board of directorsmeeting wednesday february 24 , 2021

BOARD OF DIRECTORS MEETING

Wednesday February 24, 2021 1700h –1800h

OPEN SESSION Click here to join the meeting

Or call in (audio only) (833) 827-2824,,565223495# Canada (Toll-free)

Phone Conference ID: 565 223 495# AGENDA

Board Members: David Pyper (Chair), Nicola Melchers, Denise Smith, Tom Dean, Elaine Habicher, Tim Edworthy, Katie Hamilton, Jody Stecho, Sara Alvarado, Lynn Woeller, Ian Miles, Diane Wilkinson

Ex officio Members: Patrick Gaskin, Sandra Hett, Dr. Asim Masood, Dr. Heather MacLeod, Dr. Vlad Miropolsky

of 1

*Agenda Item (* Indicates attachment) (TBC- to be circulated) Page #

Time Responsibility Purpose

Vision To provide exceptional healthcare by

exceptional people

Mission A progressive acute care hospital and

teaching facility committed to quality and integrated patient centered care

Values

Caring, Respect, Innovation, Collaboration, Accountability

1. CALL TO ORDER 1700 D. Pyper 1.1 Territorial Acknowledgement 1.2 Confirmation of Quorum (7)

Confirmation

1.3 Declarations of Conflict Declaration 1.4 Consent Agenda

(Any Board member may request that any item be removed from this consent agenda and moved to the regular agenda.) 1.3.1 Minutes of January 27, 2021* 1.3.2 CEO Report* 1.3.3 Board Work Plan* 1.3.4 Corporate Scorecard* 1.3.5 Q3 CEO Certificate of Compliance*

2 6

12 19 31

Approval

1.5 Confirmation of Agenda D. Pyper Approval 2. PRESENTATIONS - none

3. DISCUSSION ITEMS 3.1 Chair’s Report

3.1.1 General Update* 3.1.2 Events Calendar*

32 34

1705

D. Pyper D. Pyper

Information Information

3.2 Resources Committee (February 22, 2021) 3.2.1 January Financial Statements and Year-End

Forecast*

36

1715 T. Edworthy

Information

3.4 Quality Committee 3.4.1 February 17, 2021 Meeting Summary* Quality Improvement Plan (QIP)

o Corporate QIP – Narrative* o Corporate QIP Metrics/ Targets*

46 48

1725

I. Miles I. Miles I. Miles I. Miles

Information Information Information Information

3.5 Governance Committee (February 18, 2021) 3.5.1 Bylaw Review Update

1740 N. Melchers

Information

3.6 Medical Advisory Committee 3.6.1 February 10, 2021 Meeting Summary* 3.6.2 February Privileging and Credentialing*

52 58

1745

Dr. A. Masood Dr. A. Masood

Information Approval

3.7 CEO Update 3.7.1 COVID Update*

64

1755

P. Gaskin

Information

4. ADJOURNMENT 1800 D. Pyper Approval

5. DATE OF NEXT MEETING: April 28, 2021

https://teams.microsoft.com/l/meetup-join/19%3ameeting_MzdhYmE3MTctZjRmMS00ZDEyLWE5YzItNmM5MmQ0N2EyOTBj%40thread.v2/0?context=%7b%22Tid%22%3a%227f451fc4-6001-45e5-9bf1-8a5f391195f9%22%2c%22Oid%22%3a%22f4812602-92e8-4698-a7f7-ebc17885c02c%22%7d

tel:8338272824,,565223495#%20

Cambridge Memorial Hospital BOARD OF DIRECTORS MEETING Wednesday, January 27, 2021

OPEN SESSION Minutes of the open session of the Board of Directors meeting, held virtually on January 27, 2021 Present:

Mr. D. Pyper Mr. T. Edworthy Mr. I. Miles Ms. J. Stecho Ms. E. Habicher Mr. T. Dean Ms. D. Smith Dr. V. Miropolsky Ms. D. Wilkinson Mr. P. Gaskin Ms. K. Hamilton Dr. A. Masood Ms. N. Melchers Ms. S. Hett Ms. L. Woeller Dr. H. MacLeod Ms. S. Alavardo

Regrets: none Staff Present:

S. Beckhoff, T. Clark Guests: Recorder: Ms. C. Vandervalk P- Present, R – Regrets, T – Present via Teleconference 1. CALL TO ORDER

Mr. Pyper called the meeting to order at 1700 hours.

