LOCATION: Room 2E51, MUMC BOARD OF DIRECTORS AGENDA Package - Nove… · HHS Board of Directors...

DATE: Thursday, November 27, 2014

TIME: 4:00 PM to 7:00 PM LOCATION: Room 2E51, MUMC

BOARD OF DIRECTORS AGENDA

Presentation: Physician Engagement - Dr. Richard McLean

1. Call to Order

1.1 Quorum 1.2 Approval of the Agenda 1.3 Conflict of Interest

Paul Chapin

2. Consent Agenda (to be received or approved) 2.1 Minutes of the Meeting of September 25, 2014 2.2 Minutes of the Meeting of October 6, 2014 2.3 Certificate of Compliance to October 31, 2014 2.4 Report of WLMHCAC - September 2014 2.5 Report of Audit Committee - October 2014 2.6 Report of Medical Advisory Committee - October 2014 2.7 Report of Medical Advisory Committee - November 2014 2.8 Credentials Report - October / November 2014 2.9 Report of Governance Committee - October 2014 2.10 Report of Executive Committee - October 2014 2.11 Report of Performance Monitoring Committee - October 2014 2.12 Report of Finance Committee - October 2014 2.13 Report of Finance Committee - November 2014 2.14 Report of Quality Committee - November 2014 2.15 Inner Circle Newsletter - Fall 2014 2.16 Correspondence 2.16.1 MOHLTC - HIRF Funding 2.16.2 MOHLTC - Base Funding - Infectious Disease 2.16.3 MOHLTC - Base Hospital Funding

Paul Chapin

3. 2014/15 Q2 Strategic Initiatives Report (to be received)

Rob MacIsaac

4. Strategic Goals / Objectives / 2015/16 Strategic Initiatives (for approval)

Rob MacIsaac

5. Clinical Service Visioning (for information)

Kelly Campbell

6. West Haldimand Management Services Agreement (for approval)

Brenda Flaherty

7. Report of the President & CEO / HHS Foundation Update (for information)

Rob MacIsaac

8. In Camera Session (see separate agenda)

Paul Chapin

9. Adjournment

Paul Chapin

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Physician Engagement - UPDATE

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My Voice Matters Survey Update

flies! time ITS BEEN OVER A YEAR SINCE the results of the My Voice Matters physician survey were shared.

Departments and teams across the organization began working on corporate & departmental/service level action plans to enhance the engagement of our people.

Executive Summary – Physician Survey

• 63% response rate for Physicians

• 57 % of Physicians are engaged

OUTCOME

• 427 Physicians surveyed

• 32 Questions, 1 comment option

2012 SURVEY

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2012 Engagement Survey

PURPOSE: To establish a baseline measurement of physician engagement at HHS (based on the following definition of engagement):

Engagement = is the extent to which we [at HHS] are motivated to contribute to [the HHS] vision and are willing to go above and beyond to continuously enhance the quality of care and the patient experience at HHS.

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Here’s what PHYSICIANS said…

Connection to the vision – we want leadership to

communicate a vision that motivates us

Feeling Valued – we want to feel valued for our contribution

These four areas are the most important to physicians at HHS in order to feel engaged on a daily basis:

Communication – we need open communication and greater

autonomy in decision making

Focus on our well being – Leadership focus on physician’s

morale and well being

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Here is what

HAS BEEN HAPPENING

SINCE THE SURVEY…

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ACTION PLANS - were created

DEPARTMENT AREA OF FOCUS (stemming from survey results)

ACTION PLAN

Medicine

• Vision/Leadership

• Work/Life Balance

• Improve accessibility and flow of computer access among GIM physicians (eliminate repeat login times by implementing swipe access) • Perform a flow evaluation w/in primary clinical areas for placement of equipment and tools to maximize accessibility & use. • Chief to attend council meetings with Clinical Director to provide a forum for open discussion and knowledge share (highlight critical incidents, positive patient experience etc.) • Implement “Red Rules” – a system to build positive working relationships (examples set by MD leaders)

DEPARTMENT/SERVICE LEVEL EXAMPLE:

CORPORATE EXAMPLE :

DEPARTMENT AREA OF FOCUS (stemming from survey results)

ACTION PLAN

ALL

• Vision/Leadership

• Rob MacIsaac, President & CEO, and Dr. Richard McLean, Executive Vice-President & Chief Medical Executive to attend departmental meetings.

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PHYSICIAN REPRESENTATION & FEEDBACK integrated into strategic planning

since the beginning. For example – physicians, along side members of the Executive Team formed an “Expert Team” to inform HHS’s overall strategy.

STRATEGY PLANNING REFRESH – Rob MacIsaac, President & CEO held 1:1

meetings with each Departmental Chief to inform the refresh

PHYSICIAN-HOSPITAL PARTNERSHIP working group – created to address

the specific need for a Physician Engagement strategy, identified as part of the Corporate Goal #5 – an organization of choice for talented people.

PHYSICIAN INVOLVEMENT - in Strategic Planning

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*

*

Mandate = recommend a Physician Engagement Plan

Membership = • Chair of MAC • EVP Inter-Professional Practice & Chief Medical Executive • Human Resources & Organizational Development • Inter-Professional Practice • Public Relations & Communications • McMaster Post-Graduate Resident • Medical Staff Association President

• Physician Departmental Representation: • Surgery • Anesthesia • Emergency Medicine • Complex Care & Aging and Palliative Care • Laboratory Medicine • Oncology • Medicine • Diagnostic Imaging • Obstetrics & Gynecology

PHYSICIAN-HOSPITAL WORKING GROUP created

* Purpose = To achieve cultural alignment between physicians and the hospital through shared goals, yielding stronger relationships and increased engagement

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PHYSICIAN-HOSPITAL WORKING GROUP members

Attendee: Position: Department/Service

Dr. Richard McLean EVP Inter-Professional Practice & Chief Medical Executive Medical Affairs

Jennifer Denney Director, Medical Affairs Medical Affairs

Lisa Reid Manager, Medical Affairs Medical Affairs

Carla Mans Medical Affairs Specialist Medical Affairs

Elaine Principi Chief of Inter-Professional Practice Inter-Professional Practice

Lisa Gilmour Manager, Health & Wellness Human Resources & Organizational Development

Roxanne Torbiak Senior Public Relations Specialist Public Relations & Communications

Rebecca Repa President – St. Peters Hospital St. Peter’s Hospital

Dr. John Mernagh Physician, Radiologist Department of Diagnostic Imaging

Dr. Kesava Reddy Interim Surgeon-in-Chief Department of Surgery (Neurosurgery)

Dr. Dale Williams Orthopedic Surgeon Department of Surgery

Dr. Paul Miller ED Physician & Chair Medical Advisory Committee Department of Emergency Medicine

Dr. Patricia Smith Physician Department of Obstetrics & Gynecology

Dr. Richard Seeley Chief Department of Complex Care & Aging and Palliative Care

Dr. Britta Laslo Physician Department of Complex Care & Aging and Palliative Care

Dr. Catherine Ross Pathologist Laboratory Medicine

Sharine Caron Physician Emergency Medicine

Dr. Richard Kolesar Chief Department of Anesthesia

Dr. Laura Stover Anesthesiologist Department of Anesthesia

Dr. Debra Marcellus Physician, Hematology Department of Oncology

Dr. Nishma Singhal Physician, Infectious Disease & General Internal Medicine Department of Medicine

Sandra Ramelli Director, Organizational Development Organizational Development

Tristan Ali PGY5 – Resident in the Department of Anesthesia McMaster University Post-Graduate

Dr. Barry Lumb Physician-In-Chief Department of Medicine

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PHP-WG work to date

Identified areas of focus for Physician Engagement at HHS by physicians, for physicians

Review & incorporation of engagement survey results

Front-line physician sub-committee work

Review of best practices

Defined engagement for the physician group

Comprehensive literature review

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What does physician engagement mean at HHS?…

Physician Engagement = “Engagement refers to the active interest and participation of physicians in organizational and system change and improvement activities. It is their commitment to the institution and willingness to be involved in initiatives that enhance the delivery of health care, beyond the individual patient-physician relationship.”

- Defined by the HHS Physician-Hospital working group, 2014

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The Recommended Plan…

1. Development of a Physician-Hospital Compact – an agreement that clearly states the

commitment of the medical staff and hospital leadership to one another for the purpose of improving patient care and furthering the shared goals

2. Create a Physician Leadership Program through a blended approach to increase leadership development opportunities

3. Involve Physicians in Processes/Projects at HHS

4. Develop mechanism for on-going two-way communication between physicians and

the hospital administration

Next Steps…

1. Develop the Physician-Hospital Partnership Implementation Group 2. Continue to share results and key learnings from the My Voice Matters surveys 3. Provide continuous progress updates on Physician engagement work to date 4. This is just the beginning – there’s still a lot of work to be done!

Areas of focus for the next 5 years:

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How to get involved

PHYSICIAN-HOSPITAL PARTNERSHIP IMPLEMENTATION GROUP:

Name/Title Contact

Chair: Dr. Richard McLean, EVP Inter-

Professional Practice & Chief Medical Executive

Email – [email protected] Phone – 905-521-2100 ext. 42030

Co-Chair: Dr. Nishma Singhal, Department of

Medicine, HHS

**The next My Voice Matters survey is coming Nov.27**

Please respond! We want to hear from you!

Email – [email protected]

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mailto:[email protected]


Hamilton Health Sciences Board of Directors

A meeting of the Board of Directors took place on Thursday, September 25, 2014 at 4:00 PM in Room 2E51, McMaster University Medical Centre. In attendance: Norm Col (Chair), Rob MacIsaac, Chantel Broten, Anita Isaac, Julia Kamula, Richard Koroscil, Terry Shields, Mary Volk, Kirsten Krull, Paul Miller, Scott Maki, John Mernaugh, Glenn Gibson, Kurt Whitnell, Mary Catherine Lindberg, John Kelton, Cathy Rozman – recording secretary Regrets: Paul Chapin, Charles Criminisi, Mark Rizzo Guests: Kathy Watts, Sharon Pierson, Kelly Campbell, Peter Fitzgerald, Ralph Meyer, Brenda Flaherty, Andrew Doppler, Fran Agnew, Aaron Levo, Mark Farrow, Rebecca Repa, Teresa Smith, Vickie Baird – Education Session, Frank Naus – Item 7.3 Education Session: Alternate Level of Care (ALC) Overview (attached to master copy of the minutes as Schedule ‘A’) – Brenda Flaherty spoke to the attached report and presentation. Vickie Baird author of the Hamilton Community Transitional Wellness Capacity Project was introduced. At the present time there are 174 patients in HHS beds that have been designated as requiring an alternate level of care. It is anticipated that the senior population in the Hamilton community will grow by 93% by 2033. The impact on the health care system as a result of the patients waiting for care was outlined. It was also noted that frail and elderly patients in hospital lose 5% of their ability to function daily when they are not eating and mobile or living independently and are also at risk for hospital acquired infections. Past and current ALC designation rates were reviewed, noting that rates are currently at 20%, the rate did decrease with the introduction of the ‘Home First’ strategy and the number of patients identified as ALC has decreased from 12 to 3 per week. Vickie Baird was engaged by the LHIN to identify short, medium and long term strategies to address the issue, and has stayed on with HHS/SJHH and the CCAC to assist in implementation of the short term strategies including the planned opening of 68 transitional beds in the community on October 1, 2014. There has been acceptance that this is both a social and health care issue requiring community wide solutions. Vickie Baird spoke to the refresh of the Home First strategy and her work with the retirement homes to designate the transitional beds that will assist approximately 40% of ALC designated patients in their journey towards receiving the most appropriate care in the right place. Vickie Baird added that the City of Hamilton has been a supportive partner. A question period followed comments included:

Many innovative programs developed but not implemented due to a lack of an overarching leadership

HHS is working closely with CCAC

Community is looking to CCAC to provide quality care within the new environment o MOH has increased funding to CCAC in support of home care

CCAC improving data collection – target 5 days from hospital designation to placement

Need to look at different care models at the provincial level 1. Call to Order 1.1 Quorum – The secretary advised that quorum was present.

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HHS Board of Directors September 24, 2014 Page 2

1.2 Approval of the Agenda – On motion duly moved by Terry Shields, seconded by Mary Volk and unanimously carried, it was “Resolved, That the agenda be adopted as distributed.” 1.3 Conflicts of Interest – No conflicts of interest were declared. 2. Consent Agenda - On motion duly moved by Julia Kamula, seconded by Scott Maki and unanimously carried, it was “Resolved, That the following items be received and/or approved: 2.1 Minutes of the Meeting of June 23, 2014 be approved; 2.2 Certificate of Compliance to August 31, 2014 (Schedule ‘B’) be received; 2.3 Report of Quality Committee – September 2014 (Schedule ‘C’) be received; 2.4 Report of Finance Committee – September 2014 (Schedule ‘D’) be approved, including approval of the Approval Authority Schedule as attached; 2.5 Report of WLMHCAC – June 2014 (Schedule ‘E’) be received; 2.6 Report of Medical Advisory Committee – June 2014 (Schedule ‘F) be received; and 2.7 Credentials Report – September 2014 (Schedule ‘G’) be approved.” Norm Col added that Finance Committee is pleased to report that the PCB Transformer Project is scheduled to be completed by September 20th, three months ahead of schedule. 3. Capital Requirements (Schedule ‘H’) – Norm Col reported that Finance Committee had considered and deferred the capital financing request in light of indications that 2014/15 hospital funding letters would be released on Friday, September 26th. It has been suggested that there is potential for negative funding adjustments for some hospitals. Finance Committee agreed that once funding is known, the committee would be better able to understand the impact of additional debt on operations. Rob MacIsaac added that the capital planning process is under review and a five year forecast will come forward to the November meeting. Funding strategies will still need to be worked through. It was noted that capital challenges face many hospitals, with the Province equally fiscally challenged. A special board meeting may be required to further consider the recommendation. 4. Strategy Refresh Update (Schedule ‘I’) – Rob MacIsaac spoke to the attached presentation and report. For approval, is the refreshed strategic framework which focuses on improved quality within a sustainable state. Initiatives and metrics will be addressed at the October Board and Executive Council retreat. The journey to date and the planning drivers were reviewed. Revisions to the goal statements presented in June were reviewed, identifying suggested changes resulting from broad consultation undertaken over the past two months. In response to questions raised it was noted that:

Innovation piece not limited to research and learning, included in sustainability pillar Innovation considered a broader path to sustainability Organizational redesign to align with and reinforce strategies

o Move from geographical to patient care / disciple based Need to consider the impact of culture change

o Should be embedded in performance management Development of HHS unique management system adapted from three top US

organizations

Need to ensure infrastructure is in place to support the plan On motion duly moved by Kurt Whitnell, seconded by Julia Kamula and unanimously carried, it was “Resolved, That the revised strategic framework (Figure 2 in attached Schedule ‘I’) be approved for the purpose of: 1. Discussion at the October Board retreat;

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HHS Board of Directors September 24, 2014 Page 3

2. Development of preliminary metrics and initiatives for the 2015-16 annual strategic plan; and 3. Identification of risk and mitigation strategies.” 5. 2014/15 Q1 Strategic Initiatives Report (Schedule ‘J’) – The Q1 Report was received. It was noted that mapping from the old strategic plan and the refreshed plan will be undertaken. 6. Report of the President & CEO / HHS Foundation Update (Schedule ‘K’) – Rob MacIsaac spoke to the attached presentation. He began by congratulating Brenda Flaherty on her McMaster Alumni Community Impact Award presented earlier this week. EVP recruitment efforts are nearing completion. A report on master programming will come forward to the November meeting. The MCHC building remains on time and budget. Building on a yet to be finalized government relations strategy, meetings have taken place and/or planned with a number of MPPs and bureaucrats.

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A special meeting of the Board of Directors took place on Monday, October 6, 2014 at 4:00 PM in Room 2E51, McMaster University Medical Centre. In attendance: Scott Maki (Chair), Charles Criminisi, Mary Volk, Rob MacIsaac, Anita Isaac, Teleconference - Mark Rizzo, Julia Kamula, Terry Shields, Kirsten Krull, John Mernaugh, Mary Catherine Lindberg, Cathy Rozman – recording secretary Regrets: Paul Chapin, Chantel Broten, Glenn Gibson, Kurt Whitnell, Paul Miller, Richard Koroscil, John Kelton Guests: Kathy Watts, Kelly Campbell, Brenda Flaherty, Dick McLean, Ralph Meyer, Fran Agnew, Peter Fitzgerald, Angelo Zingaro, Peter Fitzgerald, Rebecca Repa, Pearl Veenema, Aaron Levo 1. Call to Order 1.1 Quorum – The secretary advised that quorum was present. 1.2 Approval of the Agenda – On motion duly moved by Mary Volk, seconded by Charles Criminisi and unanimously carried, it was “Resolved, That the agenda be adopted as distributed.” 1.3 Conflicts of Interest – Charles Criminisi declared a conflict of interest for Item 2. 2. Capital Investment & Financing – The proposal is attached to the master copy of the minutes as Schedule ‘A’. The funding presentation is attached as Schedule ‘B’. Kathy Watts provided an update on the funding workbooks distributed to all hospitals on September 26th. Kathy added that HHS received approximately $5M more than budgeted for through the Quality Based Funding (QBP) funding allocation under the Health System Funding Reform (HSFR) formula. The increase was mainly driven by medical QBP volumes (not controlled by hospitals (e.g. COPD, stroke, CHF) from 2013/14. The detailed workbooks are being worked through by staff. With the commitment to a 2014/15 balanced budget, the plan is to apply the increased funding to the bottom line with a decision on how it will be used taken at year end. At this time management recommends moving forward with the proposed $15M loan. This will allow for some cash flow flexibility and will take advantage of the loan interest rate (lower than the current line of credit). Kathy Watts added that borrowing costs have been absorbed into the budget. HHS was one of four teaching hospitals that received an increase in funding; MOHLTC recognition of efficiencies achieved. While funding reductions have been capped at 3%, funding increases have had the 3% cap removed, resulting in WLMH received its full base funding. Rob MacIsaac stated that management will be bringing forward a multi year operating and capital plan with process and controls in place to ensure all capital funding sources are identified. Scott Maki reported that Finance Committee reviewed the capital and financing plans in light of the funding allocation and recommended approval of the proposal. In response to a question raised, it was noted that the proposed capital projects were reviewed for potential deferral. No additional opportunities were identified.

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HHS Board of Directors October 6, 2014 Page 2

On motion duly moved by Anita Isaac, seconded by Mary Volk and carried, it was “Resolved, THAT The fiscal 2014-2015 Capital Investment Plan for $60M; THAT the financing strategy for $15M 5-year Banker’s Acceptance (BA) Interest Rate Swap offered by the Royal Bank of Canada (RBC) be accepted to finance the remaining unfunded capital investment; and THAT management bring forward a 5-year Capital Investment Plan with accompanying financing alternatives for discussion and approval for the December 2014 board meeting be approved.” Abstaining: Charles Criminisi 3. Data Management Centre (Schedule ‘C’) – Scott Maki reported that Finance Committee is also recommending the approval of the Data Management Centre capital project. The improvement will mitigate current risks of ICT capacity and the aging infrastructure. On motion duly moved by Julia Kamula, seconded by Anita Isaac and unanimously carried, it was “Resolved, That the Data Centre Augmentation project as outlined in the attached Schedule ‘C’, at a total budget of $4.3M, with $1.98M to be funded from the 2014/15 capital budget and the balance included in the 2015/16 Capital Budget be approved.” 4. Adjournment – On motion duly moved by Mary Volk, seconded by Charles Criminisi and unanimously carried, it was “Resolved, That the meeting be adjourned at 4:20 PM.” Scott Maki Chair

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BOARD OF DIRECTORS October 2014

Compliance Declaration I, K. Watts, Vice President, Finance and Chief Financial Officer, declare that, to the best

of my knowledge, the Hospital has complied with all laws, rules and regulations

pertaining to the payment of salaries, vacation pay, pension contributions, EI, CPP,

income tax, EHT, union dues, WSIB and other deductions (including withholding tax of

all kind).

Signed:

Kathy Watts Vice President, Finance and CFO Date: November 6, 2014

Kathy Watts, VP Finance and CFO Hamilton Health Sciences 1200 Main Street West, Room 2E35 Hamilton ON L8N 3Z5 905-521-2100 x46889 email: [email protected]

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REPORT TO THE BOARD OF DIRECTORS WEST LINCOLN MEMORIAL HOSPITAL COMMUNITY ADVISORY COMMITTEE

SEPTEMBER 2014 Committee: A. Smith (Chair), G. Benson, P. Ellens, R. Gark, A. Goddard, M. Lucarelli, J. Riddell, M. Yungblut, P. Zulauf Staff: L. Badzioch, K. Campbell, A. Levo, R. Repa, A. McMaster (recorder) COMMITTEE RECOMMENDATIONS/REPORT The West Lincoln Memorial Hospital Community Advisory Committee (the CAC) meets on a quarterly basis for the purpose of providing community specific advice to the Board of Directors of Hamilton Health Sciences and facilitating communication and outreach to the West Lincoln Memorial Hospital community. The last meeting was held on September 24, 2014. The CAC was informed that the Functional Integration Teams (FITs) formed for the amalgamation are moving forward with their work in integrating operations. Also, a new Obstetrics/Perioperative Manager, a new Site Chief for Emergency, a third Internist and a third Obstetrician have been added at the site. Information was presented regarding architects retained to plan project work at the site in relation to the $5 million received from the MOH for infrastructure improvements. Work should begin in the Spring of 2015, taking approximately two-three years to complete. A presentation on communications and government relations outlined strategies on internal and external communications, including distribution of “key messages” document to all committee members to use when speaking to the public. The CAC is scheduled to meet again on November 26, 2014.

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Hamilton Health Sciences

Report of Audit Committee – October 2014 A meeting of the Audit Committee took place on Wednesday, October 1, 2014 at 5:00 PM in Room 2E51, McMaster University Medical Centre. In attendance: Scott Maki (Chair), Norm Col, Richard Koroscil, Kurt Whitnell, Cathy Rozman – recording secretary Guests: Rob MacIsaac, Brenda Flaherty, Kathy Watts, Diana Rozich, Fran Agnew, Sandra Licata, Mark Farrow – Item 3.2 and 3.3, Sharon Pierson/Sue Alderson – Item 3.1, Kyle Watts – Item 3.3, Stephen Lesch (PwC) – Item 4 For Approval: MOHLTC Audits – Audit Committee received the audited financial statements for specialty programs funded by the MOHLTC as required under the agreements between HHS and the MOHLTC. Audit Committee recommends approval of the audits and that the Chair of the Board of Directors be authorized to sign the submissions on behalf of the Board. The statements are available through the board office or portal. Audit Committee recommends to the Board of Directors: “That the Audited Statement of Revenue and Expenditures for the year ended March 31, 2014 for the following programs be approved;

Diabetes Strategy – Self-Management Project

Internationally Educated Nurse Integration Project

Technology Access Clinic Assistive Devices Program; and That the Board Chair be authorized to sign the submissions on behalf of the Board of Directors.” Ministry of Children and Youth Services Program (MCYS) Engagement Statements of Revenue & Expenditures – Audit Committee received the Engagement Statements of Revenue and Expenditures for the year ended March 31, 2014 for the MCYS. MCYS requires Board of Directors approval of the statements and authorization for the Board Chair to sign the submission on behalf of the Board. The statements are available through the board office or portal. “That the Audited Statement of Revenue and Expenditures for the year ended March 31, 2014 for Ministry of Children and Youth Services programs be approved; and That the Board Chair be authorized to sign the submission on behalf of the Board of Directors.” MOHLTC Account Reconciliation Reports for HHS and WLMH -– Audit Committee received the Account Reconciliation Reports for HHS and WLMH for the year ended March 31, 2014 and the related Auditor’s Report. MOHLTC requires Board of Directors approval of the statements and authorization for the Board Chair to sign the submission on behalf of the Board. The statements are available through the board office or portal.

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Audit Committee October 1, 2014 Page 2

“That the 2013/14 Account Reconciliation Report for Hamilton Health Sciences and the 2013/14 Account Reconciliation for West Lincoln Memorial Hospital for the year ended March 31, 2014 be approved; and That the Board Chair be authorized to sign the submission on behalf of the Board of Directors.” Acting as the Finance Committee, it was recommended to the Board of Directors that the Capital Investment and Financing Strategy and Data Management Centre Proposal be approved as discussed at the September 27, 2014 board meeting. A special board meeting is scheduled for October 6, 2014 for consideration of the two items. For Information: Review of Internal Controls for Billing & Accounts Payable – Audit Committee received the review of internal controls for billing & accounts payable. Internal controls are reviewed by Audit Committee on a rotating basis. No gaps were identified. Finance / Audit Committee Terms of Reference – Minor changes were recommended by Audit Committee and will go forward to Governance Committee for review. Internal Audit Plan Update – The semi-annual internal audit plan update was received by Audit Committee. The committee examined the results of the JCC Pharmacy Audit in detail. The audit focused on the safeguarding of inventory and physical adjustments, accentuated by the high cost of oncology drugs. Recommendations have been implemented. It was noted that drug wastage and patient safety will be improved by the introduction of pharmacy robots. Enterprise Risk Management Update – The committee was updated on ERM activities. Management is committed to bringing forward a ERM frame-work by year end. The framework will include strategic risk and mitigation plans to address those risks. External Audit Management Letter – PwC reported two letter points raised (retention of documentation for the population of changes for six months and user access revalidation was not performed for Meditech or ePayables for FY2014), however, mitigating controls and review processes have been implemented. No other concerns were identified.

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Medical Advisory Committee

REPORT TO THE BOARD OF DIRECTORS

A meeting of the Medical Advisory Committee took place on

October 8th, 2014 at 4:30 pm in room 2E51, MUMC

Present: P. Miller (Chair), H. Flageole, K. Gulenchyn, L. Huang, D. Koff, R. Kolesar, B. Krizmanich, E. Lipman, B. Lumb, S. Nesathurai, D. Price, M. Stacey,

C. Sawchuk, R. Tozer, C. Ricci, J. Mernagh, L. Reid, E. Dore, B. Flaherty,

K. Krull, R. MacIsaac, R. McLean, T. Smith, G. Benson, C. Goslin (recorder)

Regrets: V. Chaudhary, V. Alexopoulou, N. Leyland, C. Col, R. Lloyd, D. Mertz, W. Orovan, R. Repa, R. Meyer

FOR APPROVAL OF THE BOARD OF DIRECTORS: 1. The Medical Advisory Committee recommends the appointment of Dr. Troy

Johnson as Site Chief for Emergency at West Lincoln Memorial Hospital, for a term of 5 years effective October 1, 2014. Dr. Johnson practices in Emergency

Medicine and Anaesthesia, and previously served as the Chief of Surgery/Anaesthesia at WLMH.

DISCUSSION ITEMS:

1. Lisa Reid, Manager of Medical Affairs, presented an update of the Credentials Office.

2. Marita Tonkin, Chief of Health Professional Practice, presented the Medication

Safety Committee QPSST Quarterly Report. 3. Dr. Paul Miller and Dr. Richard McLean reviewed confidential critical incidents and

the group discussed recommendations. 4. There was discussion around the discontinuation of HHS’ subscription to UpToDate,

and the selection of DynaMed as the primary point-of-care tool for HHS patient care providers.

ITEMS APPROVED BY THE MAC:

1. The Credentials Report was approved as distributed. There are 19 new appointments.

2. The following were approved as distributed within the consent agenda:

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MAC Report to the Board of Directors 2

a. Revised Policies:

IC – Acute Respiratory Infection (ARI) Surveillance Protocol Infection Prevention and Control During Patient Transport

Ebola and other Viral Hemorrhagic Fever Protocol b. Medical Directives - New:

McMaster Children’s Hospital Emergency Department Point of Care Testing

McMaster Children’s Hospital Emergency Department Analgesic for Extremity Pain

Neurosurgery Physician Assistant c. Medical Directives - Renewals:

51001 – Nurse Performed Flexible Sigmoidoscopy 51002 – Colorectal Cancer Pathway

54010 – Gyneoncology DST New Patient Referrals (JCC)

98001 – Gyneoncology DST Clinics (JCC) 98002 – Central Nervous System DST Clinics (JCC)

98004 – Hematology DST Clinics (JCC) d. Order Sets:

Outpatient/Same Day Overnight Gynecology Oncology Post-operative Outpatient/Same Day Overnight Urology Surgery Post-operative

The MAC meeting adjourned at 5:45pm.

Dr. P. Miller

Chair, MAC October 9, 2014

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Medical Advisory Committee

REPORT TO THE BOARD OF DIRECTORS

The Medical Advisory Committee electronically voted to approve the following items,

in lieu of the November regularly scheduled meeting.

Approved by: P. Miller (Chair), V. Alexopoulou, H. Flageole, K. Gulenchyn, L. Huang, D. Koff, R. Kolesar, E. Lipman, B. Lumb, D. Price, C. Sawchuk,

M. Stacey, R. Seeley, R. Tozer, D. Hunt, R. MacIsaac

FOR APPROVAL OF THE BOARD OF DIRECTORS: 1. The Medical Advisory Committee recommends the appointment of Dr. Ellen Lipman

as Chief of the Department of Child & Adolescent Psychiatry at Hamilton Health Sciences, effective November 1, 2014 for a term of five (5) years, renewable once.

ITEMS APPROVED BY THE MAC:

1. The Credentials Report was approved as distributed. There are 23 new appointments.

The Medical Advisory Committee Retreat is taking place on Friday, November 28th at Royal Botanical Gardens. Following this, a separate Report will be submitted to the

Board of Directors summarizing the discussion and approval items.

