AGENDA...June 17, 2020 Prepared for and attended the Medical Advisory Committee meeting Dr. Andre...

AGENDA OPEN SESSION BOARD MEETING

Wednesday, June 24, 2020 Zoom Videoconference

4:30 pm Directors:

Marg Dragan, Treasurer Anthony Iafrate Bill Gillam Jenny Greensmith

Louis Guimond Brian Knott, Vice-Chair Katherine Mantha

Rachael Simon Fred Vanderheide Paul Wiersma, Chair Kirk Wilson

Ex-Officio Directors: Mike Lapaine Dr. Michel Haddad

Shannon Landry Dr. Andre Rudovics

Dr. Lincoln Lam

Invited Participants: Samer Abou-Sweid Julia Oosterman

Laurie Zimmer Kathy Alexander

Paula Reaume-Zimmer Dr. Dhiraj Dhanjani

Invited Guests: Pat Davis Beverly Hand Lorri Kerrigan

Art Mamouhdi Jason McMichael Marcie Myers

Tom Salmoni John Sottosanti Jennifer Wilson

Recorder: Melissa Rondinelli *attached

NO. TOPIC ACTION TIME PRESENTER

1.0 CALL TO ORDER: WELCOME AND OPENING REMARKS 4:30 Paul Wiersma

2.0 AGENDA APPROVAL

2.1 Report on the May In-Camera Board Meeting Information Paul Wiersma 2.2 Approval of Agenda Decision

2.3 Declaration of Conflict of Interest Decision

3.0 CONSENT AGENDA Paul Wiersma

3.1 INFORMATION ITEMS TO BE RECEIVED

3.1.1 Board Chair Report* Paul Wiersma

3.1.2 Professional Staff Association Report* Dr. A. Rudovics

3.1.3 Facilities Quarterly Report* Marg Dragan

3.1.4 Whistleblower Report*

3.1.5 Extension of Service Accountability Agreement(s) (“Extending Letter”)*

3.1.6 Board Work Plan* Anthony Iafrate

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

NO. TOPIC ACTION TIME PRESENTER

3.2 ITEMS FOR APPROVAL 3.2.1 Open Session Board Minutes – May 27, 2020* Decision Paul Wiersma

3.2.2 Broader Public Sector Accountability Act (BPSAA) Attestation*

Marg Dragan

4.0 BOARD DECISIONS/OVERSIGHT

4.1 Resource Utilization & Audit Committee (RUAC) Highlights*

Information 4:33 Marg Dragan

4.2 Revised 2020-21 Operating Plan* Decision

4.3 Monthly Financial Statement* Decision

4.4 Resource Utilization and Audit Committee Performance Scorecard*

Discussion

4.5 Quality Committee Highlights* Information 4:45 Brian Knott

4.6 Quality Committee Performance Scorecard* Discussion

5.0 CHIEF OF PROFESSIONAL STAFF REPORT* Information 4:50 Dr. Haddad

6.0 POLICY FORMATION – None

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

4:55 Paul Wiersma

8.0 REPORT ON IN-CAMERA AGENDA ITEMS Information Paul Wiersma

9.0 ADJOURNMENT: Next Meeting – June 24, 2020 5:00 Paul Wiersma

Bluewater Health Board of Directors

Open Session Meeting June 24, 2020

Proposed Motions

AGENDA ITEM MOTION

2.1 Agenda to approve the agenda as presented 3.0 Consent Agenda to receive the reports presented and to

approve the following items in the Consent Agenda:

• Open Session Board Minutes – May 27, 2020

• to authorize the Board Chair to sign the annual attestation.

4.2 Revised 2020-21 Operating Plan to endorse the 2020-21 proposed operating plan as presented and that this revised plan will be used to populate the Hospital Accountability Planning Submission.

4.3 Financial Statements to approve the Financial Statement for the period ended April 30, 2020 as presented

Board Chair Report

I would like to highlight my activities as Chair for the period of May 27, 2020 to June 24, 2020: May 27, 2020 Prepared for and chaired the BWH Board meetings June 1, 2020 Attended and spoke at the quarterly Professional Staff

Association meeting June 8, 2020 Prepared for and chaired the BWH Executive meeting for

elected directors June 9, 2020 Met with the President and CEO to prepare for the June Board

meetings and to discuss hospital and Board business June 11, 2020 Attended and participated in the Resource Utilization and

Audit Committee Meeting June 16, 2020 Met with the President and CEO to discuss performance

evaluation and succession planning June 17, 2020 Met with the Chief of Professional Staff to discuss

performance evaluation and succession planning June 24, 2020 Prepared for and chaired the BWH Board meetings and

Annual General Meeting Various dates Communicated with BWH staff and Board members regarding

hospital and Board business

Paul Wiersma

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President of the Professional Staff Association (PSA) Report

June 2020 I would like to highlight my activities as PSA President: May 27, 2020 Prepared for and attended the Bluewater Health Board meeting June 1, 2020 Prepared for and chaired the quarterly Professional Staff

Association meeting

June 17, 2020 Prepared for and attended the Medical Advisory Committee meeting Dr. Andre Rudovics

Performance and Utilization Committee Report Prepared by: Facilities Planning & Development Period Ending June 2020 Capital Projects

FPD – RUAC Report – June 2020 Page 1 of 1

Bluewater Health Capital Project List Combined Heat & Power Project (CHP) Project Budget; $4,900,000 Funding Source; Capital Status; In Progress Anticipated Start; Apr.2019 Anticipated Completion; Dec. 2020 Comments;

• Hydro One application “Request to Connect” Approved • Bluewater Health to complete Noise Abatement requirements to meet MOE orders by go live • CoGen engine pretender awarded to AB Energy Sept. 2020 Delivery • CoGen installation awarded to GHD Contractors

Diesel Tank Replacement Project Budget; $500,000 Funding Source; HIRF – 2019/20 Status; Completed Anticipated Start; Apr.2019 Anticipated Completion; Mar. 2020 Comments;

Parking Equipment Upgrade Project Budget; $150,000 Funding Source; Capital Status; In Progress Anticipated Start; May 2018 Anticipated Completion; July 2020 Comments;

• Refresh of all parking equipment • Project starting in CEEH first • Cabling and infrastructure renewal underway at both sites to support new equipment

CEEH Acute Care Bathroom Upgrades Project Budget; $60,000/rm Funding Source; HIRF 2019/20 Status; Planning Anticipated Start; Aug. 2020 Anticipated Completion; Oct. 2020 Comments;

• Creation of AODA compliant private bathrooms • Convert Acute Care rooms to all private with one three bed ward including Palliative room • RFP spec package Completed mid-June Release

Performance and Utilization Committee Report Prepared by: Facilities Planning & Development Period Ending June 2020


CEEH Enabler Project – Boiler Plant Project Budget; $650,000 Funding Source; HIRF 2019/20 Status; In Progress Anticipated Start; Nov. 2019 Anticipated Completion; June 2020 Comments;

• Project nearing completion • Construction of new boiler plant • This is a portion of the CEEH Mechanical Upgrades

CEEH Enabler Project – Permanent Generator Project Budget; $400,000 Funding Source; HIRF 2019/20 Status; In Progress Anticipated Start; June 2020 Anticipated Completion; Aug. 2020 Comments;

• Installation of new Generator • Project awarded to JMR • This is a portion of the CEEH Electrical upgrades Phase 2 awaiting funding

Mental Health In-Patient Patio Project Budget; $300,000 Funding Source; Capital 2020/21 Status; Planning Anticipated Start; Aug. 2020 Anticipated Completion; Oct. 2020 Comments;

• Renovations to Mental Health outdoor space to create an “All Season Room”

HIRF 2020/21 Exceptional Circumstances Submissions (ECP) CEEH Enabler Project – Electrical Upgrades Phase 2 Project Budget; $2,000,000 Funding Source; HIRF 2020/21 – ECP Submission Status; Planning Anticipated Start; Sept. 2020 Anticipated Completion; Mar.2021 Comments;

• Replacement and relocation of all onsite transformers and electrical services • Tender package complete – Release late June

Performance and Utilization Committee Report Prepared by: Facilities Planning & Development Period Ending June 2020


HIRF 2020/21 Exceptional Circumstances Submissions (ECP) Cont’d CEEH Enabler Project – Mechanical Upgrades Project Budget; $1,500,000 Funding Source; HIRF 20/21 – ECP Submission Status; Planning Anticipated Start; Aug. 2020 Anticipated Completion; Dec. 2020 Comments;

• Conversion of Steam Plant to Hot Water and relocated to new boiler room • Replacement of Steam pipe system/ Install new head end. • Specification and Tender package complete – Release mid-June

Russel Building Roof Replacement Project Budget; $270,000 Funding Source; HIRF 2020/21 – ECP Submission Status; Planning Anticipated Start; Aug. 2020 Anticipated Completion; Sept. 2020 Comments.