1.1. Territorial Acknowledgement Mr. Pyper presented the Territorial Acknowledgement.

1.2. Confirmation of Quorum Quorum requirements having been met, the meeting proceeded, as per the agenda.

1.3. Conflict of Interest

Board members were asked to declare any known conflicts of interest regarding this meeting. There being none the meeting continued as per usual.

1.4. Consent Agenda o Minutes of November 25, 2020* o CEO Report* o Corporate Scorecard* o Board Work Plan*

The consent agenda was approved as circulated.

1.4 Confirmation of Agenda MOTION: (Edworthy/Smith) that, the agenda be approved as circulated CARRIED

2. Presentations

2.1 none

2

Board of Directors Meeting (Open Session) January 27, 2021 Page 2

3. Discussion Items

3.1 Chair’s Report 3.1.1 General Update The Chair provided an update of his activities of late.

3.1.2 Events calendar The events calendar was reviewed.

3.2 Resources Committee 3.2.1. December Financial Statements and Year-end Forecast

In December, CMH had a year-to-date operating deficit of $1.5M after building amortization and related capital grants (down from a $2.6M YTD deficit in November) which represents a $4.2M negative variance from budget. The year-to-date negative variance was driven by a shortfall of PCOP revenue, a shortfall of elective and urgent QBP revenue, and a reduction of parking revenue, technical fees and preferred accommodation, and offset, in part, by positive variances in the Perioperative program due to the cancellation of elective surgeries, positive variances in salaries and benefits due to unfilled positions and less than expected maternity payments, and positive variances in supplies. The Ministry also flowed funding to compensate for uninsured patients and additional COVID incremental funding for the month of March.

Activity volumes reflect a 17% increase in Medicine, a 25% increase in Rehab, a 12% decrease in Surgery, an 18% decrease in Emergency and a 6% decrease in Mental Health.

With respect to funding, $1.9M of the possible $10.8M PCOP clinical revenue has been recognized YTD, with the shortfall attributed to the decrease in surgical volumes as a result of COVID. To date, CMH has received $6.8M of the $8.8M of the COVID related operating expenses and $1.4M of the $1.5M of the COVID related capital expenses submitted to the MOH. Assessment Centre revenue and funding for 10 additional medicine beds starting November 1 has also been recognized.

Overtime was over budget by $154k in December and over budget year-to-date by $869k. Sick time was below year-to-date budget by $8k.

The balance sheet for December reflected a positive cash position, and CMH’s working capital ratio meets Ministry requirements. Of the $83.6M paid in November in settlement of CRP phases 1 and 2, $72.1M will be funded by the Ministry. The hospital received an $8.2M rebate from Revenue Canada for the CRP payment HST amount of $9.6M.

The forecasted deficit for the year is $2.2; the major drivers of the deficit is unearned PCOP ($5M) and urgent QBP revenue ($1.4M). Key assumptions for the forecast include achieving PCOP targets starting in November, no negative impact of a second wave of COVID on surgical volumes or number of medical beds available, full Ministry funding for all COVID related operating and capital costs, and the Assessment Centre volume targets met to maximize funding.

Lots of advocacy is going on to get clarification from the government to understand if they will allow us to keep any unused QBP and bundled care funding. There is an openness to this and a commitment to making hospitals whole. If we are able to keep the funding it will change our positon significantly.

3


PCOP have also had a significant impact on CMH as well, and we will be advocating that we can keep a portion of the funding. With goal of ending the year balanced.

3.3 Audit Committee

3.3.1. January 18 Meeting Summary Representatives from KPMG presented the audit plan for the Committee’s information. The audit plan approach and strategies for areas of significant risk were highlighted. A review of the impact of the COVID-19 pandemic on financial reporting implications (i.e. capital spending resulting from COVID and associated government funding) is the most significant change to the audit approach over the previous fiscal year. Also, the audit will be conducted remotely this year to comply with the provincial mandate to limit in-person work. The auditors advised that no audit requirements pertaining specifically to COVID have been issued from the Ministry of Health to date.