Dr. P. Miller Chair, MAC

November 18, 2014

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The following physicians are recommended

for appointment, having completed

an application as required by

Hamilton Health Sciences Bylaws,

and having been reviewed at the following:

• Credentials Committee meeting on September 19th, 2014

October 17th, 2014

• Medical Advisory Committee on November 12, 2014

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HHS CATEGORIES OF THE PROFESSIONAL STAFF [Medical/Dental/Midwifery]

Category Description Length of term Privileges

Active • Primary clinical/hospital care provided at HHS • Can not hold Active staff appointment at

another institution unless related to leadership position (i.e. City-wide Chief of Department)

• One year • Eligible for

annual reappointment

Yes

Associate • Applicants who are applying to the Active Staff are designated as Associate for a minimum of 1 year prior to formal appointment to Active staff;

• Performance reviews completed every 6 months

• Minimum of 1 year

• Maximum of 2 years

Yes

Special Professional

• Individuals employed by the Hospital with specific professional expertise who are not members of a regulated health profession and who have clinical/education/research and/or clinical/education/research/administrative responsibilities;

• Do not provide direct patient care



No

Courtesy • Has an Associate or Active staff appointment at another hospital at which the physician’s primary activities are based;

• Where an applicant is meeting an academic need within the faculty of Health Sciences;

• Where an applicant is meeting a specific clinical need



Yes/No

Term • To meet a specific clinical or academic need for a defined period of time not to exceed one (1) year [subject to renewal for a further period of up to one (1) additional year

• May permit renewal beyond two (2) years in exceptional circumstances

Yes/No

Clinical Scholar

• Include individuals wishing to provide an extra period of time for specialized post-certification training which involves both patient care and academic pursuit

• Must be fully trained to function in his or her specialty (licensed and, where appropriate eligible for certification) and be a certified by the Royal College of Physicians & Surgeons

• One year and may be subject to renewal for one (1) additional year

• In exceptional circumstances additional one year appts. may be approved to a maximum of four years

No

Yes – if requested by Chief of Dept. in concurrence with the Chair of the University Department

Clinical Assistant

• Applicants who have an independent license; • May be engaged in post-graduate training; • Required to support specific duties as

designated by the particular Department involved;

• Work under the supervision of an Active Staff member



No

Affiliate • Unaffiliated with a healthcare/hospital organization within LHIN 3 and 4 to gain access to the Clinical Connect system.



No

Page 28/207

Temporary • Have met all application criteria and are granted temporary appointment pending formal Board approval; or

• To meet a specific singular requirement by providing a consultation and/or operative procedure; or

• To meet an urgent expected need for a Professional service

• Shall not extend beyond date of next MAC meeting

• Continue on the recommendation of the MAC until the next Board meeting

No

Yes - if granted pending formal

approval of appointment

Honorary • Former membership on the Active Staff; or • Identified by the Board as an individual

determined to be qualified for such appointment;

• Do not provide direct patient care



No

Page 29/207

REPORT: COMMON CREDENTIALS COMMITTEEHAMILTON HEALTH SCIENCESHeld on September 19, 2014 at 0700 hours, General Site

BoardNovember 2014

Page 1 of 13

The following recommendations were reviewed and found to be satisfactory and appropriate for submission to the Board of Directors.

1 NEW APPOINTMENTS:

DEPARTMENT OF ANESTHESIA

DASS, Philippe D., MD

Current Appointment(s) NoneTemporary Appointment Aug. 8, 2014-Nov. 30, 2014Staff Appointment (Category) TermDates Dec. 1, 2014 -April 30, 2015DEPARTMENT OF Anesthesia

Impact Analysis Not RequiredCompliant with The Communicable Disease Surveillance Protocols for Ontario Hospitals

References Obtained YesReason for Hire Term CoverageProcedural Privileges Requested Anesthesia - Standard - ALL

HEIKKILA, Andrew J., MD

Current Appointment(s) NoneTemporary Appointment Aug. 11, 2014-Nov. 30, 2014Staff Appointment (Category) Clinical ScholarDates Dec. 1, 2014-June 30, 2015DEPARTMENT OF Anesthesia

Impact Analysis ApprovedCompliant with The Communicable Disease Surveillance Protocols for Ontario Hospitals

References Obtained YesReason for Hire ReplacementProcedural Privileges Requested Anesthesia - Standard - ALL

DEPARTMENT OF CRITICAL CARE

BELLEY-COTE, Emilie-Prudence, MD

Current Appointment(s) NoneTemporary Appointment Aug. 8, 2014-Nov. 30, 2014Staff Appointment (Category) Clinical AssistantDates Dec. 1, 2014-June 30, 2015DEPARTMENT OF Critical Care

Secondary Appointment Temporary Appointment Aug. 8, 2014-Nov. 30, 2014Staff Appointment (Category) Clinical Assistant (SMRE)Dates Dec. 1, 2014-June 30, 2015DEPARTMENT OF Medicine

Service General Internal Medicine

Pre-Placement Health (Immunization & 2-step TB Test)


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BoardNovember 2014

Page 2 of 13


References Obtained YesReason for Hire CoverageProcedural Privileges Requested Critical Care Medicine - Critical Care Clinical Assistant -

Standard ALL


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BoardNovember 2014

Page 3 of 13


SPENCE, Jessica MD

Current Appointment(s) NoneTemporary Appointment July 11, 2014-Nov. 30, 2014Staff Appointment (Category) Clinical AssistantDates Dec. 1, 2014-Jun. 30, 2015DEPARTMENT OF Critical Care

Impact Analysis Not Required

Compliant with The Communicable Disease Surveillance Protocols for Ontario Hospitals


Standard ALL

TUNG, L K Connie, MD

Current Appointment(s) NoneTemporary Appointment July 31, 2014-Nov. 30, 2014Staff Appointment (Category) Clinical AssistantDates Dec. 1, 2014-June 30, 2015DEPARTMENT OF Critical Care




Standard ALL

DEPARTMENT OF DIAGNOSTIC IMAGING

BHAN, Sasha N, MD, MBA

Current Appointment(s) NoneTemporary Appointment Aug. 8, 2014 - Nov. 30, 2014Staff Appointment (Category) TermDates Dec. 1, 2014 - Sept. 30, 2015DEPARTMENT OF Diagnostic Imaging


References Obtained YesReason for Hire CoverageProcedural Privileges Requested Diagnostic Imaging: Standard

Interpretation of General Radiographic StudiesInterpretation and Performance of All Ultrasound Imaging Including Doppler




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BoardNovember 2014

Page 4 of 13

Interpretation of Magnetic Resonance Imaging: Excludes Cardiac MRIInterpretation of CT ImagingUpper and Lower Gastrointestinal StudiesGeneral Angiographic ProceduresGeneral Interventional RadiologyDiagnostic Imaging: SpecificJRCC - Ontario Breast Screening Galactography of the Breast; Percutaneous Needly Biopsy/Drainage or Aspiration of Lesions of the Breast; Under Mammographic,Ultrasonic, CT Guided, or MRI Guided ControlPercutaneous Needle Biopsy Under Fluoroscopic, Mammographic, Ultrasonic, CT Guided, or MRI Guided Control (ie. Lesions of the breast, lung, liver, etc.)Interventional Techniques to Include Abscess Drainage, Billary Drainage, RFA and NephrostomiesMusculo-Skeletal Interventional Procedures; Including RFA

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BoardNovember 2014

Page 5 of 13

ELYAS, Remon G., MD

Current Appointment(s) NoneTemporary Appointment Aug. 8, 2014-Nov. 30, 2014Staff Appointment (Category) TermDates Dec. 1, 2014- Nov.30, 2014DEPARTMENT OF Diagnostic Imaging



References Obtained YesReason for Hire Term CoverageProcedural Privileges Requested Diagnostic Imaging: Standard

Interpretation of General Radiographic StudiesInterpretation and Performance of All Ultrasound Imaging Including DopplerInterpretation of Magnetic Resonance Imaging: Excludes Cardiac MRIInterpretation of CT Imaging

HARIRI, Arvin, MD, FRCPC

Current Appointment(s) NoneTemporary Appointment Aug. 1, 2014 - Nov. 30, 2014Staff Appointment (Category) TermDates Dec. 1, 2014 - Nov. 30, 2015DEPARTMENT OF Diagnostic Imaging

Service Radiology


References Obtained YesReason for Hire Term CoverageProcedural Privileges Requested Diagnostic Imaging - Standard

Interpretation of General Radiographic StudiesInterpretation and Performance of All Ultrasound Imaging Including DopplerInterpretation of MRI'sInterpretation of Magnetic Resonance Imaging EXCLUDING Cardiac MRIInterpretation of CT ImagingUpper and Lower Gastrointestional StudiesDiagnostic Imaging - SpecificPercutaneous Needle Biopsy under Fluoroscopic, Mammographic, Ultrasonic, CT-Guided, or MRI-Guided Control (ie. Lesions of the Breast, Lung, Liver, etc.)Musculo-Skeletal Interventional Procedures Including RFA

MAMMEN, Thomas, MD, RCPSC

Current Appointment(s) NoneTemporary Appointment Aug. 8, 2014 - Nov. 30, 2014



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BoardNovember 2014

Page 6 of 13

Staff Appointment (Category) TermDates Dec. 1, 2014 - Sept. 30, 2015DEPARTMENT OF Diagnostic Imaging


References Obtained YesReason for Hire CoverageProcedural Privileges Requested Diagnostic Imaging - Standard

Interpretation of General Radiographic StudiesInterpretation and Performance of All Ultrasound Imaging Including DopplerInterpretatioin of magnetic Resonance Imaging: Excludes Cardiac MRIInterpretation of CT ImagingUpper and Lower Gastrointesetional StudiesDiagnostic Imaging - Specific Percutaneous Needle Biopsy Under Fluoroscopic, Mammographic, Ultrasonic, CT Guided, or MRI Guided Control (ie. Lesions of the Brest, Lung, Liver, etc.)

DEPARTMENT OF EMERGENCY MEDICINE

SOLLAZZO, John N., MD, CCFP (EM)

Current Appointment(s) NoneTemporary Appointment Sept. 8, 2014-Nov. 30, 2014Staff Appointment (Category) CourtesyDates Dec. 1, 2014-Nov. 30, 2015DEPARTMENT OF Emergency Medicine


References Obtained YesReason for Hire New Addition to Staff ComplementProcedural Privileges Requested Emergency Medicine - Standard

Extreme CircumstancesEmergency Medicine - Standard - ALLEmergency Medicine - AdvancedInsertion of Transvenous PacemakerEmergency Department Targeted UltrasoundSupra Pubic CatheterizationDiagnostic Peritoneal LavageCardiorrhaphy (Sutures to Heart)

DEPARTMENT OF FAMILY MEDICINE

MATOS, Aldina

Current Appointment(s) NoneTemporary Appointment Sept. 10, 2014- Nov. 30, 2014Staff Appointment (Category) Affiliate



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BoardNovember 2014

Page 7 of 13

Dates Dec. 1, 2014 - Oct. 31, 2015DEPARTMENT OF Family Medicine

Impact Analysis Not RequiredNot Required

References Obtained YesReason for Hire Clinical Connect AccessProcedural Privileges Requested None

DEPARTMENT OF MEDICINE

PERERA, Kanjana S., MD, FRCPC

Current Appointment(s) NoneTemporary Appointment Aug. 6, 2014-Nov. 30, 2014Staff Appointment (Category) Clinical ScholarDates Dec. 1, 2014-June 30, 2015DEPARTMENT OF Medicine

Service Neurology


References Obtained YesReason for Hire New HireProcedural Privileges Requested Medicine - Standard

Lumbar PunctureMedicine Neurology - OtherInjection of Botox

SIEGAL, Deborah M., MD, FRCPC

Current Appointment(s) NoneTemporary Appointment July 22, 2014-Nov. 30, 2014Staff Appointment (Category) Clinical ScholarDates Dec. 1, 2014-June 30, 2015DEPARTMENT OF Medicine

Service Hematology



Bone Marrow Aspiration and BiopsyMedicine Hematology - OtherPlasmapheresis

SIBBALD, Matthew G., MD, MHPE, PhD, FRCPC

Current Appointment(s) NoneTemporary Appointment July 1, 2014 - Nov. 30, 2014Staff Appointment (Category) AssociateDates Dec. 1, 2014-Nov. 30, 2015

Pre-Placement Health



Page 36/207


BoardNovember 2014

Page 8 of 13

DEPARTMENT OF MedicineService Cardiology



ECG InterpretationStress Test Supervision and InterpretationHolter Monitor InterpretationArterial Blood Gases and InterpretationLumbar PunctureParacentesis: Bedside, Diagnostic, TherapeuticIntraarticular Aspiration and InjectionThoracentesisArterial Catheter InsertionCentral Venous Catheter InsertionEmergency Defibrillation Elective CardioversionEmergency CardioversionElective PericardiocentesisEmergency PericardiocentesisEndotracheal IntubationChest Tube InsertionTemporary pacemaker insertionUse of Non-Invasive Ventilation (CPAP or BIPAP)Medicine Cardiology - SpecificPulmonary Artery Catheter Insertion

Temporary Transvenous Pacemaker Insertion and AssessmentTransthoracic EchocardiographyMedicine Cardiology - Specific, HIU

Right Heart Catheterization only, including Swan-Ganz InsertionCardiac Catheterization, Right and/or Left, Pressure Measurement onlyCoronary Angiography, including Pulmonary Anglography and Right and Left VentriculographyPercutaneous Coronary InterventionIntraortic Balloon Pump Insertion and Assessment

WRIGHT, Douglas, MD, FRCPC

Current Appointment(s) NoneTemporary Appointment Aug. 15, 2014-Nov. 30, 2014Staff Appointment (Category) Clinical ScholarDates Nov. 30, 2014-June 30, 2015DEPARTMENT OF Medicine

Service Cardiology


References Obtained YesReason for Hire New Hire



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BoardNovember 2014

Page 9 of 13

Procedural Privileges Requested Medicine Standard Elective PericardiocentesisEmergency PericardiocentesisMedicine Cardiology - SpecificTranseophageal EchocardiographyTransthoracic Echocardiography

Page 38/207


BoardNovember 2014

Page 10 of 13

DEPARTMENT OF PEDIATRICS

FERA, Evridiki V., MD

Current Appointment(s) NoneTemporary Appointment Aug. 18, 2014-Nov. 30, 2014Staff Appointment (Category) TermDates Dec. 1, 2014-Dec. 31, 2015DEPARTMENT OF Pediatrics

Service Emergency Medicine


References Obtained YesReason for Hire Term CoverageProcedural Privileges Requested Pediatric Emergency Care Standard - ALL

Pediatrics - SpecificSedationThoracentesisParacentesisPediatric Emergency Care Non-Invasive Mechanical Ventilation (BIPAP/CPAP)Elective CardioversionEmergency TracheotomyChest Tube InsertionPericardiocentesisBedside Ultrasound Guided TherapyArthocentesisSplints/Back Slabs (uncomplicated #)Closed Reduction of Non-Fracture DislocationsGastric LavagePercipitous Vaginal DeliveryNasal Packing - ArteriorFracture Treatment and Immobilization:a) Simple Undisplaced Fractureb) Cast Application and RemovalPediatrics - Specific - Pediatric Emergency CareWound Repair:b) Burnsc) Abscess, Hematoma Incision and DrainageComplex Laceration RepairRegional Nerve Block


JONES, Kevin C., MD

Current Appointment(s) NoneTemporary Appointment July 1, 2014 - Nov. 30, 2014Staff Appointment (Category) AssociateDates Dec. 1, 2014-Nov. 30, 2015DEPARTMENT OF Pediatrics

Service Neurology

Impact Analysis Approved


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BoardNovember 2014

Page 11 of 13


References Obtained YesReason for Hire Patient NeedsProcedural Privileges Requested Pediatrics - Standard - ALL

Pediatrics - SpecificSedationPediatric NeurologyEvoked Potential InterpretationECG InterpretationVideo EEG Interpretation

WONG, Jackson Y.W., MD

Current Appointment(s) NoneTemporary Appointment July 30, 2014-Nov. 30, 2014Staff Appointment (Category) AssociateDates Dec. 1, 2014-Sept. 30, 2015DEPARTMENT OF Pediatrics

Service Respirology


References Obtained YesReason for Hire New HireProcedural Privileges Requested Pediatrics - Standard ALL

Pediatrics RespirologyFiveroptic Bronchoscopy with BiopsyFiberoptic Bronchoscopy without BiopsyPulmonary Function Testing and Interpretation

DEPARTMENT OF PHYSICAL MEDICINE & REHABILITATION

FELOIU, Florin D., MD

Current Appointment(s) NoneTemporary Appointment July 23, 2014-Nov. 30, 2014RECOMMENDATIONStaff Appointment (Category) AssociateDates Dec. 1, 2014-Nov. 30, 2015DEPARTMENT OF Physical Medicine & Rehabilitation


References Obtained YesReason for Hire Replacement for Dr. J. MillardProcedural Privileges Requested Physicial Medicine & Rehabilitation - Standard - ALL

Physicial Medicine & Rehabilitation - SpecificLumbar PuncturePeripheral Nerve BlockSpinal InjectionsPhysicial Medicine & Rehabilitation - Other




Page 40/207


BoardNovember 2014

Page 12 of 13

Muscle BiopsyMinor Surgical DabridementInjection of BotoxEMG Performance and Interpretation

2

ASSOCIATE TO ACTIVEDepartment Chiefs recommend appointments be changed from Associate to Active Staff.Courtesy Appointments at other facility aligned with Associate staff appointment

Department Child and Adolescent PsychiatryName Soh-Yoon Min

Associate Staff Appointment Oct. 1, 2013 - Sept. 30, 2014Change to Active Dec. 1, 2014 - Feb. 28, 2015Designated Active Staff Member Dr. E. Lipman

Department Laboratory MedicineName Dr. Alexandre Odashiro

Associate Staff Appointment Oct. 1, 2013 - Sept. 30, 2014Change to Active Dec. 1, 2014 - Feb. 29, 2016Designated Active Staff Member Dr. J. Cutz

Department PediatricsName Dr. Stacey L Marjerrison

Associate Staff Appointment Oct. 1, 2013 - Sept. 30, 2014Change to Active Dec. 1, 2014 - Dec. 31, 2015Designated Active Staff Member Dr. Anthony Chan

Department PediatricsName Dr. Jennifer E Twiss

Associate Staff Appointment Oct. 1, 2013 - Sept. 30, 2014 Change to Active Dec. 1, 2014 - Dec. 31, 2015

ASSOCIATE EXTENSIONSDepartment Chiefs Recommend Associate Staff Appointment be Extended

Department Family MedicineName Dr. Al D Alipio

Staff Appointment (Category) CourtesyEffective Dates of Extension Jul. 1, 2014 - Jun. 30, 2015Cross Appointment at SJHH Associate

3 APPOINTMENT EXTENSIONS

Department Family MedicineName Dr. Erin M Frotten

ASSOCIATE STAFF

Page 41/207


BoardNovember 2014

Page 13 of 13

Staff Appointment (Category) TermAppointment Start Date February 1, 2012Effective Dates of Extension February 28, 2015Designated Active Staff Member Dr. K. Bracken

Department SurgeryName Dr. Anwar M AliStaff Appointment (Category) Clinical Assistant (Assisting at Surgery)Appointment Start Date May 1, 2012Effective Dates of Extension September 30, 2015Designated Active Staff Member

4 RESIGNATIONS

Department Obstetrics & GynecologyName Dr. Valter FeylesStaff Appointment (Category) CourtesyEffective Date of Resignation August 5, 2014

Department Laboratory MedicineName Dr. Bekim SadikovicStaff Appointment (Category) Special ProfessionalEffective Date of Resignation August 31, 2014

Department MedicineName Dr. Marilyn KorzekwaStaff Appointment (Category) CourtesyEffective Date of Resignation September 30, 2014

5 LAPSE OF APPOINTMENTS

Department Surgery

Name Dr. Adel M A Dyub

Staff Appointment (Category) Clinical AssistantEffective Date of Lapse December 1, 2014Designated Active Staff Member Dr. I. Cybulsky

Page 42/207

REPORT: COMMON CREDENTIALS COMMITTEEHAMILTON HEALTH SCIENCESHeld on October 17, 2014 at 0700 hours, General Site

BOARDNovember 2014

Page 1 of 14

The following recommendations were reviewed and found to be satisfactory and appropriate forsubmission to the Board of Directors.

1 NEW APPOINTMENTS:

DEPARTMENT OF ANESTHESIA

CARROLL, David MD

Current Appointment(s) NoneTemporary Appointment Sept. 10, 2014 - Nov. 30, 2014Staff Appointment (Category) TermDates Dec. 1, 2014 - Apr. 30, 2015DEPARTMENT OF Anesthesia

Impact Analysis Not RequiredPre-Placement Health Compliant with The Communicable Disease (Immunization & 2-step TB Test) Surveillance Protocols for Ontario HospitalsReferences Obtained YesReason for Hire Term CoverageProcedural Privileges Requested Anesthesia - Standard ALL

DEPARTMENT OF COMPLEX CARE, AGING & PALLIATIVE CARE

GENERAL, Stacey, MD

Current Appointment(s) NoneTemporary Appointment Jul. 14, 2014 - Nov. 30, 2014Staff Appointment (Category) AssociateDates Dec. 1, 2014 - Nov. 30, 2015DEPARTMENT OF Complex Care, Aging & Palliative Care

ADD SECONDARY Staff Appointment DEPARTMENT Family MedicineCATEGORY Associate

Temporary Appointment Aug. 11, 2014 - Nov. 30, 2014Effective Date(s) Dec. 1, 2014 - Sept. 30, 2015

Impact Analysis ApprovedPre-Placement Health Compliant with The Communicable Disease (Immunization & 2-step TB Test) Surveillance Protocols for Ontario HospitalsReferences Obtained YesReason for Hire Replacement for Dr. J. KaganProcedural Privileges Requested Family Medicine - Standard

Supportive CareFamily Medicine - Specific# In Hospital Palliative Care: IV/SC Infusion of Opiates/Midazolam/Anti-Emetics# In Hopsital Palliative Care: Infusion Pumps for Opiates/Midazolam/Anti-Emetics

KANANI, Sabira, MD

Current Appointment(s) NoneTemporary Appointment Aug. 11, 2014 - Nov. 30, 2014Staff Appointment (Category) AssociateDates Dec. 1, 2014 - Nov. 30, 2015DEPARTMENT OF Complex Care, Aging & Palliative Care

ADD SECONDARY Staff Appointment

Page 43/207


BOARDNovember 2014

Page 2 of 14

DEPARTMENT Family MedicineCATEGORY Associate

Temporary Appointment Aug. 11, 2014 - Nov. 30, 2014Effective Date(s) Dec. 1, 2014 - Sept. 30, 2015

Impact Analysis ApprovedPre-Placement Health Compliant with The Communicable Disease (Immunization & 2-step TB Test) Surveillance Protocols for Ontario HospitalsReferences Obtained YesReason for Hire Replacement for Dr. MantleProcedural Privileges Requested Family Medicine - Standard

Supportive CareFamily Medicine - SpecificThoracentesisAbdominal Paracentesis Emetics Opiates/Midazolam/Anti-Emetics


CANERS, Kyla, MD

Current Appointment(s) NoneTemporary Appointment Sept. 15, 2014 - Nov. 30, 2014Staff Appointment (Category) Clinical AssistantDates Dec. 1, 2014 - Jun. 30, 2015DEPARTMENT OF Critical Care

Impact Analysis Not RequiredPre-Placement Health Compliant with The Communicable Disease (Immunization & 2-step TB Test) Surveillance Protocols for Ontario HospitalsReferences Obtained YesReason for Hire CoverageProcedural Privileges Requested Critical Care Medicine - Critical Care Clinical Assistant - ALL

PETROSONIAK, Andrew M., MD, FRCPC


Impact Analysis Not RequiredPre-Placement Health Compliant with The Communicable Disease (Immunization & 2-step TB Test)

Surveillance Protocols for Ontario Hospitals

References Obtained YesReason for Hire CoverageProcedural Privileges Requested Critical Care Medicine - Critical Care Clinical Assistant - ALL

SMALLFIELD, Audra Lynn, MD


Page 44/207


BOARDNovember 2014

Page 3 of 14

Impact Analysis Not RequiredPre-Placement Health Compliant with The Communicable Disease (Immunization & 2-step TB Test) Surveillance Protocols for Ontario HospitalsReferences Obtained YesReason for Hire CoverageProcedural Privileges Requested Critical Care Medicine - Critical Care Clinical Assistant - ALL

DEPARTMENT OF DIAGNOSTIC IMAGING

KENNEDY, Shauna M., MD, FRCPC

Current Appointment(s) NoneTemporary Appointment Jul. 1, 2014 - Nov. 30, 2014RECOMMENDATIONStaff Appointment (Category) AssociateDates Dec. 1, 2014 - Nov. 30, 2015DEPARTMENT OF Diagnostic Imaging

Service Neuroradiology

Impact Analysis ApprovedPre-Placement Health Compliant with The Communicable Disease (Immunization & 2-step TB Test) Surveillance Protocols for Ontario HospitalsReferences Obtained YesReason for Hire Replacement for Dr. M. EllinsProcedural Privileges Requested Diagnostic Imaging - Standard

Interpretation of General Radiographic StudiesInterpretation and Performance of All Ultrasound Imaging Including DopplerInterpretation of MRI's

Interpretation of Magnetic Resonance Imaging EXCLUDING Cardiac MRIInterpretation of CT ImagingUpper and Lower Gastrointestinal Studies

DEPARTMENT OF EMERGENCY MEDICINE

ATRIE, Damon, MD, FRCPC

Current Appointment(s) Clinical AssistantTemporary Appointment Jul. 16, 2014 - Nov. 30, 2014RECOMMENDATIONStaff Appointment (Category) CourtesyDates Dec. 1, 2014 - Feb. 29, 2016DEPARTMENT OF Emergency Medicine

Impact Analysis Not RequiredPre-Placement Health Compliant with The Communicable Disease (Immunization & 2-step TB Test) Surveillance Protocols for Ontario HospitalsReferences Obtained YesReason for Hire New StaffProcedural Privileges Requested Emergency Medicine - Standard

Extreme CircumstancesEmergency Medicine - Standard - ALLEmergency Medicine - AdvancedInsertion of Transvenous PacemakerEmergency Department Targeted UltrasoundSupra Pubic CatheterizationDiagnostic Peritoneal LavageCardiorrhaphy (Sutures to Heart)Point of Care UltrasoundAdmit Privileges - No

Page 45/207


BOARDNovember 2014

Page 4 of 14

LABIB, Noura A M., MD

Current Appointment(s) Clinical AssistantTemporary Appointment Jul. 11, 2014 - Nov. 30, 2014Staff Appointment (Category) TermDates Dec. 1, 2014 - Feb. 29, 2016DEPARTMENT OF Emergency Medicine

Impact Analysis Not RequiredPre-Placement Health Compliant with The Communicable Disease (Immunization & 2-step TB Test) Surveillance Protocols for Ontario HospitalsReferences Obtained YesReason for Hire Term CoverageProcedural Privileges Requested Emergency Medicine - Standard

Extreme CircumstancesEmergency Medicine - Standard - ALLEmergency Medicine - Advanced - ALL

LAIDLEY, Ian F., MD

Current Appointment(s) NoneTemporary Appointment Jul. 23, 2014 - Nov. 30, 2014Staff Appointment (Category) TermDates Dec. 1, 2014 - Feb. 28, 2015DEPARTMENT OF Emergency Medicine

Impact Analysis Not Required Pre-Placement Health Compliant with The Communicable Disease (Immunization & 2-step TB Test) Surveillance Protocols for Ontario HospitalsReferences Obtained YesReason for Hire StaffingProcedural Privileges Requested Emergency Medicine - Standard

Extreme CircumstancesEmergency Medicine - Standard - ALLEmergency Medicine - AdvancedInsertion of Transvenous PacemakerEmergency Department Targeted UltrasoundSupra Pubic CatherizationDiagnostic Peritoneal LavageCardiorrhaphy (Sutures to Heart)Point of Care Ultrasound

DEPARTMENT OF FAMILY MEDICINE

DATEMA, Jason A., MD

Current Appointment(s) NoneTemporary Appointment Sept. 10, 2014 - Nov. 30, 2014Staff Appointment (Category) CourtesyDates Dec. 1, 2014 - Oct. 31, 2015DEPARTMENT OF Family Medicine

Service General Family Practice

Impact Analysis Not RequiredPre-Placement Health Compliant with The Communicable Disease (Immunization & 2-step TB Test) Surveillance Protocols for Ontario HospitalsReferences Obtained YesReason for Hire CoverageProcedural Privileges Requested Family Medicine - Standard - ALL

Family Medicine - Specific - Minor Surgical Procedures - ALLFamily Medicine - Specific

Page 46/207


BOARDNovember 2014

Page 5 of 14

# Admit and Direct In-Patient Care (Excluding Obstetrical and Newborn Care)ThoracentesisAbdominal ParacentesisChronic Wound Care Debridement# In-Hospital Palliative care: IV/SC Infusion of Opiates/Midazolam/Anti-Emetics# In-Hospital Palliative Care: Infusion Pumps for Opiates/Midazolam/Anti-Emetics

SHOUR, Rachel S., MD, CCFPEducation/Training/Work History

• BSc, York University: 2007• MD, McMaster University: 2010• Residency (Family Medicine), McMaster University: 2010-2013

Current Staff Appointment(s)• None

Certifications• Family Medicine: 2013

Current Appointment(s) NoneTemporary Appointment Aug. 1, 2014 - Nov. 30, 2014Staff Appointment (Category) TermDates Dec. 1, 2014 - Oct. 31, 2015DEPARTMENT OF Family Medicine

Impact Analysis Not RequiredPre-Placement Health Compliant with The Communicable Disease (Immunization & 2-step TB Test) Surveillance Protocols for Ontario HospitalsReferences Obtained YesReason for Hire Community PhysicianProcedural Privileges Requested Family Medicine - Standard - ALL

Family Medicine - Specific Shared Low-Risk Obstetrical Care (Protocol in place)# Newborn Care

