogue across and at all levels of stakeholder groups within each LHIN. The tour for the Central LHIN was the first of these series and was held jointly with the Toronto Central LHIN on September 9, Central LHIN s CEO and Critical Care Lead provided opening remarks at the session The objectives of the policy, processes and accountabilities required to support the provision of timely and appropriate care for patients with life or limb threatening conditions and efficient repatriation were the focus of this meeting. The meeting was well attended and representation included: emergency department physicians, hospital s chiefs of staff, critical care clinicians, patient flow and repatriation coordinators, and hospital senior leadership. The final policy is being reviewed by the Ministry s and will be disseminated to the LHINs in the coming months. The expected implementation of this policy across the province is by January 1st, In the coming months, Central LHIN s Critical Care Lead and staff will be working with the key stakeholders to implement this policy across all Central LHIN hospitals 8.18 Summary of Hospital Compliance Reports As of April 1, 2011, under the Broader Public Sector Accountability Act, 2010, ( BPSAA ) and the Directives to Hospitals in respect of reporting Requirements under the BPSAA, every Central LHIN Board of Directors Page 10 CEO Report September 24, 2013

109 Central LHIN CEO Report- Items for Information hospital is required to prepare and submit to the LHIN compliance reports and reports on the hospitals use of consultants. The following summarizes the results: All six public and three private hospitals have submitted their declarations of compliance and report on the use consultants; Four hospitals declared non-compliance on procurement contracts as part of a shared-service arrangement for contract management. All hospitals have received a plan from the shared services organization to address this non-compliance issue; In addition, two hospitals declared non-competitive consulting contracts. The reasons for the non-competitive contracts were within the allowable exclusions under the Agreement on Internal Trade, and were within the hospital CEO s delegation of authority to approve Q4 Community Sector Performance Appendix F 53 of the 55 Community Sector Health Service Providers (HSP) within the Central LHIN reported their 2012/13 fourth quarter financial and activity performance results as per Article 8.1 (b) of the Multi-Sector Service Accountability Agreement. The following is a summary of the results: 36 HSPs (65%) achieved both a balanced budget and at least 80% of the performance indicators in the Multi-Sector Service Accountability Agreement were within corridor; 13 HSPs (24%) achieved a balanced budget but did not achieve 80% of the performance indicators within corridor in the Multi-Sector Service Accountability Agreement; 4 HSPs (7%) did not achieve a balanced budget but achieved at least 80% of the performance indicators in the Multi-Sector Service Accountability Agreement. 2 of the 4 HSPs had surpluses in excess of 2%, and 2 of the 4 HSPs had deficits in excess of 2% of the budgets; 2 HSPs (4%) did not submit the Q4 report. The attached scorecard details the specific Health Service Providers in each category as described above. Central LHIN staff has followed up verbally and through with the Health Service Providers that did not achieve either balanced budgets or 80% of volume targets to determine causes. A non-compliance letter will be sent to each agency. Central LHIN tracks non-compliance and considers this as a factor when allocating discretionary funds. In addition, staff is reviewing the current year MSAAs for these agencies to determine whether a funding or volume adjustment is required on a case by case basis. A memo has been sent to the two agencies that did not submit their Q4 reports Q4 Hospital Sector Performance Appendix G As per the reporting requirements outlined in the Hospital Service Accountability Agreement, Central LHIN Hospitals have submitted reports with details of performance through the fourth quarter 2012/13. Overall, Central LHIN hospitals performed well compared to the targets set out in the Agreements. There are three indicators, Percentage Alternate Level of Care Days, Current Ratio, and Rate of Hospital Acquired Clostridium Difficile Infections (C.diff), which continue to be a challenge to several Central LHIN hospitals through the fourth quarter of 2012/13. Alternate Level of Care (ALC) There has been a positive trend in Central LHIN's percentage ALC days as compared to from the same quarter (Q3) in 2011/12. While Central LHIN did not meet the MLPA performance Central LHIN Board of Directors Page 11 CEO Report September 24, 2013

110 Central LHIN CEO Report- Items for Information target and three of Central LHIN s public hospitals did not meet their hospital-specific targets, an improvement from the baseline was achieved. There was a decrease in the number of patients waiting in hospital as ALC for a long-term care bed with an offsetting increase in ALC patients waiting to go to other destinations such as home with CCAC services. This is primarily related to a renewed and broadened Home First Philosophy being implemented by all Central LHIN hospitals. Wait times for other destinations are shorter and Central LHIN staff is working with CCAC staff to closely monitor this shift in discharge destination for these ALC patients. Other efforts that are expected to improve results include: Enhanced adoption of best practice pathways for patients with hip fracture, stroke and other conditions waiting as ALC for inpatient rehab; Continued focus on Senior Friendly hospital care; Continued success with initiatives such as: assess and restore programs, and the specialized Behavioral Support Unit at Cummer Lodge (expansion from 8 to 16 Beds). Explanations for current ratio and Rate of Hospital Acquired Clostridium Difficile Infections (C.diff) performance are included in the hospital-specific comments below. The following summaries detail highlights of financial and clinical performance by hospital for fiscal 2012/13. A full performance dashboard can be found in Appendix G. 1. Humber River Hospital LHIN Base Funding: $247.3 million Number of Beds (average): 498 Year-end Surplus/(Deficit): $(2.2) million Total Margin (H-SAA indicator): $87,116 Cash and Investments as of Mar 31: 9.4 million Number of FTEs (average): 2,453 Long-term Debt as of Mar 31: $0 Humber River Hospital is generally performing well compared to Hospital Service Accountability Agreement (H-SAA) targets with the exception of those indicators noted below. Total Inpatient Acute Activity Weighted Cases: While total cases increased in 2012/13, a decrease in Resource Intensity Weight (RIW) resulted in a decrease in weighted cases. 90 th Percentile Wait Time for Knee Replacement: To improve performance, the hospital will assign open operating room blocks to surgeons who are over their average wait times. Also, surgeons offices are being reminded to close patient records when there are changes in status. Rate of Hospital Acquired Cases of C. Difficile Infections: The endemic rate at the Church site is traditionally higher due to the high number of dialysis and nursing home patients at the site. The hospital is continuously working on improvements in hand hygiene, antibiotic utilization and the quality of cleaning to improve performance. Central Line Infection Rate (CLI): The hospital is undertaking quality improvement initiatives to address performance, including: review of Safer Healthcare Now! (SHN!) protocols and audit of compliance with the SHN! bundles Central LHIN Board of Directors Page 12 CEO Report September 24, 2013