• Replace final section of Roof on Russel Building

Ministry Capital Projects CEEH Redevelopment Project Project Budget; $9,000,000 Funding Source; Ministry Capital Submission Status; Planning Anticipated Start; Sept. 2015 Anticipated Completion; Comments;

• Ministry approval to proceed with Stage 2 Received • RFP release in January to procure consultant to complete Stage 2 submission

Addictions Centre Project Budget; $8,500,000 Funding Source; Ministry Capital Submission Status; Planning Anticipated Start; Sept. 2015 Anticipated Completion; Comments;

• Master Planning/Programming continues permanent solution.

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Bluewater Health Briefing Note

Name of Committee: Board of Directors Date of Meeting: June 24, 2020 Submitted by: Samer Abou-Sweid, VP Operations Subject: 2019/20 Whistleblower Report Purpose of Report: Information Input Approval

Situation The Resource Utilization and Audit Committee is to report incidents annually in accordance with the Whistleblower Policy (Board Policy C-7 and CDR-QRM-A-2.230). Background Bluewater Health entered into a contract in 2008 with WhistleBlower Security, an independent third party administrator, as part of the recommendations from the Smith Investigation. The service is completely confidential. Although hospitals are not mandated to offer the whistleblower service, management felt the service should continue to be provided. In addition, it was recommended to the Chatham-Kent Health Alliance (CKHA) in 2017 to provide the service as a result of its investigation, and for transparency purposes – further supporting the decision to keep the services as best practice. Bluewater Health is committed to maintaining a safe, fair and productive environment in which all those receiving healthcare services, working at or visiting the hospital behave in a professional manner that respects the rights of others and contributes to an environment that is free from verbal or physical abuse, unlawful harassment or discrimination. The hospital provides a process for any person associated with the hospital to communicate any legitimate and genuine concerns in relation to: • Criminal activity, breach of legal obligations, financial malpractice, fraud, or any attempt

to conceal information relating to the above, including information that is considered confidential

• Harassment or discrimination of anyone receiving healthcare services, working at or visiting the Hospital

• Patient, visitor, staff, physician, volunteer or student safety within hospital premises

WhistleBlower Security released a system upgrade to its IntegrityCounts Case Management System platform modernizing the look and feel to encourage reporting and make case management easier. The platform allows proxy reporting – allowing managers to file in-person reports on an employee’s behalf; enhanced search features; location based alerts; and customized reporting. WhistleBlower Security will report any disclosures to the CEO, and any concerns related to the CEO are reported to the Board Chair.

X

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The availability of the service is periodically promoted in the newsfeed of the hospital’s intranet, which is available to all staff. Analysis Bluewater Health considered using the same provider as CKHA in order to save costs; however, the cost of Bluewater Health service is $5000 which is slightly less than other hospitals. The cost is based on the size of the hospital. There were no incidents to report in 2019-20. A case was submitted but was directed to Human Resources as it was a staff complaint since it did not meet the threshold of a “Whistleblower Incident” The service will again be promoted on the intranet and the Communications & Public Affairs department will also profile the service in the hospital’s weekly e-newsletter.

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Name of Committee: Board of Directors Date of Meeting: June 24, 2020 Submitted by: Marlene Kerwin Subject: Service Accountability Agreement Extending Letter Purpose of Report: Information Input Approval

Situation The Ministry of Health requires Board approved accountability agreements between the Erie St. Clair Ontario Health West region and Bluewater Health (BWH) to allow for the continued flow of funding for hospital operations and community sector programs managed through the hospital.

Background Each year, the Board is asked to approve the Service Accountability Agreement (SAA). BWH received the attached Notice and Extension of the SAA Agreement from the Ontario Health West Region on May 28th as the current agreement expires June 30, 2020.

Analysis The requested approval of the Service Accountability Agreement (SAA) Extending Letter is to extend the term of the SAA to March 31, 2021 and the extend the Schedules for the period June 29, 2020 to March 31, 2021. The HSAA reflects the Hospital Accountability Planning Submission for the 2019/20 fiscal year, which was approved by the Board on February 27, 2019.

Recommendation The Board Chair and CEO sign the Service Accountability Agreement (SAA) Extending Letter extending the Schedules to March 31, 2021 prior to seeking approval at the June Board meeting in order to meet the June19th deadline.

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

Via Email May 28, 2020 Mike Lapaine President & Chief Executive Officer Bluewater Health 89 Norman Street Sarnia, ON N7T 6S3 Dear Mr. Lapine: Re: LHSIA s. 20 Notice and Extension of Service Accountability Agreement(s)

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

In this COVID-19 outbreak, the LHIN hereby gives notice and advises Bluewater Health (the “HSP”) of the LHIN’s proposal to amend each and every service accountability agreement (as described in the Local Health System Integration Act, 2006) currently in effect between the LHIN and your HSP (each a “SAA”).

Subject to the HSP’s acceptance of this Extending Letter, each SAA will be amended with effect on June 30, 2020. All other terms and conditions of the SAA remain in full force and effect.

The terms and conditions in the SAA are amended as follows.

1) Term – With respect to a SAA that is a hospital service accountability agreement only, in section 2.2, “June 30, 2020” is deleted and replaced by “March 31, 2021”.

2) Schedules – The Schedules in effect on June 29, 2020 shall remain in effect until March 31, 2021, or until such other time as may be agreed to by Parties.

Unless otherwise defined in this letter, all capitalized terms used in this letter have the meanings set out in the SAA.

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2. Please indicate the HSP’s acceptance and agreement to the amendment of the SAA as described in this Extending Letter by signing below and returning one scanned copy of this letter by e-mail no later than the end of business day on June 19, 2020, to: Annette Masalsky at [email protected] (the “LHIN Contact”).

The HSP and the LHIN agree that the Extending Letter may be validly executed electronically, and that their respective electronic signature is the legal equivalent of a manual signature. The electronic signature of a party may be evidenced by one of the following means and transmission of the Extending Letter may be as follows:

1) a manual signature of an authorized signing representative placed in the respective signature line of the Extending Letter and the Extending Letter delivered by facsimile transmission to the other party;

2) a manual signature of an authorized signing representative placed in the respective signature line of the Extending Letter and the Extending Letter scanned as a pdf and delivered by email to the other party;

3) a digital signature, including the name of the authorized signing representative typed in the respective signature line of the Extending Letter, an image of a manual signature or an Adobe signature of an authorized signing representative, or any other digital signature of an authorized signing representative with the other party’s prior written consent, placed in the respective signature line of the Extending Letter and the Extending Letter delivered by email to the other party; or

4) any other means with the other party’s prior written consent.

Should you have any questions regarding the information provided in this Extending Letter, please contact Erin Link at [email protected].

Sincerely,

Zeynep Danis

Vice President, Finance & Corporate Services,

Ontario Health (West)

ZD/am

mailto:[email protected]

mailto:[email protected]

AGREED TO AND ACCEPTED BY

Bluewater Health

By:

__________________________________ Date:____________________

Mike Lapine (mm/dd/yyy) President & Chief Executive Officer I have authority to bind the HSP

And By:

__________________________________ Date:____________________

Paul Wiersma - Board Chair (mm/dd/yyyy) I have authority to bind the HSP

June 11, 2020

June 11, 2020

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No. Work Plan Item Responsible Committee

Alignment Board Policy/

Strategic Plan/ Legislation

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Status (CompleteIn ProgressDeferred)

Comments

1.1 Monitor Strategic Plan annually G&N A-2/E-3 x x x Complete

1.2 Monitor strategic goals and quality/resource objectives via Balanced Scorecards and provide oversight for remediation/improvement plans

Quality/RUAC ECFAASP

A-3/E-3

x x x x x x x Complete

1.3 Review/approve/monitor Quality Improvement Plan (QIP) Quality C-1/E-3ECFAA

x x x x x Complete

1.4 Establish annual performance indicators and targets Quality/RUAC ECFAASP

A-3/C-1/E-3

x x Complete

1.5 Monitor development of local Ontario Health Team as required All F-2 x x x x x x x Complete OHT development on hold due to pandemic.

2.1 Complete CEO/CoPS performance evaluation and approve goals/objectives

Exec B-3 x x x Complete

2.2 Establish annual CEO/CoPS performance expectations Exec B-3 x x Complete 2.3 Review/approve Executive Compensation Framework Exec B-3 x NA Executive salary

frozen effective August 13, 2018

2.4 Ensure CEO/CoPS establish an appropriate succession plan for BWH leaders and Professional Staff

Exec B-1/E-3 x x Complete

2.5 Review/approve annual HR and Physician HR plans RUACMAC

E-3 x Complete

2.6 Review/approve executive performance-based compensation relative to Quality Improvement Plan performance

Exec B-3ECFAA

x x Complete

2.7 Review/approve salary recommendation for non-union compensation

RUACEC

B-3ECFAA

x x Complete

2.8 Review/approve Medical Director and other medical leadership appointments as required

MAC E-3 x x x x x x x Complete

BLUEWATER HEALTH WORK PLAN 2019-20

1.0 Establishing Strategic Direction

2.0 Providing for Excellence Management

3.0 Ensuring Program Quality and Effectiveness

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3.1 Monitor Quality and Patient Safety program annually Quality C-1/C-8SP

x Complete

3.2 Monitor accreditation activities and respond as required (timing aligned with accreditation cycle)

Quality/G&N C-1/E-3/E-10 x x Partially Complete

Management reviewed new governance Accreditation Standards against 2018 version. BWH continues to meet all governance standards.