The impact of the pandemic on CMH’s final position remains unknown.

3.4 Quality Committee

3.4.1 January 20,2021 Meeting Summary* The Quality Committee had a truncated meeting and there were no presentations from the various departments. The goal is to have these resume in March. Of highlight from the meeting an update was provided on the Annual Senior Friendly report as it was refreshed to include the focus on COVID-19 and is extended to 2022.

3.5 Governance Committee 3.5.1 Board Recruitment Update

Ms. Stecho provided an update on the Board recruitment to date. The skills assessment and intention survey has been completed and there are 3 vacancies thus far. The Board ad will be posted on February 1 and remain posted for approximately 3 weeks in conjunction with the CMH Foundation. Advertising will be done via social media outlets as well. If the Board has any recommendations, they are asked to forward them to Jody or Cheryl who will provide the applicant the link to apply.

3.6 Medical Advisory Committee 3.6.1 December 9, 2020 Meeting Summary

Dr. Masood provided a highlight on the following: • HSMR update

Results look unfavorable for CMH. A formal analysis and a review of coding is being explored. There are no findings that were any quality issues and the review conclusion is leaning towards coding issues. A review of the 2021 data that is not completed/submitted yet will be reviewed and briefing note will be brought to the Board with the findings

3.6.2 January 12, 2021 Meeting Summary

Dr. Masood provided a highlight on the following: • Rules for New Admission Policy

4


The works and came about due to concerns raised by the ICU group and GIM group, that when they admitted a patient to the hospitalist service, their name stayed as MRP through the patient’s admission, which presented a safety concern. We have opted to have the nighttime admission physician and the day admission physician, admit specifically to one of the physicians who will be on the next day. During handover, now when patients are missed, it shows up on Meditech list for physician patient had been admitted to.

3.6.3 Dec/Jan Privileging and Credentialing

Dr. Masood presented the applications for privileging and credentialing and attested that due diligence was exercised and the following names have been brought forward for approval.

MOTION: (Dean/Alvarado) that, the Privileges for ratification and granting recommended to the Board be approved. CARRIED

3.7 CEO Update 3.7.1 COVID Update

Covid update provided for information. Collaborative approach amongst the community partners and with the work being done. Undoubtedly, the connections within the OHT have made for smooth planning and flow of information.

3.7.2 CCM Current Status

Update provided for information. Community has supported and rallied around CCM. CMH conducted a family teleconference in December shortly after the management

order. Communication at the beginning was the main concern but they have since stabilized.

4. ADJOUNMENT

The meeting adjourned at 1800h. (Stecho/Hamilton)

5. DATE OF NEXT MEETING The next scheduled meeting is February 24, 2021 David Pyper Board Director CMH Board of Directors

Patrick Gaskin Board Secretary CMH Board of Directors

5

of 6

CMH President & CEO Report March 2021

for CMH (Feb), CMHF (Feb), CMHVA (Feb), MAC (Mar)

This report provides a brief update on some key activities within CMH. Stories are organized by three strategic pillars and the COVID-19 pandemic. As always, I’m happy to answer questions and discuss issues within this report or other matters.

Prove Patient Matter Most Key priority “accelerate access to care for patients…” description:

• Recap of the goal: o By March 31, 2021 the hospital will seek to accelerate access to care for our

patients by achieving planned PCOP (post-construction operating plan) growth

o Sandra Hett is the executive sponsor for this priority with Nicole Craven and Kim Siegel as operational leads

• Key activities and accomplishments this past month include: o The Surgical Program goal is to add 463 weighted cases per month. This

has been stalled due to the restrictions imposed by the pandemic. Despite this, the following continues: Emergency surgery High risk cancer surgery Ambulatory surgery that do not require a post-surgical bed (e.g.,

cataracts) In February, additional operating room capacity was added. Joint

replacement surgery was restarted with OR time on weekends to address wait lists

o Medicine program goal defined as decreasing two (2) conservable beds and decrease overall ALC volumes. This will be done by: Continued focus on ED flow with a target of 15 hours or less for

90% of admitted patients- challenges with mental health volumes and medicine requiring isolation protocols

6

of 6

On-going physician education with chart audits to capture accurate HIG weights. Education and feedback to the health records staff as improvement opportunities identified

Decrease conservable beds with focused interdisciplinary planning Focus on CHF and COPD pathways to understand opportunities to

reduce length of stay in this patient group Decrease ALC in collaboration with regional partners with the

creation of intense transitional teams Visits resume

• CMH’s doors opened and care partners were once again able to visit patients in hospital. This occurred shortly after the region was downgraded from lockdown to the red zone on February 16.