111 Central LHIN CEO Report- Items for Information to achieve and sustain a zero rate of CLI. 2. North York General Hospital LHIN Base Funding: $230.8 million Year-end Surplus/(Deficit): $9,750; Total Margin (H-SAA Indicator): $3.1 million Number of Beds (average): 413 Cash and Investments as of Mar 31: $26.6 million Number of FTEs (average): 2,123 Long-term Debt as of Mar 31: $17.3 million North York General Hospital is performing favorably with respect to H-SAA targets, with no exceptions noted. 3. Southlake Regional Health Centre LHIN Base Funding: $260.2 million Number of Beds (average): 397 Number of FTEs (average): 2,252 Year-end Surplus/(Deficit): $(5.6) million Total Margin (H-SAA indicator): $1.1 million Cash and Investments as of Mar 31: $6.9 million Long-term Debt as of Mar 31: $47.7 million Southlake Regional Health Centre is performing well compared to H-SAA targets, with the exception of those indicators noted below. Complex Continuing Care RUG Weighted Patient Days: While total chronic patient days is in line with budget, actual Resource Utilization Group (RUG) weighting was significantly lower than budgeted weights, which resulted in lower than expected RUG Weighted Patient Days. Current Ratio: The timing of year-end accruals affected the hospital s current ratio. Current ratio is improving during Q1 2013/14 and the hospital is making continued efforts to improve this indicator. The hospital may be eligible to receive assistance through the provincial Working Funds Deficit Initiative. Rate of Hospital Acquired Cases of C. Difficile Infections: The hospital continues to focus efforts on Antimicrobial Stewardship strategies and continues to place emphasis on the importance of Hand Hygiene as well as environmental cleaning. Full year performance is in line with the provincial average rate for similar sized community peer hospitals. Included as one of the hospital s antimicrobial strategies is the pocket information card for prescribers. The hospital is updating pocket cards to inform health care providers of the antimicrobial susceptibility patterns that are relevant for their patient population. Central Line Infection Rate: Full year performance was slightly higher than the hospital s performance corridor. This indicator is being actively monitored on the hospital scorecard. 4. Mackenzie Health LHIN Base Funding: $184.9 million Number of Beds (average): 351 Year-end Surplus/(Deficit): $9.8 million Total Margin (H-SAA indicator): $10.3 million Cash and Investments as of Mar 31: $49.1 million Number of FTEs (average): 1,557 Long-term Debt as of Mar 31: $0 Mackenzie Health is performing well on H-SAA indicators except for the following: Central LHIN Board of Directors Page 13 CEO Report September 24, 2013

112 Central LHIN CEO Report- Items for Information Year End Total Margin: The hospital ended the year with a $10.3M surplus due to the recognition of $9.6M in deferred PCOP funding late in the fiscal year. 5. Markham Stouffville Hospital LHIN Base Funding: $117.4 million Number of Beds (average): 245 Number of FTEs (average): 1,162 Year-end Surplus/(Deficit): $(2.2) million Total Margin (H-SAA indicator): $1.4 million Cash and Investments as of Mar 31: $39.2 million Long-term Debt as of Mar 31: $39.9 million Markham Stouffville is performing well on H-SAA indicators with the exception of those indicators noted below. Rate of Hospital Acquired Cases of C. Difficile Infections: Markham Stouffville Hospital s Uxbridge site is a small hospital and its rate of 1.11 equated to only one case. All inpatient cases including this case are reviewed by the Antibiotic Stewardship team. Monthly hand hygiene audits are conducted and results are shared and discussed with staff and managers. Monthly environmental cleaning audits are also conducted and reported. Tools have been given to all nursing staff to assist them in early identification of suspected C. Difficile Infection patients and prompt implementation of precautions. Current Ratio: Markham Stouffville Hospital has a high current ratio compared to the target of 0.8 due to the current expansion project. The current ratio is heavily influenced by the timing of cash flows from MOHLTC for capital project expenses and PCOP. 90 th Percentile ER LOS for Admitted Patients: Markham implemented a new admission assessment unit (AAU) in May 2013 with the goal of reducing the length of time to admit ED patients to an inpatient bed. The provisional Q1 2013/14 results are significantly improved. 6. Stevenson Memorial Hospital LHIN Base Funding: $18.4 million Year-end Surplus/(Deficit): $12,923 Total Margin (H-SAA indicator): $107,227 Number of Beds (average): 38 Cash and Investments as of Mar 31: $0.8 million Number of FTEs (average): 176 Long-term Debt as of Mar 31: $200,000 Stevenson is performing well compared to H-SAA targets, with the exception of those indicators noted below. Current Ratio: Stevenson was not able to meet a current ratio of 0.8. The lack of Small Hospital Funding added to the financial challenges of the hospital during 2012/13. A plan to generate a surplus has been established and is in process. 90 th Percentile Wait Time for Cataract Surgery: Stevenson has a relatively small number of surgeries; therefore, a few cases in excess of the access target impacted the hospital s performance. The hospital has implemented weekly monitoring and increased communication with surgeons booking staff to improve performance. Rate of Hospital Acquired Cases of C. Difficile Infections: The hospital experienced two cases of C. diff. in November 2012 with no cases reported since that time. A new IPAC (Infection Prevention and Control) Coordinator has been Central LHIN Board of Directors Page 14 CEO Report September 24, 2013

113 Central LHIN CEO Report- Items for Information assigned to the function and an increase in hand hygiene awareness and audits have been implemented Funding Allocations Delegated Authority Appendix H Description of the funding delegations approved by Central LHIN staff since the Last Board of Directors meeting in June 2013 are indicated in Appendix H. Central LHIN Board of Directors Page 15 CEO Report September 24, 2013

114 Appendix A Provincial physiotherapy reform: Helping Seniors Stay Healthy, Physically Active and Independent Presentation to Central LHIN Board September 24, 2013

115 Agenda 1. What is physiotherapy reform? 2. Background and rationale for change 3. Update on five streams of reform In-home physiotherapy Long-Term Care Homes Community Falls Prevention and Exercise Classes Clinic-based physiotherapy Family Health Care Strategies 6. Implementation challenges 7. Feedback received 2

116 What is Physiotherapy Reform? A major change has occurred in Ontario related to how physiotherapy services, that were previously funded under the OHIP budget, are now funded. The intent is to improve the availability of these services across the province to significantly boost access for seniors and others in need. 3

