BOARD OF DIRECTORS MEETING OPEN SESSION Thursday, … · 2020. 6. 3. · Dr. Algie reported the...

BOARD OF DIRECTORS MEETING

OPEN SESSION

Thursday, January 25, 2018

5:30 pm – Hot Buffet Dinner Provided – La Verendrye General Hospital

6:00 pm – La Verendrye General Hospital – Board Room

A G E N D A

Item Description Page

1. Call to Order – 6:00 pm – Reading of the Mission Statement *

1.1 Quorum

1.2 Conflict of Interest and Duty

2. Presentation – LHIN Sub-region Planning – Tracy Stevenson3. Patient / Resident Safety Moment4. Consent Agenda

4.1 Board Minutes – November 23, 2017 *4.2 Chair’s Report – No Report4.3 President & Chief Executive Officer Report – T. Scholten *4.4 Health Services Report – L. Maki *4.5 Operations Report – H. Gauthier *4.6 Long Term Care Report – M. Griffiths *4.7 Chief of Staff & President of the JMS Report – Dr. R. Algie/Dr. L. Jenks *4.8 Governance Committee Report – J. Ogden *4.9 Audit & Resources Committee Report – C. Sanders *4.10 Quality Safety Risk Committee Report – S. Weir *4.11 Riverside Foundation for Health Care Report *4.12 Auxiliary Reports *

5. Motion to Approve the Agenda

6. Business Arising

7. New Business7.1 Board Chair – Verbal Report7.2 Health Hub Update *7.3 CAC Update *

8. Opportunity for Public Participation

9. Move to In-Camera

10. Other Motions/Business

11. Date and Location of Next Meeting: February 22, 2018

12. Adjournment

* denotes attached in board package

**denotes circulated under separate cover

*** denotes previously distributed

Board of Directors - Open Session January 25, 2018 1 of 68

Pg 4

Pg 8Pg 10Pg 12

Pg 15Pg 16

Pg 17Pg 48

Pg 51Pg 55

Pg 62

Pg 67Pg 68

BOARD OF DIRECTORS MEETINGANTICIPATED MOTIONS – OPEN SESSION

Thursday January 25, 2018

5. Motion to Approve the Agenda THAT the RHC Board of Directors approve the Agendaas circulated/amended

9. Move to In-Camera THAT the RHC Board of Directors move to in camerasession at (time)

10. Other Motions/Business

12. Adjournment THAT the RHC Board of Directors meeting beadjourned at (time)


H


Minutes of the Open Board Meeting – November 23, 2017 Page 1

RIVERSIDE HEALTH CARE FACILITIES INC.MINUTES

OPEN SESSION

Date of Meeting: November 23, 2017 Time of Meeting: 6:00 pm

Location of Meeting: Rainycrest Long Term Care – Board Room

PRESENT: J. Beazley J. Ogden V. Nowak T. ScholtenD. McDonald C. McKinnon J. Forbes D. RobinsonDr. L. Jenks Dr. R. Algie S. Weir C. Sanders*via OTN/teleconference

STAFF: M. Griffiths, B.Booth, L. Maki,

REGRETS: H. Gauthier

GUEST: J. Buffinton, Dr. R. Green

1. CALL TO ORDER:

J. Beazley called the meeting to order at 6:00 pm. B. Booth recorded the minutes of this meeting.D. McDonald read the Mission Statement. Jan welcomed Marva to the meeting.

1.1 Quorum

Jan shared there were no regrets. Quorum was present.

1.2 Conflict of Interest

Shanna and Dr. Algie noted they sit on the Health Hub which is being discussed later on the agenda.

2. Presentation – Physician Initiatives – Funding Initiatives/How Clinics Work – Dr. Algie & Dr. Jenks

Dr. Algie and Dr. Jenks provided a power point presentation on Physician Initiatives/How Clinics Work.Dr. Algie highlighted the following:

• Fee for service• Family Health Team – Dr. Algie noted Nelson Medicine is a Family Health Organization (FHO)• Non-fee for service• Primary care in Ontario• Focus services• Fee for service blended models – Dr. Algie shared this is how Dr. Moorhouse operates• Family health group• Family health networks• Salaried models – Dr. Algie noted Emo, Rainy River, and Atikokan fall under this group• # of enrolled patients by model• Physician bonuses• Rostering patients• Sources of income

Discussion took place regarding physicians selecting their patients. It was noted that ethically physiciansare not supposed to do this however some do.

Dr. Jenks discussed issues around recruiting new physicians into the FHO. Dr. Jenks highlighted thefollowing:

• Overhead fees• How the accounting piece and payment works• Emergency is paid hourly• Bonuses for being on-call (HOCC)

Item 4.1



• Recruitment• Building a new clinic and how/if this will impact overhead

Dr. Algie reported the main issues with recruitment are overhead fees and there is no guaranteed wage.We are competing with areas that can guarantee wages. Discussion took place around what RHC couldbe doing to help and it was noted to continue to support recruitment and locums. Further discussion tookplace around funding for physician recruitment.

Jan thanked Dr. Algie and Dr. Jenks for their presentation.

3. Patient / Resident Safety Moment

Jan welcomed Joy Buffington to the meeting who spoke about an issue regarding her mother. Loriprovided a history on the issue noting meetings have taken place. Joy shared her mother’s story notingshe currently resides in the hospital; however the hope is to have her moved to Rainycrest. Joydiscussed the barriers at Rainycrest noting the facility infrastructure will not accommodate her mother’swheelchair. Joy shared her mother’s limitations. Lori noted risks and alternatives were discussed.Marva highlighted Ministry applications and shared they are looking at a smaller wheelchair. It was notedthat the deadline for Rainycrest to be brought up to code is 2025. Lori reported they will be following upwith Joy and her mother once further investigation is complete. Discussion took place around the need toaccommodate bariatric patients and around HIRF funding.

Jan thanked Joy for sharing her story and shared the Board looks forward to an update from SeniorLeadership in the future.

4. CONSENT AGENDA

The Chair asked if there were any items to be removed from the consent agenda to be discussedindividually. The following was removed:

• 4.9 Audit & Resources Committee Report

5. MOTION TO APPROVE THE AGENDA:

ADD: 7.7 Community Advisory Council (CAC)7.8 Audit & Resources Committee Report

6. BUSINESS ARISING:

There was no business arising.

7. NEW BUSINESS:

7.1 Welcome to Marva Griffiths

Ted welcomed Marva and provided a history of her experience. Marva thanked Ted for the opportunityand is looking forward to working with the team.

7.2 Auditor RFP

Ted reviewed the briefing note.

It was,

MOVED BY: D. Robinson SECONDED BY: D. McDonald

THAT the Board approves the Agenda as amended.CARRIED.



7.3 Health Hub Update

Ted reviewed the briefing note reporting all the documents were approved at the last Health Hub meeting.He shared the next meeting is December 5, 2017. Ted circulated and reviewed the meeting notes fromthe November 14, 2017 meeting. Ted confirmed that the committee worked with the LHIN on the contentof the documents. Jan highlighted the membership noting there is one group now and the SteeringCommittee no longer exists. Jan noted regular updates will be provided.

7.4 OHA Health Achieve Update

Jan noted there were 3 Board members that attended this session; Joanne, Cindy and herself as well asTed and some senior management. Joanne and Cindy provided an overview of the sessions. Cindyhighlighted the Effective Governance for Quality and Patient Safety session she attended and reviewedher power point presentation and reflective questions that she presented to the Quality, Safety, and Risk(QSR) Committee. Cindy also highlighted the session she attended on Porter Airlines noting theimportance of customer service. Jan thanked Cindy for her presentation and all the work she put into it.Jan shared we will be looking at some of the information discussed at the Effective Governance forQuality and Patient Safety session and how we can implement this into the QSR Committee.

Jan provided an overview of the Governance Session she chaired noting we need a strong Governancedecision making framework. She noted a small group will be formed to work on this which will flowthrough the Audit & Resources Committee. Jan discussed the new indicators that need to be addressedfor Accreditation.

Dr. Jenks highlighted the MOREOB

program noting this is about patient safety and the program has beenopened up to all staff and the focus is on communication.

7.5 Effective Governance for Quality & Patient Safety Update

Discussed with Item 7.4.

7.6 Board Quality Metrics – Q4 (October – December 2017)

Shanna reviewed the metrics noting indicator 2 was reviewed. She reported we did not meet the targetfor completing Board Evaluation surveys. Shanna shared on average 7 out of 9 members complete thesurveys which are done every second month. Shanna reminded all to complete the survey even if not inattendance reminding all that there is a question asking whether you attended. Shanna noted thatdiscussion will take place on what indicators will be evaluated in the future.

7.7 Community Advisory Council (CAC)

Jan reported only 3 applications have been received out of the 6 required. Discussion took place aroundoptions; advertise again, Board members approach individual people to recruit, or start the CAC withoutthe full 6 community members. It was decided by consensus to move forward and start the council inJanuary or February.

ACTION: Ted to follow up with individuals that were recommended by Board members.

It was,

MOVED BY: J. Ogden SECONDED BY: J. Forbes

THAT the Board of Directors approves that BDO Dunwoody be appointed auditor of theCorporation for 2017-18.

CARRIED.



7.8 Audit & Resources Committee Report

Discussion took place around the CEO Certificate of Compliance and the exception of the HST. Craigprovided clarification and Ted confirmed this is now complete and everything was submitted correctly.

8. OPPORTUNITY FOR PUBLIC PARTICIPATION

Jan welcomed Dr. R. Green. Dr. Green provided an overview of his experiences as a physician andshared he would like to be considered as a resource for the Board. He further noted he will submit someinformation on his background for consideration. Jan thanked Dr. Green for attending.

9. MOVE TO IN-CAMERA:

10. OTHER MOTIONS/BUSINESS:

There was no other motions/business.

11. DATE AND LOCATION OF NEXT MEETING:

January 25, 2018

12. ADJOURNMENT:

It was,

MOVED BY: J. Ogden

THAT the meeting be adjourned at 9:16 pm.CARRIED.

_______________________________ ___________________________________Chair Secretary/Treasurer

It was,

MOVED BY: D. McDonald SECONDED BY: J. Forbes

THAT the Board go in-camera at 7:32 pm.CARRIED.

It was,

MOVED BY: J. Forbes SECONDED BY: C. Sanders

THAT the Board of Directors approves the Audit & Resources Committee Report as discussed.CARRIED.


President & Chief Executive Officer Report - January 2018

Page 1

Strategic Pillars & Directions:

Quality

• General Practice Anesthesia (GPA) amendments to Alternate Funding Agreement between the OMA, the MOHLTC,and the GPAs are still pending although Dr. Nugent has relayed that the negotiations are close to completion.

• North West Health Alliance: Met Dec 11 as a full board including all CEOs as well as one community member. Thisshared service entity manages many regional initiatives and projects funded through Small Hospital TransformationFund. RHC, along with 2 other HSPs provided a submission for funding for Clinical Operational review, per NW LHINrequest. The submissions were not discussed as it was clarified that there was currently not any unused fundsavailable due to the allocations currently earmarked for NWHA IT needs. Much discussion with respect to subcommittees of the Alliance ensued. I particularly voiced my concern that as Governors, we should not be theoperational decision makers. Alliance Executive Director shared the plan was to formalize sub-committees that willoperationalize the process for informed decision making.

• Northwest Health Network: Met Dec 11 immediately following the NWHA. There was much discussion on thepossibility of combining the 2 Committees. For now the Alliance and NWHN will function independent of one anotherbut meetings will be back to back. Discussion on how the SHTF is managed and protocol for approval of allocating anyunspent funds to submissions followed.

Organizational Health

• Physician Recruitment Committee has been very active. An invite has been extended to Gizhewaadiziwin HealthAccess Centre to join the committee. A request for additional financial support was submitted to the Town of FortFrances. This led to Todd providing an update to the Economic Development Advisory Council (EDAC). They wereinformed of the current recruitment status, efforts to date, and previous requests for supporting funds frommunicipalities, and larger local corporations.

o In Fort Frances we are recruiting for three Primary Care Family Physicians and two GP Anesthetists (GP-A).A 2

ndGeneral Surgeon was secured in December 2017, allowing one of our local surgeons to retire. We have

a commitment from a Family Physician for the fall of 2018 and two additional promising prospects areconsidering one year commitments to Fort Frances beginning September 2018. However, one of thelongtime local physicians is retiring at the end of 2018.