• The process was similar to the one developed during the first introduction of visitors to hospitals and is tied to the region’s colour status. The one change was to limit visits to one dedicated care partner throughout the patient’s stay. Prior to the second lockdown, a patient could receive any one person, per visit.

• Visits are limited to certain hours and the number of people in hospital at one time is controlled through bookings. Care partners can book their visits on-line of by phone.

• As the region moves through and eases restrictions from the pandemic, the hospital will also expand the number of visits allowed and the times by which these visits can be made.

• The current visitor policy for end-of-life, Women & Children Program and the Emergency Department has not changed.

Increase Joy in work Key priority “keep staff and physicians safe and engaged” description

• Recap of the goal: o CMH will continue to work through its employee engagement strategy and

focus on keeping staff and physicians safe and engaged o The executive sponsors of this priority are Sandra Hett and Trevor Clark

with Susan Toth and Kim Siegel as operational leads • Key activities and accomplishments this past month include:

o Work on tactics continue, despite ongoing corporate efforts to manage the pandemic within hospital and in our health care system

7

of 6

o Equity, Diversity and Inclusion sessions were offered to the leadership team. Three sessions were booked over January and February 2021.

Plan the parade! We are #242

• It is often said that good things come in threes. Late December 2020, the COVID-19 vaccinations started within our region. On January 18, we had a birthday party for the amazing Wing A patient care wing and on January 27, we received notice that we made Forbes’ Canada’s Best Employers list for 2021!

• While it wasn’t a surprise to learn that we were recommended, this unforeseen accolade made for a pleasant distraction from the bustle of COVID-19.

• CMH ranked #242, with partner organizations Guelph General Hospital and St. Mary’s General Hospital being named as top employers.

• To determine the list, Statista – a company hired by Forbes - surveyed more than 8,000 Canadians working for businesses with at least 500 employees. All the surveys were anonymous, allowing participants to openly share their opinions. The respondents were asked to rate, on a scale of zero to ten, how likely they’d be to recommend their employer to others. Statista then asked respondents to nominate organizations other than their own. The final list ranks the 300 employers that received the most recommendations

Lead Boldly Key Priority “meet evolving needs of our community through adaptive execution

of CRP Phase 3” description • Recap of the goal:

o The CRP project is starting up again with the complete refurbishment of the Wing B patient care facility. The hospital will deliver the Phase 3 part of this project on-time and on-budget.

o Mike Prociw is the executive sponsor of this priority with Bill Prokopowich as the operational lead

• Key activities and accomplishments this past month: o A 48-month base line schedule has been agreed to with EllisDon. By mid-

February, CMH is expected to receive an updated schedule that will overlay the impacts of the three change directives that have been issued to date - Infrastructure Upgrade; Operation Room Renovation: and Exiting. With regards to the Exiting requirements, the project schedule may be increased by an additional 14 months and be accompanied by a delay claim that would be cost shared with Zurich.

o For February, the following work has started or is on-going: Excavation of the Soiled Elevator servicing MDRD;

8

of 6

Renovation of General Radiology, CT and Mammography space in the old Emergency Department;

Old Operating Room Renovation; Wing B Infrastructure upgrades; The Co-Generation project is delayed by about five months. Final

testing is on-going and it is hoped that the system is operational by early March. It is likely that negotiations between CMH and JCI regarding Liquidated and Delay Damages will follow;

The kitchen renovation was met with some unplanned abatement work. This has set back the completion date of the project. While timelines are being revisited it is expected that it will be delivered to CMH by the end of May;

Related, but not part of the CRP project is a heating system upgrade for Wing C. This is important work as patient care has resumed in this wing and will be act as decanting space for Surgery, Medicine and Rehabilitation programs once construction starts in Wing B. The infrastructure that will support the required heating in C Wing will be constructed in Q4 with a targeted completion date of the end of March.