3.3 Review Critical Incident Aggregated Data reports (Excellent Care for All Act legislation: at least twice annually)

Quality C-1ECFAA

x x Partially Complete

Second report deferred due to COVID-19. Critical incidents can be found on scorecard and were discussed with Quality Committee Chair.

3.4 Monitor litigation claims Quality C-2/E-10 x Deferred Deferred to fall due to COVID-19.

3.5 Monitor Risk Assessment Checklist Quality C-2/E-10 x Complete

3.6 Monitor ethical framework outcomes and related policies (minimum annually)

Quality C-4 x Complete

3.7 Monitor research being undertaken within the organization (minimum annually)

Quality C-3 x Complete

3.8 Monitor pandemic plan and emergency preparedness (i.e. Disaster plan and other related activities) - annually

Quality C-1/C-8 x Complete

3.9 Monitor Quality Improvement Initiatives through program reports and education articles

Quality E-10 ECFAA

x x x x Partially Complete

Monthly Program reports received up to pandemic.

3.1 Review recommendations from MAC on any systemic/recurring issues related to quality of care provided by professional staff as required

Quality/MAC C-1PHA

x x x x x x x Complete

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3.11 Receive minutes from the Quality and Patient Experience Committee

Quality E-10 IV x x x x x x x Complete

3.12 Monitor patient experience results via Concerns/Compliments reports and 4 principles of PFCC

Quality C-2/C-5ECFAA

SP

x x x Partially Complete

Third report deferred due to COVID-19. Patient experience metrics are on the scorecard.

3.13 Provide update on Workplace Violence (also incorporated into 2018_19 QIP & scorecard) - twice annually

Quality ECFAA x x Partially Complete

Second report deferred due to COVID-19. Workplace violence metrics are on the scorecard

3.14 Monitor staff, professional staff and volunteer engagement survey results

Quality ECFAASP

x Deferred The Excellence Canada Mental Health & Well-Being Survey Results were shared with RUAC in February. The Employee Engagement Survey scheduled for April has been delayed due to COVID-19.

3.15 No One Waits (N.O.W.) Initiative update - quarterly Quality/RUAC SP x x x x Partially Complete

June Update deferred to the fall due to COVID-19.

3.16 Review/approve Professional Staff appointments, reappointments, privileges as required

MAC PHA x x x x x x Partially Complete

Annual reappointments deferred to fall.

3.17 Review fairness/effectiveness of credentialing process annually MAC x x Deferred Annual reappointments deferred to fall.

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3.18 Receive reports from the CEO in relation to the 3rd party whistleblower service

RUAC C-7 x Complete

3.19 Monitor Integrated Risk Management (IRM) quarterly - include best practices' 3 corporate priorities

Quality C-2SP

x x x x Complete

3.20 Hospital Standardized Mortality Rate report - twice annually Quality SP x x Partially Complete

Second report deferred due to COVID-19.

3.21 Health and Wellness Update RUAC SP x Complete

3.22 Receive Quality of Care Information Protection Act (QCIPA) & Quality Care Review Recommendations in aggregate twice per year (used to be combined within the Quality & Patient Safety Program report)

Quality ECFAAE-10 IV

x x Partially Complete

Second report deferred due to COVID-19.

3.23 Receive annual Occupational Health and Safety Program Report RUAC OH&SA / HPPAC-8

x Complete

3.24 Receive an update on environmental stewardship outcomes annually

RUAC C-9 x Deferred Update deferred to September to align with Green Hospital Scorecard results

3.25 Receive annual report on AODA accountabilities, progress and compliance

RUAC AODAE-3

x Complete

4.1 Monitor financial performance via monthly financial statements RUAC D-1/D-2 x x x x x x x Complete

4.2 Review/approve annual operating plan RUAC/Quality C-1/D-1 x x x x Complete

4.3 Review/approve Hospital Accountability Planning Submission (HAPS)

RUAC D-1/D-2 x(draft HAPS)

x(Final HAPS)

x x NA Nothing received from LHIN/Ontario Health.

4.0 Ensuring Financial Viability

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4.4 Review/approve/monitor capital expenditure plan RUAC D-1/D-2 x x x x x x x Complete Monitored via balanced scorecard.

4.5 Review/approve Hospital Service Accountability Agreement (H-SAA)

RUAC D-1/D-2 x x Complete

4.6 Review/approve Community Accountability Planning Submission (CAPS) and Multi-Sectoral Accountability Agreement (M-SAA)

RUAC D-1/D-2 x(draft CAPS)

x(Final CAPS)

x x x Complete

4.7 Review/approve Chief Financial Officer Report - ensuring legislative requirements at met

RUAC C-2/D-2/D-3/E-3/E-10

x x x x Complete

4.8 Monitor business/financial risk management RUAC C-2/D-2/D-3/E-3/E-10

x x x x Complete

4.9 Review/receive quarterly report on investments and loans RUAC D-3/D-4/E-10 x x x x Complete

4.10 Review/monitor physician bank loans annually RUAC D-3/D-4/E-10 x Complete4.11 Review/receive Human Resources Report quarterly RUAC E-10 x x x x Complete

4.12 Review/receive Facilities Report quarterly RUAC D-1/E-10 x x x x Complete

4.13 Review/receive insurance annually RUAC D-3 x Complete

4.14 Review/approve banking arrangements/resolutions RUAC D-3 x Complete

4.15 Review/approve audit activities as required(post-audit/management letter, management's response and action plan, audit plan, financial statements, firm/compensation)

RUAC E-3/E-10 x x x Complete

4.16 Review/approve Executive and Director expenses RUAC BPSAAD-6/E-2/E-18

x x Complete

4.17 Review/approve Public Sector Salary Disclosure Attestation RUAC PSSDAE-2

x Complete

4.18 Review/approve BPSECA Attestation - annual executive compensation

RUAC BPSECAD-1

x NA

4.19 Review/approve BPSAA Attestation - consultant use, perquisites, lobbyist rules, etc.

RUAC BPSAAD-6/E-18/E-2

x Complete

4.20 Provide update on HIS or any other significant technology investments as needed

RUAC SPD-1

x x x x x x x Partially Complete

Updates on hold since onset of pandemic.

4.21 Provide update on cyber security annually RUAC C-2 x Complete

Extension of Service Accountability Agreement(s) (“Extending Letter”) in place until March 31, 2021

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4.22 Monitor/approve decisions related to property matters as required

RUAC D-1 x x x x x x x Partially Complete

Updates on hold since onset of pandemic.

4.23 Monitor status of the development of the 5-Year Plan - services, facilities, capital equipment, and technology

RUAC E-3SP

x Complete

5.1 Develop/approve annual work plan All E-15 x x Complete5.2 Review/revise/approve Terms of Reference All E-10 x Complete5.3 Develop/approve/monitor Board Goals G&N/All E-15/E-19 x x x Complete 5.4 Complete Board/Director/NDCM/Committee/Meeting

evaluations as required and address opportunities identified by results

All E-11/E-12/E-13/E-14/E-19


Board evaluations scheduled post pandemic deferred for the year.

5.5 Strengthen Board Orientation/Education/Team Building All E-9SP

x x x x x x x Complete Recommend all face-to-face education sessions be postponed for the year. Governance best practice articles to be shared electronically as available.

5.6 Complete Board succession planning, recruitment and nomination process

G&N E-8/E-9 x x x x x Complete

5.7 Review Board/NDCM member meeting attendance and education record

G&N E-19 x Deferred Deferred due to the pandemic.

5.8 Review/revise/approve Board policies and By-Laws All E-1 x x Complete 5.9 Plan for Annual General Meeting G&N E-10 x x x x x x Complete

5.10 Review/receive annual FIPPA/PHIPPA compliance report and complete FIPPA Delegation of Authority

Quality C-6FIPPA

PHIPPA

x Deferred Deferred due to pandemic.

5.11 Complete Board meetings without Management Board E-17 x x x Complete

5.0 Ensuring Board Effectiveness

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5.12 Consider Generative Discussion items for Board meetings G&N E-9 x x x x x x x x Partially Complete

Item deferred post pandemic.

6.1 Review/receive Global Communication and Community Engagement Plan

G&N E-2/E-3/F-1 x Deferred Item deferred to September.

6.2 Review/receive reports from CEO/Board liaison representatives re: stakeholder relationships as necessary i.e.. Governance Advisory/Foundation Boards/CAP/RHAP

G&N E-2/E-3/F-1/F-2SP


CEO has provided regular updates regarding pandemic response.