117 Background Information Regulation 552 of the Health Insurance Act prescribes the non-universal patient coverage, care settings and payment model for OHIP-funded physiotherapy services Clients Served Residents of Long-Term Care (LTC) Homes Patients over 65 years (90% of billed services), those under 20 (<1% of services) and Ministry of Community and Social Services clients between 20 and 64 years of age People of all ages needing physiotherapy in their home or after overnight hospitalization Care Settings OHIP previously funded physiotherapy in clinic settings (11% of billed services), in patient s home (29% of services), and in LTC Homes (60% of services) ~90 OHIP funded clinics were in operation in Ontario Geographically concentrated in the Greater Toronto Area A single referral (physician or Registered Nurse in Long Term Care Homes) entitled a patient to services indefinitely, subject to assessments by a physiotherapist employed by an OHIP funded clinic 4

118 Rationale for Change Expenditures growing disproportionately to demand and demographics Physiotherapy services not well defined by current regulation (time-limited and goal oriented versus maintenance and activation) Funding model not reflective of best practices Inequity in access Need for changes supported by experts (Dr. Walker and Dr. Sinha reports, Drummond report) 5

119 In-home Physiotherapy- Stream 1 of 5 CCACs are the single point of access for in-home physiotherapy services All clients receiving in-home CCAC physiotherapy can access service and are assessed for physiotherapy services in the same manner Assessment for physiotherapy is part of a more comprehensive assessment of supports needed to keep seniors at home Opportunity to expand options for providing physiotherapy in group/congregate settings Approximately 3000 new clients will be coming onto CCAC service in Central LHIN 6

120 Long-Term Care Homes- Stream 2 of 5 Homes are receiving direct funding through LHINs to provide physiotherapy All 46 Central LHIN LTCH have service and signed contracts in place Residents who have an assessed need for physiotherapy in their plan of care are receiving one-on-one, episodic physiotherapy in their LTC home to help them restore their mobility and function Residents will continue to enjoy services provided as part of the LTC home s recreation and social activities program, like exercise classes 7

121 Community Exercise and Falls Prevention Classes Stream 3 of 5 LHINs are maintaining the exercise and falls prevention services currently in place and affected by the changes (retirement homes, assisted living sites and seniors buildings) LHINs will expand exercise and falls prevention classes to improve access to these services for more seniors in more communities across LHIN geographic areas Funded to provide 395 exercise classes and 247 falls prevention classes Currently providing approximately 51 exercise and 27 falls prevention classes to 50 sites (replacement) Central LHIN has selected Carefirst Seniors and Community Services Organization, Better Living Health and Community Services, and Circle of Care to deliver exercise and falls prevention programs 8

122 Clinic-based Physiotherapy- Stream 4 of 5 Physiotherapy services funded by the Ministry Current physiotherapy service providers were offered opportunity to enter into new agreements 14/15 accepted in Central LHIN (1 clinic closed) Ministry issued a request for proposals to increase the number of access points 106 proposals were submitted for Central LHIN LHINs provided recommendations on geographic distribution in June 2013 Central LHIN has identified the following areas of need for clinic-based physiotherapy services: Alliston, Bradford, East Gwillimbury, Georgina, King, Stouffville, Vaughan, Richmond Hill and Markham (currently, the majority of clinics are located south of Steeles Ave.) LHINs requested to review proposals and submit recommendations by end of September

123 Family Health Care Settings- Stream 5 of 5 Program-based integration of physiotherapists into primary care settings (i.e. integration of physiotherapists into chronic disease management, healthy aging, seniors care programs, etc.) funded by the Ministry Ministry issued a Call for Applications for Community Health Centres (CHCs), Family Health Teams (FHTs), Nurse Practitioner Led Clinics (NPLCs) and Aboriginal Health Access Centres (AHACs) for approval of new physiotherapy positions and to fill existing vacancies 7 primary care teams submitted applications in Central LHIN Ministry requested LHINs to review applications by mid September 80% Ministry and 20% LHIN weightings to proposals 10

124 Implementation Challenges Judicial Review process delayed original start date of August 01, to August 22, 2013 Identification of replacement group exercise and falls prevention sites Change management Limited exercise equipment available LHIN/Ministry exploring funding options Health human resource recruitment and retention 11

125 Feedback to Date: Key Themes Clinic Based Physiotherapy Many inquiries from the public regarding new clinics locations Exercise and Falls Prevention Many inquiries from the public with respect to class locations Enthusiasm and interest generated in community Satisfaction with new programs 1:1 In home Physiotherapy Concerns with perceived reduction of services Individualized care plan developed 12

126 August 13, Congratulations to all the ACE Award nominees! For Ministry of Health and Long-Term Care employees Minister s Medal to honour health system partners/providers HEALTHY CHANGE The ministry has announced a new recognition program open to all health system partners/providers to celebrate their achievements and acknowledge the excellent work they deliver. The Minister s Medal Honouring Excellence in Health Quality and Safety is designed to showcase Ontario s ongoing commitment to advancing the quality and safety agenda in Ontario. The awards program was announced Aug. 1, This recognition program provides the ministry with an opportunity to highlight and showcase the achievements of our health system partners and their ongoing commitment to advancing health quality and safety. It s unprecedented in scope and breadth, spanning across providers. It not only recognizes teams, but also individual champions in achieving value-driven, outcome-based success for better patient care, said Deputy Minister Saäd Rafi. This[Minister s Medal] is also a wonderful opportunity for the winners to not only provide an example but also serve as a resource for the entire sector in driving quality efforts across the system, wrote MOHLTC Minister Deb Matthews in a letter to health care providers posted on the Minister s Medal webpage. Recognition program part of a collaborative effort The Health Quality Branch (HQB) of the Negotiations & Accountability Management Division (NAMD) has led the development of the recognition program over the past year, working closely with the Communications and Marketing Division (CMD), Local Health Integration Networks (LHINs) and Health Quality Ontario (HQO). Champions of excellence in health service delivery are helping to transform the health care system. This opportunity for recognition by the minister is a tremendous acknowledgement of their commitment to quality and safety, said Kim Baker, Chief Executive Officer, Central LHIN. Consultations have also occurred with similar recognition and awards programs in Ontario and with other jurisdictions. Rollout of the medal is supported by a communications strategy developed by CMD. LHINs will advertise and promote the medal to local health system providers/partners, and will be involved in the review of applications as part of a comprehensive, rigorous review process. At the local level, Local Health Integration Networks are excited to take the lead in promoting and coordinating recognition of these champions who are truly making Ontario s health care system better for all, said Baker. Focus on health quality, safety and transitions in care Susan Fitzpatrick, Assistant Deputy Minister, NAMD, said while the ministry has had award programs in the past, the medal is unique, because, it s a way to honour the excellent work being done across the system, Fitzpatrick said. The principles and criteria align with priorities of the Action Plan for Health Care, the Excellent Care for All Strategy and the goals of Health Links. While every year the focus will be on health quality and safety, which Fitzpatrick said are...continued on page 2 Champions of excellence in health service delivery are helping to transform the health care system. This opportunity for recognition by the minister is a tremendous acknowledgement of their commitment to quality and safety. Kim Baker, Chief Executive Officer, Central LHIN.