Key Priority “prepare for clinical transformation though re-initiating our

evaluation of a new HIS system” description • Recap of the goal:

o CMH current Health Information System (HIS) is out of date. By the end of March 2021, the hospital will prepare for digital transformation by reinitiating the evaluation of a new HIS system.

o The reason for this key priority is that the outdated system is creating inefficiencies and the need to seize opportunities to enhance patient care through digital transformation. The hospital is also obligated, through its Ontario Health Team (OHT) partnership to adopt digital tools. Finally, there is a need to improve information management at the hospital.

o Mari Iromoto is the executive sponsor. Walter Winkler and Cheryl Livingston are the operational leads.

• Key activities and accomplishments this past month include: o The organization very much vested in pursuing the replacement of our HIS

system. Given the number of competing demands on the organization, a decision was made to reschedule a number of key Expanse activities.

o All recorded sessions from the primary and secondary interviews to fully understand functional needs for each program have been posted.

o All of the Expanse demos are posted to the Meditech portal. o A number of Expanse demonstrations for key programs will be conducted

in the mid-March timeframe. These include live demonstrations for Business and Clinical analytics, inpatient physicians and diagnostic radiology.

o Virtual site visits with comparable Canadian and US hospitals are planned in April to observe and further understand Meditech Expanse workflow.

9

of 6

o A virtual sandbox is planned for May to allow CMH staff and physicians the ability to experience the system first hand.

Adam Isaacs – Supervisor, Perioperative Services

• Adam Isaacs started as our new Supervisor for Perioperative Services on February 22. Adam joins the Perioperative team with a focus on operational leadership, organization of workflows and staffing, promotion of evidence-based practices and continuous process improvement.

• Adam is a Registered Nurse (RN) with more than 25 years of clinical and professional healthcare experience in Emergency Medicine, Critical Care Services, Risk and Emergency Management and Cardiac Surgery.

• He completed his RN and Nurse Practitioner (NP) training in the United Kingdom at Bradford University, is a certified Healthcare Emergency Manager, holds a graduate certificate in Commerce and is currently completing his Master’s in Business Administration at Charles Sturt University.

• Adam’s most recent clinical and managerial experience is from Halton Healthcare (Milton Site), Hamilton Health Sciences Centre and Trillium Health Partners.

• Adam was integral to developing the clinical operations of cardiac surgical services at the Hamilton General Hospital site. He led an inter-professional team of greater than 100 members to deliver the highest cardiac surgery volume provincially. He co-led the development and implementation of a Perioperative Specialist and Physician Assistant program to reduce length of stay and better support the post-operative patient population. Adam is also experienced in continuous quality improvement, the establishment of metrics and associated focused strategic plans.

COVID-19 Pandemic COVID-19 vaccination update

• In January, the government announced reductions in the supply of vaccine. This promoted a renewed focus on vaccinating long-term care and retirement home residents and workers.

• The government also provided new timing of second vaccination doses, with supporting evidence from the National Advisory Committee for Immunization. It noted that receiving the second does within 42 days is still effective. As such, health care workers that received their first dose were rescheduled to receive their second dose within 42 days. This strategy provided some assurance that enough vaccine was available for the remaining long-term care and retirement home stakeholders.

10

of 6

• In early February, second doses were offered again to hospital staff ensuring all would be inoculated against COVID-19 before the 42-day period was up.

• By mid-February, the government announced a new shipment of vaccine. Cambridge Country Manor update

• On January 28, Cambridge Country Manor (CCM) and Cambridge Memorial Hospital, in collaboration with Public health, declared the outbreak over.

• With that, the repatriation of the remaining residents transferred to hospital became a priority. The final patients were transferred from hospital on February 12, the same day all residents received their second dose of the COVID-19 vaccine. It was an early Valentine’s Day for them!