DEPARTMENT OF MEDICINE

AHMED, Amna N., MD

Current Appointment(s) NoneTemporary Appointment Sept. 8, 2014 - Nov. 30, 2014Staff Appointment (Category) Clinical Assistant (SMRE)Dates Dec. 1, 2014 - Jun. 30, 2015DEPARTMENT OF Medicine


Impact Analysis Not RequiredPre-Placement Health Compliant with The Communicable Disease (Immunization & 2-step TB Test) Surveillance Protocols for Ontario HospitalsReferences Obtained YesReason for Hire SMRE CoverageProcedural Privileges Requested Medicine - SMR Equivalent - ALL

ATTAR, Ahmed, MD, FRCPC

Current Appointment(s) NoneTemporary Appointment Sept. 1, 2014 - Nov. 30, 2014Staff Appointment (Category) AssociateDates Dec. 1, 2014 - Nov. 30, 2015DEPARTMENT OF Medicine

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BOARDNovember 2014

Page 6 of 14

Service Neurology

Impact Analysis ApprovedPre-Placement Health Compliant with The Communicable Disease (Immunization & 2-step TB Test) Surveillance Protocols for Ontario HospitalsReferences Obtained YesReason for Hire New Addition to StaffProcedural Privileges Requested Medicine - Standard - ALL

Medicine - Neurology Specific - ALLMedicine - Neurology Other - ALL

DUNCAN, Andrew W., MD

Current Appointment(s) Clinical AssistantTemporary Appointment Aug. 5, 2014 - Nov. 30, 2014Staff Appointment (Category) Clinical ScholarDates Dec. 1, 2014 - Jun. 30, 2015DEPARTMENT OF Medicine


Impact Analysis Not RequiredPre-Placement Health Compliant with The Communicable Disease (Immunization & 2-step TB Test) Surveillance Protocols for Ontario HospitalsReferences Obtained YesReason for Hire Clinical ScholarProcedural Privileges Requested Medicine - Standard

ECG InterpretationStress Test Supervision and InterpretationArterial Blood Gases and InterpretationLumbar PunctureBone Marrow Aspiration and BiopsyRigid SigmoidoscopyParacentesis: Bedside, Diagnostic, TherapeuticIntraarticular Aspiration and InjectionPunch Biopsy of SkinThoracentesisArterial Catheter InsertionCentral Venous Catheter InsertionEmergency DefibrillationElective CardioversionEmergency CardioversionElective: PericardiocentesisEmergency PericardiocentesisEndotracheal IntubationTemporary pacemaker insertionUse of Non-Invasive Ventilation (CPAP and BiPAP)

RAUT-DESHPANDE, Pooja, MD

Current Appointment(s) NoneTemporary Appointment Aug. 6, 2014-Nov. 30, 2014Staff Appointment (Category) AssociateDates Dec. 1, 2014 - Nov. 30, 2015DEPARTMENT OF Medicine




ECG Interpretation


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BOARDNovember 2014

Page 7 of 14

Stress Test Supervision and InterpreationHolter Monitor InterpretationArterial Blood Gases and InterpretationLumbar PunctureBone Marrow Aspiration and BiopsyParacentesis: Bedside, Diagnostic, TherapeuticIntraarticular Aspiration and InjectionBunch Biopsy of SkinArterial Catheter InsertionCentral Venous Catheter InsertionEmergency DefibrillationElective CardioversionEmergency CardioversionEndotracheal IntubationChest Tube InsertionTemporary pacemaker insertionUse of Non-Invasive Ventilation (CPAP or BiPAP)

RAHMAN, S. Tanzil, MD

Current Appointment(s) NoneTemporary Appointment Jul. 11, 2014 - Nov. 30, 2014Staff Appointment (Category) TermDates Dec. 1, 2014 - Jun. 30, 2015DEPARTMENT OF Medicine


Impact Analysis Not RequiredPre-Placement Health Compliant with The Communicable Disease (Immunization & 2-step TB Test) Surveillance Protocols for Ontario HospitalsReferences Obtained YesReason for Hire JH CTU CoverageProcedural Privileges Requested Medicine - Standard

ECG InterpretationStress Test Supervision and InterpretationHolter Monitor InterpretationArterial Blood Gas and InterpretationLumbar PunctureBone Marrow Aspiration and BiopsyParacentesis - Bedside, Diagnostic, TherapeuticIntraarticular Aspiration and InjectionPunch Biopsy of SkinThoracentesisArterial Catheter InsertionCentral Venous Catheter InsertionEmergency DefibrillationElective CardioversionEmergency CardioversionEndotracheal IntubationChest Tube InsertionUse of Non-Invasive Ventilation (CPAP or BiPAP)

DEPARTMENT OF OBSTETRICS & GYNECOLOGY

COLL-BLACK, Mary C., MD

Current Appointment(s) NoneTemporary Appointment Sept. 24, 2014 - Nov. 30, 2014Staff Appointment (Category) TermDates Dec. 1, 2014 - Oct. 31, 2015DEPARTMENT OF Obstetrics & Gynecology

Impact Analysis Not RequiredPre-Placement Health Compliant with The Communicable Disease

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BOARDNovember 2014

Page 8 of 14

(Immunization & 2-step TB Test) Surveillance Protocols for Ontario HospitalsReferences Obtained YesReason for Hire FellowProcedural Privileges Requested Obstetrics & Gynecology - Gynecology Standard - ALL

Obstetrics & Gynecology - Gynecology Specific - ALLColposcopy Including Cervical Cryotherapy and LEEP ProceduresGlobal Endometrial AblationPre Sacral NeurectomyHypogastric Artery LigationVaginal HysterectomyOperative Hysterectomy: Endometrial AblationDivision of Uterine SeptumMyomectomySterilizationLaparoscopic Assisted Vaginal HysterectomyTotal or Subtotal Laparoscopic HysterectomyLaparoscopic MyomectomyLaparoscopic UrethropexyLaparoscopic Vault SuspensionLaparoscopic Pre Sacral NeurectomyLaparoscopic Appendectomy for Appediceal EndometriosisTrans Vaginal Tape Procedures for Urinary Incontinence Retropubic UrethropexyRepeat Retropubic UrethropexySacrocolpopexyDiagnostic Cystoscopy Related to Urogynecologic Investigation and SurgeryTotal Omentectomy

PATEL, Nita G., MD

Current Appointment(s) NoneTemporary Appointment Aug. 27, 2014 - Nov. 30, 2014Staff Appointment (Category) TermDates Dec. 1, 2014 - Oct. 31, 2015DEPARTMENT OF Obstetrics & Gynecology

Impact Analysis Not RequiredPre-Placement Health Compliant with The Communicable Disease (Immunization & 2-step TB Test) Surveillance Protocols for Ontario HospitalsReferences Obtained YesReason for Hire Term CoverageProcedural Privileges Requested Obstetrics & Gynecology - Standard ALL


FLEMING, Adam J., MD, FRCPC

Current Appointment(s) NoneTemporary Appointment Sept. 15, 2014 - Nov. 30, 2014Staff Appointment (Category) AssociateDates Dec. 1, 2014 - Nov. 30, 2015DEPARTMENT OF Pediatrics

Service Pediatric Hematology/Oncology

Impact Analysis ApprovedPre-Placement Health Compliant with The Communicable Disease (Immunization & 2-step TB Test) Surveillance Protocols for Ontario HospitalsReferences Obtained YesReason for Hire New HireProcedural Privileges Requested Pediatrics - Standard - ALL

Pediatrics - Specific

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Page 9 of 14

Pediatric Hematology/OncologyExchange TransfusionBone Marrow Aspiration & BiopsyIntrathecal Chemotherapy

SCHINDLER, Nathalie L., MD, FRCPC

Current Appointment(s) NoneTemporary Appointment Aug. 1, 2014 - Nov. 30, 2014Staff Appointment (Category) AssociateDates Dec. 1, 2014 - Nov. 30, 2015DEPARTMENT OF Pediatrics

Service Emergency Pediatrics

Impact Analysis ApprovedPre-Placement Health Compliant with The Communicable Disease (Immunization & 2-step TB Test) Surveillance Protocols for Ontario HospitalsReferences Obtained YesReason for Hire New Addition to StaffProcedural Privileges Requested Pediatric Emergency Care - Standard - ALL

Pediatrics - Specific - ALLPediatric Emergency CareNon-Invasive Mechanical Ventilation (BiPAP/CPAP)Central Line InsertionArterial Line InsertionElective CardioversionEmergency CricothyroidotomyChest Tube InsertionPericardiocentesisBedside Ultrasound Guided TherapyArthocentesisSplints/Back Slabs (uncomplicated #)Closed Reduction of Non-Fracture DislocationsGastric LavagePrecipitous Vaginal DeliveryNasal Packing:a) Anteriorb) PosteriorFracture Treatment and Immobilization:a) Simple Undisplaced Fractureb) Cast Application and Removalc) Closed Reduction of FracturesPediatrics - Specific -Pediatric Emergency Carea) Exterior Tendon Repairb) Burnsc) Abscess, Hematoma Incision and DrainageComplex Laceration RepairRegional Nerve Block

DEPARTMENT OF SURGERY

NEWMAN, David J., MD

Current Appointment(s) NoneTemporary Appointment Aug. 22, 2014 - Nov. 30, 2014Staff Appointment (Category) Clinical Assistant (Assisting At Surgery)Dates Dec. 1, 2014 - Dec. 31, 2015DEPARTMENT OF Surgery

Service Orthopedic Surgery

Physician Orientation Impact Analysis Not Required

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Pre-Placement Health Compliant with The Communicable Disease (Immunization & 2-step TB Test) Surveillance Protocols for Ontario HospitalsReferences Obtained YesReason for Hire Assist at SurgeryProcedural Privileges Requested Surgery - Assist at Surgery - ALL

DEPARTMENT OF SURGERY

STACEY, Michael, MD

Current Appointment(s) NoneTemporary Appointment Oct. 6, 2014 - Nov. 30, 2014Staff Appointment (Category) ActiveDates Dec. 1, 2014 - Dec. 31, 2015DEPARTMENT OF Surgery

Service Vascular Surgery

Impact Analysis ApprovedPre-Placement Health Compliant with The Communicable Disease (Immunization & 2-step TB Test) Surveillance Protocols for Ontario HospitalsReferences Obtained YesReason for Hire New Surgeon-in-ChiefProcedural Privileges Requested Surgery - Vascular Surgery Standard - ALL

Surgery - Vascular Surgery SpecializedSupra - Aortic TrunksRepair/Reconstruction Brachiocephalic TrunkRepair/Reconstruction Carotid ArteryRepair/Reconstruction Subclavian ArterySternotomyRepair/Reconstruction Renal ArteryExcision Intracaval TumourRepair/Reconstruction Celiac Trunk/Inferior Mesenteric Artery/Superior Mesenteric ArteryRepair/Reconsturction Thoracic AortaThoraco-Abdominal Repair (TAA)Surgery - Vascular Surgery Specialized Endovascular - ALL

2

ASSOCIATE TO ACTIVE

Department AnesthesiaName Dr. Yannick Le Manach

Associate Staff Appointment July 1, 2013Change to Active July 1, 2014Designated Active Staff Member Dr. R. Kolesar

Staff Appointment (Category) ActiveEffective Dates of Extension Jul. 1, 2014 - Apr. 30, 2015[Cross Appointment at SJHH/HHS] None

Department Family MedicineName Dr. Hugh F Boyd

Associate Staff Appointment July 1, 2012Change to Active July 1, 2014Designated Active Staff Member Dr. D. Price

Staff Appointment (Category) Courtesy

ASSOCIATE STAFF

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Effective Dates of Extension Jul. 1, 2014 - Oct. 31, 2015 [Cross Appointment at SJHH/HHS] Active

Department MedicineName Dr. Y Juliana Li

Associate Staff Appointment April 1, 2013Change to Active April 1, 2014Designated Active Staff Member Dr. A. Freitag

Staff Appointment (Category) CourtesyEffective Dates of Extension Apr. 1, 2014 - Jun. 30, 2015[Cross Appointment at SJHH/HHS] Active

Department MedicineName Dr. Alejandro Torres-Trejo

Associate Staff Appointment October 1, 2012Change to Active October 1, 2014Designated Active Staff Member Dr. J. Turnball

Staff Appointment (Category) ActiveEffective Dates of Extension Oct. 1, 2014 - Jun. 30, 2015[Cross Appointment at SJHH/HHS] Courtesy

Department SurgeryName Dr. Adul M A Dyub

Associate Staff Appointment January 1, 2013Change to Active December 1, 2014Designated Active Staff Member Dr. I Cybulsky

Staff Appointment (Category) ActiveEffective Dates of Extension Dec. 1, 2014 - Dec. 31, 2015[Cross Appointment at SJHH/HHS] Courtesy

3 SECONDARY APPOINTMENTS:

ADD A SECONDARY STAFF APPOINTMENT

PRIMARY APPOINTMENT Clinical AssistantName Dr. Serena Gundy Certification(s) NoneLiability Coverage #14 - TraineesADD SECONDARY Staff Appointment

DEPARTMENT MedicineCATEGORY Clinical Assistant (SMRE)

Temporary Appointment Aug. 27, 2014 - Nov. 30, 2014Effective Date(s) Dec. 1, 2014 - Jun. 30, 2015Procedural Privileges Requested Medicine - SMRE Equivalent - ALL

4 REINSTATE LAPSED APPOINTMENT [Re-appointment application received late]

Department Family MedicineName Dr. Mark R G Grafham

Lapsed October 31, 2014RE-APPOINT December 1, 2014

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Page 12 of 14

Effective Date(s) Dec. 1, 2014 - Oct. 31, 2015Designated Active Staff Member N/A

Department Family MedicineName Dr. Margaret A BridgeLapsed October 31, 2014RE-APPOINT December 1, 2014Effective Date(s) Dec. 1, 2014 - Oct. 31, 2015Designated Active Staff Member N/Awith changes to procedural privileges Delete All

Department Critical CareName Dr. Abdulrahman M F Al-Harbi

Lapsed July 1, 2014RE-APPOINT December 1, 2014Effective Date(s) Dec. 1, 2014 - Jun. 30, 2015Designated Active Staff Member ICU Intensivist On-Call

5 CHANGE IN CATEGORY

Department Family MedicineName Dr. Margaret A BridgeCHANGE FROM Courtesy TO HonoraryEffective Date(s) Dec. 1, 2014 - Oct. 31, 2015

6 APPOINTMENT EXTENSIONS

Department AnesthesiaName Dr. Andrei E GagarineStaff Appointment (Category) TermAppointment Start Date January 1, 2012Effective Dates of Extension Oct. 1, 2014 - Jan. 31, 2015Designated Active Staff Member Dr. R. Kolesar

Department AnesthesiaName Dr. Edwin K T Ho

Staff Appointment (Category) Clinical ScholarAppointment Start Date November 1, 2013Effective Dates of Extension Oct. 1, 2014 - Apr. 30, 2015Designated Active Staff Member Dr. R. Kolesar

Department Complex Care, Aging & Palliative CareName Dr. Britta C LasloStaff Appointment (Category) TermAppointment Start Date December 1, 2013Effective Dates of Extension Nov. 1, 2014 - Apr. 30, 2015Designated Active Staff Member Dr. R. Seeley

SECONDARY Department Family MedicineName Dr. Britta C LasloSecondary Staff Appointment TermAppointment Start Date Dec. 1, 2013Effective Date of Extension Nov. 1, 2014 - Apr. 30, 2015Designated Active Staff Member Dr. D. Price

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Department Emergency MedicineName Dr. Julian J OwenStaff Appointment (Category) TermAppointment Start Date October 1, 2013Effective Dates of Extension Oct. 1, 2014 - Feb. 28, 2015Designated Active Staff Member Dr. W. KrizmanichNotes Moving to Associate

Department Medicine Name Dr. Kimberly J LegaultStaff Appointment (Category) Clinical ScholarAppointment Start Date July 1, 2013Effective Dates of Extension Nov. 1, 2014 - Jan. 31, 2015Designated Active Staff Member Dr. A. Cividino

Department Obstetrics & GynecologyName Dr. Andre M LaRocheStaff Appointment (Category) TermAppointment Start Date October 1, 2013Effective Dates of Extension Oct. 1, 2014 - Sept. 30, 2015Designated Active Staff Member Dr. N. Leyland

Department SurgeryName Dr. Anwar M AliStaff Appointment (Category) Clinical Assistant (Assisting at Surgery)Appointment Start Date May 1, 2012Effective Dates of Extension Oct. 1, 2014 - Dec. 31, 2015Designated Active Staff Member Dr. J. Mah

7 RESIGNATIONS

Department AnesthesiaName Dr. Roger BellStaff Appointment (Category) ActiveEffective Date of Resignation October 7, 2014

Department PediatricsName Dr. Ehud RosenbloomStaff Appointment (Category) ActiveEffective Date of Resignation June 30, 2014

Department MedicineName Dr. Andriy KolchakStaff Appointment (Category) CourtesyEffective Date of Resignation September 24, 2014Designated Active Staff Member

8 LAPSE OF APPOINTMENTS

Department SurgeryName Dr. Matthew R DanterStaff Appointment (Category) TermEffective Date of Lapse Dec. 1, 2014Designated Active Staff Member Dr. W. Stephen

Department Critical CareName Dr. Elaheh AdlyStaff Appointment (Category) Clinical Assistant

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Page 14 of 14

Effective Date of Lapse July 1, 2014Designated Active Staff Member ICU Intensivist On-Call

Department Critical CareName Dr. Annemaria De TinaStaff Appointment (Category) Clinical AssistantEffective Date of Lapse July 1, 2014Designated Active Staff Member ICU Intensivist On-Call

Department Critical CareName Dr. Susan JoStaff Appointment (Category) Clinical AssistantEffective Date of Lapse July 1, 2014Designated Active Staff Member ICU Intensivist On-Call

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DEPARTMENT OF FAMILY MEDICINEHAMILTON HEALTH SCIENCES REAPPOINTMENTS - NOVEMBER 1, 2014 - OCTOBER 31, 2015

BOARDNOVEMBER 2014

PAGE 1 of 11

ALL CURRENT APPOINTMENTS EXTEND TO OCTOBER 31, 2014 UNLESS OTHERWISE NOTED.

NAME HHS APPOINTMENT OTHER AFFIL

HONORARY HHS Dr. Clarence Bankay HonoraryHHS Dr. Gerald S Cohen HonoraryHHS Dr. May Cohen HonoraryHHS Dr. Joseph J Homer HonoraryHHS Dr. Farhang Jabbari HonoraryHHS Dr. Robert A James HonoraryHHS Dr. Khalid Khan HonorarySJH Dr. K Nancy Lennard HonoraryHHS Dr. Cheryl A Levitt HonoraryHHS Dr. Peter A Loveless Honorary

Resigned effective October 31, 2014HHS Dr. George Mann HonoraryHHS Dr. Donald W McLean HonoraryHHS Dr. Felix S Mihic HonoraryHHS Dr. Edward R Naganobu HonoraryHHS Dr. Marie G Noronha HonoraryHHS Dr. John W Ridge HonorarySJH Dr. Nicholas A Rizzo HonoraryHHS Dr. Robert J Roy Honorary H.WESTHALD Courtesy

Resigned effective October 31, 2014SJH Dr. Carmelo Scime HonoraryHHS Dr. Franklyn Shapiro HonorarySJH Dr. Philip E P Shea HonoraryHHS Dr. Stanley S Yu HonorarySJH Dr. Steve P Zamora Honorary

ACTIVE STAFF HHS Dr. Ragini (Gina) Agarwal ActiveHHS Dr. Jonathan Aguanno ActiveHHS Dr. Cheryl L Allaby Active

SECONDARY APPT (CA)- Medicine

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Dr. Cheryl L Allaby continued SECONDARY CHIEF RECOMMENDS REAPPOINTMENTSJH Dr. Rossano L Allega CourtesySJH Dr. Bryan J Alton CourtesySJH Dr. Christopher J Ambis CourtesyHHS Dr. Robert J S Ambis ActiveHHS Dr. Karen M Antoniuk ActiveHHS Dr. Ogunroti Ayibiowu ActiveHHS Dr. Osama Badawi ActiveHHS Dr. Judy L Baird ActiveHHS Dr. Gary S Beaufield ActiveSJH Dr. Desa Bibic CourtesySJH Dr. Barbara A K Bielecki CourtesySJH Dr. Morry P Black CourtesySJH Dr. Richard D Black CourtesySJH Dr. Elaine M Blau CourtesyHHS Dr. Laura Blew ActiveHHS Dr. Helene Boutin ActiveSJH Dr. Anne Boyle CourtesySJH Dr. Keyna Bracken CourtesySJH Dr. Margaret A Bridge Courtesy

CHIEF RECOMMENDS APPOINTMENT LAPSEHHS Dr. Cleopatra V Bruma ActiveHHS Dr. Lana Bullock ActiveHHS Dr. Kenneth Burgess ActiveHHS Dr. Peter Bzonek Active H.JOBRANT CourtesyHHS Dr. Denis J Callaghan ActiveSJH Dr. Lauren M Cameron CourtesyHHS Dr. Angela M Carol ActiveHHS Dr. David H Chan ActiveHHS Dr. Ho Man N Chan ActiveHHS Dr. Stephen J Chin ActiveHHS Dr. John P Chong ActiveHHS Dr. P C Peter Chu Active H.WESTHALD Courtesy

SECONDARY APPT (Active)- Surgery H.BGH.BRNT CourtesySECONDARY CHIEF RECOMMENDS REAPPOINTMENT

SJH Dr. Maureen E P Cividino CourtesySJH Dr. Ellen D R Clarke Courtesy H.BGH.BRNT Locum TenensSJH Dr. Brenda E Copps CourtesyHHS Dr. Lee Anne H Coren Active

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BOARDNOVEMBER 2014

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SJH Dr. Giovanni Corsini CourtesyHHS Dr. Terrence M Creatchman ActiveSJH Dr. Benjamin G Croft CourtesyHHS Dr. Carrie A Crombie ActiveSJH Dr. Fionnella S S Crombie CourtesyHHS Dr. Aida Crosthwaite ActiveHHS Dr. Steven L Cusimano ActiveSJH Dr. Mehboob Damji CourtesyHHS Dr. Meghan C Davis ActiveHHS Dr. Andrea R De Rubeis ActiveSJH Dr. Monica DeBenedetti CourtesySJH Dr. Danielle Derrington CourtesyHHS Dr. Nathalie A Desbois Active H.JOBRANT AffiliateHHS Dr. Mohsin N Dhalla ActiveSJH Dr. Bruno L Di Paolo CourtesySJH Dr. Robert C Dickson CourtesySJH Dr. B Jane Dobson CourtesyHHS Dr. Cindy-Lou Donaldson Active H.JOBRANT CourtesyHHS Dr. Wade C Elliott Active

SECONDARY APPT (CATAS)- SurgerySECONDARY CHIEF RECOMMENDS REAPPOINTMENT

HHS Dr. Anna-Marie Emili ActiveSJH Dr. Julie-Anne Emili CourtesySJH Dr. Ralph Epstein CourtesyHHS Dr. Jennifer L Everson ActiveHHS Dr. Joseph S A Falletta ActiveHHS Dr. Luming Feng ActiveHHS Dr. Alcantro B A Fernandez ActiveHHS Dr. Peter T Ford ActiveHHS Dr. Nancy C Fowler ActiveHHS Dr. Frederick D Fraser ActiveSJH Dr. Christina Fugere CourtesyHHS Dr. Gordon H Fulthorpe ActiveHHS Dr. Carol Gideon Active H.BGH.BRNT CourtesySJH Dr. Cindy Goebel CourtesyHHS Dr. Bronte L Golda ActiveHHS Dr. Margaret E Goodacre ActiveSJH Dr. Mark R G Grafham Courtesy

CHIEF RECOMMENDS APPOINTMENT LAPSE

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BOARDNOVEMBER 2014

PAGE 4 of 11

HHS Dr. Janet E Graham ActiveHHS Dr. Allen S Greenspoon Active

REQUESTED / RECOMMENDED DELETION OF THE FOLLOWING PROCEDURAL PRIVILEGES:FAMILY MEDICINE: SPECIFICSurgical Assist (Including C-Section)FAMILY MEDICINE: SPECIFICConduct of normal pregnancyVertex delivery Episiotomy and simple repairRepair of first and second degree lacerationsApplication of scalp clip for electronic fetal monitoringProvision of postpartum and newborn careInduction for postmaturity

Induction for spontaneous rupture of membranes not in established labour >36 weeksAugmentation of labour in uncomplicated dystociaFAMILY MEDICINE: SPECIFIC, Obstetrical Privileges Advanced: Low or Outlet Vacuum Assisted Delivery

SJH Dr. Tanya Grieci CourtesyHHS Dr. C Dale Guenter ActiveSJH Dr. Steven J Hadcock CourtesySJH Dr. Lydia Hatcher CourtesyHHS Dr. Judith M Hindson ActiveHHS Dr. Geoffrey M Holdway Active H.GRHC CourtesyHHS Dr. Arlene R Holek ActiveHHS Dr. Lind Holland ActiveHHS Dr. Lily A Hope ActiveHHS Dr. Adrian A Hornich ActiveHHS Dr. Jorge O Irazuzta Active

REQUESTED/RECOMMENDED CATEGORY CHANGE TO HONORARYSJH Dr. Katalin Ivanyi CourtesyHHS Dr. Serali Jamani ActiveHHS Dr. Thomas P Jaskot ActiveHHS Dr. David Johns ActiveSJH Dr. Jennifer K. Jones CourtesySJH Dr. Amjad Junaid Courtesy

SECONDARY APPT (Courtesy)- Emergency MedicineSECONDARY CHIEF RECOMMENDS REAPPOINTMENT

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PAGE 5 of 11

HHS Dr. Darrel Juriansz ActiveHHS Dr. Sandra Kane-Corriveau ActiveSJH Dr. Dennis M Kavalsky CourtesySJH Dr. Olasunkanmi A Kehinde CourtesySJH Dr. William E Kennedy CourtesySJH Dr. Bashir Khambalia CourtesyHHS Dr. Joginder S Khera ActiveSJH Dr. Sarah C Kinzie CourtesyHHS Dr. Oded Klinghoffer ActiveSJH Dr. Janice J Koole CourtesyHHS Dr. Allan Kopyto ActiveHHS Dr. Steven J Koziak ActiveSJH Dr. Danny J J Kraftcheck CourtesyHHS Dr. Margaret Krol-Szpakowski ActiveHHS Dr. Alex Kronenwald ActiveSJH Dr. Trevor P H Kwok CourtesySJH Dr. Leda Lagrotteria CourtesyHHS Dr. Lino P Lagrotteria ActiveHHS Dr. Eleonora C Lalli ActiveHHS Dr. Sheilah B Lamb ActiveSJH Dr. Anne S Lapinsky CourtesySJH Dr. Julian G Lapinsky CourtesyHHS Dr. De Le ActiveHHS Dr. Guy Leblanc ActiveHHS Dr. Peter J Leggett ActiveSJH Dr. Baldwin J Leong CourtesyHHS Dr. David R Levy Active H.JOBRANT CourtesySJH Dr. Mark E Levy CourtesySJH Dr. Richard M Levy CourtesyHHS Dr. William S Liang Active H.WESTHALD Courtesy

SECONDARY APPT (Active) - Emergency Medicine and Surgery H.MILTD.HH CourtesySECONDARY CHIEF RECOMMENDS REAPPOINTMENT

HHS Dr. Henry Lim ActiveHHS Dr. Stephen R Lloyd Active

SECONDARY APPT - (Active) Pediatrics and Emergency MedicineSECONDARY CHIEF RECOMMENDS REAPPOINTMENT

HHS Dr. Brenda B Loewith ActiveHHS Dr. Keith F Lummack ActiveSJH Dr. Salvatore E Macaluso Courtesy

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BOARDNOVEMBER 2014

PAGE 6 of 11

SJH Dr. Judith MacKinnon CourtesyREQUESTED / RECOMMENDED ADDITION OF THE FOLLOWING PROCEDURAL PRIVILEGES:FAMILY MEDICINE: INDIVIDUAL SPECIFIC - Endometrial Biopsy

HHS Dr. Denise I Marshall Active H.WESTLINC CourtesyHHS Dr. Perry V Mayer Active

REQUESTED / RECOMMENDED ADDITION OF THE FOLLOWING PROCEDURAL PRIVILEGES:FAMILY MEDICINE: SPECIFICChronic Wound Care Debridement

HHS Dr. Kimberley C McCallum ActiveSJH Dr. Tracey McCarty CourtesyHHS Dr. Barbara L McMeekin Active H.JOBRANT AffiliateHHS Dr. James D McMillan ActiveHHS Dr. Sharon K McMillan ActiveSJH Dr. Nadia F Mercante CourtesyHHS Dr. Cornelia I Mielke ActiveHHS Dr. Jonel Miklea Active H.OTM.HH CourtesyHHS Dr. Connie L Milroy ActiveHHS Dr. Afshan Mohatarem ActiveHHS Dr. Ainsley E Moore ActiveSJH Dr. Tracey A Moriarity CourtesyHHS Dr. C Ruth Morris ActiveSJH Dr. Jean Mullens CourtesyHHS Dr. Juan E Munoz ActiveHHS Dr. E Lynn I Nash ActiveHHS Dr. W Scott Nash ActiveHHS Dr. Barbara A Nathanson ActiveSJH Dr. Ieva M Neimanis CourtesyHHS Dr. John J Nelson ActiveSJH Dr. Lynda K Newkirk CourtesySJH Dr. Cindy K W Ng Courtesy H.MACK CourtesyHHS Dr. Donald V Noad ActiveSJH Dr. Garth T Noad CourtesyHHS Dr. Ravinder P S Ohson ActiveHHS Dr. Douglas Oliver ActiveHHS Dr. J Anthony Opie ActiveHHS Dr. Walter D J Owsianik Active

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BOARDNOVEMBER 2014

PAGE 7 of 11

SJH Dr. Tamar Packer CourtesyHHS Dr. Deborah Parachin ActiveSJH Dr. Tejal Patel CourtesyHHS Dr. Adrienne D Penderell Active