Our GP-A needs remain critical. We have one full time GP-A covering 24/7 call, all obstetrics,general surgery and emergency. Our only community GP-A is supported by occasional locum GP-A’s. We have one GP-A interested in Fort Frances, he had a two week locum in the fall and isreturning for more time in spring 2018. Long term, our GP-A locums offer insufficient support forthe volume of services required. As noted above, the GP-A Alternate funding agreement remainsstalled in negotiations with the MOH, OMA and regional GP-A’s.

Our ER locum program is successful but stipend costs are depleting our recruitment resources.Our GP-A locum program, moderately successful, but is also impacting our budget with sametravel stipend costs being allocated to recruitment. We are exploring options to recoup essentialstipend and travel expenses with LHIN, HFO and MOHLTC.

o Emo has two full time Family Physicians providing office/clinic Monday to Friday, long term care and acutecare at the Emo Health Centre. With the expectation of retirement, Emo is recruiting for one full timeFamily Physician and does have some support with locum services.

o Rainy River has one full time Family Physician covering office/clinic Monday to Friday, 24 hour emergencyand long term care at the Rainy River Health Centre. Two physicians share coverage in Rainy River on a 7day-on rotation, supported by locums that cover the same time period. Rainy River should have two fulltime Family Physicians in the community. Currently both physicians practicing in Rainy River do not live inthe area and commute to cover their week of service.

o There is also an effort to establish a Northwestern Ontario Recruiter Network, with all recruiters fromNorthwestern Ontario working together. Planning session for this new approach to recruiting physicians toNorthwestern Ontario is set for January 2018. Committee will be well represented at an upcoming Healthand Human Resources Physician Recruitment Summit, January 24 where Todd Hamilton, Dr. Algie, Dr.Kowal, and I are attending. This is a joint effort supported by the NWLHIN, Health Force Ontario, and theNorthern Ontario School of Medicine.

o Revisions have been made to the Physician Return of Service Agreement

Item 4.3


President & Chief Executive Officer Report - January 2018

Page 2

o Todd to present an R&R Committee update at next Foundation meeting

• Communications Lead- Kathryn Pierroz joined our team on January 15, 2018. Kathryn brings over 15 years ofexperience in the private sector to this newly created position. In her previous employment Kathryn has held variouslevels of communications, marketing, and business development roles. In addition to her considerablecommunication and marketing experience Kathryn brings with her significant knowledge on social media outreachand development, project management practices, as well as employee and employer branding tactics.

Partnerships

• Rainy River District Sub Region Planning Table has held Initial Meeting of Committee Dec 14:

Objectives of the meeting were outlined as follows:1. To build trust and relationships among sub-region partners2. To set the context for change and provide an overview of planning process3. To discuss population health profile4. To discuss the current state of population health within the sub-region5. To begin to set the desirable future state for the sub-region population

Draft Terms of Reference (TOR) for the Committee were reviewed and many suggestions were provided. Of particularconcern was the draft TOR outlined that the committee was advisory and had no decision making authority. Feedback wasgathered and revised TOR to be circulated for review prior to approval at next meeting. Key characteristics of thepopulation were discussed as well as strengths, opportunities and challenges.

Goal for Future State: improved access to care, including access to primary care and mental health.Preliminary discussions regarding outcome metrics, identified need to develop lead/lag indicators (life expectancy,potential years lost, etc.), as well as need to focus on social determinants of health.

Respectfully Submitted,

Ted ScholtenPresident and CEO


Health Services and CNE Report – January 2018

Page 1

Strategic Pillars & Directions:Quality

• Failure Mode Effect Analysis (FMEA)

o Quality, Safety, Risk & Privacy Coordinator, nursing, switchboard and maintenance representatives havebeen performing a FMEA to address security issues, particularly as they arise in/out of the emergencydepartment at LVGH. Four of the six scheduled meetings have transpired, to date, and a number ofactions/opportunities have already been identified.

• Quality Based Procedure (QBP) Order Sets:o Effective December 22, 2017, Riverside received formal recognition and congratulations for our “go live”

with the Provincial Digital Quality-Based Procedures (QBP) Order Sets. Over the last several months, theQBP project team have been working diligently to prepare for this significant milestone. The followingdigital order sets are now live at RHC:

-Community Acquired Pneumonia Admission Order Set-Congestive Health Failure Admission Order Set-Chronic Obstructive Pulmonary Disease (COPD) Exacerbation Admission Order Set

• Riverside’s participation in the Provincial Digital QBP Order Sets Program is instrumental to bringing standardized QBPclinical best-practices to the bedside and improving care delivery for Ontarians. With the continued support of theThink Research Team, we will continue on our QBP journey. The next QBP Order Sets will be those for Cardiac CriticalCare Coronary Artery Disease, NSTEMI and STEMI Admission Orders.

Congratulations to Cindy Cole and Tammy McNally for their dedicated efforts in driving this initiative forward!


• Health Human Resourceso Hired a full time Mental Health Counsellor, commencing February 8, 2018o Interviewing for a Director, Community Counsellingo Pending interviews for Health System Navigatoro Posting of Clerk position at Riverside Community Counselling Services (pending retirement)o Occupational Therapist hired and commenced on January 11, 2018o Continue to recruit for a physiotherapist, as prospective recruit had declined the offer.

• SURGE Capacityo Since Christmas, our inpatient census at LVGH has been on a significant rise, requiring a high level of staffing

up on our first and second floor nursing units to meet the increased patient care demands and number ofadmissions. With our beds full to capacity, it has been necessary to admit patients to the emergencydepartment overnight, and also to cancel elective surgical procedures on one particular occasion. Theinfluenza outbreak at Rainycrest Long Term Care has further compounded our ability to move our ALCpatients to empty beds. This situational crisis has become more systemic and we have been engaging withour NW LHIN to obtain approval for category 1 crisis designation. A communications strategy is currentlybeing initiated for appropriate distribution.

• Capitalo Meetings with Directors/Managers to review capital requests and granting of preliminary approvals for

submission.

Partnerships

• Attended at the grand opening of Mino Ayaa Ta Win Healing Centre (Detox and Treatment) –December 1, 2017

• Health Hub meeting – December 5, 2017

• Meetings with Fort Frances OPP regarding Form 1 and security

• Sub region Planning meeting (full day) – December 14, 2017

• Confederation College Board of Governor’s Retreat (Thunder Bay) – January 9, 2018

• Confederation College Board of Governor’s meeting (Thunder Bay) – January 10, 2018

• Opioid Funding Strategyo Additional one-time funding opportunity offered by the NW LHIN, to be expended by March 31, 2018.

Riverside, in partnership with the RRDSSAB has requested funding to host one-time training for front line

Item 4.4


Health Services and CNE Report – January 2018

Page 2

staff, service providers and community stakeholders across the Rainy River District, related to offeringopioid training. This community based proposal provides an opportunity for a collaborative learning andeducational experience, as singularly, organizations are not in a position to deliver this robust learningopportunity within already limited financial and health human resources.

• Dietitian Serviceso A successful application by the Family Health Team, in partnership with RHC, has secured a 0.5 FTE dietitian.

Meetings have and are being held to determine how to best complement this position with dietitianservices at RHC, particularly with respect to inpatient, outpatient, long term care and other communityservice opportunities.

• North West Health Alliance (NWHA) Committeeso The NWHA reorganized its committee structure to provide enhanced guidance to the CEO Group; a primary

focus of this committee redesign was to extend regional resources across committees to lead to smallermore functional groups that would be more efficient in advancing regional change management. Thefollowing is a summary of the new committee representatives from RHC.

• Executive Steering Committee - Henry Gauthier & Lori Maki

• IT/IS Advisory Committee - Marie Brady

• IT Infrastructure Working Group – no representation

Thank you to the Clinical Services Managers and Directors for their invaluable assistance in preparing this report.

Respectfully submitted,

Lori MakiVice President, Health Services and CNE


Operations Report – January 2018


• RecruitmentRiverside successfully recruited a new Director, Human Resources and Financial and Statistical Officer. Jason Marchand

and Dawn Redford have joined our team at Riverside and interviews for the Human Resource Generalist position will

commence on January 18th

.

• Clinical Operational Review

KM&T provided a draft clinical operational review report at the end of September. After review by the RHC team, it wasdetermined that considerable rework of the report was required to meet RHC requirements. On November 1 the teammet with KM&T representatives to outline high level concerns with the report. Over the next month there was follow upwith KM&T and in December they issued a redesign of the first section of the report; further follow up occurred regardingthis section and KM&T was expected to deliver the balance of the revised report by the new year. To date, they haveindicated that they are still updating the report to meet our requirements and an amended report is expected by January18

th. At this juncture, there remain concerns around the timeliness and, more importantly, depth of the report in

meeting the deliverables outlined in our RFP.

• Performance ConversationsThe 2016 Performance Conversation compliance rate was 63% with the Rainycrest Director of Care portfolio included and76% with it excluded. In 2017 this rate was 65% with the Rainycrest Director of Care portfolio included and 77% with itexcluded; our current year target was 72%. Our 2017 final results are a significant improvement over the September2017 compliance rate that was only at 48%. Moving forward, RHC has elected to conduct performance conversationsevery two years although we will continue to monitor and follow up on monthly results to ensure we sustain the requiredlevel of momentum. Rainycrest Long Term Care has been challenged in meeting the large Director of Resident Careportfolio performance conversation requirements the past two years due to management gaps. However, with themanagement team now at full complement, there will be a focus on improving compliance for this group in 2018.

• Integrative Organizational SupportsOn December 20

tha meeting was held in the Rainycrest Board Boom to initiate formal engagement between the

Rainycrest, Rainy River and Emo Health Centres onsite leadership and the corporate leads located at the LaVerendryeGeneral Hospital location. The meeting focused on promoting open dialogue regarding challenges, opportunities andmechanisms to achieve synergies amongst our leaders. RHC faces inherent challenges with its leaders extended acrossmultiple sites and a face to face meeting focused on these challenges was determined by the group to be a good firststep. To supplement existing engagement, integrative organization supports meetings will continue quarterly or as theneed arises to ensure the ongoing development of the RHC team.

• Executive CompensationRHC submitted its executive compensation plan on September 29

th. On December 28

thand 29

thRHC received notice of

non-legislated limitations that the Ministry was enforcing, including a 5% per year maximum increase to executive salariesdespite a wage freeze back to 2010. On January 9

thRHC was informed of additional content changes required to our

executive legislation plan and on January 14th

we submitted a 2nd

revision. At this juncture, we are awaiting presentationof our plan to the Minister and, should our submission be successful, we will initiate the 30 day public postingrequirement immediately thereafter.

• Bill 148Bill 148, the Fair Workplaces, Better Jobs Act, received Royal Assent on November 27, 2017. This act implements changesto the Employment Standards Act and the Ontario Labour Relations Act over a two year period, effective on January 1,2018 and January 1, 2019. While RHC believes it provides a Greater Right or Benefit than many of the changes require,there are other changes that will impact us both operationally and financially. In 2018 the two most prominent changesthat may impact RHC include:

o pregnancy and parental leave –increase from 12 to 18 months will impact top up costs and coveragerequirements;

o personal emergency leave - employee is entitled to take a total of two days of paid leave and eight days ofunpaid leave each calendar year

• Employee and Family Assistance Program (EFAP)The new EFAP program provided by the Behavioral Sciences Centre of St. Joseph’s Care Group in Thunder Bay began onJanuary 15, 2018. A meeting occurred between St. Joseph’s and RHC representatives with the program rollout as itsfocus. The program is being communicated through a number of avenues including: health and safety topics, RHC healthcare news, email, posters and other materials and management packages.

• Workplace SafetyA FMEA (Failure Mode and Effects Analysis) is being conducted to review the afterhours Emergency Department processto identify risks and safety issues related to workplace violence. Future meetings will be conducted by the team to review

Item 4.5



existing control methods and identify each control failure as well as its likelihood of occurrence. Process improvementrecommendations are anticipated to be outlined in February.

Partnerships

• Tbaytel Free WifiOn January 4

thRHC began to offer free WiFi services at Rainycrest and its three hospital locations, as provide by Tbaytel.

Tbaytel is providing an Internet Gateway that is accessible through Riverside’s network infrastructure. This service is nowavailable to our patients, residents, clients, families and visitors. This complimentary service is made available through apartnership between RHC, TBaytel and the North West Health Alliance. Riverside extends its appreciation to Tbaytel forits ongoing support in improving the patient experience!