6.0 Fostering Relationships

MINUTES

OPEN SESSION BOARD MEETING Wednesday, May 27, 2020

Directors:

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

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

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

Ex-Officio Directors:

Mike Lapaine √ Dr. Michel Haddad √

Shannon Landry √ Dr. Andre Rudovics √

Dr. Lincoln Lam – R

Participants: Samer Abou-Sweid √ Julia Oosterman √

Laurie Zimmer √ Kathy Alexander √

Paula Reaume-Zimmer √ Dr. Dhiraj Dhanjani –R

Invited Guests: Pat Davis - R Beverly Hand - R Lorri Kerrigan √

Art Mamouhdi √ Jason McMichael - R Marcie Myers – R

Tom Salmoni - R John Sottosanti √ Jennifer Wilson – R

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

1.0 CALL TO ORDER: 5:04 pm

Paul Wiersma welcomed everyone to the meeting and noted the Non-Director Committee Members had been invited to attend the meeting.

1.1 Traditional Territory Acknowledgement Paul read the traditional territory acknowledgement.

1.2 Report on the March and April In-Camera Board Meetings Paul reported the Board made decisions at the March and April meetings regarding Professional Staff credentialing, non-union compensation, and pay for performance executive compensation related to the Quality Improvement Plan (QIP). The Board also received information updates on COVID-19, 2019 employee salaries and benefits, and the CEO and Chief of Professional Staff performance management and evaluation process.

1.3 Patient Story Julia Oosterman shared two patient stories from family members of COVID-19 patients exemplifying how acts of kindness can make a positive impact on the patient and family experience. Kathy Alexander reported one of these families made a donation on behalf of their loved one, and the story has been shared with the Intensive Care Unit team.

Bluewater Health – Open Meeting May 27, 2020 Page 2 ____________________________________________________________________________ 2.0 AGENDA APPROVAL

2.1 Approval of Agenda* Motion duly made, seconded and carried: to approve the agenda as presented.

2.2 Declaration of Conflict of Interest - None declared. 3.0 CONSENT AGENDA 3.1 ITEMS TO BE RECEIVED

3.1.1 Board Chair Report* 3.1.2 Professional Staff Association

Report* 3.1.3 Analysis of the Loans and

Investments*

3.1.4 Audit Planning Letter* 3.1.5 Board Work Plan* 3.1.6 Board Goals*

3.2 ITEMS FOR APPROVAL

3.2.1 Open Session Board Minutes – March 25, 2020* 3.2.2 Chief Financial Officer Certificate*

Motion duly made, seconded and carried: to receive the reports presented and to approve the following items in the Consent Agenda: Open Session Board Minutes – March 25, 2020 and the Chief Financial Officer Certificate.

4.0 COVID-19 Update Mike Lapaine reported the province began lifting Directive #2 measures last evening which means Bluewater Health can slowly begin to ramp up services subject to: occupancy levels, prevalence of COVID-19 in the community, personal protection equipment (PPE) availability, regional approval, etc. Mike noted it is far more complicated to ramp up than it was to scale back operations at the onset of the pandemic. Significant planning is underway analyzing wait lists and backlogs to determine how to best serve patients that have been delayed care due to the crisis. It is expected Directive #2 will not be fully rescinded until provincial COVID-19 “hot spots” are under better control, which will impact Bluewater Health’s ability to ramp up. Mike also noted Bluewater Health has implemented a universal masking policy in all public areas of the hospital for staff, patients and visitors. Next, Mike reported Bluewater Health is working with various partners to address the outbreak at the Vision Nursing Home. He provided an overview of the COVID-19 infection rates at Vision and discussed challenges the organization is facing. Options to manage the

Bluewater Health – Open Meeting May 27, 2020 Page 3 ____________________________________________________________________________

crisis are being considered and Bluewater Health will continue to support Vision. This crisis will impact the hospital’s ability to ramp up services. Dr. Haddad added there has been great engagement from medical staff throughout the pandemic and they are included in the committees working to re-establish services and procedures. He reported he is encouraged by the innovation taking place with virtual care and scheduling opportunities, and pleased Bluewater Health has not been impacted by an outbreak. This is evidence that staff and physicians are following processes and PPE requirements. Questions were raised about whether Bluewater Health staff are staying on site at Vision, what the role of Public Health is in containing the Vision outbreak, the status of pandemic pay, the overall morale at Bluewater Health, if staff impacted by reduced hours are transitioning back to work, the status of reprocessing N95 masks and the type of masks provided to patients and visitors. It was reported Bluewater Health staff are not staying on site at Vision and their service will be dedicated to Vision during their redeployment. There was confirmation Public Health has a role in the outbreak. Partners agreed this week that going forward Bluewater Health will direct and lead efforts regarding infection prevention and control, PPE, environmental services, communications and employee resilience at Vision. Mike reported the hospital continues to await funding and direction on the issue of pandemic pay. Paula Reaume-Zimmer indicated morale is variable with everyone experiencing the weight of the pandemic differently. The Resilience Team continues to round and is completing check-outs at the end of shifts to support and recognize staff. She noted universal masking has provided peace of mind and ongoing communication and information will be key to ensuring engagement and resilience. Staff impacted by reduced hours will begin to get more hours as services ramp up. Bluewater Health is awaiting Ministry approval to use the machine purchased to reprocess N95 masks. This machine will provide added assurance that PPE needs can be met as N95 mask usage increases with the ramp up of services. Patients will be provided with donated masks.

5.0 BOARD DECISIONS/OVERSIGHT

5.1 Annual General Meeting (AGM)* Anthony Iafrate presented a Briefing Note regarding planning for this year’s AGM. He noted

the Board previously recommended the AGM be held at the Lambton College Event Centre. Management has considered several meeting options for this year’s AGM. Although there is opportunity to delay the AGM to the end of August, it is unknown when restrictions on


gatherings of more than five people will be lifted, therefore, it is recommended the meeting proceed on the original date by videoconference. Furthermore, it is recommended the meeting be limited to Board members and invited guests as it would be cumbersome to manage an Open meeting securely, and there has been little public attendance in the past year. The agenda package will continue to be published to maintain transparency.

Motion duly made, seconded and carried: to approve that:

• the resolution approving the AGM be held at Lambton College Event Centre be revoked;

• the Board hold the AGM on June 24, 2020 by videoconference for Directors, invited participants, and Non-Director Committee Members only; and

• Bluewater Health communicate its decision to not invite the public to this year’s AGM due to the pandemic, with assurance all material and decisions will be shared publicly.

It was recommended members of the media be invited to the AGM. Julia Oosterman was

open to inviting the media as suggested. 5.2 Financial Statements*

Marg Dragan presented the financial statements for the period ended March 31, 2020. She reported the hospital originally projected a $1.3M deficit and is expected to end the year with an $885K surplus. This is due to recognition of surge funding, an energy rebate of $1.8M and $2.1M in sustainability funding. Marg then discussed shortfalls in quality based procedure (QBP) volumes due to the pandemic, specifically noting QBP funding for hips and knee surgeries is not expected to be clawed back, however, funding for cancer surgeries is. Next, Marg noted capital spending is less than expected and the hospital’s working capital is not a robust as it has been. This is because Bluewater Health has been financing the Combined Heat and Energy Project through working capital. A recommendation for a loan for this project will be presented to the Resource Utilization and Audit Committee in June. If approved, Bluewater Health’s working capital will return to a positive position. Marg also noted the audit is underway and recognized the Finance team for supporting this work virtually.

Motion duly made, seconded and carried: to approve the Financial Statement for the period ended March 31, 2020 as presented.

The hospital was questioned whether there is any risk of losing funding grants for

projects because of pandemic delays. Samer Abou-Sweid reported all projects covered through the Hospital Infrastructure Renewal Fund (HIRF) will be completed on time. The $1.2M grant related to the Combined Heat and Energy Project is on the line if the project is not completed by the end of December, however, the vendor is committed to


completing the project on time. As a precautionary measure, Bluewater Health will be asking for an extension.

5.4 Resource Utilization and Audit Committee Performance Scorecard * Marg noted there was debate about bringing the scorecard forward given the impact of

the pandemic on the indicators. She then presented the scorecard indicators updated this month and highlighted:

• positive results for the 90th Percentile Time to Inpatient Bed and Alternate Level

of Care Rate • the absenteeism rate is slightly off target and will be impacted in the latter part

of March due to isolation requirements related to the pandemic • steady progress with the Emergency Department Cost per Visit indicators • the QBP, surplus and working capital indicators were already discussed with

agenda item 5.3.

Paul asked if capital spending is typical and whether there is any risk related to deferred capital items. It was noted there is no risk, and because there is a short window to complete the Request for Proposal (RFP) process, it is typical that the hospital does not hit the capital spend target. Approved capital items are carried over to the following year. If the work is not completed within that year, the item is required to be vetted through the capital planning process again.