SECONDARY APPT (Active) - OncologySECONDARY CHIEF RECOMMENDS REAPPOINTMENT

HHS Dr. Susan Piccinin ActiveHHS Dr. Preeti Popuri ActiveHHS Dr. Michael J Pray ActiveSJH Dr. Nora Premi CourtesyHHS Dr. David J Price ActiveHHS Dr. Ralph Profetto ActiveSJH Dr. Sheelagh M Pyper CourtesyHHS Dr. Sparrow L Rabideau ActiveSJH Dr. Alia W Rana CourtesyHHS Dr. Asad Razzaque ActiveSJH Dr. Shelley J Rechner CourtesyHHS Dr. Lynda J Redwood-Campbell ActiveHHS Dr. Eugene E Ricci Active

CHIEF RECOMMENDS APPOINTMENT LAPSEHHS Dr. Cathy L Risdon ActiveSJH Dr. David Robinson CourtesyHHS Dr. Domenic Rosati ActiveHHS Dr. Ingeborg Schabort ActiveHHS Dr. Hendrik A Scholtens Active H.JOBRANT AffiliateSJH Dr. Michael Schweitzer CourtesySJH Dr. B Karen Selwyn CourtesyHHS Dr. Rachelle Sender ActiveHHS Dr. Lionel S Sewchand ActiveSJH Dr. Elizabeth A Shaw CourtesySJH Dr. Maliha Sherman CourtesySJH Dr. Henry Y H Siu Courtesy

HHS Dr. Patricia E Smith Active H.GR.GRHC Special Courtesy

HHS Dr. Leslie V Solomon ActiveSJH Dr. Phillip M Staibano CourtesySJH Dr. Rebecca E Steen Courtesy

SECONDARY APPT (CATAS) - SurgerySECONDARY CHIEF RECOMMENDS REAPPOINTMENT

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PAGE 8 of 11

HHS Dr. Lilianna Stefanczyk-Sapieha Active H.UNIHEAL Clinical Assistant

SECONDARY APPT (Active) - OncologySECONDARY CHIEF RECOMMENDS REAPPOINTMENT

HHS Dr. Brenda Steinnagel ActiveSECONDARY APPT (CATAS) - SurgerySECONDARY CHIEF RECOMMENDS REAPPOINTMENT

HHS Dr. Michael J Stephenson ActiveSJH Dr. Colin Stevenson Courtesy

REQUESTED / RECOMMENDED DELETION OF THE FOLLOWING PROCEDURAL PRIVILEGES:FAMILY MEDICINE: OTHER SPECIFIC Minor Surgical ProceduresInsertion, Removal of IUDREQUESTED / RECOMMENDED ADDITION OF THE FOLLOWING PROCEDURAL PRIVILEGES:FAMILY MEDICINE, OTHER: Transfusion Orders

HHS Dr. Thangamani Subramanian ActiveHHS Dr. Mary B Syty-Golda ActiveHHS Dr. Steve L Szarka ActiveHHS Dr. Abraham Szereszewski ActiveHHS Dr. Imre Z Szilvassy ActiveHHS Dr. Alan Taniguchi ActiveHHS Dr. Barbara A Teal ActiveHHS Dr. Pamela A Thompson ActiveHHS Dr. Denny Toffolo ActiveHHS Dr. Kien V Trinh ActiveHHS Dr. A Karen Trollope ActiveHHS Dr. Holtby M Turner ActiveHHS Dr. Irene M Tuttle ActiveHHS Dr. Richard H Tytus ActiveHHS Dr. Susan L van Baardwijk ActiveSJH Dr. Inge M Vasovich CourtesyHHS Dr. Harshala P Vora ActiveSJH Dr. Gyula Voros Courtesy H.OTM.HH ActiveHHS Dr. Kathleen J Walker ActiveHHS Dr. Allyn E Walsh ActiveSJH Dr. Heather M Waters CourtesyHHS Dr. Irma A S Webb ActiveHHS Dr. Michael James West ActiveHHS Dr. James E Williams Active

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PAGE 9 of 11

HHS Dr. Samantha P Winemaker ActiveHHS Dr. Scott Wooder ActiveSJH Dr. Anne Woods CourtesyHHS Dr. Lauren Woods ActiveHHS Dr. Ilka S Wright ActiveHHS Dr. Sophia Xenoyannis Active H.JOBRANT AffiliateHHS Dr. David F Yanover ActiveSJH Dr. Naveeda Yasmeen CourtesyHHS Dr. Joel W Yellin ActiveSJH Dr. Joyce Zazulak CourtesySJH Dr. Angelo J Zizzo CourtesySJH Dr. Dean J Zizzo CourtesySJH Dr. Richard A Zizzo CourtesyHHS Dr. Linuo Zou ActiveSJH Dr. Christine Zrinscak Courtesy

COURTESY ONLY STAFF SJH Dr. Amie J Davis Courtesy H.JOBRANT ActiveHHS Dr. Carolynne E Locke Courtesy H.BGH.BRNT ActiveHHS Dr. Nadia R Plach Courtesy H.JOBRANT ActiveHHS Dr. Cadi M Reece Courtesy H.TRILLIUM ActiveHHS Dr. J Graham Swanson Courtesy H.JOBRANT Active

TERM STAFF HHS Dr. Shpresa Aliu-Berisha Term

CHIEF RECOMMENDS APPOINTMENT LAPSESJH Dr. Meaghan L Brown Term

CHIEF RECOMMENDS APPOINTMENT EXTENSION TO OCTOBER 31, 2015HHS Dr. Courtney B Field Term

NOT SUBJECT to re-appointment SJH Dr. Erin M Frotten Term

NOT SUBJECT to re-appointment SJH Dr. Alain-Remi Lajeunesse Term H.NOTREDHE

CHIEF RECOMMENDS APPOINTMENT LAPSESJH Dr. Rachel H Loewith Term

CHIEF RECOMMENDS APPOINTMENT EXTENSION TO APRIL 30, 2015

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PAGE 10 of 11

SJH Dr. Leah A Mawhinney TermNOT SUBJECT to re-appointment

HHS Dr. Danielle M O'Toole TermCHIEF RECOMMENDS APPOINTMENT EXTENSION TO APRIL 30, 2015

HHS Dr. Puneet Seth Term H.OTM.HHCHIEF RECOMMENDS APPOINTMENT LAPSE

HHS Dr. J Grant Taylor TermCHIEF RECOMMENDS APPOINTMENT LAPSE

HHS Dr. Frank G Vona TermCHIEF RECOMMENDS APPOINTMENT EXTENSION TO APRIL 30, 2015

HHS Dr. Laura E Wright TermCHIEF RECOMMENDS APPOINTMENT EXTENSION TO OCTOBER 31, 2015

ASSOCIATE STAFF SJH Dr. Al D Alipio Courtesy

NOT SUBJECT to re-appointment SJH Dr. Michelle R Barrington Courtesy

NOT SUBJECT to re-appointment SJH Dr. Tavis J Basford Courtesy

NOT SUBJECT to re-appointment SJH Dr. Hugh F Boyd Courtesy

NOT SUBJECT to re-appointment HHS Dr. Marta A Fundamenski Associate H.KIRKDIST Locum Tenens

NOT SUBJECT to re-appointment HHS Dr. Janice A Harvey Associate

NOT SUBJECT to re-appointment HHS Dr. Lorna Junker-Andersen Associate

NOT SUBJECT to re-appointment SECONDARY APPT - (ASSOC) Oncology and (HON) Emergency Medicine

SJH Dr. Stephan J Nalezny CourtesyNOT SUBJECT to re-appointment

SJH Dr. Emily J Ow Courtesy NOT SUBJECT to re-appointment

SJH Dr. Jason R Profetto Courtesy H.WESTLINC Courtesy ConsuNOT SUBJECT to re-appointment

SJH Dr. Ranjith K Ratnasingam CourtesyNOT SUBJECT to re-appointment

SJH Dr. Michael Savatteri Courtesy H.WESTLINC Locum TenensNOT SUBJECT to re-appointment

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BOARDNOVEMBER 2014

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SJH Dr. Steven V Zizzo CourtesyNOT SUBJECT to re-appointment

WEST LINCOLN MEMORIAL HOSPITAL AMALGAMATION Not Subject to Reappointment due to pending Credentials review of all WLM Physicians in relation to the amalgamation process.

HHS Dr. Gary L Benson Courtesy H.WESTLINC ActiveSJH Dr. Paul B Cano Courtesy H.WESTLINC Active

AFFILIATE STAFFHHS Dr. Kevin D Mayer Affiliate

NOT SUBJECT to re-appointment HHS Dr. Shalini Sharma Affiliate

NOT SUBJECT to re-appointment

Please Note - Medical Directors, Medical Affairs office, Chiefs of Staff and/or Vice-Presidents from the following hospitals where Courtesy Staff physicians hold their primary appointments, indicate procedural privileges are appropriate for reappointment:BGH.BRNT - Brantford General HospitalJOBRANT - Joseph Brant Memorial HospitalTRILLIUM - Trillium Health Centre

Legend:GR.GRHC - Grand River Hospital (Grand River Hospital Corporation)MILTD.HH - Milton District Hospital (Halton Healthcare)OTM.HH - Oakville-Trafalgar Memorial Hospital (Halton HealtCARE)WESTHALD - West Haldimand General HospitalH.SMH.GRHC - St. Mary’s General Hospital [part of Grand River Hospital Corporation –if by site]H.MACK - Mackenzie Health (formerly) H.YORK – York General HospitalH.NOTREDHE - Notre Dame Hospital (Hearst)H.HALDIMAN - Haldimand War Memorial HospitalH.WMH - Haldimand War Memorial HosptialH.KIRKDIST - Kirkland & District Hospital

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DEPARTMENT OF OBSTETRICS AND GYNECOLOGY - MIDWIFERY SERVICEHAMILTON HEALTH SCIENCESREAPPOINTMENTS - NOVEMBER 1, 2014 - OCTOBER 31, 2015

BOARD NOVEMBER 2014

PAGE 1 of 3



ACTIVE STAFFSJH Ms. Shirin Aghili CourtesyHHS Ms. Elisabeth Boulanger ActiveHHS Ms. Sarah Bradley ActiveHHS Ms. L Kate Demers ActiveHHS Ms. Connie Fetterly ActiveHHS Ms. Kelly Jane Gascoigne ActiveHHS Ms. Emily Gillard ActiveHHS Ms. Simone Griffith ActiveHHS Ms. Jessica Jones ActiveHHS Ms. Kristi Kemp Active

NOT SUBJECT to re-appointment SJH Ms. Tonya MacDonald CourtesySJH Ms. Susan Martin CourtesySJH Ms. Helen McDonald CourtesyHHS Dr. Patricia S McNiven, PhD ActiveSJH Ms. Sylvia Miedinger CourtesyHHS Ms. Salimah Moffett Active H.BGH.BRNT Associate

REQUESTED/RECOMMENDED CATEEGORY CHANGE TO COURTESYHHS Ms. Beth Murray-Davis ActiveSJH Ms. Lisa M Nussey CourtesyHHS Ms. Katherine M Penczak Active H.BGH.BRNT CourtesySJH Ms. Angela Reitsma CourtesyHHS Ms. Genevieve Romanek Leave of Absence

CHIEF RECOMMENDS APPOINTMENT LAPSE HHS Ms. Lisa Rosanne Sabatino ActiveHHS Ms. Christine Sandor Associate

NOT SUBJECT to re-appointment HHS Ms. Lynlee Spencer Associate

NOT SUBJECT to re-appointment HHS Ms. Heather Jean Taylor ActiveSJH Ms. Shannon M Taylor Courtesy

NOT SUBJECT to re-appointment

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BOARD NOVEMBER 2014

PAGE 2 of 3

HHS Ms. Kristin C Trevisan ActiveSJH Ms. Georgia Tsouluhas Leave of AbsenceSJH Ms. Katrienne C Walton CourtesyHHS Ms. Elise Williamson Associate

NOT SUBJECT to re-appointment HHS Ms. Tamara P Youngberg Active

COURTESY STAFFHHS Ms. Tanja Bos Courtesy H.BGH.BRNT ActiveHHS Ms. Erin Little Courtesy H.BGH.BRNT AssociateHHS Ms. Daya Lye Leave of Absence H.BGH.BRNT Affiliate

CHIEF RECOMMENDS APPOINTMENT LAPSE

TERM STAFFSJH Ms. Mona Abdel-Fattah Term

NOT SUBJECT to re-appointment HHS Ms. Lauren Columbus Term

CHIEF RECOMMENDS APPOINTMENT EXTENSION TO OCTOBER 31, 2015HHS Ms. Kristen Dalton Term

CHIEF RECOMMENDS APPOINTMENT EXTENSION TO OCTOBER 31, 2015HHS Ms. Sarah Donnelly-Hyde Term

CHIEF RECOMMENDS APPOINTMENT EXTENSION TO OCTOBER 31, 2015HHS Ms. Alisha L Julien Reid Term

NOT SUBJECT to re-appointment SJH Ms. Masoudeh Kazemiashtiani Term

NOT SUBJECT to re-appointment HHS Ms. Ashley Keen Term

NOT SUBJECT to re-appointment HHS Mr. A Otis Kryzanauskas Term

CHIEF RECOMMENDS APPOINTMENT EXTENSION TO OCTOBER 31, 2015HHS Ms. Jenny Pizzale Term

CHIEF RECOMMENDS APPOINTMENT EXTENSION TO OCTOBER 31, 2015HHS Ms. Olivia A Schliep Term

NOT SUBJECT to re-appointment HHS Ms. Marie-Pierre Tendland-Frenette Term

CHIEF RECOMMENDS APPOINTMENT EXTENSION TO OCTOBER 31, 2015

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BOARD NOVEMBER 2014

PAGE 3 of 3

Please Note - Medical Directors, Medical Affairs office, Chiefs of Staff and/or Vice-Presidents from the following hospitals where Courtesy Staff physicians hold their primary appointments, indicate procedural privileges are appropriate for reappointment:BGH.BRNT - Brantford General HospitalJOBRANT - Joseph Brant Memorial HospitalLEGEND:OTM.HH - Oakville Trafalgar Memorial Hospital [Halton Healthcare]

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DEPARTMENT OF OBSTETRICS AND GYNECOLOGYHAMILTON HEALTH SCIENCES REAPPOINTMENTS - NOVEMBER 1, 2014 - OCTOBER 31, 2015

BOARDNOVEMBER 2014

PAGE 1 OF 3



HONORARYHHS Dr. M Corinne Devlin HonorarySJH Dr. Murray W Enkin HonoraryHHS Dr. Ernest J Ewaschuk HonoraryHHS Dr. Sleem Feroze HonorarySJH Dr. David A Lamont HonorarySJH Dr. Francis S Lynes HonorarySJH Dr. Indra P Rastogi HonoraryHHS Dr. Paula Roth Honorary

ACTIVE STAFFHHS Dr. Shilpa Amin ActiveHHS Dr. Carolyn Best ActiveHHS Dr. Barbara G Brennan Active H.CREDVALL CourtesyHHS Dr. Rolando R Cepeda ActiveSJH Dr. Jean E Chamberlain CourtesyHHS Dr. Ann Marie Chen ActiveHHS Dr. Dustin J Costescu Associate

NOT SUBJECT to re-appointment SJH Dr. Amie Cullimore CourtesyHHS Dr. Bryon F DeFrance Active

SECONDARY APPT (Active) - Diagnostic ImagingSECONDARY CHIEF RECOMMENDS REAPPOINTMENT

SJH Dr. Cara Donnery CourtesyHHS Dr. Marie Josee Dube Active H.BGH.BRNT ConsultingSJH Dr. Susan M Ellis CourtesyHHS Dr. Mehrnoosh Faghih ActiveHHS Dr. Donna M Fedorkow ActiveSJH Dr. Nirupama Gangam CourtesyHHS Dr. Aseel Z Hamoudi ActiveHHS Dr. Boi-Ngoc T Hoang ActiveHHS Dr. Edward G Hughes Active

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BOARDNOVEMBER 2014

PAGE 2 OF 3

HHS Dr. Robert J Hutchison ActiveHHS Dr. Megan F Karnis ActiveHHS Dr. John A Lamont ActiveHHS Dr. Nicholas A Leyland ActiveHHS Dr. Margaret Lightheart ActiveSJH Dr. Margot E Loosley-Millman CourtesyHHS Dr. Sarah D McDonald Active

SECONDARY APPT (Active) - Diagnostic ImagingSECONDARY CHIEF RECOMMENDS REAPPOINTMENT

HHS Dr. Patrick T Mohide ActiveSECONDARY APPT (Active) - Diagnostic ImagingSECONDARY CHIEF RECOMMENDS REAPPOINTMENT

HHS Dr. Michelle L Morais AssociateNOT SUBJECT to re-appointment

SJH Dr. Richard J Persadie CourtesySJH Dr. Raj Ramanna CourtesyHHS Dr. Carmela Sciarra ActiveHHS Dr. Caroline A Sibley ActiveSJH Dr. David R J Small Courtesy

REQUESTED / RECOMMENDED DELETION OF THE FOLLOWING PROCEDURAL PRIVILEGES:OBSTETRICS AND GYNECOLOGY: GYNECOLOGY, SPECIFICUse of Therapeutic Laser Devices: Intra Abdominal

HHS Dr. Patricia A Smith ActiveSJH Dr. Richard G Stopps CourtesyHHS Dr. Stephanie Winsor Active

SECONDARY APPT(Active) - Diagnostic ImagingSECONDARY CHIEF RECOMMENDS REAPPOINTMENT

CLINICAL ASSISTANTHHS Dr. Tina D Gai Clinical Assistant (Assisting at Surgery)HHS Dr. J Barry Hunter Clinical Assistant (Assisting at Surgery) H.JOBRANT CourtesyHHS Dr. Leyla F Mangaloglu Clinical Assistant (Assisting at Surgery) H.JOBRANT Associate

SECONDARY APPT (Term)- Obs and GyneCHIEF RECOMMENDS SECONDARY APPOINTMENT EXTENSION TO OCTOBER 31, 2015

HHS Dr. Dragana Matanovic-Todorovic Clinical Assistant (Assisting at Surgery)

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BOARDNOVEMBER 2014

PAGE 3 OF 3

COURTESY ONLY STAFFHHS Dr. Valter Feyles Courtesy H.LONDON Active

Resigned effective October 31, 2014HHS Dr. Valerie Mueller Courtesy

TERM STAFFHHS Dr. V Shola Akinsooto Term

NOT SUBJECT to re-appointment HHS Dr. Kristina Arendas Term

CHIEF RECOMMENDS APPT EXTENSION TO OCTOBER 31, 2015HHS Dr. Andre M LaRoche Term

NOT SUBJECT to re-appointment HHS Dr. Henry F Muggah Term

NOT SUBJECT to re-appointment HHS Dr. Ally Murji Term

NOT SUBJECT to re-appointment HHS Dr. Clara Sacchini Term

CHIEF RECOMMENDS APPT EXTENSION TO OCTOBER 31, 2015HHS Dr. Mara L Sobel Term

CHIEF RECOMMENDS APPT EXTENSION TO APRIL 30, 2015

Please Note - Medical Directors, Medical Affairs office, Chiefs of Staff and/or Vice-Presidents from the following hospitals where Courtesy Staff physicians hold their primary appointments, indicate procedural privileges are appropriate for reappointment:LONDON - London Health Sciences

H.CREDVALL - Credit Valley Hospital H.BGH.BRNT - Brantford General Hospital H.THUNDER - THUNDERBAY REGIONAL HEALTH SCIENCESH.TIM&DIST - TIMMINS & DISTRICT HOSPITALH.HEADWAT - HEADWATERS HEALTHCARE CENTREH.JOBRANT - JOSEPH BRANT MEMORIAL HOSPITAL

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Hamilton Health Sciences Report to the Board of Directors

Governance Committee – October 2014

A meeting of the Governance Committee took place on Tuesday, October 14, 2014 at 5:00 PM in Room 2E51 at McMaster University Medical Centre. In attendance: Mark Rizzo (Chair), Terry Shields, Mary Volk, Julia Kamula, Charles Criminisi, Paul Chapin, Rob MacIsaac, Cathy Rozman – recording secretary Regrets: Anita Isaac For Approval: Policy Approvals – Governance Committee reviewed three policies as part of the three year policy review cycle. Minor wording changes are recommended. It is recommended that the policy – ‘Community Members on Board Committees’ be executed at the discretion of the Board. The current two community members final terms will be completed in June 2015. Governance Committee recommends: Approval of the following policies, as attached:

• Attendance Policy • Meeting Communication Facilities • Community Members on Board Committees

Committee/Advisory Council Terms of Reference – Annual review of standing committee terms of reference is required under Policy 1.7 Committee Principles & Structure. Governance Committee reviews all recommended changes to committee terms of reference as a whole. Governance Committee recommends: Approval of the revised terms of reference for Governance Committee and Finance and Audit Committee as attached. Governance Committee also reviewed the terms of reference for the West Lincoln Memorial Hospital Community Advisory Committee. Clarification around reporting process was included. Governance Committee recommends: Approval of the revised terms of reference for the West Lincoln Memorial Hospital Community Advisory Committee as attached. For Information: Governance Committee Workplan – The committee’s workplan for 2014/15 was approved. October Retreat Planning – Governance Committee received an update on retreat planning. OHA Governance Self Assessment Survey Provincial Results – Province wide results from those organization’s participating in the OHA’s Governance Self Assessment Survey were shared with participating hospitals. HHS results were similar to other organizations. It was suggested that a strategy to increase participation might be considered when the survey is next administered.

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Appendix A: Attendance Policy


Policy Type: Governance Process Policy Title: Attendance Policy Policy Number: 1.6 Date of Approval: September 26, 2002 Reviewed /Revised May 22, 2006

March 12, 2009 May 21, 2011

Policy

To ensure the continuous and effective contribution of board and committee members’ expertise to the business affairs of Hamilton Health Sciences. Guidelines

• Board and committee members are expected to attend all meetings in person. o Attendance expectations will be outlined during member recruitment and

in the orientation session o Attendance will be a consideration when a member is under consideration

for re-election • The policy applies to both elected and ex-officio board members and non-board

members of committees As outlined in HHS Bylaw Section 4.05 (a) if a Director, without being granted a leave of absence by the Board, is absent for three (3) or more consecutive meetings of the Board, or if a Director is absent for one quarter (1/4) or more of the meetings of the Board in any twelve (12) month period an attendance problem occurs.

Response Process

The Governance Committee is responsible for insuring ensuring that the rules of conduct are adhered to. When an attendance problem is identified, the Chair of the Governance Committee will advise the Board Chair, who will promptly meet with the member and share the response with the Governance Committee. The Governance Committee may make a recommendation to the Board of Directors regarding the member’s future membership. In the case of an ex-officio member of the Board, any attendance issues will be brought forward to the parent organization.

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Appendix B: Meetings – Electronic, Telephone or Other


Policy Type: Governance Process Policy Title: Meetings - Electronic, Telephone or other

Communications Facilities Policy Number: 1.22 Date of Approval: May 19, 2011 Reviewed /Revised Policy

Serving on the Board of Directors requires a commitment of significant time and attention on the part of directors. Members have committed to a willingness to prepare rigorously for, attend and participate in all board and committee meetings. To ensure the effective contribution of individual’s expertise to the business affairs of Hamilton Health Sciences Board and committee members are expected to attend all meetings in person (See Governance Process - Attendance Policy 1.6). Guidelines In May 2014, the Board of Directors approved the Annual Director Declaration and Consent that provides consent for the participation of any director, or member of a committee, at a meeting of the board or a committee of the board by such telephone, electronic or other communication facility.If all the Directors present at or participating in the meeting consent, a meeting of Directors or a meeting of a committee of the Board may be held by such telephone, electronic or other communication facilities that permit all persons participating in the meeting to communicate with each other simultaneously and instantaneously, and T the Director or committee member participating in the meeting by those means is deemed to be present at the meeting. To function better as a collective, Board members need to pay attention to behaviours, bolster relationships and relate to each other as peers and partners. This is best facilitated through face to face participation in the board room. Engagement in the workings of the board is a crucial metric in any director performance assessment process and both attendance and the means of attendance will be considered.

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Appendix C: Community Members of Board Committees


Policy Type: Governance Process

Policy Title: Community Members of Board Committees Policy Number: 1.9 Date of Approval: May 21, 2009 Reviewed /Revised June 28, 2012 Introduction: As outlined in Policy 1.7 Committee Principles and Structure, members of the community may be appointed to committees of the Board, with the exception of Executive and Governance Committees. Community members on board committees allows: (a) the committee to bring specific competencies or experience to the committee and/or (b) individuals interested in board membership exposure to the work of the Board of Directors and its committees while (c) keeping the governance of the organization connected to its stakeholders. Limiting the terms of community members on committees ensures regular review of the competencies, skills and perspectives required to complete the committee’s work. Process: 1. A board committee shall determine the skills and competencies required to fulfill its

mandate. 2. Recruitment of individuals meeting the criteria set out by the committee shall be the

joint responsibility of Governance Committee and the committee itself. 3. All community membership appointments shall be recommended to the Board of

Directors through Governance Committee and in accordance with the Committee Principles and Structures Policy (Policy 1.7). No more than two community members may serve on a standing committee of the Board.

4. Community membership shall be limited to two two-year terms. The appointment of

the second term shall be subject to the approval of the Board of Directors and shall be based on evaluation of the member’s performance by the committee chair and Governance Committee.

5. Community members shall be subject to the same attendance requirements as

members of the Board of Directors (see Policy 1.6 Attendance Policy and Policy 1.22 Meetings – Electronic, Telephone and Other Communications Facilities).

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Governance Committee

Terms of Reference

Purpose: Governance Committee will assist the Board of Directors in fulfilling its mandate in matters relating to governance, governance structures, evaluation of board effectiveness, recruitment, and board its development, at all times considering established governance best practices. Committee Objectives: The Governance Committee shall: (a) Regularly review and recommend to the Board of Directors, aligned with governance best

practices, an appropriate governance model for achieving the work of the Board including; (i) Regularly review the size and operating structure of the Board and its committees,

including composition, size, structure, mandates and procedures (b) Recommend to the Board of Directors individuals for nomination for election to the Board of

Directors and community committee members at its annual meeting including; (i) Ensure a nominations process policy is in place and reviewed on an annual basis (ii) Working with the Board Chair, consider the competencies and skills necessary for the

Board as a whole and the individual skills required by the Board, including those of each existing director

(c) Develop and review on an annual basis, a succession plan for officer positions. (i) Oversee the process for selecting the officers and recommend individuals for election

(d) On going development and education of directors, including an orientation session for new directors ensuring

(i) Ongoing development of board members through regular education sessions at board meetings, retreats and external education opportunities

(ii) Ensure a comprehensive orientation session is provided to all new members (iii) Working with the Board Chair and President & CEO organize at a minimum one board

retreat a year (e) Develop, implement, analyze and recommend actions to the Board of Directors resulting from

regular effectiveness evaluations of the Board, its Committees and individual board members. (i) Establish and implement an evaluation program for over all Board performance,

committees and committee chair performance and individual director performance which will be considered with renewal of terms for existing directors

(f) Develop and monitor compliance with Board Governance Policies and the By-law, recommending amendments as required, including:

(i) Regular review of existing governance policies (ii) Regular review of the HHS By Law (iii) Annual review of Conflict of Interest and Director’s Code of Conduct

(g) Other duties that may be assigned by the Board of Directors. Composition: At least three (3) elected Directors, including the Past Chair of the Board of Directors (if available) whom shall be appointed Chair; President & Chief Executive Officer; and Other members as deemed appropriate

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Meetings: The Governance Committee shall meet quarterly from September until June and at the call of the Chair. November 2011 June 2013

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Appendix A Hamilton Health Sciences

Board of Directors

Finance & Audit Committee

Terms of Reference Purpose: The Finance Committee is responsible for assisting the Board of Directors in fulfilling its oversight responsibilities over financial related matters and practices ensuring the long term financial sustainability of the organization. Committee Objectives: Finance Committee shall: (a) Review and recommend to the Board of Directors the annual operating and capital budgets; (b) Monitor performance and compliance with the annual operating plan and other financial

targets; (c) Review and recommend capital and unbudgeted operating expenditures that exceed

management’s spending authority; (d) Review and recommend financial strategies around investment including regular review and

oversight of compliance with the Board of Directors investment policy; (e) Develop and monitor a set of key performance indicators relative to financial position; (f) Review and recommend capital redevelopment proposals, project financing and funding

strategies; (g) Monitor debt obligations, cashflow and repayment planning; (h) Review and recommend to the Board on the financial aspects of proposed business cases /

contracts and transactions related to operations; (i) Regularly review and recommend delegate signing authority and signing officers for Hamilton

Health Sciences; and (j) Receive reports, monitor and recommend approval of Board authorized trust accounts

Purpose: The Audit Committee is responsible for assisting the Board in fulfilling its oversight responsibility by reviewing financial statements, the adequacy and effectiveness of internal controls, risk management plans, audit processes and ensuring compliance with laws and regulations. Committee Objectives: The Audit Committee shall:

(a) Review the scope of the annual audit, the audited financial statements and auditor’s report and make recommendations to the Board of Directors;

(b) Recommend to the membership of Hamilton Health Sciences the reappointment or appointment of external auditors;

(c) Review and approve the external auditor’s engagement letter; (d) Review the performance of the external auditors as required;

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(e) Review all audit and non-audit services to be performed by the external auditors and review the auditor’s reports on independence;

(f) Recommend to the Board the compensation rate of external auditors; (g) Review and monitor compliance with an enterprise wide risk management plan and

processes; (h) Annually review the type and amounts of insurance carried by Hamilton Health Sciences; (i) Review, approve and monitor the annual internal audit plan and management’s

responses to the findings and recommendations; (j) Review the appropriateness and effectiveness of the internal control processes including

key policies; and (k) Review compliance with regulatory and statutory requirements.