127 ...continued from cover 2 both important for improving care, this year the medal will recognize successes that improve transitions in care for those with multiple, complex conditions. Winners will be formally announced and recognized at HQO s Health Quality Transformation 2013 on Nov. 21. HEALTHY CHANGE Minister s Medal criteria The award is a self-nominated process. Teams as well as individuals, who have demonstrated outstanding achievement, can apply for the medal. The application template includes a set of weighted criteria that prioritizes: 1. Demonstrated collaboration across health system partners for improved transitions in care. 2. Improvement in outcomes supported by data/ performance results. 3. Providing system value while delivering quality care. 4. Ensuring a plan is in place to facilitate the spread of evidence and sustainability of the success over time. A patient/client testimony is also part of the application process and will outline how the initiative/ program has impacted their health care experience. A representative selection committee will review and score the applications. Members of the committee will include LHIN representatives, system leaders representing fields such as e-health and information technology, quality methods and performance measurement, financial value, transformation/change management, a patient representative, and other representatives from across care sectors. The medal s legacy As for the legacy of the medal program, Fitzpatrick said it is three fold. First, it s an ongoing recognition program that provides the ministry with the opportunity to identify and recognize champions of excellence in health quality and safety. It reinforces the minister s commitment to quality and safety. Secondly, it builds Ontarians confidence that their health care providers are working together to provide high-quality, patientcentred care. Lastly, it acknowledges the efforts of health care providers to make a difference in the system and encourages them to continue their improvement efforts and spread best practices. How to apply Health care partners/providers who would like to apply for the medal can contact their LHIN or visit the MOHLTC website for the application template, frequently asked questions, and a letter from the Minister announcing the medal to Ontario s health care providers. The deadline for submissions is Sept. 16. Employees are encouraged to help spread the word to health system providers and partners. For more information about the Minister s Medal, contact Sarah Costa, senior policy consultant, HQB at Sarah.Costa@ontario.ca. n Congratulations to all the ACE Award nominees! This year, the ministry received 32 exciting ACE Award nomination submissions, up seven per cent from the ACE Award year. Want to know who s nominated? Read a summary of each initiative in all five categories: customer service, innovation, outstanding achievement, cross functional teams, and partner relations, on the ACE Awards page. Nomination packages have been sent to the selection committee members for review. Winners will be announced in the fall. Be sure to mark Nov. 28 in your calendar and plan to join Deputy Minister Saäd Rafi as he hosts the ACE celebrations in the Ontario Room at Queen s Park from 1 to 3 p.m. Or, watch the festivities live from your desktop via ALI. Details will be released closer to the event. n Inside Health is published for employees of the Ministry of Health and Long-Term Care by the Communications and Marketing Division. We welcome your story suggestions, tips on upcoming events, photo submissions and comments. us at: askmohltc@ontario.ca Editor and writer: Nana Quainoo Contributing writer: Sarah Costa

128 MOHLTC/LHIN Capital Planning Process Planning Submissions Appendix C Provider Project Pre-Capital Submission Humber River Hospital Mackenzie Health Markham Stouffville Hospital Part A LHIN 1 Part B MOHLTC 2 Part A LHIN Stage 1 Proposal Part B MOHLTC Part A LHIN Stage 2 Functional Program Part B MOHLTC Stage 3 Design Stage 4 Tender RFP Stage 5 Construction Starts Stage 6 Occupancy Comments Site Consolidation: New Anticipated occupancy (in X Hospital Facility patient site) Ambulatory Care Centre Master Plan Updates Finch Site Joint comments for Part A issued by the Central LHIN management July 19, X X Part B comments sent by Ministry on July Endorsement letter will be needed. Two Site Model for Clarification requested Hospital Services August 1, (Vaughan and Richmond X X Anticipated Board of Hill) Directors endorsement will be sought for Fall Redevelopment X Winter Land Conveyance Central LHIN informed on July 30, 2013 of the need to convey land to the City of Markham for purpose of expanding hurch Street. Central LHIN awaiting business case in Fall Upon completion of Central LHIN review, Board of Directors endorsement will be sought, prior to submission to the Ministry. Legend: 1 Program and Service Elements 2 Physical and Cost Elements 1

129 MOHLTC/LHIN Capital Planning Process Planning Submissions Appendix C Provider Project Pre-Capital Stage 1 Stage 2 Stage 3 Part A Part B Part A Part B Part A Part B Design LHIN 1 MOHLTC 2 LHIN MOHLTC LHIN MOHLTC North York General Hospital Southlake Regional Health Centre Stevenson Memorial Hospital Master Plan Redevelopment General Site. Fit up of 7 th & 8 th Floors Mental Health 8-12 beds Cardiac Electro Physiology Redevelopment of Emergency Department, Operating Rooms, Diagnostic Imaging Laboratory. X X X X X X Stage 4 Tender RFP Stage 5 Construction Starts Stage 6 Occupancy Comments Under Central LHIN and Ministry review. Project approved. Anticipate occupancy April Under Central LHIN review. Submission received August 9, Targeting initial Central LHIN staff, review for completion in by November Clarification request sent May 15, Legend: 1 Program and Service Elements 2 Physical and Cost Elements 2