5.5 Quality Committee Scorecard* Brian Knott presented the scorecard noting Bluewater Health will see the major impact

of the pandemic on the April and May results. He then highlighted the following: • there was one high severity incident related to an overdose • the ALC rate has increased due to the pandemic • the repeat visits to the Emergency Department (ED) for Mental Health concern

results are positive (lag indicator) • patient experience indicators were lower in the ED during December and January

likely due to challenges with physician coverage and increased volumes • the internal survey for patients is one hold due to the pandemic • kindness results were positive • the hospital continues to collect workplace violence data • gross conservable days is off target

There were no questions, concerns or comments.

Bluewater Health – Open Meeting May 27, 2020 Page 6 ____________________________________________________________________________ 5.6 Quality Improvement Plan (QIP) 2020-21 Brian noted the QIP was approved by the Board in March. The original submission

deadline of March 31st was extended by Health Quality Ontario (HQO) due to the pandemic and Bluewater Health held off submitting the plan. Recently, Bluewater Health made the decision to submit the plan and continue to monitor the situation, despite the uncertainty of the pandemic. An update from HQO is expected in June. There were no questions or concerns.

5.6 Strategic Plan Progress Report* Mike presented the Strategic Plan Progress Report noting that a different reporting

approach was taken this year due to the pandemic. He highlighted progress made with the No One Waits (NOW) initiative, how the pandemic has advanced the work of Ontario Health Teams (OHT), the importance of Employee Engagement, and the hospital’s response to the COVID-19 pandemic. Paul celebrated the positive progress seen over the years and commended the Bluewater Health team on the results. An inquiry was made about OHT progress. Mike reported the work has been paused, however, he has reached out to the Steering Committee to bring the group together again. He reported there has been a shift in local thinking and suggested the OHT is in a better place than prior to the pandemic, with strengthened relationships and Bluewater Health emerging as a leader through the crisis. There were no further questions or comments.

5.7 Chief of Professional Staff Report* Dr. Haddad presented the report from the most recent Medical Advisory Committee

Meeting. He reported the Committee reviewed policy changes and discussed physician engagement and wellness. He also noted cancellation of education opportunities and student placements due to the pandemic. It is expected student placements will begin again in July, pending adequate PPE supply. There were no questions, comments or concerns.

5.8 Bluewater Health Foundation Report*

Kathy Alexander presented her report noting the COVID-19 fund generated tremendous generosity and messages of appreciation for staff. She also acknowledged the Board of Directors for their contributions and the Bluewater Health Finance team for their work on the Foundation’s audit. There were no questions, concerns or comments.

6.0 POLICY FORMATION - None 7.0 OPEN FORUM - There was no discussion.

Bluewater Health – Open Meeting May 27, 2020 Page 7 ____________________________________________________________________________ 8.0 IN-CAMERA MEETING AGENDA ITEMS

Paul reported on the items to be covered in camera including decisions about Board succession planning, Professional Staff credentialing and information updates about Director and executive expenses, banking arrangements, procurement for audit services, CEO and COPS emergency succession planning, and CEO and COPS performance evaluation process.

9.0 ADJOURNMENT – Next Meeting: June 24, 2020 Motion duly made, seconded and carried: to adjourn the meeting at 6:17 pm. ________________________ ____________________________ Paul Wiersma Mike Lapaine Chair Secretary Board of Bluewater Health Board of Bluewater Health

________________________ Melissa Rondinelli Senior Executive Assistant, Recorder

TO: The Board of Bluewater Health, (the “Board”)

FROM: Mike Lapaine, President and Chief Executive Officer

DATE: June 11, 2020

RE: April 1, 2019 to March 31, 2020 (“the Applicable Period”)

On behalf of Bluewater Health (the Hospital), I attest to:

• the completion and accuracy of reports required of the Hospital pursuant to Bill 122, section6 of the Broader Public Sector Accountability Act, 2010 (BPSAA) on the use of consultants;

• the Hospital’s compliance with the prohibition in section 4 of the BPSAA on engaging lobbyistservices using public funds;

• the Hospital’s compliance with any applicable expense claims directives issued under section10 of the BPSAA by the Management Board of Cabinet;

• the Hospital’s compliance with any applicable perquisite directives issued under section 11.1of the BPSAA by the Management Board of Cabinet; and

• the Hospital’s compliance with any applicable procurement directives issued under section12 of the BPSAA by the Management Board of Cabinet, during the applicable period.

In making this attestation, I have exercised care and diligence that would reasonably be expected of a President and Chief Executive Officer in these circumstances, including making due inquiries of Hospital staff and those of our procurement agency, TransForm Shared Service Organization that have knowledge of these matters.

I further certify that any material exceptions to this attestation are documented in the attached Schedule A. Dated at Sarnia, Ontario this 11th day of June, 2020.

Mike Lapaine President and Chief Executive Officer, Bluewater Health

I certify that this attestation has been approved by the Board of Bluewater Health on this June 24, 2020.

Paul Wiersma Chair of the Board, Bluewater Health Prepared in accordance with section 15 of the Broader Public Sector Accountability Act, 2010 (BPSAA)

SCHEDULE A to Attestation

1. Exceptions to the completion and accuracy of reports required in section 6 of the BPSAA on the use of consultants;

No known exceptions 2. Exceptions to the Hospital’s compliance with the prohibition in section 4 of the

BPSAA on engaging lobbyist services using public funds; No known exceptions

3. Exceptions to the Hospital’s compliance with the expense claims directive issued under section 10 of the BPSAA by the Management Board of Cabinet;

No known exceptions

4. Exceptions to the Hospital’s compliance with the perquisites directive issued under section 11.1 of the BPSAA by the Management Board of Cabinet; and

No known exceptions

5. Exceptions to the Hospital’s compliance with the procurement directive issued under section 12 of the BPSAA by the Management Board of Cabinet.

No known exceptions

Name of Hospital: Bluewater HealthLHIN: ESC LHINReporting Period: April 1, 2019 to March 31, 2020

SiteConsultant Firm

Name(s)

Name and Title of Consulting Contract

Contract Term (If the contract term has been extended, please include the

original contract term and the amended contract term)

Procurement Value(A) Original value plus

(B) Value of amendments and© Total procurement value

($) / Total Paid

Consultant Selection Process(Open Competitive,

Invitational Competitive, Non-competitive)

If non-competitive, please provide an explanation

Modifications to Agreement (Yes/No)

If Yes, did the procurement documents permit

modifications to the term or value of the agreement?

BWHAviotec

International

Surface Level Heliport Feasibility

StudyMarch 25, 2019 - July 31, 2019 10,700.00$ Invitational Competitive No

BWHCorpus Sanchez

International (CSI) Consultancy Inc.

Facilitation Services

September 18, 2019 - March 31, 2020

88,820.00$ Invitational RFS - Second Stage

Selection process via MGCS VOR

No

Hospital Report on Consultant Use

Resource Utilization and Audit Committee (RUAC) June 11, 2020

Highlights Human Resources Quarterly Report The Committee was informed Human Resources’ focus has been on the utilization of employees through the COVID-19 pandemic. Staff have been re-deployed to other departments/units within the hospital, including the COVID unit, and/or sent to assist in nursing homes. Some staff were cross-trained to work in the other units. The ONA central arbitration award was settled. The award aligns with the Protecting a Sustainable Public Sector for Future Generations Act. Occupational Health and Safety Program Report The Committee received an update on the 2019-20 influenza vaccination rates for staff and physicians, and the work undertaken to address workplace violence. The Committee was informed new software has been implemented to capture the influenza vaccination rates automatically and a Violence Prevention Committee was established to identify trends, best practices and make recommendations to mitigate incidents. Accessibility for Ontarians with Disabilities Act (AODA) Annual Report The Committee received an update on the initiatives undertaken in 2019 in accordance with AODA; in particular: ensuring patient information and pamphlets are available in an accessible format for the visually impaired; improved signage at both sites; and improved lighting in Registration. The Committee was informed an additional Patient Experience Partner (PEP) was added to the Accessibility Advisory Committee and that their input has been valuable. The Committee does its own audits throughout the year to address concerns received from the public, patients and/or their families. The 2019 Accessibility Compliance Report was submitted to the Ministry. Annual Insurance Coverage The Committee received an update on the hospital’s insurance coverage with the Healthcare Insurance Reciprocal of Canada (HIROC). BWH’s coverage aligns to peer hospitals of similar size. Updates to cyber-security coverage were also highlighted. In addition, the following items will be coming forward separately for Board approval/discussion:

- Auditor’s Report and 2019-20 Financial Statement - Appointment of the Audit Firm - Facilities Quarterly Report - Whistleblower Report - Revised 2020-21 Operating Plan - Service Accountability Agreements - Monthly Financial Statement - Broader Public Sector Accountability Act (BPSAA) Compliance – Consultant

Use/Allowable-Perquisites - Balanced Scorecard

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

1


Name of Committee: Board of Directors Date of Meeting: June 24, 2020 Submitted by: Marlene Kerwin Subject: Revised 2020-21 Operating Plan Purpose of Report: Information Input Approval