Composition: At least four (4) elected Directors, one of who shall be appointed as Chair; President & Chief Executive Officer; Up to two financially literate members of the community; and Other guests as may be deemed appropriate. Meetings: The Finance Committee shall meet at least five times a year or at the call of the Chair. The Audit Committee shall meet at least quarterly or at the call of the Chair. Draft – September 2013

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West Lincoln Memorial Hospital Community Advisory Committee (WLMHCAC) Terms of Reference

Purpose: The WLMHCAC will provide community specific advice to the Board of Directors, through the President, WLMH, and upon request, will provide support and advice to the West Lincoln Memorial Hospital Foundation and West Lincoln Memorial Hospital Auxiliary and will facilitate communication and outreach to the West Lincoln Memorial Hospital community*.

Committee Objectives:

The West Lincoln Memorial Hospital Committee Advisory Committee shall:

(a) Provide advice to the Board of Directors on the following:

• Program and service delivery planning in the Grimsby, Lincoln and West Lincoln Community

• Capital redevelopment planning for the WLMH site • Identifying and advising the HHS Board of Directors on priority healthcare and related

issues and needs in the Grimsby, Lincoln and West Lincoln Communities • Act as a liaison with the West Lincoln Memorial Hospital Foundation and Auxiliary • Facilitate communication with key community stakeholder groups and the community at

large

(b) Perform other duties as may be assigned to WLMHCAC by the Board of Directors

Composition: At least five (5) community members at large**, one of whom shall be appointed as Chair by the Hamilton Health Sciences Board of Directors; President, West Lincoln Memorial Hospital; Chair, WLMH Auxiliary; Chair, WLMH Foundation; Medical Staff Representative; Municipal Government Representation for each of Grimsby, West Lincoln and Lincoln; and Other guests as may be deemed appropriate. Meetings: The WLMHCAC shall meet quarterly, or at the call of the Chair. *The mandate of the WLMHCAC shall be reviewed in 2016. **Members at large, as recommended by the WLMHCAC will be subject to annual appointment by the HHS Board of Directors.

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Hamilton Health Sciences Report to Board of Directors

Executive Committee – October 2014

A meeting of the Executive Committee took place on Monday, October 20, 2014 at 5:00 PM in Room 2E51, McMaster University Medical Centre. In attendance: Paul Chapin (Chair), Norm Col, Mark Rizzo, Paul Miller, Rob MacIsaac, Cathy Rozman – recording secretary Regrets: Scott Maki Acting as the Board of Directors in cases of administrative urgency Executive Committee: Approved the Base Hospital Program Audited Statement of Revenue and Expenditures, and authorized the Board Chair to sign the submission on behalf of the Board of Directors.” For Approval: Board of Directors Work Plan (attached) – Executive Committee reviewed the 2014/15 Board of Directors Work Plan. The work plan was developed to provide planning support and to ensure the Board meets its stewardship, advisory, fiduciary and monitoring roles. Executive Committee recommends:

“That the 2014/15 Board of Directors Work Plan be approved as attached.” For Information: Executive Committee Work Plan / Terms of Reference – Executive Committee approved its work plan for the upcoming year. The terms of reference were reviewed and no changes were recommended at this time.

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APPENDIX A

2014-15 HHS Board of Directors Workplan

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Annual budget planning - approval of budget directions FIN XAnnual budget approval (15/16) FIN XApproval of MSAA FIN XApproval of HSAA FIN XAudited Financial Statements AUDIT X XAppointment of Auditors AUDIT XApprove Quality Improvement Plan (QIP) (15/16) QLTY XAssessment of QIP Achievement (14/15) QLTY XCredentials Approval MAC X X X X X X

Election of Directors GOV XElection of Officers GOV XCommittee Appointments CHAIR X XAnnual Review of Committee TOR GOV XAnnual Board Workplan EXEC XAnnual Board Effectiveness Survey Results GOV XBoard Meeting Evaluation BD X X X X X X

WLMHCAC Updates WLM X X X XHHS Family of Boards Retreat (VA, Fdn, BAHT) EXEC X

Strategic Plan Framework Update BD XStrategic Plan Framework Approval BD XApproval Annual Strategic Initiatives (15/16) BD XQuarterly Reports on Strategic Initiatives (BSC) BD Q1 Q2 Q3 Q4Achievement of Annual Strategic Inititiaves BD X

Governance

Stakeholder Relations and Engagement

Operational Performance

Strategic Planning & Directions

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2014-15 HHS Board of Directors Workplan

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CEO Performance Evaluation EXEC XCEO Annual Goals & Development Plan EXEC XCEO At Risk Compensation Assessment EXEC XCEO Succession Plan EXEC XChair, Medical Advisory Committee (annual re-appt.) EXEC XChair, Medical Advisory Committee Performance Eval. EXEC X IF REQ.Board Education SessionsSept ALCNov Phys. Engagement

Jan TBCMar TBDJun TBD

Retreat 1.5 days OctRetreat .5 day X

CEO / Chair of MAC

Retreats

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Performance Monitoring Committee – October 2014

A meeting of the Performance Monitoring Committee took place on Monday, October 27, 2014 at 4:00 PM in Room 2E51, McMaster University Medical Centre. In attendance: Chantel Broten (Chair), Julia Kamula, Rob MacIsaac, Elena Szamosvari, Kurt Whitnell, Cathy Rozman – recording secretary Regrets: Glenn Gibson Guests: Aaron Levo, Fran Agnew, Brenda Flaherty, Andrew Doppler For Information Performance Monitoring Dashboard – 2014/15 Q1 (attached) – Performance Monitoring Committee reviewed the Q1 Dashboard. Tools to track the two new metrics will be implemented shortly, with targets determined early next year. Grievance resolution rates are below target, however, it is anticipated that with the recruitment of staff to fill current vacancies and an increased focus on resolution, rates will be substantially reduced by year end. The committee reviewed and agreed to Communication and Public Relations metrics that will track both conventional and social media stories measured as proactive/reactive/neutral and for sentiment expressed. Communication & Public Affairs Update – Aaron Levo provided an update on the Communications and Public Affairs Portfolio, his observations, portfolio opportunities and challenges and short term goals. Foundational policies and practices will be developed together with a review of the current corporate model and structure to support leading practices and approaches in the sectors. Both internal and external relationship and network building will continue. Annual Human Resources Report (attached) – Performance Monitoring Committee received the fiscal 2013/14 annual Human Resources Report. Highlights included:

• New HR department structure in place o Move from specialists to generalists that includes responsibilities for labour

relations • Enhanced HR information systems • Talent Management – focus on performance management, workforce management and

compensation plan • HS & W – focus on employee wellness

Challenges include the capacity of the workforce to implement change and the capacity of HR to support those changes, building a culture of engagement and empowerment while addressing the illness and disability costs associated with an aging workforce. Review of the Terms of Reference/Annual Work Plan – No changes to the terms of reference were recommended at this time. The committee’s work plan was approved.

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Appendix A – HR Annual Report 2013/2014

2013/14

HR ANNUAL

REPORT

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Introduction

The 2013/14 Human Resources Annual Report is organized along activity lines, specifically those activities that address some of our major challenges or risks from a human capital perspective.

A. Workforce Planning, B. Workforce Capability, C. Workforce Health and Ability, D. Workplace Culture, E. Regulatory Compliance and Risk Management, and F. Human Resources Portfolio Capability.

A. Workforce Planning Workforce planning can be defined as the continual process used to align the needs and priorities of the organization with those of its workforce to ensure it can meet its legislative, regulatory, service and production requirements and organizational objectives.

Turnover

The turnover rate at HHS, consisting of both voluntary and involuntary separations, has stayed relatively stable at about 4.03% of the employee population. This falls within the 25th percentile in Ontario of both academic teaching hospitals and all of health care (according to the 2012/13 PWC Saratoga Benchmarking Survey).

The turnover rate over the past four calendar years for the ONA bargaining unit (4.56 % in 2013) and the non-union group (4.40% in 2013) has consistently exceeded the rest of the Hospital, over an employee population that is sufficiently large to be statistically significant.

Additionally, the first year turnover (11.28% in 2013) rate over the past four calendar years has consistently exceeded the turnover rate for those with greater tenure, and for the past two years has flirted with the 10% mark. This is closely followed by those with less than five years of service (7.18% in 2013). In both cases, this is mostly comprised of voluntary separations; however, involuntary separations amongst these groups are also much higher than those with greater tenure. While, this is concerning given the financial cost associated with recruiting externally, it is very consistent with the experience of other hospitals in Ontario, as reflected in the 2012/13 edition of the PWC Saratoga Benchmarking Survey.

In 2013, 34.8% of those who left before the end of their first year and 33.6% of those who left with between one and five years of HHS service were nurses in the ONA bargaining unit. Their departure represented 21.4% and 9.5% of all nurses remaining with less than one year and between one and five years of services respectively. Of those nurses leaving before five years, 73% were casual or regular part-time.

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Retirement

As described in previous editions of the HR Annual Report, our workforce at HHS is not young. Although the average age of the workforce is down slightly to 42.1 years, almost 50% of our staff (48.8%) is older than 45 and 18.4% is above the age of 55 and therefore eligible for retirement. The chart below illustrates the risk is greatest amongst senior leaders and the skilled trades.

Position/Job Class Number of Incumbents Percentage above the age of 45

Percentage above the age of 55

Directors 36 83.3% 38.9% Executives 23 91.3% 60.9% Health Professionals 902 40.5% 14.1% Management 324 68.2% 24.4% Nurses 2853 48.7% 18.2% OPSEU 279 (technical) 1017 49.4% 16.8% CUPE 7800 (Trades) 127 79.5% 30.7%

When you consider the portion of our population that is eligible for a HOOPP pension (8,475 staff), 27.4% have more than 15 years of contributed HHS service towards their pension, while 20.3% have more than 20 years.

Although the average retirement age at HHS of 60.3 years is comparable to our peers and has not changed significantly from previous years, and although there is no cap to the amount of service that can be accumulated under HOOPP, there is considerable risk in having such a large percentage of our workforce that is eligible to retire, unless of course, we are well positioned to transition their knowledge and replace them.

Succession Management

Given the number of leaders that are eligible to retire, it is especially important that we develop our leadership capability at HHS, and identify and groom those with potential to step into more senior leadership positions within the organization.

In 2013, Executive Council completed the fourth cycle of the succession management process for the executive pipeline. This process, which was established in 2009, is managed within the Organizational Development (OD) department and seeks to prepare high potential staff at the director level for future opportunities at the VP level while at the same time providing no guarantees. We had a total of 15 candidates in five years. This program has been very successful, with four directors moving into VP positions at HHS and three others assuming executive positions in other organizations. Since the inception of the program only three executive positions were filled externally with one of these being the President of the JHCC which requires a Cancer Care Ontario appointment, and one other being the Surgeon-in-Chief. At the end of March 2014, there was one active candidate in the executive pipeline and four people with alumni status who are considered ready for the next suitable opportunity that comes up.

In 2013, a succession management process for the Director level of the organization was implemented. Twenty-one candidates were identified of which four have assumed a Director Role within HHS, four have assumed a Director Role in an external organization. Currently there are 12 active candidates in the Director pipeline.

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Recruitment A number of improvements were made in 2013/14 to our recruitment processes and systems to improve both outcomes as well as the user experience.

These changes have reduced the number of FTE’s required to manage the transactional recruitment process, have significantly improved data accuracy, privacy and retention, and improved applicant tracking and communication, and provided greater transparency, timeliness and accountability.

B. Workforce Capability Leadership Development

HHS is also committed to fostering leadership capability amongst non-leaders, to enable their personal and professional growth. Internal and external leadership programs are offered through OD, and include the Charge Role Development Program, the McMaster Healthcare Leadership Development Program, Leadership from the Inside Out and The Coaching Advantage. Each of these programs is unique and is designed to meet the development needs of various levels of leadership.

Course Offerings Participants

Charge Role Development Program 4 78 McMaster Healthcare Leadership

Development Program 11 214

Leadership from the Inside Out 1 12 The Coaching Advantage Program 1 27

In 2004 HHS partnered with McMaster Continuing Education to create the Healthcare Leadership Development Program (HLDP). Over the last 8 years the program successfully equipped our leaders with the skills needed to lead in a complex and ever changing environment.

This past year, OD has been worked collaboratively with administrative and physician leaders and staff to define and design a learning and development model and delivery framework for leaders, physicians and staff. This development work has set the foundation for the implementation of a sustainable program that meets the needs of a broad community of learners across our organization beyond our traditional focus on leaders. This broader based program will replace the McMaster Healthcare Leadership Development Program and have programming available to front line staff. Pilot programs are set to launch in the fall of 2014.

Executive Coaching

OD continues to offer one-on-one confidential executive coaching to leaders and physicians. The focus of the coaching is on succession planning, leadership development and “in the moment” situations where the leader requests a confidential thinking partner to work through a leadership issue. In 2013, over 40 leaders and physicians took advantage of this service.

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Physician Leadership Performance Assessment Process

HHS is committed to a comprehensive Leadership Performance Assessment process to support our physician leaders with their development. The purpose of the formal assessment process is to provide vital feedback to physician leaders about their performance and impact; to enable physician leaders to reflect on their strengths and opportunities for development and develop individual development plans with goals, objectives and appropriate accountabilities; to guide physician leaders in developing personal career goals; and to provide an opportunity for two way dialogue leading to enhanced communication, role clarity and enhanced accountability. Two assessment templates are in place for Physician Chiefs – the Annual Assessment Template and the 1st and 4th year Assessment Template which includes the LEADS 360 process.

The VIEW 360° Tool for Leaders

The VIEW 360° feedback tool provides feedback to leaders on how they model the four HHS values of respect, caring, innovation and accountability, and additionally on ethics and integrity. The VIEW 360°, an acronym for Values Impact Everyone’s Work, is used as an input into a leader’s performance review as well informs the creation of the individual’s personal development plan. Between January 1, 2013 and December 31, 2013, 130 360° reports were completed.

C. Workforce Health and Ability One of the greatest challenges, not just for HHS and the health care sector but for society at-large, is managing the escalating costs associated with staff ill health and disability. Our aging workforce, the rising cost of benefits and disability expenses, and increasing levels of workplace stress and mental ill-health, are just some of the contributing factors.

Extended Health Benefits

At HHS, Extended Health, Dental and Health Care Spending Account (HCSA) benefits are self-insured and are administered by Green Shield Canada under an Administrative Services Only (ASO) arrangement.

For the benefit year ending September 30th 2013, Green Shield Canada paid out approximately $24.1 million in claims, which was an increase of approximately 7.1% from the previous year. This breaks down into a 17.7% increase in the cost of Extended Health Care (27% of the total), a 5.7% increase in the cost of Dental (30% of the total) and a 4.1% increase in the cost of drugs (42% of the total). The remaining 1% represents hospitalization expenses, which reduced by 22.6%.

This increase in the cost of benefits was driven by a 2.4% increase in the number of participants in the plan but more significantly from an increase in the average cost per participant of 4.6%. As a result of increased utilization in the plan, a 5% increase was applied to Extended Health and Dental premiums across the board to all employee groups.

Long-Term Disability

Our Long-Term Disability benefits are underwritten by Manulife Financial, with premiums assessed based on the last five years of claim experience.

For the benefit year ending August 31st, 2013, the number of claims initiated increased by 10.4%, from 77 to 85. This follows a decline of 13.5% from the previous benefit year. The top

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three diagnosis categories remain musculoskeletal (29.1%), mental and nervous disorders (25.1%) and benign/malignant neoplasm’s (12.4%). Of note is the fact that the incidence of mental and nervous disorders at HHS is greater (by 4.4%) than that of comparable plans in the Manulife book of business. Additionally concerning is the fact that 50% of those receiving LTD benefits for mental and nervous disorders are within the relatively young age bracket of 41 to 50 years and another 22.2% within the even younger age bracket of 31 to 40 years, meaning that they have quite a few more years of benefit eligibility.

Although the average duration of claims at HHS is considerably lower than that of comparable plans in the Manulife book of business (30.7 months versus 36.4 months), it has increased by 21.7% across the top three diagnosis categories from last year. This, however, follows a decrease of 19.3% from the previous year. Duration in Months

Sep-2010 to Aug-2011 Sep-2011 to Aug-2012 Sep-2012 to Aug-2013 Diagnosis Category HHSC Industry HHSC Industry HHSC Industry Musculoskeletal 40.4 42.5 26.0 38.6 29.5 37.5 Mental & Nervous Disorders 19.2 33.1 44.9 35.9 39.5 26.7 Benign/Malignant Neoplasm’s 21.1 20.6 15.0 22.2 16.8 26.4 Overall Duration (All Diagnoses) 33.1 36.3 26.7 35.2 32.5 37.6

• Duration is measured as the number of months between the date of disability and the paid to date for all claims resolved during the period September 01, 2010 to August 31, 2013, regardless of date received.

• The industry comparison group consists of 2,010 claims, using industry range 8011 to 8091. As a result of this activity and the corresponding increase in the assessed future cost of claims, our premiums have increased by 25% effective April 1st, 2014.

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Absenteeism

According to the Canadian Institute for Health Information, health care workers are one and a half times more likely to miss work due to illness and disability than workers in other sectors. In addition to the nature of the work, attendance at work is heavily influenced by such factors as the size of the organization, the degree of unionization, employment status and the availability of benefits, poorly designed or managed workloads, role uncertainty, and perceived lack of control, many of which characterize the work environment at HHS.

HHS continues to struggle to manage absenteeism, despite the success of its Attendance Support and Management Program. The average number of sick days per year (based on a 7.5 hour day) increased between 2012/13 and 2013/14 from 9.8 to 10.1. This translates to an annual cost of over $18 million dollars. According to the most recent PWC Saratoga Survey (for the period April 2012 to March 2013), these results are consistent with other hospitals.

Workplace Insurance

Under the Workplace Safety and Insurance Act (WSIA), the Workplace Safety and Insurance Board (WSIB) insures HHS against the present and future cost of workplace injuries and illnesses.

WSIB costs are essentially split between premiums and the adjustments made to premiums through the New Experimental Experience Rating (NEER) program.

1. WSIB Premium Rates Employers in Ontario that are covered by WSIA legislation are separated by industry and size into schedules, classes, sectors, rate groups and classification units. Premium rates are set each year, and are based on the health and safety and return to work performance for each rate group. In addition to past claim costs and projected new claim costs for the rate group, the premium rate includes charges for administrative expenses (overhead and legislative), the unfunded liability, gains and losses, and bad debt expenses.

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The average premium rate is set by the WSIB each year and has increased by almost 36% over 13 years, which for HHS translates into an additional premium cost of over $1.5 million when considering total insurable payroll for the 2013 year.

2. New Experimental Experience Rating (NEER)

NEER is the prevention program under which an organization’s WSIB costs change as a result of accident or injury performance over the previous four years. Under NEER, the WSIB compares the forecasted costs of injuries for an employer against the costs that had been expected for an organization of that size. If the forecasted costs are less than expected, the organization receives a rebate and if they are more than expected, the organization is levied a surcharge. HHS was levied a surcharge in 2013 of $2.66 million. Although some of this can be attributable to the poor design of the NEER program, it is ultimately the result of a higher than expected and acceptable number of workplace injuries and illnesses at HHS, and delays in returning those injured or ill to work. The financial risk associated with NEER is attributable not only to the size of the surcharge over the last four years, but also due to its unpredictability. The NEER program has been heavily criticized for its retrospective nature, its volatility and its unpredictability. It is also easily manipulated by the WSIB, through changes to the reserve factors that underpin the calculation.

Mental Health

According to Health Canada, healthcare workers in Ontario have one of the highest disability rates of any workplace sector, with rapidly increasing rates of stress-related disorders (Health Canada 2009). This is reflected in the aforementioned LTD statistics which identify mental and nervous disorders as the second highest category of long-term absence, in the fact that general mental health support accounted for 31% of calls into our EAP provider for 2013/14 (second highest category), and 20.8% of all drug claims for benefit year 2012/13 (highest category). SHINE – Hamilton Health Sciences’ health and wellness program

The most effective and sustainable way of reducing the costs associated with ill health and disability is through the prevention, or the promotion of employee health and wellness. The SHINE wellness program (Supporting Health IN Everyone) has been in place at HHS since late 2012, and is run out of the HSW Department within Human Resources. Their small dedicated staff is supported by a strong network of champions across all HHS sites, which help inform and promote wellness program offerings and events. SHINE is also supported by an externally hosted website, launched in April 2013 and already generating significant interest and traffic, as well as a quarterly publication. Some of the more notable achievements to date of the SHINE program, supported by the Wellness Initiative under Goal 5 of the strategic plan, are as follows: Implemented a Health Risk Assessment Tool , which to date has provided 190 users with

confidential actionable information about their health and personal health practices Established dedicated wellness space at all HHS sites except for West Lincoln, the original JHCC

site having drawn over 450 active users Led the formal recognition of HHS under recognized workplace wellness framework (OHA

Quality Healthcare Workplace Award – Bronze Level)

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Developed a policy to support workplace health In partnership with Inter-professional Practice, implemented intensive Mindfulness courses,

presentations and workshops, and weekly Mindfulness for Lunch programs In partnership with Inter-professional Practice and supported by the a grant from the MOHLTC,

developed a local Mindfulness Research Group, to support ongoing research into the outcomes of Mindfulness Based Interventions for healthcare staff, including longitudinal follow-up with graduates through focus groups

Partnered with BestLifeRewarded®, an online evidence-based wellness incentive program, to help improve our individual health and well-being.

Workplace Mental Health

HSW has also embarked on two initiatives to recognize and support those in crisis and reduce workplace triggers or causes.

1. Beyond Silence Research Project

HHS has partnered with a researcher at McMaster University to increase awareness of mental health issues in the workplace through the use of peer educators. The first phase of this project, which received funding through the Research Advisory Council of the WSIB, was completed in early 2013 and has recently been published - The web of silence: a qualitative case study of early intervention and support for healthcare workers with mental ill-health.

The project was recently advised that the second phase of the project has been approved for $150,000 in funding through the Ontario Mental Health Foundation. This phase, which will run over 2 years, will focus on the impact of contact-based education on early intervention and support for the mental health of healthcare workers.

2. Psychological Health and Safety Standard

HHS has committed to implement a national voluntary standard focused on promoting employees' psychological health and preventing psychological harm due to workplace factors. Implementing this standard is expected to take 2-3 years beginning this spring with a comprehensive gap assessment conducted by Mary Ann Baynton, who served as the Chair of the Technical Committee which developed the standard itself, is the Program Director of the Great West Life Centre for Mental Health in the Workplace and the Executive Director of Mindful Employer Canada.

This commitment to adopt the standard and to improve the psychological safety of the workplace has led HHS to join Mindful Employer Canada (http://mindfulemployer.ca).

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http://www.biomedcentral.com/1471-2458/14/138

http://www.biomedcentral.com/1471-2458/14/138

http://mindfulemployer.ca/

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Accommodation and Return to Work

Since it’s repatriation from TSSI in July of 2011, the disability management program has gone through many changes. In the summer to fall of 2013, all managers and many union stewards received training in the duty to accommodate.

Despite these changes, returning people to work following illness or injury (occupational or non-occupational) remains very challenging. The need for a more proactive, efficient and consistent approach in returning employees to work especially from extended absences led to the creation of the duty to accommodate framework which made explicit the hierarchy of placement. A Complex Case Management Committee has been established with HR and inter-professional practice to help keep the most difficult cases on track, cases that often involved chemical dependency, behavioural and/or practice issues. Finally, HSW established monthly meetings with the leaders of each union and with Manulife to find common ground in solving complex cases and improve communications.

As a result of these improvements, since November 2013 HSW has driven a substantial decrease in the utilization of the modified work budget, ending the fiscal year with a budget surplus of almost $400,000. These savings have carried into 2014/15 such that the modified work budget has been reduced to $2 million from its previous level of $2.46 million.

Attendance Support and Management Program (ASMP)

The ASMP was introduced in July 2012, in an effort to better manage those employees with excessive protracted absenteeism. Developed and administered by HSW, this program addresses many of the concerns raised by leaders, staff and union representatives with the old Attendance Awareness Program

Several improvements have been made over the past six months to improve the program, including the introduction of a new compliance report to better measure progress, stricter auditing of meeting documentation, enhanced training for managers and union stewards, and increased support from both HR and HSW as employees advance into the later stages of the program. Workplace Safety

Since repatriation, HHS has made significant improvements to the safety of the workplace. There are a number of indicators that measure these, but the most common is the frequency of safety-related

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incidents in the workplace. At HHS, these are captured using the Safety Occurrence Reporting tool (SOR) which is also used to initiate the claims management and RTW process.

The number of staff SOR’s reported in 2013/14 was 2521. This represents an 11.1% increase over the average of the previous three years (2270). Prior to 2013/14 our volume of SORs has averaged an annual increase of 1%

The 2013/14 increase was driven almost entirely by an increase in first aid injuries which increased 26.3% in 2013/14 when compared against the average of the previous three fiscal years, with the other injury severity categories remaining relatively stable or showing a decrease ( Hazardous Situation: -9.1%, Medical Aid: +1.1% and Lost time: -5.8%). This increase in volume of first aid SORs indicates a trend towards earlier reporting of less severe injuries, which ultimately may provide HHS with the opportunity to control hazards before medical aid or loss time injuries are incurred.

Throughout 2013, the groundwork was being put in place to implement changes to the staff safety occurrence reporting system.

No Lost Time Injuries Lost Time Injuries Total Injuries Fiscal Year

# Injuries

Frequency (expressed per

100 Insured Workers)

# Injuries

Frequency

(expressed per 100 Insured Workers)

Total Injuries

Frequency (expressed per

100 Insured Workers)

2010/11 Total 336 3.49 199 2.07 535 5.55 2011/12 Total 354 3.67 168 1.74 522 5.41 2012/13 Total 380 3.71 154 1.51 534 5.22 2013/14 Total 326 3.24 110 1.09 436 4.33

Source: Aon, Medgate Case Management System

Claims Management Practices

In addition to making improvements in workplace safety which are driving down the number of compensable workplace injuries and illnesses, HSW continues to improve its claims management practices.

The Health Abilities Team continues to experience great success in applying for WSIB relief through the Secondary Injury Enhancement Fund (SIEF), which offsets the costs of WSIB claims for employees with a pre-existing condition. In 2013, a total of $1.6 million in cost relief was granted as a reduction in claim costs, and as of April 2014, an additional $151,000 in SIEF has been award and a significant number of additional cost relief requests are pending.

An assessment of WSIB claims management processes was completed by an external vendor, and an action plan developed. A number of recommendations will be implemented over 2014 beginning with the introduction of an additional WSIB Analyst to manage WSIB claims and claim processes. In addition, HSW undertook an RFP to select a vendor to provide WSIB consultation on complex cases, support in the appellant process and representation at WSIA tribunal hearings. Morneau Sheppell was the successful applicant and are currently involved in several of the more complex WSIB files.

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Insured Benefits

To ensure HHS remains in compliance with the BPS Procurement Guidelines, and in support of our ongoing commitment to reduce our benefit costs, in 2013 HHS issued an RFP for consulting services. Through this initiative, HHS redefined the scope of service requirements for the external benefit consultants as well as the method of payment for such services. The outcome of this initiative saw a change in providers, to AON Hewitt Consulting Services. As a result of this new partnership, HHS will realize an annual savings of over $100K through the new contract arrangement, and receive enhanced services. With Aon’s assistance, we have made some improvements to the processes by which we manage our huge benefit expenditure, including the implementation of a carrier interface as well as pre-authorized debit.

D. Workplace Culture Organizational culture, or rather the alignment of culture with the other elements of the organizational system, is critical to long-term organizational success. Engagement Survey Enhancing the engagement of staff and physicians was a high priority in 2013/14 and included as a strategic initiative under Goal 5. Under this initiative, local and corporate level action plans were developed and executed throughout 2013. 100% of leaders shared their results and 88% of leaders developed action plans. A pulse survey conducted in February 2014 revealed that:

• 86% of the staff said that they were aware of their local level results, • 60% said they were involved in a conversation about the survey, • 37% indicated that they were asked to participate in local level action planning and • 64% of those who were asked to participate noticed positive changes as a result of the

action planning, including better team work, better morale, more opportunities to be involved, improved visibility of the leaders and greater recognition from leaders and peers.

A physician engagement working group was also launched and considerable work was completed. The group analyzed best practices on physician engagement and conducted interviews with HHS physicians to define strategies that would enhance engagement. The team defined key strategies for implementation over the next three years, including a physician compact to clearly define the relationship between the hospital and physicians, physician leadership development program, communication plan, and decision making process that better involves physicians.

Recognition Initiative To better understand how people want to be recognized and feel valued, an initiative related to recognition was launched. The team developed and executed a high touch approach to solicit input on recognition practices from over 900 people across the organization. These thoughts and perspectives led to changes in current recognition events and programs and informed the development of the FY 14/15 improvement initiatives related to recognition.

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Union Relationships

Strong trusting relationships with our union partners are key when navigating the transformational change required over the next five to 10 years. Through monthly meetings between the Head of Employee and Labour Relations, the VP HR, and the President of each union local, we are leveraging a trusting relationships that will developed over time and support a stronger partnership on which the organization can meet its goals and objectives in the longer-term.

Other HR/OD Initiatives and Interventions In addition to efforts to enhance engagement, a number of other activities intended to shift the culture were executed in 2013/14 by the OD Department within Human Resources.

• HHS team development framework - has been piloted with a few leaders and their teams with positive results. The model will be finalized and formally launched in 2014.

• The Coaching Advantage Program - created a coaching sustainability plan and implemented a program to support 27 leaders in the training program, designed to embed the coach approach within the leader role and business.

• Spring and Fall Leadership Forum - 450 administrative and physician leaders participated in two forums: The focus of the spring leadership forum was to prepare our leaders to share the vision

and goals with their teams to so that our workforce (employees, physicians and volunteers) can see themselves in it and be motivated by it.