130 60 Renfrew Drive, Suite 300 Markham, ON L3R 0E1 Tel: Fax: Toll Free: Appendix D 2013/14 Targets for Central LHIN Indicator 12/13 Baseline 12/13 Target LHIN 12/13 FY Result and 13/14 Baseline (See notes) Result Most Recent Quarter Available 13/14 DRAFT Target Emergency Room/Alternate Level of Care Percentage of ALC days % 15.00% 16.27% 16.68% 15.00% 90th Percentile ER length of stay for admitted patients 2 8 hrs Provincial Interim Goal: 25 hrs th percentile ER length of stay for non-admitted complex patients 2 Provincial Target Provincial Interim Goal: 7 hrs th percentile ER length of stay for non-admitted minor/ 4 hrs uncomplicated patients 2 Surgical & Diagnostic Wait Times Percent of Priority IV Cases Completed Within Access Target for 90% NA NA 100% 100% 90% Cancer Surgery (Priority IV: 84 days) 2,3 Percent of Priority IV Cases Completed Within Access Target for 90% NA NA 96.5% 98.7% 90% Cardiac By-Pass Procedures (Priority IV: 90 days) 2,3 Percent of Priority IV Cases Completed Within Access Target for 90% NA NA 100% 100% 90% Cataract Surgery (Priority IV: 182 days) 2,3 Percent of Priority IV Cases Completed Within Access Target for 90% NA NA 96% 95% 90% Hip Replacement Surgery (Priority IV: 182 days) 2,3 Percent of Priority IV Cases Completed Within Access Target for 90% NA NA 95% 94% 90% Knee Replacement Surgery (Priority IV: 182 days) 2,3 Percent of Priority IV Cases Completed Within Access Target for 90% NA NA 48% 48% 55% Diagnostic MRI Scan (Priority IV: 28 days) 2,3 Percent of Priority IV Cases Completed Within Access Target for Diagnostic CT Scan (Priority IV: 28 days) 2,3 90% NA NA 84% 76% 85% Quality Readmission within 30 Days for Selected Case Mix Groups TBD 15.13% 15.00% 15.82% 16.83% 15.00% (CMGs) 4 Mental Health and Substance Abuse Repeat Unscheduled Emergency Visits within 30 Days for Mental Health Conditions 1 TBD 17.11% 17.00% 17.60% 19.40% 17.00% Repeat Unscheduled Emergency Visits within 30 Days for TBD 18.88% 18.70% 20.70% 22.10% 20.70% Substance Abuse Conditions 1 Access to Community Care 90th Percentile Wait Time from Community for CCAC In-Home Services Application from Community Setting to first CCAC Service (excluding case management) 1 TBD Notes: 1 Baseline based on most recent 4 Quarters of data (Q4 11/12 to Q3 12/13) 2 Baseline based on FY 12/13 result 3 Previous to 2013/14, indicator reported as the 90th percentile wait time. Therefore, 2012/13 target and baseline are not included for this indicator. 4 Baseline based on most recent 4 Quarters of data (Q3 11/12 to Q2 12/13)

131 Central LHIN - Stocktake Performance Summary - August 2013 Stocktake Category Indicators Indicator Type* Target C LHIN Performance ONT Performance Better than ONT? 90P ER LOS for Admitted Patients (Q1 13/14) MLPA/P4R LHIN Ranking** 90P ER LOS for Non-Admitted Complex Patients (Q1 13/14) MLPA/P4R P ER LOS for Non-Admitted Minor/Uncomplicated Patients (Q1 13/14) MLPA/P4R Increase ER Capacity/Performance 90P Time to Inpatient Bed (Decision to Admit to Left ER) (Q1 13/14) P4R No Target 90P Time to Physician Initial Assessment (Q1 13/14) P4R No Target Percent positive rating to the patient satisfaction survey question: Overall, how would you rate the care you received in the Emergency Department (Q3 12/13) No Target Improved from Baseline Improved from Baseline 78% - Has not improved from Baseline 20.5*** 8 3.2*** 2 a Number of ER Unscheduled Visits by quarter per 1000 population (Q4 12/13)**** No Target a N/A NLOT - Unscheduled ER visits/1,000 active LTC residents - High Acuity (Q4 12/13) NLOT - Unscheduled ER visits/1,000 active LTC residents - Low Acuity (Q4 12/13) NLOT - # of Unscheduled ER Visits/1,000 active LTC residents resulting in an inpatient admission (Q4 12/13) No Target No Target No Target 197- Improved from Baseline 14 - Improved from Baseline Has not improved from Baseline Percentage ALC Days (Q4 12/13) MLPA/HL 15.0% 15.9% 15.2% 9 N/A N/A N/A Improve Bed Utilization Reduce Repeat ER Visits within 30 Days for Mental Health and Substance Abuse 90P Time for CCAC In-Home Services - Application from Community Setting to first CCAC Service (excluding case management) (Q4 12/13) Number of Days from ALC designation to discharge by discharge destination (90th percentile days) (Q1 13/14) Repeat Unplanned ER Visits within 30 days for mental health conditions (Q4 12/13) Repeat Unplanned ER Visits within 30 days for substance abuse conditions (Q4 12/13) MLPA/HL = 10 No Target 27 N/A MLPA 17.0% 18.9% 18.8% 12 MLPA 18.7% 22.6% 29.4% 2 30 Day Readmission Rate for selected CMGs (Case Mix Groups) (Q3 12/13) MLPA/HL 15.0% 15.6% 16.1% 6 Excellent Care for All Surgical and Diagnostic Imaging Wait Times Proportion of Primary Unilateral Hip or Knee Joint Replacement patients discharged home (Q3 12/13) Average Length of Stay (days) of primary unilateral Hip or Knee Joint Replacement patients discharged home (Q3 12/13) Percent of priority IV cases completed within access target (84 days) for cancer surgery (Q1 2013/14) ~ Percent of priority IV cases completed within access target (182 days) for cataract surgery (Q1 2013/14) ~ Percent of priority IV cases completed within access target (90 days) for cardiac by-pass surgery (Q1 2013/14) ~ Percent of priority IV cases completed within access target (182 days) for hip replacement (Q1 2013/14) ~ Percent of priority IV cases completed within access target (182 days) for knee replacement (Q1 2013/14) ~ Percent of priority IV cases completed within access target (28 days) for MRI scans (Q1 2013/14) ~ Percent of priority IV cases completed within access target (28 days) for CT scans (Q1 2013/14) ~ 90% +/- 9% 92.8% 91.8% MLPA 90.0% 98.6% 95.6% 2 MLPA 90.0% 99.8% 94.3% 1 MLPA 90.0% 99.0% 98.0% 5 MLPA 90.0% 95.9% 87.7% 3 MLPA 90.0% 95.0% 82.8% 2 MLPA 55.0% 41.5% 57.5% 11 MLPA 85.0% 72.1% 78.7% 10 Supplementary The Number of ALC open cases (in hospital) by Inpatient Service Acute and Post-Acute Care (overall LHIN, by hospital, and by discharge destination) The Number of ALC Patients in hospital staying 30 days and longer by Inpatient Service Acute and Post-Acute Care (overall LHIN and by hospital) Transitional Care Program (TCP) Average Length of Stay (ALOS) by Program Type Notes * MLPA=Ministry LHIN Performance Agreement; P4R=Pay for Results; HL=Health Links ** 1 = Best Performer, 14 = Worst Performer *** Based on ER Pay For Results Operational Report_ (DoN) **** Based on Quarterly Stocktake Provincial View Report ~ Revised indicators starting August 2013 a Central LHIN tied with one other LHIN b Central LHIN tied with three other LHINs