• Sub Region PlanningOn December 14

ththe senior leadership from RHC attended a daylong session of the District of Rainy River Sub Region

Planning Table. The sub-region planning activities include the following roles:o advisory role (identify local priorities and challenges for consideration at a regional level)o champion implementation (champion implementation of regional and local priorities at local level)

• Network Infrastructure FundingThe North West Health Alliance (NWHA), through small hospital transformation funding, allocated $200,000 to RHC toupgrade cabling to the CAT6 standard at the LaVerendrye, Emo and Rainy River locations. As this funding is intended forhospitals, we are unable to access it for Rainycrest. The lowest quote for cabling has come in well under the approvedfunding level and the NWHA has agreed to engage the NW LHIN to promote reallocation of the remaining funds to thepurchase of Cisco switches for RHC in order to further enhance our network infrastructure.

• North West Health Alliance (NWHA) CommitteesThe NWHA reorganized its committee structure to provide enhanced guidance to the CEO Group; a primary focus of thiscommittee redesign was to extend regional resources across committees to lead to smaller more functional groups thatwould be more efficient in advancing regional change management. The following is a summary of the new committeerepresentatives from RHC.

Executive Steering Committee - Henry Gauthier & Lori Maki IT/IS Advisory Committee - Marie Brady IT Infrastructure Working Group – no representation

• Quarterly CFO MeetingOn January 11

ththe Northwest Local Health Integration Network held their quarterly regional chief financial officer

teleconference. The agenda for this meeting included discussion of issues related to: semi-private billings, hospitalinfrastructure renewal funding and daily bed census summary. This forum provides an opportunity for regional partnersto discuss issues related to one or more hospital.

Quality

• Human Resources SuiteRiverside has executed a contract with Logibec to provide a human resource, payroll, scheduling, business intelligenceand time clock system for Riverside. February 20-23 has been scheduled for Logibec to visit our organization and beginthe detailed requirements analysis and begin solidifying the implementation approach and timelines.

• Non Urgent TransfersRHC and Lake of the Wood District Hospital are scheduled to meet with the North West Local Integration Network onJanuary 18

thto initiate planning to select a vendor to provide non-urgent transfers. Historically, transfers between our

sites have been accommodated by the RRDSSAB ambulance service. Recognizing the impact that non-urgent transfersmay have on the RRDSSAB responding in a timely manner to urgent transfers, it has been identified that there may beopportunity to access funding to contract a private non-urgent transfer provider.

• Food Services Production, Inventory & Calorie Count SoftwareOn January 17

threpresentatives from food services, clinical nutrition and management attended an onsite demonstration

of the CompuTrition software, as organized by Aramark, to assess opportunities to enhance food production, inventoryand calorie management in order to improve patient services. Next steps include further engagement to align thesoftware needs with our acute and our long term care environments.

• Food Service – ImprovementsFood services are focusing on improvements identified in the April 2017 operational review conducted by Aramark. InDecember and January the department conducted weekly food cost tracking, reinforced rules regarding ‘no’ personalbelongings in its kitchens, tracked food substitutions and food waste at Rainycrest; these process enhancements remainin progress at this time and will be incorporated corporate wide.



• Pandemic Inventory ManagementRHC’s pandemic inventory is reaching a depleted level due to product expiration and turnover. The Northern SupplyChain, RHC’s supply chain, infection control, patient safety and clinical leadership are engaging to draft an improvedPandemic Inventory plan and to restore our inventory levels as appropriate.

Thank you to the Corporate Services Directors for their submissions that prove to be invaluable in the preparation of thisreport.

• Ed Cousineau, Director of Capital Planning, Engineering & Environmental Services

• Simone LeBlanc, Coordinator, Quality, Safety, Risk Management and Privacy

• Jason Marchand, Director of Human Resources

• Carla Larson, Director of Financial & Patient Information Services

• Marie Brady, Director of Information Systems & Technology

• Harsha Vinta, Aramark Director of Food Services


Henry GauthierVice President, Corporate Services, Chief Operating & Financial Officer


Long Term Care Report – January 2018

Page 1

Strategic Pillars & Directions:

Quality

• Environmental Services will be introducing a Lost & Found Station (by March 31, 2018) within the home for all residents, familiesand staff.

• Environmental Services have developed an Action Plan to make improvements within resident’s rooms over the next 3 years.

• Carpentry work and painting completed on both Fireplaces in SCU, lounge area.

• Serveries kitchen in SCU work is completed, with ventilation, and sufficient lighting.

• Quality Programs initiated Skin and Wound & continence, Pain and Palliative, Infection Control, Restraints/PASDs,Falls/Restorative, Responsive Behaviours. These quality Programs are in keeping with LTC Act and regulations, Sec. 48 to 52. Theprograms required that must be developed and implemented focus on Falls, skin & Wound, Continence Care, and Pain. The otherprograms have been integrated with these programs, as they are all relative.

• The CMI for April 1 /16 until March 31/17 is --- 1.0628. We anticipate an increase in funding (notice coming end of January orearly February) from our current .9252. The CMI for April 1/ 17 until Sept 30/17 is --- 1.1264. Significant increase based on the2016-2017 year ended March 31

st. To date January 2018 our CMI fluctuates between 1.12 and 1.16.

• 5 volunteers for CQI Restorative committee- 3 HCA, 1 Dietary, 1 RPN

• RAI consultant on site Dec. 2017 for 3 days.

• AIS tests completed for 2017 for all 3 sites.

• Ongoing training for gold care, bundling care plans, RUG scores, restorative, RAI RAPs.

• RAI boards updated

• Team bundling for accurate coding.

• 1:1 education for RAI coding, education on inaccurate coding.

• Ongoing education on importance of Daily care records and accurately.


• December Occupancy Reporto Rainycrest: MTD YTD

Basic Beds: 97.92% 97.83% (Occupancy Target: 97%) Interim Beds: 131.18% 96.85% (Occupancy Target: 90%) Convalescent Beds: 79.03% 72.74% (Occupancy Target: 80%) Respite Beds: 58.06% 42.60% (Occupancy Target: 50%)TOTAL ALL BEDS: 98.19% 96.51%

• Staff recruitment is ongoing for HCA’s and RN’s, RPN’s, housekeeping & Activation.

• 1 Restorative Aide hired part time.

• Rainycrest Nurse Practitioner (NP) has resigned her position effective January 17th

, 2018, to pursue another opportunity at TribalHealth. Recruitment efforts are in progress.

Partnerships

• Canadian Mental Health has scheduled monthly meetings reviewing residents with various highlighted concerns (Behavioral, Pain,Mental Health etc.) with our team of Nursing/ Dietary /Activation.

• Spiritual Care Chaplain hired.

• The Alzheimer’s Society held an education session for Care givers on feeding techniques for individuals with dementia.

• St. Michaels and JW walker schools entertained at Rainycrest Christmas concerts.

• Indigenous Christmas Celebration for our Elders at Rainycrest.

• The Fort Frances Legion held a Christmas Tea for our Vets and spouses.

• Auxiliary held their annual Christmas Party for our residents.

• Rainycrest featured staff competitively wearing ugly Christmas Sweaters. Contest for the ugliest sweater, with prizes. Greatmorale builder for staff. Residents enjoyed the activity.

• The Cantata and our “Rainycrest Corallers” performed for residents.

Thank you to the management team for providing information on their departments for this report.


Marva GriffithsAdministrator

Item 4.6


Chief of Staff Report – January 2018

Happy New Year! Hopefully there will be new opportunities for our community in 2018.

• The OMA and MOHLTC are entering in to binding arbitration. There might be some labor stability later in the

year. A number of physicians around the province and indeed in our region are refusing to be involved in

LHIN based activities.

• GP Anesthesia still has no solution in sight. Although we have regular locums this isn’t a stable situation and

has negative effects on our local physicians.

• ER staffing continues to be highly locum dependent, putting a financial strain on the Recruitment and

Retention committee’s funds.

• General surgery has some stability at present. Dr. Elkheir is willing to train for C-Sections, but the program to

facilitate that in Toronto has become dysfunctional. Dr. Jenks is providing C-Section coverage with some

support from Dr. B. Anderson. A number of other communities in the North West have GP surgeons covering

surgical obstetrics.

• Dr. Kowal had stepped up to fill in for me when I was away. She has also taken on some additional duties I

have previously fulfilled. Both Dr. Kowal and I are attending a regional Chief of Staff meeting on January 23

and we are subsequently attending the Health Human Resources Summit on the 24th

of January. The main

items for the meeting are mental health and order sets.


Dr. R. AlgieChief of Staff

Item 4.7


Governance Committee Report – January 2018

4.8.1 Governance Functioning Tool *

4.8.2 Ad hoc Policy Group Update – Section 1 *

4.8.3 Board Evaluation Effectiveness Survey Results – November 2017 *

Item 4.8


1

Guide: Governance Functioning Tool (GFT)

Purpose and Rationale

Research in health care governance has demonstrated that the responsibilities and actions of a governing board are a major factor in organizational performance.1 Specifically, boards and other governing bodies can actively encourage improvements in clinical quality and patient safety.2

The Governance Functioning Tool (GFT) is a 34-question instrument that governing bodies can use to evaluate their own functioning and identify areas for improvement. The GFT has been designed to complement the Governance Standards.

In 2016, a revised version of the GFT was released. For a detailed comparison between the current and previous versions of the GFT, see Appendix A.

Description and Type

Questions contained in the GFT measure four key dimensions of governance functioning, which are:

Dimension 1: Membership and structure

• We actively recruit, recommend, and/or select new members based on needs for particular skills, background, and experience. (q. 26)

• We lack explicit criteria to recruit and select new members. (q. 27)

• Our renewal cycle is appropriately managed to ensure the continuity of the governing body. (q. 28)

• Clear, written policies define term lengths and limits for individual members, as well as compensation. (q. 30)

• We review our own structure, including size and subcommittee structure. (q. 31)

• We have a process to elect or appoint our chair. (q. 32)


2


Dimension 2: Roles and responsibilities

• We regularly review and ensure compliance with applicable laws, legislation, and regulations. (q. 1)

• Governance policies and procedures that define our role and responsibilities are well documented and consistently followed. (q. 2)

• Subcommittees need better defined roles and responsibilities. (q. 3)

• As a governing body, we do not become directly involved in management issues. (q. 4)

• We have a process to set bylaws and corporate policies. (q. 14)

• Our bylaws and corporate policies cover confidentiality and conflict of interest. (q. 15)

• As a governing body, we oversee the development of the organization’s strategic plan. (q. 23)

Dimension 3: Meetings and decision-making processes

• Disagreements are viewed as a search for solutions rather than a “win/lose”. (q. 5)

• Our meetings are held frequently enough to make sure we are able to make timely decisions. (q. 6)

• Individual members understand and carry out their legal duties, roles and responsibilities, including subcommittee work (as applicable). (q. 7)

• Members come to meetings prepared to engage in meaningful discussion and thoughtful decision making. (q. 8)

• Our governance processes need to better ensure that everyone participates in decision making. (q. 9)

• The composition of our governing body contributes to strong governance and leadership performance. (q. 10)

• Individual members ask for and listen to one another’s ideas and input. (q. 11)

• Working relationships among individual members are positive. (q. 13)

• The composition of our governing body allows us to meet stakeholder and community needs. (q. 29)


3


Dimension 4: Process of evaluation

• Our ongoing education and professional development is encouraged. (q. 12)

• We benchmark our performance against other similar organizations and/or national standards. (q. 16)

• Contributions of individual members are reviewed regularly. (q. 17)

• As a team, we regularly review how we function together and how our governance processes could be improved. (q. 18)

• There is a process for improving individual effectiveness when non-performance is an issue. (q. 19)

• As a governing body, we regularly identify areas for improvement and engage in our own quality improvement activities. (q. 20)

• As individual members, we need better feedback about our contribution to the governing body. (q. 21)

• We receive ongoing education on how to interpret information on quality and patient safety performance. (q. 22)

• The performance measures we track as a governing body give us a good understanding of organizational performance. (q. 25)

One question does not factor into the dimensions but is deemed to be an important component of client- and family-centred care:

• As a governing body, we hear stories about clients who experienced harm during care. (q. 24)

The last two questions in the questionnaire allow respondents to assess the governing body’s impact in terms of driving improvements to patient safety and quality of care:

• Overall, what is your assessment of the board’s impact over the past 12 months in terms of driving improvements to: Patient safety (q. 33)

• Overall, what is your assessment of the board’s impact over the past 12 months in terms of driving improvements to: Quality of care (q. 34)


4


Administering the Governance Functioning Tool

As part of the accreditation process, governing bodies complete the GFT and demonstrate that actions have been taken on GFT results at least once per accreditation cycle. Governing bodies may choose to administer the instrument more frequently as a way of benchmarking and measuring their progress.