The fall forum built further alignment with our leaders at all levels as we celebrate the fact that the Best Care for All is alive in our organization and strengthen the message that we all contribute in our own way.

• HHS Film Festival and Art of Healthcare - The HHS Film Festival had over 6,000 views of our collection of videos and over 750 people attended in-person screenings. The Art of Healthcare had over 750 people attending the art exhibit. As a result of the overwhelming success and positive feedback, we are hosting our 2nd film festival in 2014.

E. Regulatory Compliance and Risk Management

Captured below are highlights of some of our efforts, and results, in 2013/14:

Hazard Accountability

Building on a new hazard accountability structure implemented in 2012, hazard clusters have all been assigned, and the executive leads provide quarterly updates to the HSW Steering Committee with respect to the level of risk posed by the hazard, the measures being taken to control the hazard and any recommendations to be considered.

Competent Supervisor Training

By the end of fiscal 2013/14, 91% of our leaders have completed the in-class training program for supervisors. This has removed a significant risk during MOL interactions, and has set the stage well for compliance with the new regulations regarding workplace safety training coming into effect on July 1st, 2014.

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Hazard Identification Tool

Over the course of 2013/14, HSW has built an annual hazard inventory survey to managers, which will assess the location and potential severity of hazards throughout the organization.

Ministry of Labour Activity

HHS has continued to foster a positive relationship with the Hamilton Branch of the Ministry of Labour that proves to be very effective in the proactive resolution of issues and concern. 2013/14 saw a reduction in interactions with the Ministry of Labour as compared to the previous three years. This was evident both in a reduction in the number of visits to HHS sites and also in the number of orders issued. Notably, there were no MOL interactions related to asbestos management in 2013/14. This can be attributed to stricter asbestos management practices put in place at the beginning of 2012. Nor were there significant MOL interactions on hazardous drugs which resulted in large number of visits and orders in 2011/12.

Visits to Hamilton Health Sciences from Ministry of Labour Fiscal Year Visits Orders 2010/11 48 25 2011/12 71 73 2012/13 35 34 2013/14 28 15

Source – internal HSW database These results are especially notable in light of the fact that, according to the MOL, the Health Care Sector experienced a 10% increase in the number of inspections in calendar year 2013, and only a 7% decrease in the number of orders issued. Critical injuries

The total number of critical injuries decreased sharply in 2013, as a result of changes to our internal reporting practices and better alignment with the MOL expectations regarding reporting. This change greatly reduced the practice of reporting injuries which were not associated with an event in the workplace (i.e. non-occupational). The number of Critical Injuries with an occupational component stayed relatively similar to previous years. Often times the MOL has been satisfied by the report that is submitted and do not visit the workplace to further investigate.

Type of Critical Injury

Occ/Non Occ

Year LOC Frac LTC LOB Occ Non Occ Total

2013 1 5 - - 6 - 6

2012 17 8 1 * - 5 21 26

2011 17 5 0 - 6 16 22

2010 9 5 1 1 8 8 16 LOC=Loss of Consciousness, Frac=Fracture, LTC=Life Threatening Condition, LOB=Loss of Blood * Life Threatening Condition resulted from an altercation between 2 non-employees outside the MUMC ED, that sent one man to Hospital

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Pay Equity Act

Significant progress was made over 2013/14 to bring this to resolution, and in March 2014 a tentative agreement was reached with CUPE that was ultimately endorsed by the Board of Directors. As of the writing of this report, the parties continue to negotiate the finer details of the Memorandum of Agreement, with resolution and communication expected by the end of June 2014.

F. Human Resources Portfolio Capability

HR Restructuring

A new structure for the HR portfolio, which was introduced in October 2013 has positioned us well to respond to some of the challenges and opportunities that have already presented themselves, including those described in more detail below and through the rest of this report.

Evolution of TSSI relationship

Planning began in the 4th quarter of 2013/14 to repatriate the HR Administration function from TSSI and to establish an employee enquiry capability to replace the TSSI Contact Centre. This change, which will take effect in June 2014, is expected to improve the employee experience, reduce administrative errors and costs, and provide us with better insight in planning the repatriation of payroll at the expiry of the TSSI contract in May 2016. During the repatriation of HR Administration, we were successful in negotiating a one-time cost reduction/credit of $250,000 to be applied to our monthly invoices in 2014/15. This credit was to compensate HHS for the many administrative errors that had occurred since the renegotiation of the MSA. This credit has enabled some of the service improvements that we expect to see with our new HR organization. Goal 5 Refresh

Even before the refresh of the organization’s strategic plan was initiated, we recognized the need to “pause, reflect on, and reframe” the strategic goal related to our workforce. This work, which began in January 2014, is proceeding at a good pace and with broad stakeholder engagement, and will nicely complement and inform the evolving strategic plan of the organization. Key drivers for this work includes:

• To improve its resonance and relevance – internally and externally • To bring greater alignment between the “people” goal statement (to be the employer of

choice for talented people), the objectives and the measures • To make it more comprehensive, driving work in all areas necessary to achieve the

people goal • To make it more reflective of all the good work underway in support of our people • To make it more inclusive, applicable not only to staff but also to physicians and

volunteers This work will inform the organization’s People Strategy, which in turn will drive the creation and execution of the HR strategy. In addition to redefining work priorities, it will also necessitate a review of structures and roles across the entire HR portfolio, to ensure that we are using our resources as efficiently and effectively as possible.

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Report to the Board of Directors

Finance Committee – October 2014 A meeting of the Finance Committee took place on Wednesday, October 29, 2014 at 4:00 PM in the Millview Room, Ancaster Mill, Ancaster, Ontario. In attendance: Norm Col (Chair), Richard Koroscil, Chantel Broten, Rob MacIsaac, Kurt Whitnell, Cathy Rozman – recording secretary Regrets: Scott Maki, Paul Chapin Guests: Brenda Flaherty, Kathy Watts, Fran Agnew, Wendy Gerrie, Item 2.2- Kelly Campbell For Approval – Annual Program Reconciliations – Finance Committee received reconciliation of revenues and expenditures reports for the 2013/14 Clinical Education Program as required by the MOHLTC and the Ministry of Children and Youth Services and Ministry of Community and Social Services program 2013/14 reconciliations. Finance Committee recommends approval of the reconciliations and recommends that the Chair of the Board of Directors be authorized to sign the submissions on behalf of the Board. The statements are available through the board office or portal. Finance Committee recommends to the Board of Directors: “That the Reconciliated Statements of Revenue and Expenditures for the year ended March 31, 2014 for the following programs be approved;

• Clinical Education Program • MCYS: Autism ABA Program • MCYS: Autism IBI, SSP & Respite Program • MCYS: Children’s Treatment Centre Program • MCYS: CYMH, IPP & CSN Programs; and • MCSS: SCS-Children & Special Needs Program; and

That the Board Chair be authorized to sign the submissions on behalf of the Board of Directors.” For Information – PCB Transformer Project – Finance Committee received the final report on the project that was completed within budget and two months in advance of the extended timeline. Monthly Operating Statements (attached) – Fund 1 Operations has a budgeted surplus position of $9.6M for 2014/15 (before building amortization and interest on long term debt). The consolidated net surplus at six months is $281K. Funding letters are anticipated to be received within the next couple of weeks. It was noted that working capital deficit increased by $14.6M, however this is a result of funding flow from the MOHLTC resulting in a cash flow timing difference together with the use of $9.9M of own funds used for capital investment for which the $15M capital loan will be used to finance.

• Anticipated year end surplus of $1-2M • Remains at risk with winter increase in patient volumes and Ebola preparedness

activities reimbursement by province • Absenteeism continues to trend upwards in spite of increased focus

o Rates within comparable to sector o Pockets of high absenteeism rates – may be related to organizational changes o Costs are absorbed at the unit level o Wellness continues to be focus for organization

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Finance Committee – October 29, 2014 Page 2

• Ebola preparedness has put strain on the organization (capital/training/equipment) The committee agreed that an update on the current financial position would be brought forward to the November board meeting. 2015/16 Budget Planning Update – Finance Committee was updated on budget planning. Proposed strategies will come forward to the next Finance Committee meeting and will be reported at the November board meeting.

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Report to the Board of Directors

Finance Committee – November 2014 A meeting of the Finance Committee took place on Tuesday, November 25, 2014 at 4:00 PM in Room 2E51, McMaster University Medical Centre. In attendance: Scott Maki (Chair), Norm Col, Richard Koroscil, Chantel Broten, Rob MacIsaac, Kurt Whitnell, Cathy Rozman – recording secretary Guests: Brenda Flaherty, Dave McCaig, Renato Discenza, Sandra Licata, Diana Simmons, Wendy Gerrie, Fran Agnew, Wendy Gerrie, Anthony Scandinavo For Approval – Trust Account Approvals – Finance Committee received the semi-annual report on internally restricted trust accounts. No concerns were identified. It was noted that trust accounts cannot be in a deficit position, with the exception of timing delays by the funder. Finance Committee recommends:

“That an allocation of $1,000 from the Corporate Trust Fund (3576.000020) to the HHS Scholarship Fund be approved.”

International Swaps & Derivatives Association (ISDA) Master Agreement – In order to secure the $15M loan agreement approved at the September meeting, a ISDA is required to fix the interest rate for five years. Finance Committee recommends:

“THAT the attached resolution (Appendix A: ISDA) be approved.”

The master agreement is available through the Board office. For Information – Monthly Operating Statements (attached) – The monthly operating report was received. YTD October surplus from hospital operations is $6.9M versus a budgeted surplus of $5.7M. ALC rates have been reduced at the General site as a result of the transitional bed strategy. The consolidated statement and finance dashboard are attached. Investment Policy, Report & Statement of Compliance – The report provided information on proposed changes to the Investment Policy Statement, compliance to the Investment Policy Statement and the restricted fund investment portfolio status. As of September 30, 2014 $285.5M of the $290M gift to Hamilton Health Sciences Research Institute has been transferred. The balance of $4.9M is expected to be transferred before year end. YTD investment income total $8.7M net of fees. Due to the sale of assets, gains were higher than budgeted and investment income is forecasted to be $10.M for F2015. Hamilton Health Sciences Research Institute – Finance Committee was provided an update on HHSRI activities. 2015/16 Budget Planning – A fulsome report will be provided at the board meeting.

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Appendix A: ISDA RESOLUTION OF BOARD OF DIRECTORS

OF [INSERT NAME OF CORPORATION]

WHEREAS there was produced before the board of directors a copy of an International Swaps and Derivatives Association, Inc. Master Agreement together with, in the form attached to this resolution as Schedule "A", a draft schedule to be entered into by [insert name of corporation] (the “Corporation”) and Royal Bank of Canada (such Master Agreement and schedule being referred to hereinafter as the "Agreement"): AND WHEREAS it is in the best interests of the Corporation to enter into the Agreement and the transactions contemplated thereunder; IT WAS RESOLVED THAT, 1. The Corporation is hereby authorized to enter into the Agreement with such

changes as the person signing the Agreement may approve, the execution by such person to conclusively evidence such person's approval of same and that such Agreement as executed is the Agreement authorized by this resolution;

2. The Corporation is hereby authorized from time to time to enter into transactions

contemplated by the Agreement; and 3. Any officer or director of the Corporation is hereby authorized to sign and to deliver

the Agreement, as supplemented, amended or modified in such form as such officer or director may in his or her sole discretion determine necessary or appropriate, for and on behalf of the Corporation.

CERTIFICATE The undersigned [Insert position - President or Secretary] of the Corporation hereby certifies that the foregoing Resolution was duly passed by the board of directors of the Corporation and is still in full force and effect as of the date hereof. DATED at __________________________, __________ ___, 2014.

__________________________________ [Insert Name] [Insert Position] [Insert Name of Corporation]

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Quality Committee – November 2014 A meeting of the Quality Committee was held on Monday, November 17, 2014 at 4:00 PM in Room 2E51 at McMaster University Medical Centre. In attendance: Paul Chapin (Chair), Mary Catherine Lindberg (teleconference) , Anita Isaac, Mary Volk, Richard Koroscil, Terry Shields, Elaine Principi, Kirsten Krull, Dr. John Mernaugh, Barbara Sullivan, Norm Col, Cathy Rozman – recording secretary Regrets: Rob MacIsaac, Dr. Paul Miller Guests: Sharon Pierson, Dr. Dick McLean, Brenda Flaherty, Kelly O’Halloran – Education Session For Information: Education Session – Health Links - Quality Committee received a detailed update on the Niagara North West Health Link (NNWHL) and Hamilton West Health Link (HWHL) projects. HWHL recently received notice that it will be receiving $1M in one time funding to support staffing, communications, technology, and other infrastructure requirements that will lead to a sustainable plan, focusing on the delivery of health services by the partners in a different way within current resource allocations. Work to date has identified service gaps that are being addressed (e.g. laboratory and consultant access) by the partners. Challenges continue with the voluntary nature of the program, privacy issues and the clarification of roles and responsibilities within the partnership. HHS will be leading the priority frail seniors collaboration in the HWHL. It was noted that the MOHLTC may be announcing structure changes to the Health Links program in the next few weeks. The full presentation is available through the board office or the portal. Annual Patient Experience Report – The 13/14 annual report was shared with Quality Committee. Highlights included:

Number of complaints remains stable

Consistent theme around improved communication

Staff education underway on service recovery A report will be developed for the next meeting that will bring together all of the mechanisms that feed into patient experience. This will BE positioned against proposed legislative changes under Bill 8 that will see the appointment of a Patient Ombudsman. This office will also have broad powers around investigation and resolution of patient complaints. The bill will also include new regulations under the Excellent Care For All Act ensuring that specific patient relations processes are in place. Quality Committee Workplan – Quality Committee approved its workplan for the upcoming year. Accreditation Planning Update – Planning for the June site visit remains on track. Accreditation teams are completing the self assessment questionnaires and developing roadmaps to address any gaps. The Governance Function Tool results will go forward to Executive Committee. Critical Incidents – The regular report was received by the committee.

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NEWSLETTERthe inner circle

the voice of HHSVA volunteers

HHSVA MissionTo enhance patient care and quality of life for the HHS community

through the donation of profits from the operation of business services and the recognition and support of volunteers.

Fall 2014

Making a Difference Program Profile: HELP Group Volunteers

The Hospital Elder Life Program (HELP) is a volunteer-focused program for inpatient seniors at Hamilton General and Juravinski hospitals. At these sites, a number of HELP volunteers have taken on the added commitment of the HELP Group volunteer role. The groups are run a few times each week.

At each HELP group, longer term, senior patients come together to participate in fun and engaging activities in a group setting. The activities are aimed to improve orientation, socialization, and basic mobility. The group theme and activities were designed by Recreation Therapist and Elder Life Specialist, Celia Chilton, to ensure that the patients get the most out of each group. The groups are always run by two HELP volunteers. This enables

the volunteers to compliment each other’s skills and experience, and build on each other’s strengths. For the volunteers, this close knit group and sense of team work has resulted in developing strong and meaningful relationships both with their fellow volunteers and with the patients.

“A group volunteer is a special type of volunteer with that little extra je ne sais quoi! They are confident and able to deal with the uncertainty that invariably comes with inpatient hospital units and they are creative and engaging in ways that motivate staff and patients to get involved,” says Erin Stirling, Elder Life Specialist, HELP program. As the HELP group continues to grow at both sites, we look forward to adding to our volunteer team.

Above, from left: HELP Group volunteers, Karen Christie and Raghad Al-Saqqar;

40 Years - In 1974 Irene began volunteering and has over 3,700 hours of service. Irene has volunteered at both General and Chedoke sites. Her current role is as a way-finder and greeter at Chedoke’s Holbrook reception desk.

Irene Nason25 Years - Rosemary began as a volunteer knitter in 1987 and took on the role of knitting convenor in 1988. At the HHSVA Annual General Meeting and Awards night in June, Rosemary celebrated 26,000 hours of service.

Rosemary Stewart

Hamilton Health Sciences Long Service AwardsOn October 16th Hamilton Health Sciences will be awarding staff and volunteers for long service. Congratulations to the following volunteers who will be receiving long service awards at this year’s event:

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Since 2001, I have had the privilege to submit messages to our volunteers for the Inner Circle. I recently took the

opportunity to reflect back through the archives, and began to reminisce on the many faces and milestones of the past thirteen years. With the ebb and flow of changing times, I’ve had the privilege of meeting countless individuals who, each in their own way, have left a special mark in the narrative of volunteerism at HHS. Over the years, hundreds of students have touched upon our doorstep for a short time to

Message from the Manager, Volunteer Resourcesvolunteer at HHS. Although many of them moved on to careers and other endeavours, their imprint remains. Some of our volunteers have passed away, but their familiar faces warm my heart from memories of times we shared.

There have been many changes within our organization and in the voluntary sector, but there is one thing that has remained consistent - the value of volunteerism is forever increasing. Volunteerism is an indispensable function within our family of hospitals. At HHS, more than ever, there is an asserted effort to improve the patient experience. Whether you’ve joined our team for a short time or a long while, know that the contributions you’re making to our

organization are helping to shape the ongoing legacy of volunteerism at Hamilton Health Sciences.

Lorraine McGrattanManager, Volunteer Resources

the inner circlethe inner circle

Batoul AbbasBatoul began volunteering at Juravinski Hospital in February 2012 in the student program. Over the past two years, Batoul has given almost 200 hours of service. She took over as a student Team Captain when her sister, Sabrin, went

away to college. She now oversees the training and orientation of all new recruited student volunteers. “Educating new students is a great experience for me, and I think it is a great experience for students, especially ones that have an interest in going into the medical field,” says Batoul. Batoul is also an active member of the Volunteer Council and assists with event planning and the department newsletter. Thank you, Batoul, for your commitment to volunteering!

Carolyn LuptonFor the past four years Carolyn Lupton has been a volunteer with St. Peter’s Hospital. Carolyn volunteers at the Palliative Care unit, often spending her time sitting

with patients at their bedside, providing comfort and companionship. She enjoys volunteering her time each week and finds spending time with patients who are at the end of their life to be very rewarding. “The patients share the most amazing stories of their lives,” says Carolyn. Carolyn has contributed more than 700 hours in her role of enhancing the experience of palliative patients. Thank you, Carolyn, for your kindness, generosity and compassion for the patients you serve!

Hamilton Health Sciences Volunteer Profiles

In Memory of Diana BeachamOn May 29th, 2014 we mourned the passing of volunteer, Diana Beacham. In addition to her volunteer work at McMaster Hospital,

Diana served as the Editor of the Inner Circle newsletter for many years. With 30 years of experience as a high school English teacher, Diana had an attention to “grammatical” detail that was second to none. Her supportive nature, kindness and dedication will surely be missed.

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the inner circle

Aman RoupraAman Roupra has been a volunteer in the Student Ward Support Program at Hamilton General since November of 2011 and has accumulated over 160 hours. She

has volunteered as a Team Captain in the Student Program. Aman is very reliable and is a great role model for our younger students. In addition to her volunteering role at HHS, Aman also volunteered with her high school student council and several other school programs. Aman just completed her last year of high school and has been accepted into the University of Waterloo’s Honours Science Program. Thank you, Aman, for your dedication! We wish you continued success in your education and plans in the future.

Judy SlackIn June of 2000 Judy began as a volunteer cuddler in the Inpatient Pediatric Program. Judy spends her time holding and cuddling babies, giving a much needed break to parents. If you ask Judy she will tell you

that she gets more than what she gives. She comes in once a week and often, while cuddling the little patients, lends an ear to parents and shares words of support. Judy also actively recruits individuals to knit or crochet afghans for patients through her church and neighbourhood. She even provides pick-up and delivery service bringing the blankets to the families of pediatric patients. She is just shy of 1,000 hours in her 14 years as a volunteer at McMaster. Thank you, Judy, for your love of children and everything you do!

Ratry TounRatry began volunteering in February of this year and has already accumulated over 60 hours of service. She provides support to the Prosthetics and Orthotics team at Chedoke. Ratry’s knowledge

and skills in working with the different materials and equipment have enabled her to fabricate the required devices quickly and efficiently. Ratry has was recently accepted into the Orthotic and Prosthetic Technical Program at George Brown College. This is quite an accomplishment as this program is the only one of its kind in Canada, and accepts as few as twenty-five students per year. Through this program Ratry will continue to build on the experience gained in her volunteer role and hopes to continue supporting the staff at Chedoke. Congratulations, Ratry!

SashaVasovich

Sasha has volunteered at the Juravinski Cancer Centre (JCC) since 2010. She volunteers every week as a way-finder at the volunteer service desk in the main lobby.

When a patient enters the Cancer Centre for an appointment or treatment, it can be very stressful and overwhelming. Sasha is there to welcome them and escort them to their appointments, whether at the Cancer Centre or over at the Juravinski Hospital. Along the way she provides support and answers any questions they may have, always with a friendly smile. Sasha is a dedicated volunteer. She is sensitive, courteous and always caring towards the patients she assists each week. Thank you, Sasha, for all that you do!

Hamilton Health Sciences Volunteer Profiles ...continued

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Hamilton Health Sciences Volunteer Association

the inner circle

The Inner Circle is an official publication of the Hamilton Health Sciences Volunteer Association. Comments? Email: [email protected] OR Mail: HHSVA, Chedoke Hospital, Wilcox Building, Rm 250, PO Box 2000, 1200 Main St W, Hamilton, L8N 3Z5 Contributors: Joan Annibale, Jody Casselman, Samantha Chivers, Tina Cooper, Liz DeLuca, Nancy Hayes, Trisha Jennings,Brian Johnston, Lorraine McGrattan, Christie Mohide, Sandra Starr and Dorothy Verboom

Annual General Meeting, Dinner & Awards Presentation The 2014 Annual General Meeting, Dinner and Awards banquet was held on Wednesday, June 11th at Liuna Station in Hamilton. Congratulations to all of our award recipients!

100 HoursOssama AdhamDouha Al WahidiIrene AlfredFatimah AliyaKatherine BarnardRebecca BarnardBerty BaskaranEzra BengiziSteven BennettAnuja BhaleraoZach Bouck Alessia BragagnoloAnnie CheungArnold CheungBonnie Cheung Daniella CisterninoAmanda CliffordCristina de Simone Annagrace Desjardins

Laura DigiovanniMatthew D’MelloNicholas DushenkoSouzan El-ChazliPaulette EwalefoYipeng GeShelby GilbertsonFeona GrantJordan GrantJasleen GrewalSrishti HarnalWaseem HijaziJessica HuaJeremiah JooChristine KempthorneBumjoon KimHelen KimNatasha KimKelly Kolkin

Jimmy Li (Hon Cheung)Steven MaConnie MacEmily MagillSpencer McDermottKlarizze MontemayorMichelle MoonesarJanada MwangaMitan MzouriAlexandra OleicheMonica PapinskiMayzelle ParawanBalaruban PoobalasundramSabitha RajarubanStephannie RajkovNicole RakowskiMatthew RaleighShakirjan RascaGlara Rhee

Aman RoupraMohammad SakhiArmush SalahadinAndree SkiptonDerek StouthJihyun SungGregory TapangTina ThomasMichael TownendHillary Tran

Eunice TsangVasillia VastisAili WangAnson WongMengchen XiSunny XiaMichelle XiongCathy Xu (Jia Nan) Lina YonnadamMaggie Zhou

2000 HoursPaul DionneDorothy JolliffeKen McKnightAudrey MullenRobert MullenD’Arcy Regan

4000 HoursMarie NeathJeanette Waugh

6,000 HoursKathy Lawrence

7,000 HoursHelen Nevin

9,000 HoursAnn Suhadolc

10,000 HoursNancy Tonner

11,000 HoursNorma StubbinsMaureen Hewins

12,000 HoursAlice BoucherLinda ScheungBetty Wodchuck

15,000 HoursBetty SchmelzleShirley McTear

18,000 HoursJean McEachern

26,000 HoursRosemary Stewart

500 HoursBonnie BoothAndrew CapiliAdrian ChanCody ChiltonMohinder ChimaKaren Anne ChristieDan CooperDebbie DemersWarren deSACarmela Flora Disanza

Joan FletcherMark HendersonSharon JohnstonSuzanne LawsonMel MatthewsFirdouse MohammedMarialuisa MontesantoRick MorrisonMurray Neath

Grace NgTom O’ShaughnessyCarol OuelletMelissa RattleJames ReganBarbara RogersHarbans SalanSharon ThiedeBrandon Westman

300 HoursKudzai ChimhungweDanielle FearonCadric GunaratnamElizabeth Irvine

Erin KehoeMohsen OleicheJiaji Xia

1,000 HoursShirley BrawnChaz FisherLinda HastingsCindy LamontGeraldine MillinAvril MurphyReginald Simser

Pat TarbuttDeborah TruscottJim VanderkolkJoan WalkerViola WarrenMarie Weatherbie

3,000 HoursPenny CormierJeanette FarrawayHelen HubardAlice Smith

Life Member AwardsMerle Brown Gary Guthro Phyllis Skeats

Volunteer Fundraiser of the YearMyrtle Miller, McMaster Hospital

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Revised: May 7, 2014 Page 1 of 5

MANAGEMENT REPORT

Report Title:

Corporate Strategy Report – Quarterly Report – Q2 2014-2015

Report Number:

Report To:

CMT Executive Council

Date of Meeting:

EXECUTIVE AUDIT GOVERNANCE FINANCE QUALITY PERFORMANCE MONITORING MEDICAL ADVISORY OTHER:

Date of Meeting:

BOARD Date of Meeting: 27/11/2014

Author(s): Sandra Ramelli, Director, Organizational Development & Strategic Management

Telephone X 74440 E-mail: [email protected]

Agenda: IN CAMERA OPEN DECISION INFORMATION

1.0 RECOMMENDATION:

THAT the Board of Directors receives for information the Q2 quarterly report for the 2014-15 Corporate Strategy Results (Appendix A: Corporate Strategy Report – Board of Directors Quarterly Report – Q2 2014-2015).

2.0 PURPOSE/SITUATION: The report updates the Board on the results of the strategic balanced scorecard measures and commentary on the progress of the strategic efforts and initiatives for the second quarter of the fiscal year July 1, 2014 to Sept. 30, 2014.

3.0 BACKGROUND: The strategic plan management process, as approved by the Board, requires that staff report on the progress of initiatives and performance against defined measures on a quarterly basis.

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4.0 RELATIONSHIP TO STRATEGIC PLAN: Choose one or more that best describes: (double click on square and select “Checked”) 1. PATIENT EXPERIENCE

Always provide excellent services Ensure patients and families are at the centre of care Apply best practices to enhance the patient experience

2. EVIDENCE-INFORMED QUALITY CARE

Use tools to implement and sustain evidence-informed practices Partner with McMaster University and other leaders in education and research to move

evidence into practice Create culture of evidence-informed practice

3. SEAMLESS HEALTHCARE SYSTEM

Use technology to improve information access for patients and healthcare providers Develop strong networks and partnership across our community and the healthcare system

4. ATTRACT AND STEWARD RESOURCES

Achieve operational efficiencies Attract and manage financial resources Promote an environment that supports health research Promote an environment that supports health discipline learning

5. TALENTED PEOPLE

Build an engaged workforce Develop and support our people Develop high-performing leaders Improve safety and well-being at work Build recognition systems

5.0 DISCUSSION/ASSESSMENT:

In Q2, good progress has been made on all of the goals. GOAL 1: PATIENT EXPERIENCE - To provide an excellent patient experience for all The initiative Best Patient Experience – Every Patient, Every Time, Everywhere has met the planned deliverables for this quarter within the four areas of focus:

• Respectful Partnerships with Patients, • Engaging the Heart in the Patient Experience, • Creating Welcoming Environments and • Hearing the Voice of the Patient.

There is no Q2 data for the surveyed measures aligned to this goal due to a delay related to recruiting of volunteers and the vetting them through the required process including police checks for survey takers. The data collection will restart in Q3. GOAL 2: MOVING EVIDENCE INTO PRACTICE - To be world leaders in moving evidence into practice to deliver the best patient care

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Foundational work continues on Integrated the Knowledge Translation and Quality Improvement Framework initiative and is on track to have a framework drafted for Q3. Meetings with additional stakeholders to identify KT/QI pilot area are in progress. An expert working group is in place to complete an analysis of clinical program quality dashboards to identify gaps of included patient outcome indicators. GOAL 3: SEAMLESS HEALTHCARE SYSTEMS - To be leaders in driving change to achieve a seamless healthcare system

Initiatives to support achievement of Goal 3 are progressing according to timelines and activities include:

• Development of Strategic Partnerships - A Stakeholder Inventory and Analysis providing a compilation of external partners has been completed. Current efforts are focused on targeted partnerships that are critical to advancing HHS’s current priorities including Alternate Level of Care (ALC).

• Implementation of Patient Transition Plans - the milestones for this initiative have been met. Care plans for Health Links patients have been started and common themes, identifying systems barriers and working on resolutions are being captured. The Patient Discharge Bundles have been implemented and random audits are providing feedback to the teams.

GOAL 4: ATTRACT AND STEWARD RESOURCES - To be a leader in attracting and stewarding resources to advance our mission The initiatives aligned to this goal are proceeding based on the FY 14/15 measures of success. Some items of note:

• Four Quality-Based Procedure (QBP) teams continue to make important progress in: Congestive Heart Failure, Chronic Obstructive Pulmonary Disease, Stroke, and Vascular Procedures. Reporting on the QBP related measure has not begun as the provincial data for COPD, CHF and Vascular QBPs is yet to be released.

• On the financial measures (Variance to Operating Budget and Net Surplus for capital from: Operations and Business Development), in Q2 show slightly above the projected surplus and expectations are that we will achieve our budgeted surplus ($9.6 million) by year end (FY14/15).

• Other efforts aligned to this goal are progressing on schedule. GOAL 5: ORGANIZATION OF CHOICE - To be the organization of choice for talented people Several initiatives are showing positive impact for this goal as evidenced by positive feedback and high participation rates in leader strategy updates, wellness activities, enhancing engagement advisory groups (IEEG), and recognition events.