132 Central LHIN Community Scorecard ( , Q4) Appendix F BALANCED BUDGET & VOLUMES WITHIN CORRIDOR Abuse Program of York Region Access Apartments Addiction Services for York Region Alzheimer Society of York Region Aphasia Institute Bayview Community Services Inc. Bernard Betel Centre for Creative Living Better Living Health and Community Services Black Creek Community Health Centre Central Community Care Access Centre Cerebral Palsy Parent Council of Toronto (Participation House, Markham) Community Head Injury Resource Service of Toronto (CHIRS) CHATS Community & Home Assistance to Seniors COTA Health Don Mills Foundation for Seniors Downsview Services to Seniors Inc. Etobicoke Services For Seniors Hesperus Fellowship Community of Ontario Jane/Finch Community and Family Centre Lance Krasman Memorial Centre for Community Mental Health North York Seniors Center North Yorkers For Disabled Persons Palliative Care Network For York Region Regional Municipality of York Rehabilitation Foundation for the Disabled - Phys. Disabled, York (Operating As Ontario March of Dime York) St. Clair West Services for Seniors St. Demetrius Supportive Care Service Corp The Canadian Hearing Society - York Region The Canadian Mental Health Association, Toronto Branch The Canadian Mental Health Association, York Region The Canadian National Institute for the Blind The Vitanova Foundation Toronto North Support Services Vaughan Community Health Centre Yee Hong Centre for Geriatric Care YOR-SUP-NET Support Services Network BALANCED BUDGET & VOLUMES NOT WITHIN CORRIDOR Across Boundaries - An Ethnoracial Mental Health Centre Chai-Tikvah Foundation Circle of Home Care Services (Toronto) Hazel Burns Hospice Humber River Regional Hospital Mackenzie Health New Unionville Home Society North York General Hospital PACE Independent Living Southlake Regional Health Centre Stevenson Memorial Hospital The Caritas School of Life Villa Colombo Home For The Aged Inc. DID NOT BALANCE BUDGET & VOLUMES WITHIN CORRIDOR City of Toronto, Long-Term Care Homes and Services (Cummer Lodge) Friuli Terrace Markham Stouffville Hospital The Canadian Hearing Society - Simcoe Region DID NOT SUBMIT Chippewas of Georgina Island Mariann Nursing Home and Residence Follow-up Process: No Follow-up Staff follow-up & review with Senior Director, Letter from Senior Director Letter from Senior Director

133 Central LHIN Public Hospital Performance Summary /13 Appendix G GLOBAL VOLUMES TORONTO Humber River Regional TORONTO North York General NEWMARKET Southlake Regional RICHMOND HILL Mackenzie Health MARKHAM Stouffville ALLISTON Stevenson Memorial Reporting Period Emergency Department - Weighted Cases (Note 1) 5,466 5,498 4,643 4,474 3,536 1,258 Q4 2012/13 Complex Continuing Care - RUG Weighted Patient Days 11,390 29,941 4,304 Q4 2012/13 Total Inpatient Acute Activity - Weighted Cases 32,223 30,530 30,371 21,685 14,471 2,371 Q4 2012/13 Day Surgery - Weighted Cases 5,836 5,776 6,543 3,091 2, Q4 2012/13 Inpatient Mental Health - Weighted Patient Days (Note 1) 18,358 18,728 11,752 8,708 10,098 Q4 2012/13 Inpatient Rehabilitation - Weighted Cases (Note 1) Q4 2012/13 Ambulatory Care - Visits 246, , , ,015 78,690 26,899 Q4 2012/13 Emergency Department - Visits 105, ,131 93,922 89,713 76,498 29,848 Q4 2012/13 ORGANIZATIONAL HEALTH TORONTO Humber River Regional TORONTO North York General NEWMARKET Southlake Regional RICHMOND HILL Mackenzie Health MARKHAM Stouffville ALLISTON Stevenson Memorial Reporting Period Current Ratio Q4 2012/13 Year End Total Margin 0.03% 0.91% 0.31% 3.80% 0.83% 0.37% Q4 2012/13 SYSTEM PERSPECTIVE TORONTO Humber River Regional TORONTO North York General NEWMARKET Southlake Regional RICHMOND HILL Mackenzie Health MARKHAM Stouffville ALLISTON Stevenson Memorial Reporting Period Percentage ALC Days 19.59% 15.45% 15.16% 14.47% 13.42% 24.35% YTD Q3 2012/13 PERSON EXPERIENCE TORONTO Humber River Regional TORONTO North York General NEWMARKET Southlake Regional RICHMOND HILL Mackenzie Health MARKHAM Stouffville ALLISTON Stevenson Memorial Central LHIN Actual Reporting Period 90th Percentile ER LOS for Admitted Patients Q4 2012/13 90th Percentile ER LOS for Non-Admitted Complex Patients Q4 2012/13 90th Percentile ER LOS for Non-Admitted Uncomplicated Patients Q4 2012/13 90th Percentile WT for Cancer Surgery Q4 2012/13 90th Percentile WT for Cardiac By-Pass Procedures Q4 2012/13 90th Percentile WT for Cataract Surgery Q4 2012/13 90th Percentile WT for Diagnostic CT Scan Q4 2012/13 90th Percentile WT for Diagnostic MRI Scan Q4 2012/13 90th Percentile WT for Hip Replacement Q4 2012/13 90th Percentile WT for Knee Replacement Q4 2012/13 PERSON EXPERIENCE TORONTO Humber River Regional TORONTO North NEWMARKET Southlake York General Mackenzie Health Finch Site Church Site Keele Site Regional Main Site Uxbridge Rate of Ventilator-Associated Pneumonia (VAP) Q4 2012/13 Central Line Infection Rate (CLI) Q4 2012/13 Rate of Hospital Acquired Cases of Clostridium Difficile Infections (C. diff) Q4 2012/13 Rate of Hospital Acquired Cases of Vancomycin Resistant Enterococcus Bacteremia (VRE) Q4 2012/13 Rate of Hospital Acquired Cases of Methicillin Resistant Staphylococcus Aureus Bacteramia (MRSA) Q4 2012/13 Organization's performance is within H-SAA performance corridor Organization's performance is outside the H-SAA performance corridor RICHMOND HILL MARKHAM Stouffville ALLISTON Stevenson Memorial Reporting Period \\LHINFPS01\LHIN-CH\D. Health Service Providers\PCA Performance\Hospital Sector\ \Q3\Hospital Sector - Q3 Performance Review Summary.xls