While it is permissible to have one member complete and submit one response on behalf of the group, Accreditation Canada recommends that organizations give all members of the governing body the opportunity to complete the survey individually.

References

1. Baker, G.R., Denis, J.-L., Pomey, M.-P., and MacIntosh-Murray, Anu. (2010). Effective governance for quality and patient safety in Canadian healthcare organizations. Ottawa, ON: Canadian Health Services Research Foundation & the Canadian Patient Safety Institute. Retrieved from http://www.chsrf.ca/Migrated/PDF/ResearchReports/CommissionedResearch/11505_Baker_rpt_FINAL.pdf

2. Carlow, D. (2010). Can healthcare boards really make a difference in quality and safety? Healthcare Quarterly. Retrieved from http://www.hqontario.ca/Portals/0/modals/qi/en/processmap_pdfs/articles/can%20healthcare%20boards%20really%20make%20a%20difference.pdf

© 2015, Accreditation Canada


5


Appendix A: Summary of revisionsBased on the findings of a psychometric validation, a revised Governance Functioning Tool was released in January, 2016. Overall, five questions were removed from the tool that were either redundant, or did not strongly measure any of the four governance functioning themes. Other changes include: the addition of two overall outcome measures; the modification of questions to incorporate reverse scoring; and minor wording changes to improve clarity.

Questions 3, 9, 21, and 27 in the revised GFT are negatively worded to reduce the likelihood of respondents agreeing with all questions. Introducing negatively worded questions can help strengthen the tool, and improve accuracy of results.

The table below provides a question-by-question comparison of the previous and current version of the GFT.

Table 1: Changes between versions Questions have been removed, reworded, and added. Bold text indicates changes.

Previous Version Pre-January 2016

Current Version Effective January 2016

1. We regularly review, understand, and ensure compliance with applicable laws, legislation and regulations.

1. We regularly review and ensure compliance with applicable laws, legislation, and regulations.

2. 2. Governance policies and procedures that define our role and responsibilities are well documented and consistently followed.

3. We have sub-committees that have clearly-defined roles and responsibilities.

3. Subcommittees need better defined roles and responsibilities.

4. Our roles and responsibilities are clearly identified and distinguished from those delegated to the CEO and/or senior management. We do not become overly involved in management issues.

4. As a governing body, we do not become directly involved in management issues.

5. We each receive orientation that helps us to understand the organization and its issues, and supports high-quality decision-making.

REMOVED

6. 5. Disagreements are viewed as a search for solutions rather than a “win/lose”.

7. 6. Our meetings are held frequently enough to make sure we are able to make timely decisions.


6




8. 7. Individual members understand and carry out their legal duties, roles and responsibilities, including subcommittee work (as applicable).

9. 8. Members come to meetings prepared to engage in meaningful discussion and thoughtful decision making.

10. Our governance processes make sure that everyone participates in decision-making.

9. Our governance processes need to better ensure that everyone participates in decision making.

11. Individual members are actively involved in policy-making and strategic planning.

REMOVED

12. The composition of our governing body contributes to high governance and leadership performance.

10. The composition of our governing body contributes to strong governance and leadership performance.

13. Our governing body’s dynamics enable group dialogue and discussion. Individual members ask for and listen to one another’s ideas and input.

11. Individual members ask for and listen to one another’s ideas and input.

14. 12. Our ongoing education and professional development is encouraged.

15. Working relationships among individual members and committees are positive.

13. Working relationships among individual members are positive.

16. 14. We have a process to set bylaws and corporate policies.

17. 15. Our bylaws and corporate policies cover confidentiality and conflict of interest.

18. We formally evaluate our own performance on a regular basis.

REMOVED

19. 16. We benchmark our performance against other similar organizations and/or national standards.

20. 17. Contributions of individual members are reviewed regularly.

21. 18. As a team, we regularly review how we function together and how our governance processes could be improved.

22. 19. There is a process for improving individual effectiveness when non-performance is an issue.


7




23. We regularly identify areas for improvement and engage in our own quality improvement activities.

20. As a governing body, we regularly identify areas for improvement and engage in our own quality improvement activities.

24. As a governing body, we annually release a formal statement of our achievements that is shared with the organization’s staff as well as external partners and the community.

REMOVED

25. As individual members, we receive adequate feedback about our contribution to the governing body.

21. As individual members, we need better feedback about our contribution to the governing body.

26. Our chair has clear roles and responsibilities and runs the governing body effectively.

REMOVED

27. 22. We receive ongoing education on how to interpret information on quality and patient safety performance.

28. 23. As a governing body, we oversee the development of the organization’s strategic plan.

29. As a governing body, we hear stories about clients that experienced harm during care.

24. As a governing body, we hear stories about clients who experienced harm during care.

30. 25. The performance measures we track as a governing body give us a good understanding of organizational performance.

31. 26. We actively recruit, recommend, and/or select new members based on needs for particular skills, background, and experience.

32. We have explicit criteria to recruit and select new members.

27. We lack explicit criteria to recruit and select new members.

33. Our renewal cycle is appropriately managed to ensure continuity on the governing body.

28. Our renewal cycle is appropriately managed to ensure the continuity of the governing body.

34. 29. The composition of our governing body allows us to meet stakeholder and community needs.

35. 30. Clear, written policies define term lengths and limits for individual members, as well as compensation.


8




36. 31. We review our own structure, including size and subcommittee structure.

37. 32. We have a process to elect or appoint our chair.

NEW 33. Overall, what is your assessment of the board’s impact over the past 12 months, in terms of driving improvements to: Patient safety

NEW 34. Overall, what is your assessment of the board’s impact over the past 12 months, in terms of driving improvements to: Quality of care


1 of 2

Governance Functioning Tool

Strongly disagree Disagree Neutral Agree

Strongly agree

Not Applicable

1. We regularly review and ensure compliance with applicable laws,legislation, and regulations.

2. Governance policies and procedures that define our role andresponsibilities are well documented and consistently followed.

3. Subcommittees need better defined roles and responsibilities.

4. As a governing body, we do not become directly involved inmanagement issues.

5. Disagreements are viewed as a search for solutions rather than a“win/lose”.

6. Our meetings are held frequently enough to make sure we areable to make timely decisions.

7. Individual members understand and carry out their legal duties,roles, and responsibilities, including subcommittee work (asapplicable).

8. Members come to meetings prepared to engage in meaningfuldiscussion and thoughtful decision making.

9. Our governance processes need to better ensure that everyoneparticipates in decision making.

10. The composition of our governing body contributes to stronggovernance and leadership performance.

11. Individual members ask for and listen to one another’s ideas andinput.

12. Our ongoing education and professional development isencouraged.

13. Working relationships among individual members are positive.

14. We have a process to set bylaws and corporate policies.

15. Our bylaws and corporate policies cover confidentiality andconflict of interest.

16. We benchmark our performance against other similarorganizations and/or national standards.

17. Contributions of individual members are reviewed regularly.

18. As a team, we regularly review how we function together and howour governance processes could be improved.

19. There is a process for improving individual effectiveness whennon-performance is an issue.

20. As a governing body, we regularly identify areas for improvementand engage in our own quality improvement activities.

21. As individual members, we need better feedback about ourcontribution to the governing body.


2 of 2

Strongly disagree Disagree Neutral Agree

Strongly agree

Not Applicable

22. We receive ongoing education on how to interpret information onquality and patient safety performance.

23. As a governing body, we oversee the development of theorganization’s strategic plan.

24. As a governing body, we hear stories about clients whoexperienced harm during care.

25. The performance measures we track as a governing body give us agood understanding of organizational performance.

26. We actively recruit, recommend, and/or select new membersbased on needs for particular skills, background, and experience.

27. We lack explicit criteria to recruit and select new members.

28. Our renewal cycle is appropriately managed to ensure thecontinuity of the governing body.

29. The composition of our governing body allows us to meetstakeholder and community needs.

30. Clear, written policies define term lengths and limits for individualmembers, as well as compensation.

31. We review our own structure, including size and subcommitteestructure.

32. We have a process to elect or appoint our chair.

Overall, what is your assessment of the governing body’s impact over the past 12 months, in terms of driving improvements to:

Poor Fair Good Very Good ExcellentNot

Applicable

33. Patient safety

34. Quality of care

Thank you for completing this survey.

© 2011, 2015 Accreditation Canada accreditation.ca


Listing of Riverside Health CareBoard Governance Policies by Section

Section I: Governance/Strategic (to provide strategic leadership to theorganization in realizing our vision, mission and strategic priorities)

GOV-I-01 Governance Policy Review – NEW ADDITIONGOV-I-05 RHC Accountability Statement – NO CHANGEGOV-I-10 RHC Mission, Vision & Strategic Priorities – PENDING – BRING

FORWARDGOV-I-15 RHC Board Meeting Policy – NO CHANGEGOV-I-20 RHC Board Confidentiality Policy – NO CHANGEGOV-I-25 RHC Role and Responsibilities of the Board Policy – REVISED – SEE

ATTACHEDGOV-I-30 RHC Code of Conduct Policy – NO CHANGEGOV-I-35 RHC Board Conflict of Interest Policy – REVISED – SEE ATTACHEDGOV-I-40 RHC Board Evaluation Policy – NO CHANGEGOV-I-45 RHC Board Succession Planning Policy – NO CHANGE

GOV-I-45.1 Board Leadership Policy – NEW ADDITIONGOV-I-45.2 Board of Directors Nominating & Selection Policy – NEWADDITION

GOV-I-50 RHC Strategic Planning Policy – NO CHANGE TO POLICY – STRAT PLANCYCLE UNDER REVIEW - PENDING

GOV-I-55 RHC Board Education and Development Policy – NO CHANGEGOV-I-60 RHC Strategic Partnerships Policy – REVISED – SEE ATTACHEDGOV-I-65 RHC Recognition of Physicians and Board Members Policy – NO CHANGEGOV-I-70 RHC Strategic Communications & Community Engagement Policy – REVISED

– SEE ATTACHEDGOV-I-75 RHC CEO and COS Performance Management and Evaluation Policy – NO

CHANGEGOV-I-80 RHC CEO and COS Compensation Policy – PENDING - DUE TO

EXECUTIVE COMPENSATIONGOV-I-85 RHC President & CEO Succession Plan Policy – NO CHANGE

GOV-I-85.1 RHC President & CEO Emergency (Unplanned) Succession Plan – NOCHANGEGOV-I-85.2 RHC President & CEO Succession (Planned) Plan Process – NOCHANGE

GOV-I-90 RHC Chief of Staff Succession Policy – NO CHANGEGOV-1-95 Contingency Plan – NO CHANGE

Section 2: Workplace of Choice: (an organization that provides a safe andhealthy work environment, where all employees, volunteers andphysicians are respected, valued and encouraged to pursue life-longlearning)

GOV-II-05 Human Resources Practices PolicyGOV-II-10 FIPPA Policy


GOV-II-15 Ethics PolicyGOV-11-15.1 Review of Ethics Issues Process for the Board of Directors

GOV-II-20 Accessibility PolicyGOV-II-25 Privacy Personal Health Information Policy

Section 3: Provider of Choice: (integrated health delivery that ensures highquality performance and health status goals for our patients/clients).

GOV-III-05 Quality Safety Risk CommitteeGOV-III-10 Credentialing PolicyGOV-III-15 MAID Policy (Overarching policy pending)

Section 4: Accountability (ensure responsive decisions are made where services aredelivered to the patient/resident/client in pursuit of the best clinical,process and community outcomes).

GOV-IV-05 RHC Board Governance and AccountabilityGOV-IV-10 RHC Document Creation, Review and ApprovalGOV-IV-15 RHC Accreditation PolicyGOV-IV-20 RHC Investment PolicyGOV-IV-25 RHC Population Health PolicyGOV-IV-30 RHC Delegation of Authority to the President & Chief Executive Officer


Governance Policy ReviewGOV-I-01

1.0 Policy

Governance policies should be: approved by the board; periodically reviewed as part of ongoinggovernance reviews and annual Governance Committee work plan; made available to new boardmembers.