Situation The hospital has received 2020-21 funding confirmation and as such a revised Operating Plan for 2020-21 with this new information requires Board approval. Background In the fall of 2019, the Finance Department developed budget envelopes for each department to identify efficiencies and savings to offset inflationary increases. The projected revenue assumed no increase to global funding as none had been announced to date by the Ministry. Program Directors worked with their physician leaders and front-line managers to review their programs and identify efficiencies and cost saving opportunities. Analysis/Considerations Bluewater Health submitted a preliminary Expenditure Plan to the Resource Utilization and Audit Committee (RUAC) in March 2020 showing a planned deficit of approximately $1.96 million for the 2020-21 fiscal year. The preliminary Expenditure Plan did not incorporate final funding information related to global funding, quality-based procedure funding, etc. (Appendix B). These adjustments and other minor revisions have now been incorporated and the hospital is proposing a revised 2020-21 Operating Plan with a surplus of approximately $434,000. The revised operating plan is attached in Appendix A. The summary of changes is outlined in the below table:

x

2

Preliminary Operating Deficit $(1,955,005) New 1% Ministry Funding Global Funding $1,442,493 Growth & Efficiency Model (GEM) Funding $917,422 Net Increase in QBP Funded Volumes $191,635 Additional Expense for Geriatrician Program ($120,000) Other Net Funding Reductions (One-Time) ($42,968) Revised Operating Surplus for 2020/21

$433,577

The 2020/21 Hospital Accountability Planning Submission (HAPS) document will be submitted to match the Board approved revised Operating Plan. Recommendation The Board endorse the 2020-21 proposed operating plan as presented and that this revised plan will be used to populate the Hospital Accountability Planning Submission.

2020/21 Operating PlanBluewater Health

Revenue $

Ministry of Health Revenue 149,861,488 152,703,229 152,110,384 155,407,864 2,704,635 CCO Revenue 7,890,666 8,271,027 8,763,233 8,763,233 492,206 Paymaster Funding 1,293,495 1,326,405 1,311,364 1,311,364 (15,041) OHIP Revenue 13,775,293 14,119,974 14,863,493 14,863,493 743,519 Patient Revenue - Other 1,410,900 1,667,070 1,711,100 1,711,100 44,030 Room Differential 2,469,000 2,952,960 2,855,000 2,855,000 (97,960) CC Co-Payment 434,000 508,833 483,000 483,000 (25,833) Recoveries-External 2,617,176 4,550,857 2,763,426 2,763,426 (1,787,431) Parking Revenue 997,000 1,004,110 1,062,000 1,062,000 57,890 Other Revenue 236,029 299,533 292,029 292,029 (7,504) Deferred Equipment Grants 2,664,474 2,525,574 1,741,228 1,741,228 (784,346) Interest and Donations 100,000 99,992 100,000 100,000 8

Total Revenue $ 183,749,521 190,029,564 188,056,257 191,353,737 1,324,173 1,324,173

Expenses $

Salaries & Wages 92,066,925 92,479,246 92,405,672 93,287,436 808,190 Medical Staff Remuneration 21,917,079 22,949,190 23,105,214 23,225,214 276,024 Employee Benefits 24,911,188 25,744,007 26,362,245 26,380,883 636,876 Employee Future Benefits 300,000 451,954 400,000 400,000 (51,954) Utilities, Buildings & Grounds 4,194,270 3,735,918 3,524,270 3,524,270 (211,648) Equipment Expense 6,693,817 7,242,736 6,619,275 6,629,275 (613,461) Supplies & Expense 10,547,873 11,527,566 12,069,497 11,947,393 419,827 Contracted Out Service 3,747,613 3,924,905 3,924,483 3,924,483 (422) Medical/Surgical Supplies 8,687,504 8,885,217 9,062,152 9,062,152 176,935 Drug Expense 6,228,291 6,992,594 7,207,741 7,207,741 215,147 Interest Expense 311,793 270,169 339,117 339,117 68,948 Amortization Expense 5,842,473 5,243,413 5,331,278 5,331,278 87,865

Total Expense $ 185,448,826 189,446,915 190,350,944 191,259,242 1,812,327

Hospital Operating Surplus/(Deficit) $ (1,699,305) 582,649 (2,294,687) 94,495 (488,154)

Net Marketed Services Surplus/(Deficit) 390,396 202,696 339,082 339,082 136,386

Net Other Votes Surplus/(Deficit) - 100,006 - - (100,006)

Ministry Operating Surplus/(Deficit) $ (1,308,909) 885,351 (1,955,605) 433,577 (451,774)

NOTES

1

2

3

The Ministry Funding increase consists of Surge Funding ($726K), 1% Growth ($1.44M) GEM Allocation ($917K), QBP Funding ($191K), and other 1x funding adjustments.

Increased Salaries Expense to match Surge Funding and other 1x funding with anticipated spending required.

Increased Med Staff Remuneration by $120K for hospital contribution towards Geriatrician until AFA is finalized.

Appendix A

19/20 Annual Budget 19/20 Year-End Actual 20/21 Preliminary Operating Plan

20/21 Revised Operating Plan

Variance from 19/20 Year-End Actual

Statement of Revenue and ExpenseSurplus/(deficit) as at April 30, 2020(000's)

Annual April April April April Prior Year Variance NotesBudget YTD YTD YTD YTD % YTD from

Budget Actual Variance Variance Actual Prior Year

Revenue $

Ministry of Health Revenue 155,408 12,706 12,666 (40) 0% 12,292 375 1Cancer Care Ontario Revenue 8,763 720 730 10 1% 733 (3) 2Paymaster Funding 1,311 108 105 (3) -3% 103 2 OHIP Revenue 14,863 1,222 470 (752) -62% 1,135 (665) 3Patient Revenue - Other 1,711 141 80 (60) -43% 197 (117) 4Room differential 2,855 235 69 (166) -71% 227 (158) 5Co-payment 483 40 21 (19) -47% 43 (21) External Recoveries 2,763 211 84 (126) -60% 185 (100) 6Parking Revenue 1,062 87 79 (8) -9% 123 (43) Other Revenue 292 24 (0) (24) -100% 3 (3) Deferred Equipment Grants 1,741 143 131 (12) -8% 191 (60) Interest and Donations 100 8 10 1 17% 8 2

Total Revenue $ 191,354 15,644 14,446 (1,198) -8% 15,240 (793)

Expenses $

Salaries and Wages 93,287 7,751 8,220 (469) -6% 7,877 (343) 7Medical Staff Remuneration 23,225 1,896 1,541 355 19% 1,784 243 3Employee Benefits 26,381 2,311 2,206 105 5% 2,221 15 Employee Future Benefits 400 33 52 (19) -58% 29 (23) Utilities, Buildings & Grounds 3,524 273 304 (30) -11% 327 23 Equipment Expense 6,629 520 519 1 0% 570 50 Supplies and Expenses 11,947 983 749 234 24% 933 184 8Contracted Out Services 3,924 323 261 61 19% 308 47 Medical/Surgical Supplies 9,062 745 270 475 64% 815 545 9Drug Expense 7,208 593 571 22 4% 600 30 Interest Expense 339 28 17 11 39% 21 4 Amortization 5,331 373 307 67 18% 396 89

Total Expenses $ 191,259 15,829 15,017 812 5% 15,881 864

Hospital Operating Surplus/(Deficit) $ 94 (185) (571) (385) n/a (642) 71

Net Marketed Service Surplus/(Deficit) 339 27 35 9 32% 6 29

Net Other Vote Surplus/(Deficit) - (9) - 9 n/a - -

LHIN Operating Surplus/(Deficit) $ 434 (167) (536) (368) (636) 100

Deferred Building Grants 8,993 739 753 14 2% 746 7 Building Amortization (10,817) (889) (877) 12 -1% (870) (8) Interest on L/T Liabilities (96) (8) (4) 4 -54% (6) 2

Operating Surplus/(Deficit) $ (1,487) (325) (664) (339) (765) 101

Notes to Financial StatementsApril 30, 2020 Actual

Note 1

Note 2

Note 3

Note 4

Note 5

Note 6

Note 7

Note 8

Note 9

Bluewater Health has a deficit of $536K at the end of April 2020. This is higher than the budgeted deficit of $368K. The majority of the negative variance pertains to lost revenue due to COVID 19. The hospital also had a negative variance in salaries and wages in April 2020 which contributes to the negative budget variance. The overall impact of COVID with lost revenue and additional incremental expense for the hospital in the month of April is approx. $1M. The hospital reports incremental COVID expenses monthly to the Ministry for potential reimbursement.

Ministry of Health Revenue is under budget by $40K in April. This negative variance is attributed to pacemaker volume achievevement compared to budget. The pandemic has impacted volume of pacemakers the hospital is able to perform. QBP funding has been recognized to align with budget for the month of April. The achievement of QBP volumes will potentially be impacted by COVID and the hospital's ability to reestablish services.