134 APPENDIX H Funding Allocations Delegated Authority Appendix H New Transfer Payment Allocations Adult Day Program- $170,389 base funding At the November 2012 Board Meeting, the Board delegated authority to the CEO to transfer the remaining Mariann Home accountability agreement funds of $170,389 to another health service provider for the provision of Day Program services. North York Seniors Centre was selected to receive base funding of $170,389 effective April 1, 2013 to provide adult day program services. The HSP demonstrated the ability to deliver services within the proposed geographic location (North York planning area), and to transition clients from an existing setting. Nurse-led Long-Term Care Outreach Teams - $255,100 one-time funding In May 2013, the Ministry notified the LHIN of one-time supplemental funding of up to $255,100 for salaries and benefits of up to three additional nursing FTEs for fiscal The Nurse-led Long-Term Care Outreach Time initiative is one of several projects implemented under Ontario s Emergency Room (ER) and Alternate Level of Care Strategy, and is intended to ensure Long- Term Care Home residents have access to timely, high quality care within their homes, and to minimize avoidable resident transfers to ERs and hospital admissions. Grants to Compensate for Municipal Taxation for Public Hospitals- $240,300 one-time funding In June 2013, the Ministry notified the LHIN of annual funding for public hospitals as compensation in lieu of Municipal Taxes. The funding is calculated at the rate of $75 per Rated Bed. Exercise and Falls Prevention- $279,880 annual base funding In June 2013, the Ministry notified the LHIN of base funding to maintain and expand exercise and falls prevention classes across the LHIN. The initiative supports Ontario s Action Plan for Health Care, specifically the focus on supporting seniors to stay healthy and stay at home longer, reducing the strain on hospitals and long-term care homes. Funding will help to maintain, expand and complement exciting exercise and falls prevention classes, improving access to service across multiple local communities. Telehomecare-South Simcoe Northern York Region Health Link- $207,978 base, $365,810 annualized In March 2013, the LHIN responded to a request for submissions from the Ministry of Health and Long- Term Care ehealth Liaison Branch, to participate in a second wave of Telehomecare expansion. Capital funds were provided in FY to Southlake Regional Health Centre for the purchase of required equipment. These funds will support the operations of the telehomecare program for South Simcoe Northern York Region Health Link. ED Pay for Results- $10,610,100 one-time funding In July 2013, the Ministry notified the LHIN of one-time funding to implement the 2013/14 Emergency Department Pay-For-Results Action plan. Initiatives undertaken in the Pay-For-Results program for 2013/14 are targeted to improve Emergency Department (ED) performance on five key indicators: - ED Length of stay for admitted patients - ED Length of stay for non-admitted complex patients - ED Length of stay for non-admitted minor patients - Time to physician Initial assessment

135 - Time to in-patient bed Health Links- $1,200,000 one-time funding To facilitate the implementation of Health Links business plan, $600,000 each was issued to: - South Simcoe and Northern York Region Health Link (Southlake Regional Health Centre) - North York Region Health Link (North York General Hospital) Health Links is an innovative approach that brings together health care providers in a community to better coordinate care for high-needs patients. Health Links will encourage greater collaboration between existing local health care providers, including family care providers, specialists, hospitals, long-term care, home care and other community supports. With improved coordination and information sharing, patients will receive faster care, will spend less time waiting for services and will be supported by a team of health care providers at all levels of the health care system. Health System Funding Reform- $42,144,200 base funding In August 2013, the LHIN was provided with the details of additional 2013/14 Health System Funding Reform (HSFR) funding. The increased funding represents reinstated base for Quality based procedures and HSFR related base funding net-of one-time mitigation. The fiscal 2013/14 HSAA included assumptions of $34,473,200. This represents an additional $7,671,000 in funding to hospital budgets. Long Term Care Funding Physiotherapy- Estimated $4,191,600 base and $171,000 one-time funding In July 2013, the Ministry approved base funding to the Long-Term Care Home sector for physiotherapy services and exercise classes. This new base funding is in support of Long-Term Care Homes being directly funded by LHINs to provide these services to residents as a result of delisting OHIP-funded physiotherapy. Funding summary is as follows: Program Funding Funding Amount Applicable to approved Long-Stay, Respite, and Interim Beds in operation Funding for exercise/activation classes $0.27 per diem Allocation for funded physiotherapy $750 per bed per year Applicable to approved Convalescent Care Beds in Operation Funding for exercise/activation classes $0.27 per diem Allocation for funded physiotherapy $750 per bed per year Additional physiotherapy subsidy $10.27 per diem Level of Care Ministry Funded- Estimated $4,808,589 base funding In June 2013, the Ministry informed the LHIN of funding increases for the Long Term Care (LTC) Home sector for resident care needs, Co-Payment increases and raw food and other accommodations expenses. The actual amount of funding that will flow to each LTC home will be determined by the number of licensed beds. The Ministry will process and determine the amounts on behalf of the LHINs.