• CCM staff that became ill with COVID have all been resolved. Only a handful remain off work, but the rest have returned and schedules are stable. Most staff have also gotten their second COVID vaccine.

• CMH staff assigned to CCM have returned to CMH – some even accepted assignment to St. Luke’s Place, another home that experienced an outbreak in early February. The last of CMH’s staff – Executive Lead Mari Iromoto and Clinical Lead Emily Quantz - left the home at the last week of February.

• The 90-day voluntary management agreement between CMH and CCM ends on March 17, 2021.

11

Agenda Item 1.3.3 BOARD WORK PLAN – 2020-21

Page 1 of 7 = Due C = Complete I = In progress D = Delayed 19 February 2021

Charter Section #4

Action (Italics-comments) Committee Responsible

Sept Oct Nov Jan Feb Apr May Jun

Tone at the Top

a-i, ii a-iii

Approve CEO goals and objectives Approve COS goals and objectives

Mid-year CEO assessment input from Board Mid-year COS assessment input from Board

Mid-year/Year-end CEO report and assessment Mid-year/Year-end COS report and assessment CEO evaluation/feedback – mid-year COS evaluation/feedback – mid-year

CEO evaluation/feedback –year end and performance based compensation COS evaluation/feedback –year end and performance based compensation

Executive

Board

Executive

Executive

Executive

C n/a

C C I I I I

√ √

√ √ √ √ √ √

Reviewing the performance assessments of the VPs – summary report provided to the Board (as per policy 2-B-10)

Executive √

b Strategic Plan: approve process, participate in development, approve plan

(done in 2017; will be done again in 2018-19) Board

b Progress report on Strategic Plan (2x year Jan for 17-19 plan) Board D

√

b-iii-c Approve annual Quality Improvement Plan (QIP) Quality √

12



Charter Section #4



b-iii-c Review and approve the Hospital Services Accountability Agreement (H-SAA)

Review and approve Multi-Sector Accountability Agreement (MSAA) Review and Approve Community Annual Planning Submission (CAPS) Review and Approve Hospital Accountability Planning Submission (HAPS)

Resources, Quality

√

√ √

b-iii-C Monitor performance indicators and progress toward achieving the quality improvement plan

Quality C

C

√

c-i-B c-i-B

Critical incidents report – (as per the Excellent Care for All Act). (Brought forward to Board at each meeting – approved Nov 27, 2019)

Monitor, mitigate, decrease and respond to principal risks

Quality

Audit

C

C

C

C

√

√

√ √

√

c-i-E c-i-F c-i-F c-i-F

Review the functioning of the Corporation, in relation to the objects of the Corporation the Bylaw, Legislation, and the HSAA

Governance

C

C

√

√

Receive and review the Corporate Scorecard

Board

I

C

C

√

√

Declaration of Compliance with M-SAA Schedule G (due Oct 31 and Apr 30 to the WWLHIN)

Resources

C

√

Declaration of Compliance with BPSAA Schedule A (due May 31 to the WWLHIN)

Resources √

Receive and review quarterly the CEO certificate of compliance regarding the obligations for payments of salaries, wages, benefits, statutory deductions and financial statements

Resources C

C

√

√

Procedures to monitor and ensure compliance with applicable legislation and regulations

Audit √

CAPS & HAPS not required for 2021/22

13



Charter Section #4



e-i-A

Receive a summary report on: • CEO succession plan and process • COS succession plan and process • Succession plan for executive management and professional staff

leadership

Executive Executive Executive

√ √ √

√

Professional Staff

f-i-A f-i-B/C

Ensure the effectiveness and fairness of the credentialing process Monitor indicators of clinical outcomes, quality of service, patient safety

and achievement of desired outcomes

MAC/Quality

MAC

I

I

I

C

√

√

√

√

f-i-C Make the final appointment, reappointment and privilege decisions for Medical/Professional Staff

Oversee the Medical/Professional Staff through and with the MAC and COS

Board

COS

C

C

C

C

C

C

√ √

√ √

√ √

√ √

Build Relationships

g Build and maintain good relationships with the Corporation’s key stakeholders The Board shall build and maintain good relationships with the

Corporation’s key stakeholders including, without limitation, MOH, Ontario Health, community leaders, patients, employees, families, other health service providers and other key stakeholders, donors and the Cambridge Memorial Hospital Foundation (” Foundation”) and the Cambridge Memorial Hospital Volunteers Association.