More details on the progress, targets and measures are included in Appendix A: Corporate Strategy Report – Board of Directors Quarterly Report – Q2 2014-2015. Sixteen initiatives, aligned to the five strategic goals, were launched or continued for the Fiscal year 2014-15. The overall performance against the defined measures on the scorecard is trending positive.

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Nine of the 13 established measures have achieved positive results toward the five-year target and are therefore rated as green (On Track) with three of the established Patient Experience measures expected to return to green (on track) once data collection resumes in Q3. The measure results for research dollars (industry) have been rated as yellow (Recovery Planned).

6.0 PATIENT IMPACT: N/A

7.0 QUALITY IMPACT N/A

8.0 FINANCIAL IMPACT: N/A

9.0 HUMAN RESOURCES IMPACT: N/A

10.0 COMMUNICATION IMPACT: N/A

11.0 LEGAL IMPACT: N/A

12.0 GOVERNMENT/REGULATORY IMPACT: N/A

Respectfully Submitted, Approved for Submission,

Fran Agnew Rob MacIsaac Executive Director President & CEO Office of the President & CEO

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Appendices: Do not embed a link/icon.

Please include the appendices in your email to F. Agnew. Appendices to include the Appendix # in the filename and appear in the header of the document(s).

Appendix A: Corporate Strategy Report - Board of Directors Quarterly Report Q2 2014-2015

Staff & Others Consulted:

Name Telephone

2T 2T

2T 2T

2T 2T

2T 2T

2T 2T

Notifications: Name Mailing or E-mail Address

2T 2T

Special Instructions: 2T

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Appendix A: Corporate Strategy Report – Board of Directors Quarterly Report Q2 2014- 2015

Nov. 14, 2014


Strategy Review Council Report to the Board

Corporate Strategy Report

Board of Directors Quarterly Report

Q2 2014-15

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Quarterly Corporate Strategy Report Board of Directors Report

2

Table of Contents

Table of Contents ................................................................................................................................................................................. 2

HAMILTON HEALTH SCIENCES STRATEGY MAP .................................................................................................................................... 3

HIGH LEVEL SUMMARY ........................................................................................................................................................................ 4

GOAL 1 - PATIENT EXPERIENCE ............................................................................................................................................................ 6

GOAL 2 – MOVING EVIDENCE INTO PRACTICE ..................................................................................................................................... 9

GOAL 3 – SEAMLESS HEALTHCARE SYSTEM ....................................................................................................................................... 10

GOAL 4 – ATTRACT AND STEWARD RESOURCES PERFORMANCE ANALYSIS ..................................................................................... 11

GOAL 5 – TALENTED PEOPLE PERFORMANCE ANALYSIS ................................................................................................................... 13

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3

HAMILTON HEALTH SCIENCES STRATEGY MAP

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4

Overall Q2 Summary of Performance Indicators (*Note: Goal 2 and 3 Measures not yet included in this table) (G = on track Y = recovery planned R = significant action required B = measure to be defined)

Goal 1 - To provide an excellent patient experience for all Goal 4: To be a leader in attracting and

stewarding resources to advance our mission Goal 5: To be the organization of choice for talented people

1 Excellent Patient Experience 1. Percentage of Patients rating their overall Patient Experience at 8 or above (on 10 point scale)

4A: Achieve and sustain operational and clinical utilization best practice performance.

4A1 Operational and Clinical Utilization Indicators for Quality Based Procedures on target

5A: Build an engaged workforce 5A1. Engagement index from the engagement survey

1A Consistently provide service excellence across HHS

1A1. Percentage of positive responses to the question "Did we demonstrate the following service excellence behaviours?"

4B: Secure and align financial resources to meet operational, capital, educational and research priorities. 4B1 Variance to operating budget (%)

4B2 Net surplus for capital from: Operations and Business Development 4B3 Research dollars generated from "peer reviewed" sources and "industry" sources (running average)

5B. Support and develop our valued talent 5B1. Workforce development dimensions from the engagement survey

1B Embrace a patient/family/relationship centred approach in the provision of quality health care

1B1. Percentage of positive responses to regular surveys about the principles of Patient/Family and Relationship Centred care which include communication, collaboration, responsiveness and personhood.

4C. Design and Sustain an environment that supports health research. 4C1 Total number of Research Ethics Board (REB) approvals

5C. Develop high-performing leaders 5C1. Percentage of formal administrative and physician leaders with documented individual annual objectives and personal development plan in place.

1C Have reliable processes and best practices that contribute to enhancing the patient experience

1C1. Percentage of positive responses from baseline on key elements of environmental assessment tools, physical environment and cleanliness. 1C2. Percentage of positive responses regarding patient wait time in ambulatory clinics.

4D. Design and Sustain an environment that supports health discipline learning. 4D1 Learner Placement Measure (Under Development)

5D. Improve safety and well-being in the work environment

5D1. Reduce the lost time injury rate 5D2. Score on the Business Health Culture Index

5E. Develop a comprehensive enterprise wide recognition system 5E1. Index of recognition dimensions from the survey

HIGH LEVEL SUMMARY

B

G

G

G G

B

G

B

B

G

Y

G

B

B

B G

G

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5

GOALS – Q2 PERFORMANCE

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6

GOAL 1 - PATIENT EXPERIENCE PERFORMANCE ANALYSIS

Quarterly Progress (G=on track, Y = recovery planned, R = significant

action required, B = measure to be defined)

Objective Measure Q3

(FY13-14) Q4

(FY13-14) Q1

(FY14-15) Q2

(FY14-15) Measure Commentary

1 Excellent Patient Experience

1. Percentage of Patients rating their overall Patient Experience at 8 or above (on 10 point scale) 3 Year Aim: 80% 5 Year Aim: 85%

G

77.5%

Q2 data Not

Available

No data collection in Q2 – due to a delay related to recruitment and orientation of volunteers including the required vetting (police checks) for survey takers to support quarterly data collection. Data collection will start in Q3 for quarterly collections

1A Consistently provide service excellence across HHS

1A1. Percentage of positive responses related to demonstration of service excellence behaviours 5 Year Aim: 93%

B Under

Development

B Under

Development

G 87.6%

Q2 Data Not

Available

No data collection in Q2 (N=0) Data collection for this dimension will reflect the following questions:

• Provided welcoming environment • Introduced ourselves and our roles • Treated you with dignity and respect • Showed kindness, compassion and

concern • Asked if you had worries or fears • Provided service exceeded your

expectations • Provided service at a hospital that was

clean • Made sure the place where you received

service was clean

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7

1B Embrace a patient/family/ relationship centred approach in the provision of quality health care.

1B1. Percentage of positive responses to regular surveys about the principles of Patient & Family Centred Care: Communicate, collaborate and respond 5 Year Aim:

• Communicate- 91% • Collaborate- 95% • Respond- 89%

B Under

Development

B Under

Development

Communicate: 85.3%

Collaborate:

93%

Respond: 83.7%

Q2 Data Not

Available

No data collection in Q2 (N=0) Data collection for this dimension will reflect input from the following areas:

• ED, Inpatients, Outpatients • MUMC, General, JHCC, JCC, St. Peter’s

*wait times are now included as one of the measures within Respond.

1C Have reliable processes and best practices that contribute to enhancing the patient experience

1C1. Percentage of positive responses from baseline on key elements of environmental assessment tools, physical environment and cleanliness.

5 Year Aim: Glitterbug Audit: Average of 90% pass rate

G Glitterbug Audits: Oct . 93.2% Nov. 94.3% Dec. 93.8%

G Glitterbug Audits: Jan . 94.2% Feb 93.6 % Mar. 95.8 %

G Glitterbug Audits: Apr: 96.5% May: 95.9% June: 95.4%

G Glitterbug

Audits: July: 94.3%

Aug.: 93.0% Sept.: 96.4%

In an effort to enhance the patient washroom scores, signage has been placed within the washroom instructing patients as to the cleaning schedule and a contact number, should the washroom require attention. Detailed Results: July - Patient Room 92.7%, Patient Washroom 95.8%, Aug - Patient Room 92.4%, Patient Washroom - 93.5%, Sept. - Patient Room 95.2%, Patient Washroom 97.5%

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8

5 Year Aim: CSS Results: 80% positive responses on dimensions of cleanliness from patient satisfaction survey.

CSS Results: Cleanliness of my Room 85% Cleanliness of my Washroom 93 % Cleanliness of the Ward/Unit 100%

Overall Cleanliness

of the Hospital

100%

CSS Results: Cleanliness of my Room 95% Cleanliness of my Washroom 83 % Cleanliness of the Ward/Unit 90% Overall Cleanliness of the Hospital 92%

CSS Results: Cleanliness of my room 100% Cleanliness of my washroom 96.2% Cleanliness of the ward/unit 92.3% Overall Cleanliness of the hospital 96.2%

CSS Results: Cleanliness of

my room 100%

Cleanliness of my washroom

96.0%

Cleanliness of the ward/unit

100%

Overall Cleanliness of the hospital

100%

In this quarter, the total number of survey results was 24 due to the summer months and the timing of the surveys. Typically, we target to have 4 for each acute site, 2 from WLMH and 2 from St. Peter’s per month which would total a maximum of 48 in a quarter. To improve the number of audits, cleanliness perceptions have been added as a question in the Patient Experience survey for both the immediate care area and the hospital. (see 1A1)

1C2. Percentage of positive responses regarding patient wait time in ambulatory clinics.

B Not Yet Defined

B Not Yet Defined

Now included in

1B1 Measure

N/A

Wait times is now included as one of the dimensions within the Respond results of the 1B1 Measure.

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9

GOAL 2 – MOVING EVIDENCE INTO PRACTICE Quarterly Progress

(G=on track, Y = recovery planned, R = significant action required, B = measure to be defined)

Objective Measure Q2(FY14-15) Measure Commentary

2A Ensure tools are readily available for the implementation and sustainability of evidence informed practice

2A1 Percentage of clinical areas that incorporate patient informed indicators that are evidence informed and presented in the form of a performance dashboard

B Reporting

Not Started

An expert working group is in place for analysis of clinical program quality dashboards to identify gaps with respect to inclusion of patient outcome indicators. Literature review to support definition of patient outcome indicators in progress.

2B Establish an integrated knowledge translation and quality improvement framework in partnership with McMaster University and evidence-based leaders

2B1 Percentage of clinical leaders with formal training in the integrated framework for knowledge translation and quality improvement

B Reporting

Not Started

Foundational work continues.. A working group, including HHS and McMaster University experts, is in place and is on track. Meetings with key stakeholders and literature review completed for framework development. A few expert team members also attending Advanced Training Program (IDEAS) to help inform planning for education and future curriculum development. Meetings with additional stakeholders to identify KT/QI pilot area are in progress.

2C Create a culture of evidence-informed practice which aligns with continuous quality improvement

2C1 Percentage of completed evidence informed quality improvement projects that measure and improve patient outcomes

B

Reporting Not Started

See commentary above for update on work that is laying the foundation for future work to drive this objective.

2C2 Consistent (percentage of) application of evidence informed targeted practices (1 targeted hospital wide practice per year)

B Reporting

Not Started

See commentary above for update on work that is laying the foundation for future work to drive this objective.

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10

GOAL 3 – SEAMLESS HEALTHCARE SYSTEM Quarterly Progress (G=on track, Y = recovery planned, R = significant action required, B = measure to be defined)

Objective Measure Q2(FY14-15) Measure Commentary

3A: Develop and implement technology that enables patients and providers to access information across the continuum of care.

3A1 Stage achievement with the Electronic Medical Record Adoption model.

B Reporting

Not Started

Reporting to begin in Q3

3B: Develop networks, partnerships and agreements that formally integrate hospitals and community care programs to advance seamless patient care

3B1 Number of formal partnerships per year that incorporate initiatives which, by objective criteria, have led to the integration of some aspects of the healthcare system.

B Reporting

Not Started

A Stakeholder Inventory and Analysis has been completed providing a compilation of external partners. Current efforts are focused on targeted partnerships that are critical to advancing HHS’s current priorities including ALC. Focus groups and stakeholder meetings with several identified partners continue to inform the services and structures of the Community Connections and Transitions Office. Partnerships continue to be prioritized and formalized.

3B2 Percentage of positive ratings of the continuity and transition dimension for NRC Picker (proxy measure at this time) B

Reporting Not Started

All milestones have been met. Care plans for Health Links patients have been started and are capturing common themes, identifying systems barriers and working on resolutions. A Frail Seniors Collaborative, including representatives from Good Shepherd, Catholic Family Services, March of Dimes, McMaster and Hamilton Family Health Teams, City of Hamilton, McNally House Hospice, HHS and St. Joseph’s had been formed. We are working with Human Resources to formalize a relationship with one of these organizations who will assist us with care planning for frail seniors. Education has been provided to all medical and cardiology units where the COPD and HF Patient Discharge Bundles have been implemented. Random audits are providing feedback to the teams.

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11

GOAL 4 – ATTRACT AND STEWARD RESOURCES PERFORMANCE ANALYSIS

Quarterly Progress (G=on track, Y = recovery planned, R = significant action required, B = measure to be

defined) Objective

Measure Q3 (FY13-14)

Q4 (FY13-14)

Q1 (FY14-15)

Q2 (FY14-15)

Measure Commentary

4A. Achieve and sustain operational and clinical utilization best practice performance

4A1. Operational and clinical utilization indicators for quality based procedures (QBPs) on target

B Not Yet Defined

B Not Yet Defined

B Not Yet Defined

B Not Yet Defined

The strategic measure is still to be determined as MOHLTC has not release provincial data for the COPD, CHF and Vascular QBPs. QBP teams continue to move forward improving quality and reducing cost. The 2013/14 QBPS (Stroke, COPD, CHF and Vascular) continue to meet on a regular basis to implement changes. The 2014/15 QBPs (Total Joint Replacement, Hip Fracture, Neonatal Jaundice and Pneumonia) teams have had kickoff meetings and are proceeding to map the current state of the clinical pathways and understand cost and quality performance. Only the Tonsillectomy QBP remains to be launched and that is scheduled for the upcoming quarter.

4B. Secure and align financial resources to meet operational capital, educational and research priorities

4B1. Variance to operating budget (%) 5 Year Aim: 0%

G $4.4

Million (forecast for 13/14 is $5M)

G $1.3

Million

Y -$136K

G

$313K

The projected surplus of $9.6 Million is on target to achieve budgeted surplus by year end. YTD surplus is 6.4% over our budgeted surplus. (Note: Q1 result adjusted to align to Q1 Board Report)

4B2. Net surplus for capital from: Operations and Business Development 5 Year Aim: $15 Million (cumulative)

G $5M

(Forecast for 13/14

is $0)

Y $0

Y $0

Y $0

Operating slightly above budgeted surplus of $4,890,431 YTD, with expectation to achieve target of a $9.6Million surplus for 2014/15. No Board restriction has been approved for FY14/15 as yet.

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12

4B3. Research dollars generated from ‘peer-reviewed’ sources and ‘industry’ sources (running average)

5 Year Aim (rolling 3 year average): Industry: >$118,565,089

Y Industry: Rolling 3 yr ave: $74.3

million (Q3:$7.8

mill)

Y Industry: Rolling 3 yr ave: $64.3

million (Q4:$9.9

mill)

Y Industry: Rolling 3 yr ave: $62.5 million (Q1: $13.4 million)

Y Industry:

Rolling 3 yr ave:

$67.1 million

(Q2:$24.1million)

Currently achieving 57% of 5 year target. Increasing revenue for research is a top priority for Research Administration and continues to be the key focus of our FY 14/15 strategic initiative Increasing Revenue for Research. Efforts continue to increase research visibility in the market andactively pursue increased revenue opportunities from industry.

5 Year Aim (rolling 3 year average): Non-Industry: >$8,572,268

Non-Industry: Rolling 3 yr ave: $13.0

million (Q3:$3.7

mill)

Non-Industry: Rolling 3 yr ave: $12.6

million (Q4:$5.0

mill)

Non-Industry: Rolling 3 yr ave: $13.6 million (Q1: $3.9 million)

Non-Industry: Rolling 3 yr ave: $13.6 million (Q2: $3.3 million)

Revenue from non-industry sources are trending positive, currently tracking to achieve 159% of 5 year target.

4C. Design and sustain an environment that supports health research

4C1 Total number of Research Ethics Board (REB) approvals 5 Year Aim: 3550 (177.5/quarter)

G 209

G 203

G 229

G 188

Currently exceeding target of 177.5/quarter Research Ethics Board approvals with a Q2 result of 188.

4D. Design and sustain an environment that supports health discipline learning

4D1. Learner Placement Measure Number of student placements each academic year and number of HHS staff actively precepting. 5 Year Aim (TBD)

B To be

defined

B To be

defined

B NA

B NA

Gap analysis which has identified the approximate global student placement growth capacity, as well as some profession-focused placement growth opportunities is nearly completed.

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13

GOAL 5 – TALENTED PEOPLE PERFORMANCE ANALYSIS

Quarterly Progress (G=on track, Y = recovery planned, R = significant action

required, B = measure to be defined) Objective Measure Q3 Q4 Q1 Q2 Measure Commentary

5A. Build an engaged workforce

5A1. Engagement index from the engagement survey 5 Year Aim: 68.5% for staff, 60% for physicians * QIP Target • 100% of leaders shared

results • 70% of leaders created

action plans

G 65% for staff and 57% for physicians (Oct 2012)

n/a –next measure Fall 2014



Key accomplishments for Q2 include: • Executed regular leader strategy update via webinars.

Two updates executed in Q2 with atotal of 7 webinars to date, averaging 100 participants per session

• Executed the front line enhancing engagement advisory group(IEEG) quarterly meetings at various sites with a total of 60 members

• Defined improvements to the Open Doors Program • Executed improvements to recognition events and

programs (see measure commentary 5E for details) • Researched aprocess for the development of a

physician-hospital agreement • Developed and piloted leader conversation cards • Embedded engagement questions into selected

decision making frameworks (eg. Budgetting process)

5B. Support and develop our valued talent

5B1. Workforce development dimensions from the engagement survey 5 Year Aim: 53.2%

G 50.7%

(Oct 2012)




A collaborative group of administrative and physician leaders and front line staff are working to define and design a learning and development model, programs and course curriculum for leaders, physicians and staff. A foundation for the implementation of a sustainable development program that meets the needs of a broad community of learners across our organization has been set.

5C. Develop high-performing leaders

5C1. Percentage of formal administrative and physician leaders with documented individual annual objectives and personal development plan in place.

B To be

defined

B To be

defined

B To be

defined

B To be

defined

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14

5D. Improve safety and well-being in the work environment

5D1. Reduce the lost time injury (LTI) rate 5 Year Aim: 0.87 LTI per 100 insured FTE

G 0.83 LTI per 100 insured

FTE’s (updated from Q1

Report of 1.19)


FTE’s (Updated from Q1 report of

0.60)


FTE’s (Updated from Q1 report of

0.99)


FTE’s

The LTI rates for 14/15 Q1, 12/14 Q4 and 13/14 Q3 have been adjusted from the previously reported rates as follows: • Q1: 0.99 up to 1.27 • Q4: 0.60 up to 1.03 • Q3: 1.19 down to 0.83

These adjustments were anticipated and reflect the maturing of WSIB data. It is important to note that this rate will likely be adjusted next quarter due to further maturing of the WSIB data. Improvements to safety awareness and compliance continue through promotion ofs internal responsibility systems, enhanced accountability for workplace hazards, and ensuring adequate oversight at an organizational level. Focus on the prevention of musculoskeletal injuries (which account for over 50% of our LTI’s), and on the prevention of incidents related to workplace violence continue. Currently in the process of updating Workplace Violence Prevention Protocol to align to the Occupational Health and Safety Act and Accreditation Canada requirements. The LTI rate continues to reflect improved safety and wellbeing in the work environment.

5D2. Score on the Business Health Culture Index (a measure of organizational health and wellness) 5 Year Aim: Index between + 0.1 and 0.49

G – 0.27

(Oct 2012)




Q2 Accomplishments include: • Continued pursual of external sponsorships to further

enhance and supplement wellness programs • Completed Psychological Health & Safety Standard

Assessment • Developed customized leadership curriculum to ensure

leaders have skills and resources for managing mental health issues in the workplace and creating a healthy workplace culture

• Launched Peer Education Mental Health project with

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15

McMaster University, including training of Peer Educators;

• Developed Mindfulness in Action toolkit to enable integratation of mindfulness into their workdays,meetings andactivities;

• Continued offerings of Mindfulness courses both internally and partnered with McMaster University

5E. Develop a comprehensive enterprise wide recognition system

5E1. Index of recognition dimensions from the engagement survey 5 Year Aim: 5% improvement over 2012 results

G (Oct 2012)

Index (staff): 34%

(Employees: Q18: 36.6% Q19: 32.1%) (Physicians: Q19: 35%)



Will be available

after engagement survey (Nov-Dec)

In Q2, branding of recognition and appreciation programs has been determined to help staff connect all of the efforts to recognize and appreciate staff. This will be done with a star logo that reflects and celebrates the diverse nature of our organization and staff. The Star motif will be incorporated into the corporate programs and collateral. Enhancements were implemented for the September Appreciation Staff BBQ’s to address the areas identified by staff as most important and priority for improvement. Specifically food selection, communication and awareness, and options for staff who cannot leave their workstation. Enhancements to the Long Service Awards process and Celebration have been implemented for the event in October. Specifically gift selections, certificates, venue, leadership participation and communication. In addition, positive feedback has been received from leaders on the changes made to the monthly service pin process, including the addition of a standard service certificate. The peer recognition program, Special Thanks and Recognition (STAR) has been developed with implementation for January 2015. The leadership resource kit to assist leaders with day to day recognition and appreciation of staff is being

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16

finalized and branded, including supporting collateral (e.g. thank you cards) .

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MANAGEMENT REPORT

Report Title:

Strategic Plan Refresh

Report Number:

2T

Report To:


Date of Meeting: 2T

EXECUTIVE AUDIT GOVERNANCE FINANCE QUALITY PERFORMANCE MONITORING MEDICAL ADVISORY OTHER: Please specify

Date of Meeting: 2T


Author(s): Rob MacIsaac, President & CEO

Telephone 2T E-mail: 2T


1.0 RECOMMENDATION:

THAT the Board of Directors approves the Strategic Plan refresh as attached in Appendix A. AND THAT staff be directed to propose: a. annual targets for the Strategic Objective Metrics and b. three to five year targets for the Strategic Goal Metrics for the Board’s consideration prior to fiscal 14/15 year end.

2.0 PURPOSE/SITUATION:

The report presents for the Board’s consideration a Strategic Plan Framework developed as a result of consultations with management, staff, physicians and the board members.

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3.0 BACKGROUND:

On September 26, 2014, the Board approved the following resolution:

THAT the Board of Directors approves the revised Strategic Framework (Figure 2) for the purpose of:

1. Discussion at the October Board Retreat; 2. Development of preliminary metrics and initiatives for the 2015-16

annual strategic plan and; 3. Identification of risks and mitigation strategies.

On June 26, 2014, the Board approved the following resolution:

THAT the Board of Directors approves the Draft Strategic Framework attached as Appendix A for the purposes of consulting with internal stakeholders on a refreshed strategic plan; AND THAT Management be directed to bring a summary of the feedback obtained from the consultation to the Board’s September meeting; AND THAT the October Retreat be used for the purposes of: - Consideration of a recommended Refreshed Strategic Framework - Development of potential metrics and targets for strategic objectives - Preliminary prioritization of potential initiatives - Identification of potential risks and mitigation strategies

And, on March 6, 2014, the Board approved the following recommendations:

THAT the Board of Directors approves the slate of proposed strategic initiatives for fiscal 2014/15; AND THAT the Board approves the annual cycle for the planning, execution, management, monitoring and reporting of the strategic plan and initiatives as outlined in the attached report Strategic Plan Update & Proposed Strategic Initiatives; AND THAT staff be directed to plan a Board-Executive retreat as outlined in the attached report Strategic Plan Update & Proposed Strategic Initiatives; AND THAT the board receives the Quarterly Corporate Strategy Report for Q3.

4.0 RELATIONSHIP TO STRATEGIC PLAN:

Choose one or more that best describes: (double click on square and select “Checked”) 1. PATIENT EXPERIENCE


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5. TALENTED PEOPLE



This report represents the conclusion of a lengthy process which began in February when the Board authorized staff to commence work on a process to refresh the HHS strategic plan. The existing plan has origins which date back five years and staff recommended that given the many intervening events and changes in healthcare policy which had transpired, a review of the plan was desire able.

The objectives of the process were to develop a plan which satisfied the following objectives: Focus: On what is absolutely essential to fulfilling our Mission over the next 5 years Relevant: Address our sustainability challenges which are dominating our day to day

activities Format: Must be compelling, engaging, and memorable Transformative: As opposed to incremental impacts Instructive: Guide us through tough decisions around resource allocation

The process began with the CEO conducting numerous 1:1 interviews with clinical and administrative leadership at HHS getting feedback on the current plan. In April, the Executive Council held a retreat where the executive agreed upon four key areas of focus for a new plan. In May and June, goal statements and objectives were developed for each of the areas of focus. At the June Board meeting, the Board authorized staff to consult with key internal stakeholder groups over the summer to gather feedback on the strategic framework. In September, the feedback and corresponding revisions were reported to the Board. At a subsequent retreat in September, the Executive turned its mind to developing

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appropriate metrics and initiatives which would allow HHS to drive action and measure success under the plan. In October, the entire plan was again brought to the board at its retreat where risks to success were considered and initiatives and metrics evaluated. The CEO has been consulting on the plan as it has evolved on an ongoing basis since April and has met with and presented to hundreds of staff members representing a broad cross section of HHS staff and stakeholders. The Plan is now before the Board for final approval. The final set of input and revisions since the last presentation to the Board is discussed below. Recommended Disposition of Input from Board Retreat At the Board-Executive Retreat, the break-out groups Strongly Agreed or Agreed with the proposed metrics with the following exceptions: Goal: Our Patients Metric #2: Hospital Standardized Mortality Ratio (HSMR) Board members felt that this metric would be better suited for the Our Patients’ objective: Continuously refine our care delivery to raise quality, improve safety, and enhance value Staff is recommending against this revision for the following reasons. HSMR was proposed as a Goal level (or “True North”) metric. These measures are longer term in nature and represent the cumulative impact of the three objectives underlying the Goal. In contrast, Objective measures are intended to be measures which staff can influence over the shorter term (1 - 3 years) and which ultimately are likely to be replaced as progress is made with other metrics. Having said that, Staff has struggled with the limitations of using HSMR as a measure of Quality but has yet to find something better. Michael Porter, author of Redefining Health Care, is currently studying this same issue and is working with willing hospitals to develop better measures of Quality.

Management is investigating Porter’s International Consortium for Health Outcomes Measurement as a possible source for Quality metrics. Accordingly, Staff is recommending this one metric be left as under development for the time being. Goal: Our People Objective: Ensure a healthy and safe workplace Metric #2: Percentage of employees taking their full vacation allotment A concern was voiced at the Retreat that this metric could be misinterpreted as a financial metric. Management agrees and is recommending that the metric be replaced with a series of pulse surveys requesting input on six relevant questions in the Stress Satisfaction Index Score. This will provide a more relevant measure for staff and physicians, while providing continuous assessment on initiative achievements. Objective: Cultivate empowered decision making and collaboration

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Metric #2: Implementation of decisions coming out of collaborative forums Management agrees with the board members advice that this metric will be difficult and time consuming to gather and analyze, and therefore will not provide timely information on the achievements of the initiatives. It is therefore recommended that this metric be eliminated. In addition, at the Retreat, consensus was reached by the board members on the following changes recommended by break-out groups: Goal: Research, Innovation & Learning Metric #2 Original: Percentage of research funding aligned with Centres of Excellence Proposed Revision: Research Funding aligned with HHS Strategic Objectives Both at the Board retreat and in consultations following, confusion existed with the definition of Centres of Excellence. It is recommended that the metric be revised to read HHS priorities (as set forth in the Strategic Plan). Objective: Align research efforts to HHS Priorities Metric #1 Original: Research FTEs devoted to Bay Area Community health issues Proposed Revision: Research FTEs devoted to HHS strategic objectives Management agrees this revision better reflects the goal’s intent. Objective: Create a culture of evidence informed practice Metric #1: Original: Percentage of eligible patients receiving standard of care for targeted practices Proposed Revision: Percentage of eligible patients receiving evidence informed standard of care for targeted practices Management agrees that adding evidence informed aligns the metric with the objective and assists in developing appropriate initiatives. On further review, the Executive Council at its Retreat on October 29th, also recommends the following refinements to the metrics: Goal: Our Sustainability Metric #1: Total Margin The intent of this metric is to gauge the overall financial health of HHS. Therefore, staff recommends that Debt Ratio is a better reflection of long-term viability.

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Objective: Transform our practices and process to improve performance Metric: Dollars saved Objective: Optimize our revenue streams Metric: Incremental Revenues In both of the above cases, staff are recommending Free Cash Flow as an improved measure to assess our ability to fund capital projects from savings in operations. There is one final recommended change to the metrics. This revision is related to management’s response to the board members concerns that the proposed Refresh Strategic Plan is ambitious in the number of initiatives and there is a need for further prioritization. Taking this into consideration, at its Retreat, the Executive Council carefully reviewed the initiatives and recommends refinements. The following metric was eliminated in that prioritization process. Goal: Our Patients Objective: Ensure seamless and timely transitions for HHS patients Metric #1: Emergency Department wait times to bed for Admitted Patients Strategic Initiatives

The Strategic Refresh presented to the Board at the Retreat, proposed 30 initiatives. As was the intent of the strategic plan refresh, the prioritization review took a hard and realistic look at HHS’ capacity to implement the initiatives within the fiscal year and to ensure that focus remained on the most important activities as outlined in the Vision, Mission and four goal areas. This resulted in a recommendation to eliminate the following six initiatives: Our Patients 2.3 Develop and implement revised Emergency Department Admission procedure 3.1 Develop and implement LOS Reduction Plan Both of these initiatives will see improvements as the ALC initiative is implemented.