Bluewater Health does OHIP billings for various physician groups. There is an offsetting Med Staff Remuneration expense for these billings. OHIP Revenue is under budget by $752K in April and down $665K compared to April of 2019. The significant drop is a direct impact of COVID 19. The reduction of services has impacted OHIP Professional Fees & Technical Fees. The reduction of Professional Fees has a corresponding underage in Med Staff Remuneration expense. The reduction of Technical Fees is lost revenue to the hospital.

Patient Revenue - Other is a combination of WSIB Revenue, Revenue from Other Provinces, Revenue from Non-Residents, and Revenue paid directly by Patients. In April, these revenues were under budget by $60K and down $117K compared to April 2019. The reduction of this revenue is attributed to COVID 19 and the reduction of services and occupancy within the hospital during the month.

Bluewater Health receives CCO funding for Oncology Drugs, QBPs, and the Ontario Breast Screening Program. For April, Bluewater Health recognized QBP funding to align with budget for Cancer Surgeries, Endoscopy and the Oncology program. The achievement of QBP volumes will potentially be impacted by COVID and the hospital's ability to reestablish services.

Supplies and Expenses are under budget $234K in April and down $184K compared to April 2019. The reduction in expenditures is due to COVID 19 with the reduction of services within the hospital.

Room Differential revenue is under budget $166K and down $158K compared to April 2019. The reduction of this revenue is attributed to COVID 19 and the lower occupancy within the hospital during the month.

Salaries are over budget by $469K in April and have increased by $343K compared to April 2019. Although occupancy is lower within the hospital, the staffing costs are higher than budget due to sick time and the necessary redeployment of staff due to COVID 19.

Med/Surg supplies are under budget $475K in April and down by $545K compared to April 2019. The hospital has incurred additional incremental med/surg supply costs per patient with the increased requirement for personal protective equipment (PPE). The drop in patient activity, most significantly in the Operating Room, is contributing to this postive variance. As the hospital reestablishes services, it is anticipated that there will be a signficant increase in med/surg supply costs.

External Recoveries are under budget $126K in April and down by $100K compared to April 2019. The reduction of services as a result of COVID 19 is the largest contributing factor to this negative variance.

Balance SheetAs at April 30, 2020Comparison to April 30, 2019(000's)

% Change

Assets

Current AssetsOperating Cash $ 6,277 5,914 6%Short-Term Investments 247 550Investments - CEE Site 690 745 -7%Accounts Receivable 4,449 6,170 -28%Accounts Receivable - MOHLTC 126 168 -25% Inventories 1,204 788 53%Prepaid Expenses 1,765 1,912 -8%

Total Current Assets 14,759 16,246 -9%

Fixed AssetsLand and Land Improvements 7,446 7,446Building/Building services Equipment 338,131 334,932Furniture and Equipment 80,852 78,487Less: Accumulated Amortization (192,401) 234,028 (178,845) 242,020 -3%Construction in Progress 1,530 1,424 7%Other Non Current Assets 368 413 -11%

Total Fixed Assets 235,927 243,857 -3%

Total Assets $ 250,685 260,103 -4%

Current LiabilitiesAccounts Payable 1,817 2,755 -34% Accounts Payable - MOHLTC 823 387 113%Accrued Salaries & Vacation Pay 10,768 10,031 7%Current Portion - Long Term Debt 1,065 1,040 2%Other Liabilities 7,184 7,495 -4%

Total Current Liabilities 21,657 21,709 0%

Long Term LiabilitiesLong Term Bank Loans Payable 675 1,836 -63%Deferred Revenue 203,356 210,821 -4%Post Employment Benefits 15,269 15,438 -1%Other L/T Liabilities 660 644 2%

Total Long Term Liabilities $ 219,960 228,739 -4%

EquityOpening Equity 9,732 10,421R&E Surplus/(Deficit) (664) (765)

Total equity 9,068 9,655 -6%

Total Liabilities and Equity $ 250,685 260,103 -4%

Hospital Accountability Agreement Indicators: Negotiated Target

Current Ratio 0.65 0.71 0.74

Adjusted Working Capital (1,193)$ 783$ -$

Note: Current ratio excludes CEEH Site Investments

Adjusted Working Capital is calculated using the definition of the Working Capital Funding Initiative

2020/21 2019/20Actual ActualApr-20 Apr-19

FOI

Italics

*

ⱡ

Q1 20/21

JAN

19

FEB

19

MAR

19

APR

19

MAY

19

JUN

19

JUL

19

AUG

19

SEP

19

OCT

19

NOV

19

DEC

19

JAN

20

FEB

20

MAR

20

APR

20Report

Period YTD

1 SarniaQIP/

P4R

25.7

hrs

14.2

hrs

<=13.9

hrs12.9 18.2 17.2 11.3 13.6 15.9 19.0 15.4 7.8 11.7 15.0 8.7 14.8 14.6 7.5 3.5

Jan -

Dec9.8 t

2 SarniaSP/

NOW

9.6

hrs

4.9

hrs ⱡ 2 hrs 5.1 6.5 6.2 4.1 4.6 5.3 6.5 4.8 3.5 4.2 4.8 3.5 4.5 4.6 3.7 1.9

Jan -

Dec3.8 t

5 HSAA 12.7% 13.6% 13.6% 17.0 14.5 13.3 16.5 14.1 12.4 11.9 13.1 12.3 15.2 14.0 9.1 10.6 12.2 14.2 14.8Jan-

Dec12.7% t

6 SP 2.8 3.34 3.03Jan-

Dec0

7 All Acute QIP 6466.0 6,626.0 5,251.0 879.1 793.9 855.1 701.8 700.0 685.4 756.7 587.7 734.8 618.3 783.2 658.9 948.3 729.5 694.0Apr-

Mar8,598.6 t

8 SP $5,431 $6,052 $5,800Apr-

Mar$6,197 t

9 $14,121 $14,493 $13,930Apr-

Mar$13,765 t

Petrolia n/a $97 $94 $89 $90 $90 $99 $97 $99 $95 $94 $94 $95 $96 $97 $97 $97 $100 $334Apr-

Mar$334 t

Sarnia n/a $156 $150 $150 $151 $149 $153 $164 $159 $150 $154 $154 $154 $156 $156 $157 $158 $162 $293Apr-

Mar$293 t

11 $637 $552 $566Apr-

Mar$598 t

12 $327 $367 $318 $321 $321 $326 $402 $400 $375 $370 $367 $378 $373 $366 $367 $368 $362 $359 $468Apr-

Mar$468 t

13 n/a ($359) $0 $78 $476 $847 $175 -$33 -$104 -$100 -$419 -$359 -$611 -$391 -$449 -$504 -$885 -$369 $0Apr-

Mar$0 t

14 n/a ($105) $434 -$654 -$663 $127 -$642 -$1,038 -$1,579 -$1,452 -$1,028 -$791 -$1,277 -$1,536 -$1,347 -$1,581 -$2,569 $885 -$536Apr-

Mar-$536 t

15 HSAA n/a $1,512 $0 $2,490 $2,982 $1,048 $783 $349 -$305 $951 $844 $1,512 $1,219 $844 $481 $806 $26 -$741 -$1,193Apr-

Mar-$1,193 t

16 n/a 17% 100% 54 56 62 1 1 2 9 13 17 18 24 26 45 48 53 18Apr-

Mar18% t

3.26

Focus on the experience of care and caring

Demonstrate accountability and efficiency

Gross Conservable Days 0

$6,052Our overall expenses for this indicator have increased by $968K

compared to Q3 18/19 and our weighted cases have decreased by

248 cases for the same period.Cost per

Weighted Case

(Actual YTD)

$6,197

$14,493Rehab Inpatient

(4% of overall activity)

Emergency Department Cost per VisitBaseline = $156, Nov result $156.02, Dec result $155.77

Our overall expenses for this indicator have decreased by $371K

compared to Q3 18/19 and our weighted cases have increased by

6 cases for the same period. The expected CPWC for Rehab for

19/20 is $13,595.

$14,134

QBP Financial Exposure (Potential lost revenue related

to QBP achievement) Actual YTD in 000s

Adjusted Working Capital Actual YTD in 000s

Ensure continuous investment in strategic infrastructure

$635

Surplus/(Deficit) Actual YTD in 000s

Our overall expenses for this indicator have decreased by $58K

compared to Q3 18/19. The weighted patient days have increased

by 990 weighted days for the same period.