2.0 Scope

A subcommittee of the Governance Committee is responsible for the review of the Board GovernancePolicies.

3.0 Responsibility

The Governance Committee is responsible for the establishment of a process for:3.01 Timely review of Governance policies (within Accreditation Cycle).3.02 Presentation of policies to board for approval3.03 Provision of copies of updated policies annually.

4.0 Purpose

As part of its responsibility for creating a culture of good governance, and sound structures;processes are needed for the Board of Directors of Riverside Health Care Facilities Inc. (RHC) toestablish, approve and periodically review the Board Governance Policies. This policy sets outprocesses to support the Board in fulfilling this responsibility.

5.0 References

Ref. Guide to Good Governance – Third Edition.


Statement of Roles and Responsibilities of the Board of TrusteesGOV-I-25

1.0 Policy

To ensure that the Riverside Health Care (RHC) board of trustees has a shared understanding ofits governance role, the board has adopted this Statement of the Roles and Responsibilities of theBoard.

2.0 Scope

All Board of Directors and members of the Board of Riverside Health Care Facilities Inc.

3.0 Responsibility of the board

3.01 The board is responsible for the overall governance of the affairs of the corporation.3.02 Each trustee is responsible to act honestly, in good faith and in the best interests of the

corporation and, in so doing, to support the corporation in fulfilling its mission anddischarging its accountabilities.

4.0 Strategic planning and mission, vision and values

4.01 The board participates in the formulation and adoption of the RHC’s mission, vision andvalues.

4.02 The board ensures that RHC develops and adopts a strategic plan that is consistent with itsmission and values, and which will enable RHC to realize its vision. The board participatesin the development of and ultimately approves the strategic plan.

4.03 The board oversees operations for consistency with the strategic plan and strategicdirections.

4.04 The board receives regular briefings or progress reports on the implementation of strategicdirections and initiatives.

4.05 The board ensures that its decisions are consistent with the strategic plan and themission, vision and values.

4.06 The board annually conducts a review of the strategic plan as part of a regular annualplanning cycle.

5.0 Performance measurement and monitoring

5.01 The board is responsible for establishing a process and a schedule for monitoring and assessingperformance in areas of board responsibility, including:a. Fulfillment of the strategic directions in manner consistent with the mission, vision and

values.b. Oversight of management performance;c. Quality of care and services;d. Financial conditions;e. External relations; andf. The board’s own effectiveness.

5.02 The board ensures that management has identified appropriate measures of performance.

TitleRoles & Responsibilities

Effective DateJun 30, 2015

NumberGOV-I-25

ApproverBoard of Directors

Issued ByPresident & CEO

Page 1 of 3

Disclaimer MessageOnce printed this document is no longer controlled and may not be the most current version.

Date/Time GeneratedJan 02, 2018 13:53

Generated ByAnonymous


6.0 Quality oversight

6.01 The board is responsible for establishing policies and plans related to quality, including QualityImprovement Plans.

6.02 The board ensures that policies and improvement plans are in place related to quality of care, safety,experience and access.

6.03 The board monitors quality performance against the board-approved quality improvement plans,performance standards and indicators.

6.04 The board ensures that management has plans in place to address variances fromperformance standards indicators, and the board oversees implementation of remediationplans.

7.0 Resource oversight

7.01 The board is responsible for stewardship of f inancial, human and capital resources,including ensuring availability and overseeing the allocation of all resources.

7.02 The board approves policies for resource planning, and approves the annual operatingand capital budget.

7.03 The board monitors financial performance against budget.7.04 The board approves investment policies and monitors compliance.7.05 The board ensures the accuracy of financial information through oversight of management

and approval of annual audited financial statements.7.06 The board ensures management has put measures in place to ensure the integrity of

internal controls.

8.0 Risk identification and oversight

8.01 The board is responsible to be knowledgeable about risks inherent in the organization’soperations and ensure that appropriate risk analysis is performed as part of boarddecision-making.

8.02 The board oversees management’s risk management program.8.03 The board ensures that appropriate programs and processes are in place to protect

against risk.8.04 The board is responsible for identifying unusual risks to the organization and for ensuring that there

are plans in place to prevent and manage such risks.

9.0 Oversight of management

9.01 The board recruits and supervises the CEO by:a. Developing and approving the CEO job descriptionb. Undertaking a CEO recruitment process and selecting the CEOc. Reviewing and approving the CEO’s annual performance goalsd. Reviewing CEO performance and determining CEO compensatione. Ensuring succession planning is in place for the CEO and senior managementf. Exercising oversight of the CEO’s supervision of senior management as part of the CEO’s

annual review.9.02 The board develops a process for selection and review of the Chief of Staff and ensures the process is

implemented and followed.9.03 The board reviews, with the CEO, the Chief of Staff’s performance and sets the Chief of Staff’s

compensation.



NumberGOV-I-25



Page 2 of 3





9.04 The board tasks the CEO to develop, implement, and maintain a process for the selection ofdepartment chiefs and other medical leadership positions, as required under RHC’s bylaws, thePublic Hospitals Act, the Long-Term Care Act and other relevant acts.

10.0 Stakeholder communication and accountability

10.01 The board ident i f ies the organizat ion’s stakeholders and understands stakeholderaccountability.

10.02 The board ensures the organization appropriately communicates with stakeholders in amanner consistent with accountability to stakeholders.

10.03 The board contributes to the maintenance of strong stakeholder relationships.10.04 The board performs advocacy on behalf of RHC with stakeholders where required, in

support of the mission, vision, values and strategic directions of the corporation.

11.0 Governance

11.01 The board is responsible for the quality of its own governance.11.02 The board establishes governance structures to facilitate the performance of the board’s

role and enhance individual trustee performance.11.03 The board is responsible for the recruitment of a skilled, experienced and qualified board.11.04 The board ensures ongoing board training and education.11.05 The board assesses and reviews its governance by per iodical ly evaluat ing board

structures, including board recruitment processes and board composition and size,number of committees and their Terms of Reference, processes for appointment ofcommittee Chairs, processes for appointment of board officers, and other governanceprocesses and structures.

11.06 The board regularly reviews and updates the bylaws of the Corporation as required.

12.0 Legal and legislated compliance

The board ensures that appropriate processes are in place to ensure compliance with legal and legislatedrequirements.

13.0 Amendment

This statement may be amended by the board.

(Source - OHA ‘Guide to Good Governance’ – Third Edition)



NumberGOV-I-25



Page 3 of 3





Board Conflict of InterestGOV-I-35

1.0 Policy

1.01 Directors shall avoid situations in which they may be in a position of conflict ofinterest. 1.02 The by-laws contain provisions with respect to conflict of interest that must bestrictly adhered to.

1.03 In addition to the by-laws, the process set out in this policy shall be followed when a conflict orpotential conflict arises.

2.0 Scope


3.0 Responsibility

This policy applies to all directors including ex-officio directors.

4.0 Purpose

All directors have a duty to ensure that the trust, confidence and integrity of the decision-makingprocesses of the board are maintained by ensuring that they and other members of the board arefree from conflict or potential conflict in their decision-making. It is important that all directorsunderstand their obligations when a conflict of interest or potential conflicting interest arises.

5.0 Description of Conflict of Interest

The situation in which potential conflicts of interest may arise cannot be exhaustively set out. Conflictsgenerally arise in the following situations:5.01 Interest of a Director “Wearing Two Hats”

When a director transacts with the corporation directly or indirectly. When a directorhas a signif icant direct or indirect interest in a transaction or contract with the corporation.5.02 Interest of a Relative

When the corporation conducts business with suppliers of goods or services or any otherparty of which a relative or member of the household of a director is a principal, officer orrepresentative.

5 . 0 3 G i f t sWhen a director or a member of the director’s household or any other person or entitydesignated by the director, accepts gifts, payments, services or anything else of morethan a token or nominal value from a party with whom the corporation may transactbusiness (including a supplier of goods or services) for the purposes of (or that may beperceived to be for the purposes of) influencing an act or decision of the board

TitleBoard Conflict of Interest


NumberGOV-I-35



Page 1 of 3


Date/Time GeneratedNov 20, 2017 14:51



5.04 Acting for an Improper PurposeWhen directors exercise their powers motivated by self - interest or other improperpurposes. Directors must act solely in the best interest of the corporation. Directors whoare nominees of a particular group must act in the best interest of the corporation even ifthis conflicts with the interests of the nominating party.

5.05 Appropriation of Corporate OpportunityWhen a director diverts to his or her own use an opportunity or advantages that belongs tothe corporation.

5.06 Duty to Disclose Information of Value to the CorporationWhen directors fail to disclose information that is relevant to a vital aspect of the corporation’saffairs.

6.0 Process for Resolution of Conflicts and Addressing Breaches of Duty

6.01 Disclosure of ConflictsA director who is in a position of conflict or potential conflict that has been determined tobe material shall immediately disclose such conflict to the board by notification to thechair, or vice-chair of the board. The disclosure shall be sufficient to disclose the natureand extent of the director’s interest. Disclosure shall be made at the earliest possible timeand prior to any discussion and vote on the matter.

6.02 Abstain from DiscussionsThe director shall not be present during the discussion of the matter in which he or she has aconflict and shall not attempt in any way to influence the voting.

6.03 Process for Resolution of Conflicts and Addressing Breaches of DutyAll directors shall comply with the requirements of the by-laws. It is acknowledged that notall conflicts or potential conflicts may be satisfactorily resolved by strict compliance withthe by-laws. There may be cases where the perception of a conflict of interest or breach ofduty may be harmful to the corporation notwithstanding that there has been compliancewith the by-laws.

A direc tor may be refer red to the process out l ined below in any of the fo l lowingcircumstances:6.03.1 Circumstances for Referral

Where any director believes that that director, or another director:a. Has breached his or her duties to the corporation;b. Is in a position where there is a potential breach of duty to the corporation;c. Is in a situation of actual or potential conflict of interest, ord. Has behaved or is likely to behave in a manner that is not consistent with the

highest standards of public trust and integrity and such behaviour may have anadverse impact on the corporation.

6.03.2 Process for ResolutionThe matter shall be referred to the following process:a. Refer matter to chair, or where the issue may involve the chair, to the vice-chair, with

notice to CEO.b. Chair (or vice-chair as the case may be) may either (i) attempt to resolve the

matter informally, or (ii) refer the matter to an ad-hoc sub-committee of theboard established by the chair. The subcommittee shall report to the board.



NumberGOV-I-35



Page 2 of 3





c. If the matter cannot be informally resolved to the satisfaction of the chair (or vice-chair as the case may be), the matter will be referred to the process outlined insection (b) (ii)above.

d. It is recognized that if a conflict, or other matter referred cannot be resolved tothe satisfaction of the board (by simple majority resolution) or if a breach ofduty has occurred, a director may be asked to resign or may be subject toremoval.



NumberGOV-I-35



Page 3 of 3





Board Leadership PolicyGOV-I-45.1

1.0 Policy

It is in the interests of the Corporation that there be succession planning and a smooth transition in the officeof the Chair.

The incoming Chair, Vice-Chair, & 2nd Vice-Chair shall:• Be a current member of the board• Be approved by the board one year prior to the conclusion of the current board Chair's term; and• In the case of the Chair, serve as Vice-Chair until the commencement of his or her own term.• In the case of Vice-Chair, serve as Chair of a Board Committee.

2.0 Scope

All Board Members of Riverside Health Care Facilities Inc.

3.0 Responsibilities

3.01 The Governance Committee is mandated to conduct the board chair selection process and torecommend to the Board, for its approval, a nominee for incoming Chair.3.02 Selection Criteria - Desirable Attributes:

• Proven leadership skills• Good strategic and facilitation skills• Ability to influence and achieve consensus• Ability to act impartially and without bias and display tact and diplomacy• Effective communicator• Political acuity• Must have the time to continue the legacy of building strong relationships between the

corporation and stakeholders• Governance and board-level experience in health sector• Understanding and appreciation of quality improvement and patient/resident safety; and• Outstanding record of achievement in one or several areas of skills and experience used to

select board members

3.03 The Chair will serve a three-year term, with the possibility of a one-year extension if sorecommended and approved by the Board. After a one-year break in service, this individual could againbe selected to Chair.3.04 Selection Process:

• The Chair or other member of the Governance Committee will canvass each board member toobtain views on the selection, and perceived strengths and weaknesses of possiblecandidates.