Our People 1.4 Implement Outstanding Vacation Day Reduction Plan 2.2 Train leaders in effective performance and development conversations Our Sustainability 3.4 Review and revise Patient Transport business model

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Our Research, Innovation & Learning 1.3 Develop skills and methods that enable extraction of hospital information from our various electronic platforms.

Wording changes to the following initiatives represent management’s intent to scope the initiative to accomplish only the most important aspects in this fiscal year. Our Research, Innovation & Learning 1.1 Evaluate opportunities for a centre for global health system transformation 1.2 Evaluate opportunities for a Hamilton region population health study 2.2 Collaborate with our academic partners around the application of knowledge implementation science. In addition, the prioritization process recognized the following two essential projects, which were not presented at the Retreat: Our Sustainability 1.2 Continue Health Links Initiative 2.2 Develop a long term Clinical Vision for HHS As part of the consultation process with staff and physicians as outline above, it was also decided to recommend wording changes to eight initiatives to improve clarification on the following. These wording changes are blacklined in Appendix B. Twelve of the 27 recommended initiatives remain as presented at the Board Retreat. It should be noted that where initiatives have been eliminated, in some cases the work will continue in any event such as the Vacation Day Reduction Plan. In other cases, Staff expects to bring them back in subsequent years of the Plan’s implementation in recognition of the fact that they remain as important activities to drive strategy. Next Steps With approval from the Board of Directors, the next step in implementation of the refreshed plan will be to develop targets for the Goal and Objective Metrics. It is staff’s proposal that those targets be presented to the board for its consideration prior to the end of this fiscal year. As in the previous year, a project management system will be established to ensure implementation and monitoring of the initiatives. A report on who is leading which Objectives and Initiatives will be brought back to the Board for its information. Specific initiative planning will commence immediately with a project charter that defines the work packages, timeline, and resources required. As a whole, the Executive Council will monitor the status of the initiatives and attainment of the metrics against the approved charters on a monthly basis. Management will continue to report to the Board on the status of the plan quarterly.

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6.0 PATIENT IMPACT: The strategic plan operationalizes the commitments that HHS board, staff, physicians and volunteers make it the Mission, Vison and Values.


8.0 FINANCIAL IMPACT: Expenses related to all initiatives will be included in the 2014-15 Budget.

9.0 HUMAN RESOURCES IMPACT: N/A

10.0 COMMUNICATION IMPACT: A comprehensive communication plan will be implemented to ensure that staff, physicians and volunteers are aware and understand the intent of the Goals, Objectives and Initiatives.



Respectfully Submitted,

Rob MacIsaac President & CEO

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Please include the appendices in your email to C. Rozman. Appendices to include the Appendix # in the filename and appear in the header of the document(s).

Appendix A: Proposed Refreshed Strategic Plan

Appendix B: Blacklined Plan


Name Telephone

2T 2T

2T 2T

2T 2T

2T 2T

2T 2T


2T 2T


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Draft Refreshed Strategic Plan – November 27 2014

Page 1 of 4

Goal Measures (*QIP) Initiatives

Our Patients Provide an Excellent Patient and Family Experience Every Time

1. Family and patient satisfaction survey – (Real Time Tool)

2. TBD: Development of outcome measurement

Objectives

1. Always deliver compassionate care that respects the needs and values of our patients and their families

1. Patient rating for service excellence

1. Implement Patient Service Excellence Program

2. Initiate Patient Advisory Councils

2. Continuously refine our care delivery to raise quality, improve safety, and enhance value

1. Success rate in achieving Performance under each QBP

1. Continue work of Quality Based Program teams

2. Pilot continuing improvement operating system

3. Ensure seamless and timely transitions for HHS patients

1. Emergency Department wait times to bed for Admitted Patients

1. Review and revise ED flow processes including Observation Unit/Express unit

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Page 2 of 4


Our People Engage, empower, and enable our people to deliver on our mission

1. Engagement survey 2. LTI Percentile ranking within rate group

Objectives

1. Ensure a healthy and safe workplace

1. LTI rate 2. Pulse survey of six questions in Stress

Satisfaction Index score

1. Improve the Musculoskeletal Injury program

2. Implement Workplace Inspection & Hazard assessment tool

3. Initiate Psychological Safety initiative

2. Develop and support our people

1. % of formal leaders with performance review and supportive development plans

1. Establish an integrated Talent Management Framework

2. Launch Centre for People Development 3. Respond to concerns identified by

Engagement Survey 3. Cultivate empowered decision making and collaboration

1. Number of collaborative forums on units

1. Pilot continuing improvement operating system (support)

2. Establish framework for team learning and development

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Page 3 of 4


Our Sustainability Meet the Healthcare needs of the communities we serve now and in the future

1. Current Ratio 2. Debt Ratio

Objectives

1. Partner with our community to ensure the right care is being delivered in the right place and at the right time

1. ALC (*percentage of ALC days)

1. Develop and implement Alternative Level Care Reduction Strategy

2. Continue Health Links initiative 3. Develop a long term Clinical Vision for HHS

2. Transform our practices and processes to improve performance

1. Free Cash Flow

1. Transform our supply chain process 2. Advance KRONOS implementation (multi-

year) 3. Develop strategy for transformation of

ambulatory care 3. Optimize our revenue streams

1. Free Cash Flow

1. Increase retail pharmacy revenues 2. Pursue revenue generating options for our

Chedoke site 3. Develop a sustainable business model for

the Urgent Care Centre

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Page 4 of 4


Our Research, Innovation & Learning Lead in research, innovation and learning for the benefit of our community and the world

1. Publications in major journals 2. Research funding aligned with HHS strategic

objectives

Objective Measures

1. Align research efforts to address HHS priorities

1. Research FTEs devoted to HHS strategic objectives.

1. Evaluate opportunities for a centre for global health system transformation

2. Evaluate opportunities for a Hamilton region population health study

2. Create a culture of evidence informed practice

1. % of eligible patients receiving evidence informed standard of care for targeted practices

1. Target and review selected clinical practices to establish baseline performance

2. Collaborate with our academic partners around the application of knowledge implementation science

3. Create excellent learning environments with our academic partners

1. Degree of student satisfaction with their learning at HHS

1. Collaborate with McMaster University and Mohawk College to improve learners experience with HHS

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Black Lined Refreshed Strategic Plan - Board Retreat October 17 & 18 2014

Page 1 of 4


Our Patients Provide an Excellent Patient and Family Experience Every Time

1. Family and patient satisfaction survey – (Real Time Tool)

2. TBD: Develop of outcome measurement Hospital Standardized Mortality Rate (HSMR)

Objectives

1. Always deliver compassionate care that respects the needs and values of our patients and their families

1. Patient rating for service excellence

1. Implement Patient Service Excellence Program

2. Initiate Patient Advisory Councils

2. Continuously refine our care delivery to raise quality, improve safety, and enhance value

1. Success rate in achieving Performance under each QBP

1. Continue work of Quality Based Program teams to drive value

2. Pilot new continuing management model designed for continuous improvement operating system in model cell

3. Develop and implement revised Emergency Department Admission procedure

3. Ensure seamless and timely transitions for HHS patients

1. Emergency Department wait times to bed for Admitted Patients

1. Develop and implement LOS Reduction Plan

2.1. Review and revise ED flow processes including Observation Unit/Express unit

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Page 2 of 4


Our People Engage, empower, and enable our people to deliver on our mission

1. Engagement survey (includes enablement index)

2. LTI Percentile ranking within rate group

Objectives

1. Ensure a healthy and safe workplace

1. LTI rate 2. Pulse survey of six questions in Stress

Satisfaction Index score % of employees taking their full vacation allotment

1. Improve the Musculoskeletal Injury program

2. Implement Workplace Inspection & Hazard assessment tool

3. Initiate Psychological Safety initiative 4. Implement Outstanding Vacation Day

Reduction Plan 2. Develop and support our people

1. % of formal leaders with performance review and supportive development plans

1. Establish an integrated Talent Management Framework

2. Launch Centre for People Development Train leaders in effective performance and development conversations

3. Respond to concerns identified by Engagement Survey

3. Cultivate empowered decision making and collaboration

1. Number of collaborative forums on units

1. Pilot continuing improvement operating Support development and implementation of new management system (support) Respond to concerns identified by Engagement Survey

2. Establish framework for team learning and development

Formatted: List Paragraph, Indent:Left: 0.25"

Formatted: Font: 12 pt


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Page 3 of 4


Our Sustainability Meet the Healthcare needs of the communities we serve now and in the future

1. Total Margin* 1. Current Ratio 2. Debt Ratio

Objectives

1. Partner with our community to ensure the right care is being delivered in the right place and at the right time

1. ALC (*percentage of ALC days)

1. Develop and implement Alternative Level Care Reduction StrategyPlan

2. Continue Health Links initiative 3. Develop a long term Clinical Vision for HHS

2. Transform our practices and processes to improve performance

1. Free Cash Flow Dollars saved

1. Transform our Develop a multi-year supply chain processtransformation strategy

2. Advance KRONOS implementation (multi- year)

3. Develop strategy for transformation of Review and revise Ambulatory Care Model

3. Optimize our revenue streams

1. Free Cash Flow Incremental Revenues

1. Increase retail pharmacy revenues 2. Pursue revenue generating options for our

Develop business case for divestiture of Chedoke site

3. Develop a sustainable business model Seek funding for Urgent Care Centre 4. Review and revise Patient Transport business Model

Formatted: Font: 12 pt, Bold

Formatted: Normal, No bullets ornumbering


Formatted: List Paragraph, Indent:Left: 0.25"

Formatted: Indent: Left: 0.25", Nobullets or numbering

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Page 4 of 4


Our Research, Innovation & Learning Lead in research, innovation and learning for the benefit of our community and the world

1. Publications in major journals 2. % of rResearch funding aligned with HHS

strategic objectivespriorities

Objective Measures 1. Align research efforts to address HHS priorities

1. Research FTEs devoted to HHS strategic objectives Bay Area Community health issues.

1. Evaluate opportunities Establish the Centre for a centre for Gglobal Hhealth Ssystem Ttransformation

2. Evaluate opportunities for Initiate the a Hamilton region population health study

3. Develop skills and methods that enable extraction of hospital information from our various electronic platforms

2. Create a culture of evidence informed practice

1. % of eligible patients receiving evidence informed standard of care for targeted practices

1. Target and review selected clinical practices to establish base line performance Identify key quality interventions or standards to be measured that are based upon disease burden and cost, priorities such as QBPS, HealthLinks, and/or risks of over utilization.

2. Collaborate with our academic partners around the application of knowledge implementation science Implement the Knowledge Transfer and Quality Improvements framework that standardizes processes for evidence utilization.

3. Create excellent learning environments with our academic partners

1. Degree of student satisfaction with their learning at HHS

1. Collaborate with McMaster University and Mohawk College to improve leaners experience with HHS.

Formatted Table

Formatted Table

Formatted: Indent: Left: 0"

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MANAGEMENT REPORT

Report Title:

HHS Clinical Services Visioning Overview

Report Number:

2T

Report To:


Date of Meeting:


Date of Meeting:


Author(s): Kelly Campbell

Telephone x46824 E-mail: [email protected]


1.0 RECOMMENDATION:

THAT the Board of Directors receives for information an overview of the Clinical Services Visioning plan, attached in Appendix A.


The report provides an overview of the Clinical Services Visioning process that HHS will conduct to establish the clinic services that will be offered over the next 10 to 20 years.

3.0 BACKGROUND: It has been over 15 years since HHS updated its Master program for all of its sites. Within that time HHS has undergone a period of significant redevelopment, clinical realignment (Access to the Best Care), as well as an amalgamation with St. Peter’s Hospital and West Lincoln Memorial Hospital. Redevelopment in this time period has seen the addition of the Rehabilitation building, a new Juravinski Hospital, the David Braley Cardiac

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Vascular and Stroke Research Institute, the Boris Clinic and a $100M renovation project including the Urgent Care Center, McMaster Children’s Hospital and the Hamilton General. As well, through Access to the Best Care in 2011, HHS realigned many clinical services to better meet the needs of our community and region. As HHS prepares to enter into the next phase of redevelopment, which will include West Lincoln Memorial Hospital, the Hamilton General, Juravinski Hospital, McMaster University Medical Center/McMaster Children’s Hospital and St. Peter’s Hospital, the Ministry of Health (MOH) requires an updated Master Program (Clinical Services Vision) as the first stage of the redevelopment process.

4.0 RELATIONSHIP TO STRATEGIC PLAN:

Choose one or more that best describes: (double click on square and select “Checked”) 1. PATIENT EXPERIENCE









5. TALENTED PEOPLE


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As HHS has grown and changed significantly since the development of its last Master Program, it is not only appropriate, but also MOH mandated, that we develop our Clinical Services Vision for the next 10-20 years. This vision will tell the story of what clinical services will be offered at each HHS site in the future. In MOH terms, this identifies the Program and Service elements, alignment with LHIN priorities, projected future demand for a program/service and alternative solutions considered to provide the program/service. With this information, we can then begin to plan the capital facilities required to provide these services. In MOH terms, this would be the physical and cost elements of the plan. The Clinical Services vision will give the MOH a view of HHS’ future clinical service plans which will in turn assist the MOH to develop their longer term capital investment plan. Staff will bring regular updates to the Board on the progress being made during the planning process to ensure the Board is comfortable with the directions being indicated.

6.0 PATIENT IMPACT: The Clinical Services Vision will tell the story of how we will provide care to our community and region over the next 10-20 years, with consideration of future growth projections and LHIN priorities.

7.0 QUALITY IMPACT Implementation of the Clinical Service Vision over the next 10-20 years will have a positive Quality Impact.

8.0 FINANCIAL IMPACT: Engaging the consultants to assist in writing our Clinical Services Vision to meet MOH requirements will cost $750k. $450k was included in this fiscal year in the Board approved 2014-15 Capital plan. The remaining funds will be coming forward to the Board as part of the multi-year capital and operating plan for 2015-2020.

9.0 HUMAN RESOURCES IMPACT: Development of the Clinical Services Vision will engage all leaders within the organization, physicians and frontline staff. It is a comprehensive process that will involve development of a Steering committee and site based committees, working closely with the consultants.

10.0 COMMUNICATION IMPACT: We will require a comprehensive communication plan to explain the process and outcome.


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12.0 GOVERNMENT/REGULATORY IMPACT:

The completed Clinical Services Vision will be submitted to the MOH as part of the pre-capital planning for future HHS site redevelopment.

Respectfully Submitted, Approved for Submission,

Kelly Campbell Rob MacIsaac VP Corporate Services & CPO President & CEO


Please include the appendices in your email to F. Agnew. Appendices to include the Appendix # in the filename and appear in the header of the document(s).

Appendix A - Clinical Services Visioning PowerPoint


Name Telephone

Kelly Campbell 46824

Name ext

2T 2T

2T 2T

2T 2T


2T 2T

Special Instructions: N/A

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Clinical Services Visioning

Appendix A

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INTRODUCTIONS

ROLES & RESPONSIBILITIES

AGENDA

3 DELIVERABLES

DISCUSSION/Q&A

1

2 4

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INTRODUCTIONS 1

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4

The future roadmap of where, how and what services/programs we will offer to our community over the next 5, 10 and 20 years

Provides a long-term vision of the future programs/services, across the organization aligned with the HHS Strategic Plan

Ongoing use for prioritizing and evaluating planning efforts Submitted as the basis to gain approval to proceed to a more detailed level of planning

(functional programming) for the LHIN and MOHLTC Involves staff and stakeholder input, supplemented with consultant experience and

knowledge Builds upon the submitted MOHLTC Pre-Capital Submission (e.g. WLMH, Juravinski) Builds upon the 2013 HHS Master Plan (what is possible given the age of our current

infrastructure) Facilitated by an expert member(s) of the Consultant Team who brings knowledge on

future trends in health service delivery and resulting impacts on facility planning Infused with international evidence from and experience with the planning of multi-sited

tertiary care, teaching health systems

What is Clinical Services Visioning?

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5

• It has been over 15 years since HHS updated it’s capital vision for all of it’s sites, and

within that time the organization has seen significant change • Amalgamation with St. Peter’s Hospital and West Lincoln • $700M investment in capital/facilities including:

- Rehabilitation/ABI - Juravinski Hospital - David Braley Cardiac Vascular and Stroke Research Institute - Boris Clinic and DeGroote Pain Center - Renovation project including the Urgent Care Center, McMaster Children’s Hospital

and the Hamilton General - McMaster Children’s Health Center

• Access to the Best Care in 2011, HHS realigned many clinical services to better meet the

needs of our community and region

Why now?

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6

Thinking about tomorrow’s care, today

Patients, Caregivers & Communities – Creating Value through person-based/patient-centered approach

Alignment with MOHLTC plan and priorities and emerging policy directions

Commitment to consensus

Tension between case for change and compelling vision

Creating dynamic processes and models

Rigorous analytics: Flexible and Clinically Detailed Forecasting

Education, engagement, leadership

Ongoing communication & knowledge translation

GUIDING PRINCIPLES

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ROLES & RESPONSIBILITIES 2

Page 167/207

8

TEAM STRUCTURE

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DELIVERABLES 3

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10

PROJECT INITIATION

Reviewing

• Review relevant background material

• Confirm deep understanding of HHS context and experience

Planning

• Meet with Steering Committee to finalize key elements of work plan

• Confirm deliverables, timing, stakeholder engagement

Visioning

• Host Clinical Services Visioning Workshop: work with Steering Committee to

develop Vision and Guiding Principles for Decision-Making • Finalize the planning principles, assumptions, decision- making process and

protocols, and parameters for consultation

Communi cating

• Advise on Communication Plan

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11

PROPOSED METHODOLOGY: Conceptual Framework

TIMELY + ACCESS + TO QUALITY + SERVICES + CLOSE TO HOME

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12

PROPOSED METHODOLOGY: Population Based Planning

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13

Phase 3. Population Projections

Phase 1. Create Health Profiles and estimate

annual service requirements

Phase 2. Assemble Community Profiles

Phase 4. Market Sharing

Better Practice Program Siting Decisions

Population estimates and growth rates

Factors for Simulation

Analysis

Changes Disease Prevalence Rates

Phase 3. Population Projections

PROPOSED METHODOLOGY: Scenarios and Simulations

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14

PROPOSED METHODOLOGY: Summary

1. Measure present and future need for service among the HHS population

2. Characterize the organization and delivery of services in Hamilton and South Central Ontario

3. Identify best opportunities for improvement by comparing current practice to better practice

4. Use the information to help the working groups examine the implications of the following factors for hospital service planning:

a. Current HHS, regional, LHIN, and provincial initiatives b. Anticipated changes in treatment intensities and modalities c. Changing rates of disease prevalence and chronicity

5. Scenarios and simulations that incorporate the working group perspectives

6. Prepare final projections for all services and resources required for master programming

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15

The consultant team will meet with the Clinical Site working groups in a collaborative, iterative process, focused on maximum input with minimum impact on your staff

User Groups will focus on defined components; review, meet and refine documentation over 2 meetings.

Space needs for all components will be based on demand projections over the 20-year horizon

Impact assessments will be developed for clinical support, diagnostic and administrative services in order to meet project timelines.

Consulting team prepares drafts; review and discuss with User Groups, then revise

Higher level decisions go to Project Steering Committee for resolution

CONSULTATION PROCESS

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16

FACILITIES / MAINTENANCE

CAPITAL PLANNING

OTHER

West Lincoln Memorial Hospital

MUMC + Children’s Hospital

Chedoke Hospital

Hamilton General Hospital

St. Peter’s Hospital

Juravinski Hospital +

Cancer Centre

MEDICINE

PEDIATRICS

ONCOLOGY

EMERGENCY + URGENT CARE

Service Delivery + Programming Validation

USER GROUPS

West Lincoln Memorial Hospital

MUMC + Children’s Hospital

Chedoke Hospital

Hamilton General Hospital

St. Peter’s Hospital

Juravinski Hospital +

Cancer Centre

HHS Validation

Site Validation

(12 IN TOTAL)

. . .

CCC

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17

Clinical Services Vision document for HHS The future roadmap of where, how and what services/programs we will offer to

our community over the next 5, 10 and 20 years Provides a long-term vision of the future programs/services, across the

organization aligned with the HHS Strategic Plan Ongoing use for prioritizing and evaluating planning efforts Submitted as the basis to gain approval to proceed to a more detailed level of

planning (functional programming) for the LHIN and MOHLTC for our sites

TIMELINE for completion: Nov 2014 – Sept 2015

FINAL DELIVERABLE

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DISCUSSION / Q&A 4

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MANAGEMENT REPORT

Report Title:

Termination of West Haldimand General Hospital Management Services Agreement

Report Number:

2T

Report To:


Date of Meeting: 12/11/2014


Date of Meeting: 2T


Author(s): Brenda Flaherty

Telephone 2T 46824 E-mail: [email protected]


1.0 RECOMMENDATION:

THAT the Board of Directors accepts West Haldimand General Hospital’s Board request to terminate the Management Services Agreement with Hamilton Health Sciences.


The report seeks the Board’s response to a request from West Haldimand General Hospital (WHGH), attached as Appendix A, to terminate the Management Service Agreement (MSA) between WHGH and HHS effective December 1, 2014.

3.0 BACKGROUND:

In 2006 following an operational review, WHGH Board approached HHS to establish a partnership with WHGH in Hagersville and enter into a MSA with HHS to provide management services to WHGH and to assist WHGH in implementing their Strategic Plan and managing the operations of WHGH.

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Under the agreement, HHS oversaw the day to day management and administration of WHGH, according to provincial standards, WHGH’s policies and procedures and under direction of WHGH’s Board of Directors. Together with the WHGH Board, HHS appointed a WHGH CEO to implement the operational review recommendations and ensure key priorities such as relationship with physicians and the community, ensuring quality and stabilizing the financial situation were embedded in their strategic and operational plan. In 2011, HHS directed the WHGH CEO to work with the WHGH Board to seek integration opportunities with the BCHS. Clinical and back office opportunities were identified and in June 2014, WHGH and BCHS announced their intentions to merge the two organizations.

4.0 RELATIONSHIP TO STRATEGIC PLAN: Choose one or more that best describes: (double click on square and select “Checked”) 1. PATIENT EXPERIENCE









5. TALENTED PEOPLE



In June 2014, the boards of WHGH and Brantford Community Hospital Systems (BCHS), which includes Brantford General Hospital and the Willett Hospital in Paris, submitted a non-binding letter of intent to the Hamilton Niagara Haldimand Brant Local Health Integration

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Network and the Ministry of Health of Long Term Care to explore how to be stronger partners and merge the two organizations. In July 2014, the WHGH Board of Directors made the decision to independently employ David Bird, the current CEO, as WHGH continued discussions to develop a stronger partnership relationship with BCHS. David Bird resigned from HHS effective August 8, 2014. Subsequently on its September 24th meeting, the Board decided to officially terminate the current MSA with HHS. In early October 2014, WHGH and BCHS announced that the governance integration between the two organizations is on hold for at least one year. HHS has encouraged the voluntary integration of WHGH and BCHS and accepting WHGH’s request to terminate the MSA with HHS will support this direction. The MSA states that the termination of this agreement requires the consent of at least a two-thirds majority of the HHS Board of Directors.

6.0 PATIENT IMPACT: N/A


8.0 FINANCIAL IMPACT: Termination of the MSA will result in a loss of revenue of $25,000 for Management Fees paid to HHS.

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9.0 HUMAN RESOURCES IMPACT:

N/A

10.0 COMMUNICATION IMPACT: N/A



Respectfully Submitted, Approved for Submission, Brenda Flaherty Rob MacIsaac Executive Vice President & COO President & CEO

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Please include the appendices in your email to C. Rozman. Appendices to include the Appendix # in the filename and appear in the header of the document(s).

Appendix A - Letter dated September 29, 2014 from WHGH


Name Telephone

David Bird President & CEO, WHGH 2T

2T 2T

2T 2T

2T 2T

2T 2T


2T 2T


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Appendix A: WHGA MSA

Page 184/207

Page 185/207

Report of the President & CEO November 25, 2014

Page 186/207

Official Welcome

to

• Renato Discenza, Executive Vice President

Enterprise & Innovation

• Dave McCaig, Executive Vice President

Corporate Affairs & CFO

• Frank Naus, Vice President Research

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Ebola Designated Site

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Quality Healthcare Workplace Award

• HHS received Silver Award from the OHA

& MOHLTC’s Health Force Ontario

– Contribution to quality of work life and quality

of care

• At HealthAchieve Conference – Nov 4th

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Top 40 Research Hospitals

CAHO Member 2013 2012 2011 2010 2009

University Health Network 1 1 1 1 1

Hamilton Health Sciences 2 7 4 2 2

Hospital for Sick Children 3 3 2 3 3

Ottawa Hospital 5 4 6 6 6

London Health Sciences/St. Joseph’s Health Care London 8 9 9 13 11

Mount Sinai Hospital, Joseph and Wolf Lebovic Health Complex 9 10 10 8 7

Sunnybrook Health Sciences Centre 11 8 7 5 8

St. Michael’s Hospital 13 13 15 15 12

Centre for Addiction and Mental Health 15 14 13 18 17

Children’s Hospital of Eastern Ontario 20 23 27 31 27

St. Joseph’s Healthcare Hamilton 21 20 19 21 21

Baycrest 26 26 26 28 29

Kingston General Hospital 27 22 23 27 28

Women’s College Hospital 31 32 33

The Royal 33 36 36 35 36

Holland Bloorview Kids Rehabilitation Hospital 36 39 34 34 35

Thunder Bay Regional Health Sciences Centre 37 38 37 40 40

Bruyère Continuing Care 38 34 38 38 37

Health Sciences North (HSN) 40

Overall rankings 2009-2013:

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Progress update on CEO

objectives • Strategic Planning

– Q2 Update: Nine of 13 achieved positive movement toward 5-year targets

– Strategy Refresh presented to Board Nov 27 after extensive consultation

• Revenue Generation

– Recruited and hired EVP Enterprise & Innovation – started Nov 24

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CEO objectives continued

• ERM – Board input at April and October retreats, reporting framework to come

• HHSRI – Charitable Status achieved

– Board established and meeting regularly with HHS executive support

– Servicing Agreement approved, investment policies in place

– Funds transferred and under management

• Captive Insurance Corporation - established

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CEO objectives continued • WLMH

Clinical Planning Process

established

to meet

MOHLTC

requirements

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CEO Objectives continued Aligning Research

• Restructuring in

place

• Early efforts

underway for

better alignment

Page 194/207

Performance Plan Update

• Capital Plan

10-year plan under

development

• Chedoke Lands

Evaluative process

presented to Board

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Other notes

• BAHT

- New interim CEO in place

• Mohawk Shared Services

- More aggressive approach being pursued by HHS

on Supply Chain strategy

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Other Notes continued Reduction in ALC Rates – Hamilton General

HGH

from

19.4 to 11.8%

39%

Improvement

Nov

9

Nov 2

Oct

26

Oct

19

Oct

12

Oct

5

Sep 28

Sep

21

Sep 14

Sep

7

Aug 31

Aug 24

Aug 17

Aug 10

Aug 3

Jul 2

7

Jul 2

0

Jul 1

3J u

l 6

Jun 29

Jun 22

Jun 15

Jun 8

Jun

1

May 25

25

22

19

16

13

10

Week ending

Perc

ent of acu

te b

eds

with A

LC p

atient

Percentage of acute beds with ALC patient May 19 - Nov 9Hamilton General Hospital

Median = 19.4% (May 19 - Jul 27)

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Other Notes continued

Reduction in ALC Rates - Juravinski

JH

from

19.2 to 18.1%

6%

Improvement Nov 9

Nov 2

Oct

26

Oct

19

Oct

12

Oct

5

Sep 28

Sep

21

Sep 14

Sep

7

Aug 31

Aug 24

Aug 17

Aug 10

Aug 3

Jul 2

7

Jul 2

0

Jul 1

3J u

l 6

Jun 29

Jun 22

Jun 15

Jun 8

Jun

1

May 25

25

22

19

16

13

10

Week ending

Perc

ent of acu

te b

eds

with A

LC p

atient

Percentage of acute beds with ALC patient May 19 - Nov 9Juravinski Hospital

Median = 19.22% (May 19 - Jul 27)

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Government Relations

• Dr. Bob Bell, Deputy Minister of Health

• Omar Khan, Chief of Staff, MOHLTC

• Minister Eric Hoskins

• David Sweet, MP

• Ted McMeekin

• Eleanor McMahon

• Premier’s Dinner

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Networking

• Carrie Gerdes, PIPSC Union

President

• Rob Hunter, PIPSC Union President

• Linda Haslam Stroud, ONA National

President

• Jim Commerford, Pres. & CEO, YMCA

Page 200/207

Networking Continued

• Ronnie Gavsie, Pres. & CEO Trillium Gift

of Life Network

• Bill Tholl, President, HealthcareCAN

• Rebecca Jamieson, President, Six Nations

Polytechnic

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Speeches/Presentations

• Rotary Club Dundas speech

• Rotary Club Hamilton speech

• MSA quarterly meeting

• Department meetings – Strategic Plan – Inter Professional Practice & Nursing

– Informatics & Technology

– Quality & Performance

– HGH Administration

– Human Resources

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Community Events

• Burlington Community Foundation Gala

• Joseph Brant Gala

• Good Shepherd Harvest Fundraiser

• HCF Speaker Event on income disparity

• Gallery of Distinction Dinner

• Gairdner Awards

Page 203/207

Development

• KPMG Seminar: Transforming

Healthcare

• OHA HealthAchieve Conference

Page 204/207

HHS Events

• HHSF Donor Appreciation Evening

• HHS Long Service Awards

• Party for Pain Fundraiser

• MCH Evening of Remembrance

• Research Day Reception

Page 205/207

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