Mental Health Inpatient Cost per Patient Day

% of Capital Budget Spent Actual YTD

$552Continuing Care Cost per Weighted Patient Day

#

Build sustainable partnerships and collaborations

90th Percentile Time to Inpatient Bed

Q3 19/20YTD

PerformanceQ2 19/20

Acute Inpatient & Day Surgery (53%

of overall activity)$5,911

3.05 3.34

Target Trending

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

Average Time to Inpatient Bed

Improve access to care

Q4 19/20

Meets/Exceeds Target

Meeting baseline but not meeting target

Performance not meeting baseline

Data Unavailable

Q4 18/19

Resource Utilization & Audit Committee Performance Scorecard

REF

. Q1 19/20

Masked due to n size <5

n size between 5 - 29

no established target

corporate target

Key Performance Indicators

Pee

r

Co

mp

arat

or

De

sire

d

Tre

nd

ing

UP

DA

TED

CommentsBaseline

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

2.973.12

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

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

ALC Rate - All Inpatient Services

(Sarnia and Petrolia)

$13,765

$598

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

10

Quality Committee Highlights June 15, 2020

The Quality Committee discussed the following items that will come forward separately for Board discussion:

- Quality & Patient Safety Plan - Integrated Risk Management as it relates to the activities and work of COVID-19

pandemic - Balanced Scorecard

Submitted by: Brian Knott Chair, Quality Committee of the Board

FOI

Italics

*

ⱡ

Q1 20/21

JAN

19

FEB

19

MAR

19

APR

19

MAY

19

JUN

19

JUL

19

AUG

19

SEP

19

OCT

19

NOV

19

DEC

19

JAN

20

FEB

20

MAR

20

APR

20Report

PeriodYTD

1 SarniaQIP/

P4R

25.7

hrs

14.2

hrs

<=13.9

hrs12.9 18.2 17.2 11.3 13.6 15.9 19.0 15.4 7.8 11.7 15.0 8.7 14.8 14.6 7.5 3.5

Jan -

Dec9.8 t

2 SarniaSP/

NOW

9.6

hrs

4.9

hrs ⱡ 2 hrs 5.1 6.5 6.2 4.1 4.6 5.3 6.5 4.8 3.5 4.2 4.8 3.5 4.5 4.6 3.7 1.9

Jan -

Dec3.8 t

Sarnia P4R34.2

hrs

20.8

hrs

<=20

hrs20.3 25.5 24.1 18.6 19.5 22.6 26.3 21.2 15.8 17.6 21.6 16.3 21.6 19.9 16.4 9.9

Jan-

Dec16.9 t

Petrolia19.4

hrs

7.6

hrs

7.5

hrs5.0 6.1 7.3 10.3 6.1 7.9 11.6 7.5 5.1 8.6 8.9 11.3 9.3 7.6 8.6 6.1

Jan -

Dec8.3 t

4 n/a 5 0Jan-

Dec1 t

5 HSAA 12.7% 13.6% 13.6% 17.0 14.5 13.3 16.5 14.1 12.4 11.9 13.1 12.3 15.2 14.0 9.1 10.6 12.2 14.2 14.8Jan-

Dec12.7% t

Sarnia HSAA 19.0% 16.5% 16.2%Apr -

Mar15.3%

Ages 12-25

yrs.QIP 16.4% 16.1%

Apr-

Mar13.4%

7 12.4% 12.8% 12.1%Jan-

Dec13.6%

8 QIP 19.2% 21.3% 16.4% 0Jan-

Dec16.4%

ED n/a 51.8% 52.0% 47.0 49.2 52.3 53.1 53.4 42.9 53.5 52.2 61.0 66.7 56.8 43.1 46.2Jan-

Dec46.2% t

Inpatient

Med/Surg65.7% 70.8% 72.2% 64.1 62.8 71.4 81.4 66.7 73.6 73.4 72.3 70.0 60.5 74.0 72.0 69.6

Jan-

Dec69.6%

ED 82.9% 84.1% 85.0% 78.5 75.4 86.4 80.4 87.9 92.0 88.7 83.1 85.2 92.7 80.4 77.0 75.6Jan-

Dec75.6% t

Inpatient

Med/Surg56.3% 57.5% 58.0% 47.6 54.8 56.1 65.2 61.7 63.0 52.4 62.9 56.7 56.1 63.3 65.4 54.5

Jan-

Dec54.5%

11Inpatient

Med/SurgQIP n/a n/a n/a

ED n/a 66.7% 68.0% 66.2 68.9 56.8 67.3 67.2 69.4 62.5 67.6 71.2 69.8 60.9 62.7 73.2Jan-

Dec73.2% t

All Inpatient n/a 82.0% 83.6% 76.0 76.7 88.0 83.1 83.9 73.9 87.2 85.9 78.8 77.3 92.3 79.2 91.7Jan-

Dec91.7% t

13 QIP n/a 335 * 35 33 41 27 28 18 22 8 17 28 46 32 26 50 25 18Jan-

Dec119 t

14 All Acute QIP 6466.0 6,626.0 5,251.0 879.1 793.9 855.1 701.8 700.0 685.4 756.7 587.7 734.8 618.3 783.2 658.9 948.3 729.5 694.0Apr-

Mar8,598.6 t

Overall Incidents of Workplace Violence

6

9

10

12

Positive score = 9 - 10

16.5 14.1This is preliminary data and subject to change

15.5

2 2 1

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

Total High Severity Patient Safety Incidents

(Level 4 - 5)

15.714.79.417.9

ALC Rate - All Inpatient Services

(Sarnia and Petrolia)

0 1

Repeat Visits to ED within 30 days for

Mental Health condition

Collecting internal data for this question within our patient and

family phone call survey.

Strengthen Patient and Family-Centred Care

Readmission with 30 days for COPD

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

Leaving hospital did patients receive

enough information - Internal Survey

Positive score = Completely; Jan n size: 22

Positive score = Yes, definitely

Was patient/family treated with kindness

Positive score = Yes

10.8

Leaving hospital did patients receive

enough information - NRC Health Survey

SP

16.5

15.8

Meets/Exceeds Target

Meeting baseline but not meeting target

Performance not meeting baseline

Data Unavailable

Q4 18/19

Quality Committee Performance Scorecard

REF

. Q1 19/20

Masked due to n size <5

n size between 5 - 29

no established target

corporate target

Key Performance Indicators

Pee

r

Co

mp

arat

or

De

sire

d

Tre

nd

ingQ4 19/20

UP

DA

TED

#

Q2 19/20

TargetBaseline CommentsTrending

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

Average Time to Inpatient Bed

Improve access to care

Build sustainable partnerships and collaborations

Ingrain patient safety

3

90th Percentile Time to Inpatient Bed

90th Percentile ED Length of Stay (LOS)

(Admitted Patients)

Q3 19/20YTD

Performance

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

facility; excluding short-stay assessments

This is preliminary data and subject to change

Positive score = Yes, definitely; Jan n size: 24

9.3

This indicator tracks the total number of incidents reported

organization wide. Collecting baseline

Focus on the experience of care and caring

Demonstrate accountability and efficiency

Gross Conservable Days 0

SP

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

Overall Rating of Experience

12.830-Day Mental Health Readmission 15.2

24.5

13.1

Positive score = 9 - 10; Jan n size: 23

Chief of Professional Staff Report to the Board

June 2020

At the Medical Advisory Committee meeting held on June 17, 2020, the following items were discussed: Quality Improvement Initiatives

Approved recommendations from the Pharmacy and Therapeutics Committee, Patient Order Sets Committee and recommendations made to the Incident Management/Command Centre from the Infection Prevention and Control Committee during the pandemic

Approved the Leaving Against Medical Advice Policy for the Emergency Department

Discussed / reviewed / received updates on:

o Development of a hospital-wide policy for patients leaving against medical advice

o Ambulatory care usage o COVID-19 pandemic and process to re-establish services

Implemented a COVID-19 molecular testing rule for Professional Staff who are working at Bluewater Health and other hospitals, in high risk areas, such ICU, Anaesthesia, or Emergency: If Regularly working at Bluewater Health in the above identified high risk units, as well as working at another hospital, then required to be tested every 4 weeks

If only occasionally working at Bluewater Health, then required to be tested 3-5 days pre-shift

o MAC scorecard, quarterly o QCR recommendations o Budget and funding o Plasma trial for Covid-19

Physician Representation on Committees

Appointed a new surgical physician representative to the Infection Prevention and Control Committee

Physician Education, Development and Engagement

Exploring options on how to offer PLI course – Building and Leading Teams

Recruitment/Succession Planning Several specialists will be starting in July, including an orthopaedic surgeon, neurologist, internal medicine specializing in geriatrics, obstetrician/gynaecologist, radiologist and four Emergency physicians. Recruitment efforts continue for a pathologist, cardiologist, otolaryngologist, neurologist, psychiatrists, anaesthesiologists, paediatricians, hospitalists, etc.

Dr. Gidwani is retiring at the end of June after practicing at Bluewater Health since 1970. He has served as the Medical Director of the Department of Laboratory Medicine since 1973. Dr. Gidwani told the MAC that he has enjoyed every year of practice, and has given his dedication to achieving the highest quality for patients. The MAC thanked Dr. Gidwani for his service and wished him the best in retirement. Linkages with Western University Medical Student clinical rotations will begin again in July. Submitted by: Michel Haddad, MD, MSc, FRCSC Chief of Staff, Bluewater Health

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