• The results of director evaluations and peer reviews shall be considered.• The Chair of the Governance Committee will meet with each nominated candidate to

ascertain interest. If the Chair of the Governance Committee is a potential nominee, he orshe shall not participate in the selection process, and the process shall be conducted by theVice-Chair or another member of the committee.

• Governance Committee will discuss findings and ultimately agree on a nominee torecommend.

4.0 References

Ref: Guide to Good Governance – Third Edition, Sample 8.2; page 203


Board of Directors Nominating & Selection PolicyGOV-I-45.2

1.0 Policy

The Board of Directors mandates a Nominations & Recruitment Committee (which is an Ad-Hoc Committee ofGovernance) to make recommendations to the Board regarding succession planning (review Nominating &Recruitment Committee terms of reference).

2.0 Scope

All Board Members of Riverside Health Care Facilities Inc.


3.01 This committee normally begins meeting in January of each year in preparation for boardsuccession in June of each year.3.02 The Committee reviews:

• Skills matrix with current board, and where we may have deficiencies• Potential vacancies coming forward, either term renewal, or otherwise• Reviews and places advertisements for upcoming positions in February/March of each year• Reviews board leadership positions for the upcoming year (see Board Leadership Policy)• Interviews any potential board candidates that have submitted an application• Nomination/Recruitment Committee Chair completes reference checks on applications (see

Reference Check Form attached)• Committee makes final recommendations to the Governance Committee by May of each year

4.0 References

Ref: By-laws, Part III – Board, No. 9Nominating & Recruitment Committee Terms of ReferenceBoard Leadership Policy (GOV-I-45.1)Board of Directors Reference Check Form (attached)


Strategic PartnershipsGOV-I-60

1.0 Policy

1.01 The Corporation will develop cooperative partnerships within our communities consistent withthe organization's strategic plan and priorities, the North West Local Health IntegrationNetwork (North West LHIN) Health Services Blueprint (reference below) and the Ministry ofHealth & Long Term Care provincial strategic priorities. We will continually increaseawareness of our programs/services within our communities and across the Rainy RiverDistrict. We will take an active role in shaping our own future through further developingrelationships with regional partners, and exploring collaborative opportunities that can besupported by existing resources.

1.02 Riverside Health Care is a member of the Rainy River District (RRD) Sub-region which iscomprised of health service providers serving the residents of the Rainy River District. Thepurpose of the RRD Sub-region is to plan and provide health care services based on theunique needs of our communities; to meet the health care needs of the population weserve; and to support individuals in accessing care as close to home as possible. TheRRD Sub-region will focus on improved access to care for stable patients/clients, includingthose with chronic conditions and mental health and addictions issues.RHC is also a member of the RR District Health West Health Hub which is a pilot projectfocused on planning and delivery of health care services to the local communities fromMine Centre west.In addition to these, RHC has membership on the Sub-region Planning Table focused onpopulation-based planning, performance /quality improvement, service alignment andintegration, and implementation of LHIN wide priorities. This NWLHIN led initiative ismeant to provide a mechanism to align and support both the regional and the localpriorities.

1.03 Services at the local level will include (but not be limited to): Primary care, CommunitySupport Services, Community Mental Health & Addictions, Acute Care, Post-Acute Careand Long term Care.

2.0 Scope


3.0 Purpose

Riverside Health Care will form, foster and/or strengthen partnerships and alliances to helpachieve our Mission, Vision, Values and Strategic Pillars (quality and patient/client safety,organizational health, partnerships, and innovation).


Strategic Communications and Community EngagementGOV-I-70

1.0 Policy

The Chief Executive Officer and/or designate, Board Chair, or any other person specificallydesignated by the Board, will be the corporation spokesperson with regard to any publicstatement of corporate policy, related issues and Board decisions.

2.0 Scope

All employees and Directors and Board Members of Riverside Health Care Facilities Inc.


3.01 Positive public relations should be promoted by corporate staff, medical and dental staff,and volunteers.

3.02 The corporation supports an on-going program of informing and educating the public, staff,and our clients in the following ways:

3.03 The weekly newsletter is published every Friday and circulated to staff and Board/corporatecommittees.3.04 Open Board Meetings and established committees: public and media are welcome to attend whereappropriate. In addition there are opportunities to leverage communication and engagement throughestablished committees of the corporation including but not limited to Patient Family Advisory Council,Residents Councils, Family Councils, and Community Advisory Council3.05 CCC Program - "Complaints/Concerns/Compliments - a formal and efficient mechanism to

address the three C's. Responses are recorded, acknowledged, addressed, and followedup in a timely manner.

3.06 At least annually, a f inancial report to the media for the purpose of keeping the localpopulation informed regarding the cost of operating the corporation.

3.07 Special releases from time to t ime to the media which the Board deems necessary tomaintain good community relations and image.

3.08 Surveys and questionnaires shall be used particularly to evaluate quality careand services and to encourage suggestions for improvement.

4.0 References

Ref: BA-V-85 - Release of Patient Information to the PublicBA-I-80 - Confidentiality PolicyRHC Strategic Communication and Community Engagement Plan

Specif ic guidelines relating to release of health information to authorizedindividuals are documented in the respective Administrative & Departmental

policies.


100.00% 7

Q1 What was the date of the meeting?Answered: 7 Skipped: 0

ANSWER CHOICES RESPONSES

The RHC Board of Directors meeting took place on:

100.00% 7

0.00% 0

Q2 Did you attend this meeting?Answered: 7 Skipped: 0

TOTAL 7

Yes

No

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%


Yes

No

Q3 Did you receive the materials in sufficient time for you to prepare forthe meeting?Answered: 7 Skipped: 0

Yes

No

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

1 / 7

November 23, 2017 Board of Directors Meeting Effectiveness Evaluation SurveyMonkey


100.00% 7

0.00% 0

TOTAL 7


Yes

No

100.00% 7

0.00% 0

Q4 Were relevant materials provided?Answered: 7 Skipped: 0

TOTAL 7

Yes

No

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%


Yes

No

100.00% 7

Q5 Were the materials sufficient to assist you in forming an opinion ordecision made by the Board?

Answered: 7 Skipped: 0

Yes

No

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%


Yes

2 / 7



0.00% 0

TOTAL 7

No

Q6 Please add any comments here:Answered: 0 Skipped: 7

85.71% 6

14.29% 1

0.00% 0

0.00% 0

Q7 Were you satisfied with your opportunity to participate in thedebate/discussion?


Total Respondents: 7

Satisfied

Somewhatsatisfied

Somewhatdissatisfied

Dissatisfied

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%


Satisfied

Somewhat satisfied

Somewhat dissatisfied

Dissatisfied

Q8 Were you satisfied with the manner in which other board memberscontributed to the debate/discussion?


3 / 7



100.00% 7

0.00% 0

0.00% 0

0.00% 0


Satisfied

Somewhatsatisfied


Dissatisfied

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%


Satisfied

Somewhat satisfied


Dissatisfied

Q9 Was the chair effective in allowing all sides/members to be heardwhile bringing the matter to a decision?


4 / 7



85.71% 6

14.29% 1

0.00% 0

0.00% 0


Satisfied

Somewhatsatisfied


Dissatisfied

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%


Satisfied

Somewhat satisfied


Dissatisfied


Q11 Were you satisfied with what the board accomplished?Answered: 7 Skipped: 0

5 / 7



100.00% 7

0.00% 0

0.00% 0

0.00% 0


Satisfied

Somewhatsatisfied


Dissatisfied

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%


Satisfied

Somewhat satisfied


Dissatisfied

Q12 Were you satisfied with the board's overall performance?Answered: 7 Skipped: 0

Satisfied

Somewhatsatisfied


Dissatisfied

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

6 / 7




# RESPONSES DATE

1 Appreciated the information on physician payment models and discussion. 11/24/2017 8:34 AM

1 / 1



Audit & Resources Committee Report – January 2018

4.9.1 November Financial Report *

Item 4.9


LHIN - Base Funding A-1 $24,548,769 $16,365,846 $16,520,488 $154,642 0.94%

QBP Funding A-2 $437,600 $291,733 $347,300 $55,567 19.05%

LHIN - One Time Funding A-3 $108,000 $72,000 $102,372 $30,372 42.18%

MOHLTC - One Time Funding A-4 $222,275 $148,183 $148,180 ($3) 0.00%

Other Revenue MOHLTC - HOCC A-5 $488,505 $325,670 $325,669 ($1) 0.00%

Paymaster A-6 $459,880 $306,587 $364,985 $58,398 19.05%

Cancer Care Ontario A-7 $21,440 $14,293 $6,534 ($7,759) -54.29%

Recoveries & Miscellaneous A-8 $1,115,005 $743,337 $754,943 $11,606 1.56%

Amortization of Grants/Donations Equipment A-9 $307,473 $204,982 $185,503 ($19,479) -9.50%

OHIP Revenue & Patient Revenue from Other Payors A-10 $1,390,367 $926,911 $1,197,483 $270,572 29.19%

Differential & Copayment A-11 $878,000 $585,333 $556,186 ($29,147) -4.98%

TOTAL REVENUE A-12 $29,977,314 $19,984,876 $20,509,643 $524,767 2.63%

Compensation - Salaries & Wages A-13 $17,042,198 $11,392,593 $11,512,684 $120,091 1.05%

Benefit Contributions A-14 $4,593,392 $3,070,651 $3,088,042 $17,391 0.57%

Future Benefits A-15 $181,200 $120,800 $108,812 ($11,988) -9.92%

Medical Staff Remuneration A-16 $1,202,582 $801,721 $875,897 $74,176 9.25%

Nurse Practitioner Remuneration A-17 $122,800 $81,867 $81,840 ($27) -0.03%

Supplies & Other Expenses A-18 $4,615,645 $3,077,097 $3,356,292 $279,195 9.07%

Amortization of Software Licenses & Fees A-19 $42,135 $28,090 $20,786 ($7,304) -26.00%

Medical/Surgical Supplies A-20 $681,455 $454,303 $476,378 $22,075 4.86%

Drugs & Medical Gases A-21 $757,599 $505,066 $565,154 $60,088 11.90%

Amortization of Equipment A-22 $764,521 $509,681 $452,408 ($57,273) -11.24%

Rental/Lease of Equipment A-23 $97,533 $65,022 $106,010 $40,988 63.04%

Bad Debts A-24 $32,915 $21,943 $35,000 $13,057 59.50%

TOTAL EXPENSE A-25 $30,133,975 $20,128,834 $20,679,303 $550,469 2.73%

SURPLUS/(DEFICIT) A-26 ($156,661) ($104,441) ($169,660) ($65,219) 62.45%

YTD Budget

YTD Actual

Dollars

Over(Under) YTD

Budget

YTD Actual

Percent

Over(Under) YTD

Budget

Fund Type 1 - LHIN Funded - Hospital Services

REVENUE

Operating Revenue & Expense Summary

YTD Actual2017/2018

Annual Budget

April 1, 2017 to November 30, 2017

Submitted By: Henry Gauthier, Senior Director, Corporate Services (CFO/CIO) Printed: 01-11-2018 at 5:43 PM November 2017 Financial Report BAckup.xls


Operating Revenue & Expense Summary

YTD Actual2017/2018

Annual Budget

April 1, 2017 to November 30, 2017

YTD Budget

YTD Actual

Dollars

Over(Under) YTD

Budget

YTD Actual

Percent

Over(Under) YTD

Budget

TOTAL REVENUE B-1 $1,373,371 $915,581 $904,719 ($10,862) -1.19%

TOTAL EXPENSE B-2 $1,373,371 $915,581 $874,920 ($40,661) -4.44%

SURPLUS/(DEFICIT) - DUE To LHIN B-3 $0 $0 $29,799 $29,799 0.00%

TOTAL REVENUE C-1 $191,238 $127,492 $138,116 $10,624 8.33%

TOTAL EXPENSE C-2 $191,238 $127,492 $121,001 ($6,491) -5.09%

SURPLUS/(DEFICIT) - DUE To Other C-3 $0 $0 $17,115 $17,115 0.00%

TOTAL REVENUE D-1 $1,033,631 $689,087 $844,584 $155,497 22.57%

TOTAL EXPENSE D-2 $1,033,631 $689,087 $843,147 $154,059 22.36%

SURPLUS/(DEFICIT) - DUE To LHIN D-3 $0 $0 $1,438 $1,438 0.00%

TOTAL REVENUE E-1 $11,405,147 $7,603,431 $7,667,477 $64,045 0.84%

Compensation & Benefits E-2 $9,846,223 $6,564,149 $6,759,739 $195,590 2.98%Supplies E-3 $1,363,600 $909,067 $904,292 ($4,775) -0.53%