136 Level of Care Per Diem Increases: Funding Envelope Per Diem Prior to April 1, 2013 Per Diem Increase Effective April 1, 2013 Per Diem Increase Effective July 1, 2013 New Per Diem Effective July 1, 2013 Nursing and Personal Care (NPC) $87.19 $ $88.93 Program and Support Services (PSS) $8.43 $ $8.60 Raw Food (RF) $ $0.12 $7.80 Other Accommodation (OA) $ $0.59 $52.76 TOTAL $ $1.91 $0.71 $ Convalescent Care Additional Subsidy Increase: Funding Envelope Per Diem Prior to April 1, 2013 Per Diem Increase Effective April 1, 2013 Nursing and Personal Care (NPC) $45.62 $0.91 $46.53 Program and Support Services (PSS) $19.56 $0.39 $19.95 Raw Food (RF) Other Accommodation (OA) $5.76 $0.12 $5.88 TOTAL $70.94 $1.42 $72.36 New Per Diem Effective April 1, 2013 Level of Care LHIN funded- $82,279 one-time funding Central LHIN created or supports funding for 64 interim, 54 convalescent care and 20 temporary beds. The LHIN is required to match the level of care funding increases approved by the Ministry. Consistent with the Ministry, increases cover nursing and personal care, program and support services, raw food and other accommodations. Convalescent Care Beds - $746,000 fiscal 2013/14 one-time and $1,072,900 fiscal 2014/15 one-time In August 2013, the Ministry approved one-time funding to convert 24 existing long-term care home beds into convalescent care beds for two years. The Convalescent Care Program is a short stay supportive care program provided to people for a period of up to 90 days. The program encompasses an assess and restore philosophy. The goal of the program is to avoid or delay the need for institutional based longterm care and enable continued living in the community for older adults with reversible loss of function Funding Allocations Management delegation of authority levels in accordance with CFIN-4 are as follows: A. New Transfer Payment from the Ministry: to $25,000 Director, Performance, Funding and Allocation to $99,999 Senior Director, Performance, Funding and Allocation to $749,999 Chief Executive Officer Greater than $749,000 Delegated by Board to Board Chair and Chief Executive Officer B. Budget Reallocations within a Health Service Provider (HSP): to $50,000 per HSP Senior Director, Performance, Funding and Allocation to $250,000 per HSP Chief Executive Officer C. Budget Reallocations between Health Service Providers: to $499,999 per provider Chief Executive Officer

137 Approvals - Health Service Provider North York Seniors Centre Southlake Regional Health Centre Mackenzie Health Humber River Hospital Stevenson Memorial Hospital Markham Stouffville Hospital Southlake Regional Health Centre Mackenzie Health Humber River Hospital North York General Hospital Delegation Type Approval Date 2013/14 One-Time Funding 2013/14 Base Funding Annualized Base (if different) Description A May 2013 $170,389 Adult Day Program A July 2013 $85,033 Support Nurse-led Outreach teams A July 2013 $85,034 Support Nurse-led Outreach teams A July 2013 $85,033 Support Nurse-led Outreach teams A July 2013 $5,775 To compensate for municipal taxes A July 2013 $22,050 To compensate for municipal taxes A July 2013 $31,575 To compensate for municipal taxes A July 2013 $44,025 To compensate for municipal taxes A July 2013 $69,525 To compensate for municipal taxes A July 2013 $67,350 To compensate for municipal taxes Carefirst A July 2013 $105,600 Exercise and Falls Prevention Better Living A July 2013 $174,280 Exercise and Falls Prevention Southlake Regional Health Centre Stevenson Memorial Hospital Markham Stouffville Hospital Southlake Regional Health Centre Mackenzie Health Humber River Hospital North York General Hospital Southlake Residential Care Village A July 2013 $207,978 $365,810 Telehomecare- South Simcoe and Northern York Region Health Link A July 2013 $871,500 ED Pay for Results Program A July ,270,100 ED Pay for Results Program A July 2013 $2,638,000 ED Pay for Results Program A July 2013 $1,796,700 ED Pay for Results Program A July 2013 $1,657,900 ED Pay for Results Program A July 2013 $2,375,900 ED Pay for Results Program A June 2013 $20,367 Funding formula change for 32 Interim beds

138 Health Service Provider Mackenzie Health Long- Term Care) Unionville Home Society York Region Maple Health Centre Hawthorne Place Care Centre Southlake Regional Health Centre North York General Hospital Stevenson Memorial Hospital Markham Stouffville Hospital Southlake Regional Health Centre Mackenzie Health Humber River Hospital North York General Hospital Aurora Resthaven Delegation Type Approval Date 2013/14 One-Time Funding 2013/14 Base Funding Annualized Base (if different) Description A June 2013 $20,164 Funding formula changes for 32 Interim and 20 temporary beds A June 2013 $11,597 Funding formula change for 15 Convalescent Care Beds A June 2013 $11,598 Funding formula change for 15 Convalescent Care Beds A June 2013 $18,554 Funding formula change for 24 Convalescent Care Beds A A A A A A A A August 2013 August 2013 August 2013 August 2013 August 2013 August 2013 August 2013 August 2013 September 2013 Hawthorne Place A September 2013 A $600,000 South Simcoe and Northern York Region Health Link $600,000 North York Region Health Link $217,600 Health System Funding Reform $5,095,500 Health System Funding Reform $10,809,800 Health System Funding Reform $5,049,100 Health System Funding Reform $9,383,800 Health System Funding Reform $11,588,400 Health System Funding Reform $377, convalescent care beds 2013/14 $625,858 Fiscal 2014/15 one-time amount $369, convalescent care beds 2013/14 $447,042 Fiscal 2014/15 one-time amount

139 ITEM 11.0 A PRESENTATION TO THE CENTRAL LHIN BOARD SEPTEMBER 24, 2013 Dr. Rakesh Kumar Central LHIN ED LEAD

140 Central LHIN ED Strategy The aim of the ED strategy at the Central LHIN is to have an action plan in place to reduce: ED LOS for Admitted Patients ED LOS for Non-Admitted Complex Patients ED LOS for Non-Admitted Minor Patients Time to Physician Initial Assessment Time to In-Patient Bed

141 90P ED LOS Admitted Patients

142 90P ED LOS Non-Admitted Complex

143 90P ED LOS Non-Admitted Minor

144 90P Time to PIA

145 90P Time to Inpatient Bed

146 Positive outcome contributors System Initiatives Home first program Ambulatory Clinics GEM nurses Health care connect Performance improvement program Nurse Led outreach teams Rapid Response Nurses

147 Positive outcome contributors Health Service Provider s Initiatives Medical Assessment units Focussed Discharge Planning Improved access to support services especially Diagnostic services Improved admission Processes Improved ED processes Hospitalist program Focus on consultant response time

148 Next Steps ED processes PIA times Extend DI Access/ hours Admission Processes Access to consultants Access to admission team Improve Discharge processes Improve communication with Primary care Start Discharge process on admission LTC/ CC/RH admission/ readmission

149 Future Opportunities Extend support services / Diagnostic Services Admission/ Readmission to LTC/CC/RH Availability of consultants/ Crisis workers/ admission team after hours Extending GEM nurse availability Improve ED processes further Improve communication with primary care further Outbreaks and LTC/CC/RH

150 Discussion and Questions