Service Recipient Specific Supplies E-4 $0 $0 $0 $0 0.00%

Sundry E-5 $156,233 $104,155 $146,400 $42,245 40.56%

Equipment E-6 $80,000 $53,333 $121,390 $68,057 127.61%

Contracted Out E-7 $9,291 $6,194 $6,387 $193 3.12%

Building & Grounds E-8 $25,327 $16,885 $6,455 ($10,430) -61.77%TOTAL EXPENSE E-9 $11,480,674 $7,653,783 $7,944,663 $290,880 3.80%

SURPLUS/(DEFICIT) including unfunded liabilities E-10 ($75,527) ($50,351) ($277,186) ($226,835) 450.50%

Less: Unfunded Future Benefits E-11 $0 $0 $53,472 $53,472 0%

Less: Unfunded Amortization Expense E-12 $0 $0 $5,229 $5,229 0%

SURPLUS/(DEFICIT) excluding unfunded liabilities E-13 ($75,527) ($50,351) ($218,485) ($168,134) 333.92%

Operating Surplus(Deficit) - Hospitals &

Long Term Care ONLY ($232,188) ($154,792) ($388,145)

Total Operating Margin - Hospitals & Long

Term Care ONLY -0.56% -0.56% -1.38%

Fund Type 2 - LHIN Funded - Counselling & Non Profit Housing Programs

Mental Health - Case Management - Housing - Addictions - Problem Gambling

Fund Type 2 - LHIN Funded - RainyCrest Community Support Services

(Home Support, Assisted Living, Adult Day, Meals on Wheels)

Fund Type 3 - Other Ministry/Agency Funded - Non Hospital Services

Partner Assault Response - Family Violence

Fund Type 2 - LHIN Funded - RainyCrest

Long Term Care

Submitted By: Henry Gauthier, Senior Director, Corporate Services (CFO/CIO) Printed: 01-11-2018 at 5:39 PM November 2017 Financial Report - Hospital.xlsBoard of Directors - Open Session January 25, 2018 50 of 68

Quality, Safety, Risk Committee Report – January 2018

4.10.1 Critical Incident Report Template *

Item 4.10


Rainycrest CIS ACTION PLAN 2017

Total % Rate # of Beds 165

Loss of essential services 0 0 0.00 # of Days in Q 91

Sudden/Unexpected Death 0 0 0.00

Missing Res>3hrs 0 0 0.00

Missing Res with injury 0 0 0.00

Abuse 5 0.7142857 0.33

Outbreak of Communicable Disease 0 0 0.00

Contamination of Water Supply 0 0 0.00

Missing Res<3hrs 0 0 0.00

Envir. Hazard>6 hrs 0 0 0.00

Missing or unaccounted for controlled substances 0 0 0.00

Injury Resulting in transfer to hospital 2 0.2857143 0.13

Adverse drug reaction requiring hospitalization 0 0 0.00

Other 0 0 0.00

TOTAL CIS FOR QUARTER 7

3rd Quarter CIS By TYPE

Loss of essential services Sudden/Unexpected Death Missing Res>3hrs Missing Res with injury

Abuse Outbreak of Communicable Disease Contamination of Water Supply Missing Res<3hrs

Envir. Hazard>6 hrs Missing or unaccounted for controlled substances Injury Resulting in transfer to hospital Adverse drug reaction requiring hospitalization

Other

Template - example only

C:\Users\ccole\AppData\Local\Temp\notes6FEBE2\Critical Incident Log Workbook - Rainycrest\QuarterlySummary (4) 11/01/2018


Rainycrest CIS ACTION PLAN 2017

0.00

0.05

0.10

0.15

0.20

0.25

0.30

0.35

Q3 Rate of CIS by Type Template - example only



Rainycrest CIS ACTION PLAN 2017REVIEW PERIOD: OCTOBER to DECEMBER

Was an action plan developed in the previous quarter? (Click on the yellow cell and select 'Yes' or 'No') no

Based on the above, were the actions implemented effective in addressing the trend identified? (Click 'Yes' or 'No')

TREND & ACTIONS CHART

# Trend Identified Outcome Desired ActionsPerson

Responsible

Date

Initiated

Reassess

Date

1

Resident to Resident

Abuse

Management of

responsive Behaviours

There will be referrals sent to BSO team, and appropriate

interventions initiated, evaluated to reduce responsive

behaviours DOC

2

Staff to resident

Abuse

No staff to resident

abuse

Re-education to all staff, on zero tolerance for Abuse to

residents. DOC

3

Falls result in injury Reduced falls with no

harm

A Falls management program will be initiated in January 2018.DOC

4

Date Reviewed by Administrator:

Provide an analysis of CIS data for the immediate past quarter; compare with previous quarter, comment on most freqent CIS reason, comment on significant

increases or decreases in types of CIS reports and actions that will be taken if your action plan for

5 cases were related to abuse. 2 resident to resident. 1 verbal abuse by visitor to resident.1 verbal and rough by staff (not founded) 1 staff to resident founded.

2 falls resulted in injury to resident. All CIS trending and actions will be carried over to 2018 as program is in place.

If 'Yes' above, provide an evaluation of the effect the actions implmented had on the CIS data for this quarter:

If the actions were not effective include additional actions to address the trends identified in your new action plan below:

Template example only



Riverside Foundation for Health Care

Board of DirectorsMinutes of Meeting

DATE: Monday, November 27, 2017 TIME: 11:30 p.m.

LOCATION: LVGH Board Room

PRESENT: Bev Langner Donna McDonaldKim Jo Bliss June KeddieLivia Lundon Bill GushulakTed Scholten Deane CunninghamCarla Larson Rob GeorgesonDelaine McLeod Samantha MantyHenry Gauthier

1. Call to Order

Bill called the meeting to order at 11:40 p.m. Sandra Beadle recorded the minutes of thismeeting.

2. Adoption of Agenda

IT was,

MOVED BY: Deane Cunningham SECONDED BY: Kim Jo Bliss

THAT the Agenda be accepted as circulated.CARRIED.

3. Conflict of Interest

There was no conflict of interest.

4. Approval of Minutes

IT was,

MOVED BY: Deane Cunningham SECONDED BY: Donna McDonald

THAT the Minutes from the October 18, 2017 meeting be amended as follows:6.7 Kim Jo Bliss, Tammy Kellar, Livia Lundon and Delaine McLeod met on October 18th

to review job descriptions.

CARRIED.

Item 4.11


5. Correspondence

There was correspondence regarding an email from Todd Hamilton. Todd would like toattend a board meeting on behalf of Physician Recruitment and Retention. Samantha willinvite him to do so at the January meeting.

6. On-Going Business

6.1 Board Vacancy – Emo Auxiliary

There is no representative to date. Kim Jo will get in touch with Mary Curtis, thepresident of the Emo Health Centre Auxiliary.

6.2 Planned Giving Launch

No Update at this time.

6.3 TV for Rainycrest

Samantha has reached out to Heather Hudson for additional information. She gaveHeather a couple other ideas of items from the Capital List that would benefit theresidents of Rainycrest (Blinds for the Activation Area $4,000., or Dinnerware for theSpecial care Unit $3,000) She has yet to hear back from Heather. Samantha will followup.

6.4 Job Description - Foundation Director

6.5 Draft Job Description – Public Relations & Events Specialist

It was,

MOVED BY: Delaine McLeod SECONDED BY: Livia Lundon

THAT items 6.4 and 6.5 be moved to “In Camera” at the end of this meeting.

CARRIED.

6.6 Christmas Appeal

Samantha completed the Christmas Appeal. Volunteers stuffed the envelopes includinghigh school students and Front Street Manor residents. Thank you to them, and a bigthank you to Bill for helping deliver the envelopes to the post office. There was a twoday delay on getting the envelopes out due to issues with Samantha’s corporate creditcard. On a positive note, the ask won’t go out with the flyers but instead will go on theirown. The crew in stores are very excited about the Foundation’s decision to support theCourier Truck, they are very grateful. Samantha is working on a design for the thank youcard to be sent to major donors.


7. New Business

7.1 Fundraising Request

Liana and Rob Frenette would like our support in helping them do a $6,000 matchingchallenge to purchase 2 new Renal Dialysis chairs for our satellite unit. They recentlyopened TBT Engineering here and in Sioux Lookout and would like to do the challengein both communities. They would like our help to launch the project in March. This wasdiscussed and Samantha has some questions to ask the Frenettes. She will bring back tothe next meeting.

7.2 Capital Purchase of Beds re: Special Events Funds

As the Board knows, the Special Event Committee was highly successful in raising nearly$36,000 for the purchase of new beds across the district.

It was,

MOVED BY: Kim Jo Bliss SECONDED BY: Bev Langner

THAT the funds from the Special Event Fall Gala be used to purchase 2 LTC beds each inEmo, Rainy River and Rainycrest as approved on the Capital List in the amount of $33,000.00.

CARRIED

7.3 Food Hampers

It has been requested of the Board to support 28 Christmas Hampers for the Dialysis Unit.The hampers are expected to cost about $30 each for a grand total of $800.00. We havesupported this cause in the past, and have received donations for the Dialysis Unit of over$3,000 mainly in memorial donations over the past year. It was suggested that we reviewour mandate, and create a policy so it is clear what we do fund and what we do not fund.

It was,

MOVED BY: Donna McDonald SECONDED BY: Rob Georgeson

THAT Riverside Foundation use memorial funds directed towards the Dialysis Unit to providefunding for up to 28 food hampers at $30 each.

CARRIED.

7.4 Other

Capital Equipment Request

There has been an urgent request for a Tandberg Unit for the ER in Rainy River HealthCentre. The Tandberg provides videoconferencing capabilities to the physician to speak


to a specialist. The specialist is able to see the patient and speak to the care team at thesame time. The Tandberg cost is around $25,000 to $30,000 and has been approved byRiverside Health Care as an urgent purchase. The Rainy River Health Centre Auxiliaryhas agreed to fundraise towards the purchase of the unit along with the sit/stand lift. TheFoundation would purchase the unit and the Rainy River Auxiliary would pay back theamount.

It was,

MOVED BY: Deane Cunningham SECONDED BY: Kim Jo Bliss

THAT the Foundation support the Rainy River Health Centre Auxiliary in their fundraisingefforts towards the Tandberg Unit.

CARRIED.

Bev will take to the Auxiliary and see if they would like to request that the Foundationrelease some funds designated towards the Rainy River Health Centre to be used towardsthe purchase of this equipment.

8. Outstanding Reports

8.1 Finance Report

Carla reported on the Revenue & Expense Summary for April 1, 2017 to October 31,2017. We show a Year to Date Deficit of ($35,393). Interest continues to improve. Noactivity to date in the Planned Giving.

It was,

MOVED BY: Livia Lundon SECONDED BY: Donna McDonald

THAT the Finance Report be accepted.

CARRIED.

8.2 Special Event Committee Report

Livia reported that at the last meeting they discussed the Spring Event. The event willtake place on Sunday, May 6, 2018 at the Robert Moore Auditorium. They are workingon a theme. There were 2 members of the Special Event Committee who stepped down;they will continue to recruit for new members. The Christmas Party for the Special EventCommittee will be on Thursday, November 30, 2017 at Flint House.


IT was,

MOVED BY: Delaine McLeod SECONDED BY: June Keddie

THAT the Foundation Special Events Committee Report be accepted.

CARRIED.

8.3 Hospital Auxiliaries Update

June reported that the LVGH Raffle Tickets for the 50/50 draw are $2/each and will bedrawn on December 11th. The Gift Shop sale is December 1st. The Auxiliary Luncheonis at the Rendezvous on December 11th, they invited Emo and Rainy River auxiliaries tojoin them for the luncheon. The LVGH Auxiliary received a RBC grant in the amount of$500.00

June also reported for the Rainycrest Auxiliary. Samantha will call June Caul to talkabout the items they are waiting for. The Choir at Rainycrest will be doing a concert onDecember 13th at 1:30 p.m. The Bazaar at Rainycrest on Saturday November 25th raisedover $4,000.00 !! The Resident Christmas party will be on December 8th.

Bev reported that Rainy River will have their Bazaar on Sunday December 3rd at 2:00p.m. at the Recreation Centre. They are purchasing gifts for the residents at Rainy River.As above they will be fundraising for the Tandberg Unit along with the Sit/Stand lift.

There was no formal report for the Emo Auxiliary, but Kim Jo reported the Auxiliary willbe collecting food items at the parade for Holly Days this weekend.

8.4 Foundation Director Report

Samantha has been working on the Christmas Appeal. She has also reorganized the filingsystem in her office, moving old documents upstairs for storage. Bill has called monthlydonors, and Samantha has added new pledges. Samantha will be looking at the budget;there is a pre-meeting set up with Lindsay and Carla on December 1st.

IT was,

MOVED BY: Donna McDonald SECONDED BY: Delaine McLeod

THAT the Hospital Auxiliaries Update be accepted.

CARRIED.


IT was,

MOVED BY: Kim Jo Bliss SECONDED BY: Bev Langner

THAT the Foundation Director Update be accepted.

CARRIED.

8.5 Riverside Corporate Report

Ted reported (attached) he highlighted the following:• Northwest Health Alliance. The three Senior Admin from Riverside will be

members of the Northern and Eastern Region.• Physician Recruitment• Rural Health Hub

Ted also spoke about the expansion of the Orthopaedic program and doing more hips andknees. They may be approaching the Foundation to purchase surgical trays in the future,the cost is about $10,000.00.Ted also mentioned the new Administrator Marva Griffith has started work at Rainycrest.

It was,

MOVED BY: Deane Cunningham SECONDED BY: June Keddie

THAT the Riverside Corporate Report be accepted.

CARRIED.

8.6 Other

None

9. Next Meeting

The next meeting will be on Monday, January 29, 2018 at 11:30 a.m. in the BoardRoom at LVGH.

The meeting proceeded to “In Camera”

It was,

MOVED BY: Deane Cunningham

THAT the meeting move out of “In Camera”

CARRIED


10. Adjournment

It was,

MOVED BY: Donna McDonald

THAT the meeting be adjourned at 1:30 p.m.

CARRIED.

_________________________________Bill Gushulak, Chair

28/11/2017

/sb


Auxiliary Report – January 2018

Emo

The Emo Hospital Auxiliary held their December 14 meeting after visiting each resident at the EmoHealth Centre. We sang a Christmas wish and gave each one a gift bag full of useful items to theseresidents who have come from right across the district, from Fort Frances, Nestor Falls and West. Ourdetermination to obtain smaller items such as blood pressure cuffs to larger items such as a workingshower was strengthened by these visits. We hope to see tangible results of our pledge of $33,500 soonin the New Year.

La Verendrye General Hospital

See Attached.

Rainycrest

See Attached.

Rainy River

No Report.


Item 4.12

LAVERENDRYE GENERAL HOSPITAL AUXILIARYEXECUTIVE MEETINGDECEMBER 5, 2017

LOCATION: Main floor meeting room

PRESENT:Judy Webster, Irene Laing, Shirley Scofield, Janet Lambert, Dixie Badiuk,

Linda Larocque, Monica Sus, Laureen Vandetti, Joy Lockman, Donna Penney, Marnie

Cumming, Diane Glowasky

REGRETS: Joyce Lafreniere, June Keddie, Lawrie Kosowick, Dolores Fraser.

CALL TO ORDER: The meeting was called to order by the chairperson at 1:00 pm.

APPROVAL OF AGENDA/ADDITIONS: The addition to the agenda was the forming of

a nomination committee.

CONFLICT OF INTEREST: None declared

MINUTES of the November 7th meeting were declared accepted by the Chairperson.

TREASURER’S REPORT: The Chairperson declared that the Financial Report be

accepted.

BUSINESS ARISING FROM THE MINUTES

Fall Tea Venue – Motion by Diane G and seconded by Dixie B that we have the FallTea at New Beginnings Church on October 12, 2018. Carried

Vests: Shirley will look at contacting a supplier in London, ON

Refrigerator removal: Judy made contact with outside individuals and now it is up to thehospital maintenance to remove the refrigerator.

MOTION made by Irene L and seconded by Donna P that we pay $40.00 plus tax forthe removal of the Freon to K J Refrigeration from the shop refrigerator. Carried.

MOTION made by Diane G and seconded by Dixie B that we have the fall tea at NewBeginnings Church on Sat. October 12, 2018. Carried

We talked about sending a letter to the CEO regarding electrical outlets in the hospitallobby at the Nov meeting. Monica S. advised at this meeting that she was going to meetwith Samantha to discuss her issues with the lobby electrical outlets and asked theChairperson to come with her to the appointment with the CEO to discuss our issuesand our pledge. We felt that this was a better route to take.

C0RESPONDENCE – none

DIRECTOR and COMMITTEE REPORTS

• Shop: Monica Sus advised that the lobby sale was a huge success this yearalthough she felt that we could have had more chocolate dainties. We raised 706.50.

• Membership: Bev Johnson has resigned. We are looking for a new member.


• Social: Diane advised that the menu has been changed by the Rendezvous to aham dinner. Party is set for Monday Dec 11th.

• Communications: Linda L would like submissions for the newsletter by mid-January.The newsletter comes out in February.

• Patient Services: No report

• Foundation: No report

• Sick and Visiting: Donna gave a report of the number of cards sent out. There were2 get well, 1 sympathy and 3 thinking of you.

• Historian: No report

• Phoning: Marnie C will update the phoners with the new membership list.

• Lobby Lottery: Dixie Badiuk advised that she deposited $820.00 since last month.She presently has $245.00 and our lottery book balance is $19,264.34.

• Irene L advised that it looks like we will not be able to sell all the 50/50 tickets beforeDecember 11th which is the date of the draw.

MOTION made by Shirley S and seconded by Irene L to accept the committee reports.Carried.

NEW BUSINESS

Discussion regarding the purchase of Christmas gifts for Sandra Beadle, Maintenance,Samantha Manty and the kitchen staff.

MOTION by Janet L. and seconded by Joy L that we purchase Christmas gifts forSandy Beadle, Maintenance staff, kitchen staff and Samantha Manty as a “thank-you”for all the help they have given the auxiliary. Value of gifts to be at the discretion of thechairperson. Carried

NEXT MEETING February 6, 2017 ADJOURNMENT : The meeting adjourned at 2:30p.m.

________________________ ____________________

Judy Webster, Chairperson Shirley Scofield, Secretary


Rainycrest Auxiliary Meeting

The Rainycrest Auxiliary meeting was held Wednesday, Dec. 13, 2017 at 1:30PMin the Activation Room at Rainycrest Long Term Care Home.

Before the meeting was called to order Heather Hudson introduced the NewAdministrator, Marva Griffth. Marva spoke about her background working inseveral Home Care Homes. She is from the Toronto area. Marva is verypersonable and seems very interested in our Auxiliary.

After the Administrator left, the meeting was called to order by President JuneCaul. All members present joined in reciting the Auxiliary prayer.

MEMBERS PRESENT: June Caul, Judy Karpinen, Laurel Halverson, Bev Angus,Verena Zucchiatti, Gloria Bergner, Donna McKelvie, Shirley Scofield, JudyKarpinen and Judy Anderson

MINUTES OF LAST MEETING: The minutes of the November meeting werepresented by June Caul. Donna McKelvie made the motion to accept the Minutesand Judy Karpinen seconded it. Carried

FINANCIAL REPORT : Sheila McMillen was not able to attend the meeting buthad done up a December report which was presented by June Caul,

A motion to accept the Financial Report and pay outstanding bills was made byMargaret-Ann Hudson and seconded by Laurel Halvorsen.

OLD BUSINESS: Fall Bazaar: Bev Angus gave a report about the Fall Bazaarwhich was held on Saturday, Nov. 25th. We made close to $4,000. Everythingwent well. Bev stated that we received a lot of help from Rainycrest Activationgroup as well as her hubby, Larry and of course Laurel Halvorsen and all theworkers who made this all possible.

Residence Christmas Party: Shirley Scofield stated that all went well. Againthere was lots of groceries left over. 100 people attended out of the 200 peoplethere. Ruth Caldwell was Santa again this year and did an awesome job. Shestated it was nicer to have the event in the Hallet Hall but this year it was held inthe entrance area of Rainycrest

CORRESPONDENCE: June Caul received a letter from Sandra Brunetta who hasresigned from her position as a Publicity Director with the Auxiliary.

DIRECTORS’S REPORTS: The Directors Report was skipped as several peoplewere not available and involved in the Christmas Choir which was at the sametime. June Caul stated that we will have the Report at the next meeting in January.


-2-

NEW BUSINESS: June Caul stated that Samantha Manty resigned her positionwith the Riverside foundation.

CAPITAL LIST: June Caul will be meeting with Marva Griffth regarding the newfurniture in the entrance. This needs approval from the Administrator.

June Caul stated that anything under $1,000 can be purchased by us withoutgoing through anyone for approval.

June Caul also read from a list of items that is needed by Rainycrest residentswhich we can donate from our $75,000 surplus.

We will purchase the following items:

- Approximately 25 new tablecloths for Hallett Hall- Purchase of some Activity Books which Heather Hudson previously asked for.- Furniture in the front lobby entrance

A motion to accept this list was made by Bev Angus and seconded by MargaretAnn Hudson.

June Caul asked if we should buy Pointsettas this year for the Nurse’s station andtables. It was decided not to do it this year as it is getting late in the season.

ADJOURNMENT

June Caul moved to adjourn the meeting. Bev Angus motioned to adjorn andGloria Berner seconded it. Carried

Next Meeting: Wednesday, January 10, 2018.

______________________________ ______________________________

President- June Caul Acting Secretary-Judy Karpinen


BRIEFING NOTE

TO: RHC Board of Directors

FROM: Ted Scholten, President & CEODATE: Jan 17, 2018SUBJECT: Rainy River West Rural Health Hub (RRDWHH)

Review of Mental Health and Addiction Services.SUMMARY

As part of the RRDWHH, project leads from Canadian Mental Health AssociationFort Frances (CMHAFF) and Riverside Health Care (RHC) have selected TheHealth Innovations Group (HIG) to perform a Review of Mental Health andAddiction Services.

• Expressions of Interest (EOI) were sent out November 27th and 3 proposals werereceived and reviewed.

• Work is expected to begin early February and be concluded by March 31st 2018.It is expected that 2 HIG team members will be in the district at least 8 days, atotal of 16 of the 27 days allocated to the review, representing 60% of the projecttime.

• This phased project will include Initiation in January/ Current State analysis inFebruary/ Future State Options and Implementation recommendations in March.Final Report is due end of March.

RECOMMENDATION

Provided for information purposes


Item 7.2

BRIEFING NOTE

TO: RHC Board of Directors

FROM: Ted Scholten, President & CEODATE: January 17, 2018SUBJECT: Community Advisory Council (CAC)SUMMARY

The Community Advisory Council has not yet formed as there has been difficultyattracting interest/ applications for community members.

• We have now received 5 of 6 known interested community member applicationsfrom across the District and the last application is expected to be submitted nextweek.

• Per the terms of reference, the applications must be reviewed by the Committee todetermine fit, and the information will be shared with the CAC membership and,if accepted, recommended for approval.andThe Board must approve new members, upon recommendation of the CAC.

• Having reviewed applications received to date, and since the Committee has yetto meet, I would like to propose that the Board approve 6 applications formembership listed below:

Norma ElliottJaunita Hunter-ConnonDebbie McTaggartIrene LangCynthia DonaldPeter Howie

• First CAC meeting will be scheduled in February.

RECOMMENDATION

THAT the Board of Directors approves the 6 applications received to date for CACCommunity Membership for 2 year terms effective immediately.


Item 7.3

BOARD OF DIRECTORS MEETING OPEN SESSION Thursday, … · 2020. 6. 3. · Dr. Algie reported the...

Documents

Transcript of BOARD OF DIRECTORS MEETING OPEN SESSION Thursday, … · 2020. 6. 3. · Dr. Algie reported the...