Present Annual Volunteer Association Presentation

Board

C

Financial Viability

14



Charter Section #4



h-i-A,C h-i-A,C h-i-A, B h-i-A i-i-C

Review and approve multi-year capital strategy Review and approve multi-year information technology strategy

Resources Resources

√

√

Review and approve annual operating plan – service changes, operating plan, capital plan, salary increases, material amendments to benefit plans, programs and policies

Resources/ Quality

C

√

Approve the year-end financial statements Board √

Approve key financial objectives that support the corporation’s financial needs (including capital allocations and expenditures) (assumptions for following year budget)

Review of management programs to oversee compliance with financial principles and policies

Resources

Resources

I

√

√

Board Effectiveness

i Establish Board Work Plan Board C

i-i-A Ensure Board Members adhere to corporate governance principles and guidelines Declaration of conflict agreement signed by Directors

Governance

√

i-i-B Ensure the Board’s own effectiveness and efficiency, including monitoring the effectiveness of individual Directors and Board officers and employing a process for Board renewal that embraces evaluation and continuous improvement

Governance/ Board

√

i-i-C Ensure compliance with audit and accounting principles Audit √ i-i-D

Periodically review and revise governance policies, processes and structures as appropriate

Governance

C

C

C √ √ √

Fundraising

15



Charter Section #4



k Support fundraising initiatives including donor cultivation activities. (through Foundation Report and Upcoming Events)

Foundation C

C

C

C √ √ √ √

Public Hospitals Act required programs

l-i-A l-i-B l-i-C

Ensure that an occupational health and safety program and a health surveillance program are established and require accountability on a regular basis

Audit

Next due 2021

Ensure that policies are in place to encourage and facilitate organ procurement and donation

Quality

√

Ensure that the Chief Executive Officer, Nursing Management, Medical/Professional staff, and employees of the Hospital develop plans to deal with emergency situations and the failure to provide services in the Hospital

Quality

C

Recruitment

n

Approve Interview Committee membership (noted in By-law) Governance C

Review recommendations for new Directors, non-director committee members (2-D-20)

Governance

√

Conduct the election of officers (2-D-18) Governance √

Review evaluation results and improvement plans for the Board, the Board Chair (by the Governance Chair), Board committees, committee chairs (2-D-40)

Review committee reports on work plan achievements (2-A-16)

Governance

Governance

√ √

16



ON GOING AS NEEDED Charter Section #4

Charter Item Action (Italics-comments) Committee Responsible

Current Year 2020-21

i-i-E Board Effectiveness Compliance with the By-Law Governance Refresh of By-Law 1 to be

completed by June 2021

c-i-A, B Corporate Performance Ensure there are systems in place to identify, monitor, mitigate, decrease and respond to the principal risks to the Corporation:

o financial o quality o patient/workplace safety

Audit, Resources Quality

c-i-C

Corporate Performance Oversee implementation of internal control and management information systems to oversee the achievement of the performance metrics

Resources

c-i-D Corporate Performance Processes in place to monitor and continuously improve upon the performance metrics

Resources/ Quality

c-i-G Corporate Performance Policies providing direction for the CEO and COS in the management of the day-to-day processes within the hospital

Governance/ Executive

d-ii-A,B CEO and COS Select the CEO, delegate responsibility and authority, and require accountability to the Board

Executive

d-ii-C CEO and COS Policy and process for the performance evaluation and compensation of the CEO (up for review 2022)


(January 30, 2019)

2-D-50 d-ii-D, E CEO and COS

Select the COS, delegate responsibility and authority, and require accountability to the Board

Executive Completed Sept 2020

d-ii-F CEO and COS Policy and process for the performance evaluation and compensation of the COS (up for review 2022)


(January 30, 2019)

2-D-50 h Financial Viability Approve collective bargaining agreements Board h Financial Viability Approve capital projects Resources

17



ON GOING AS NEEDED – Led by CEO/COS – reported in CEO report/Quality Presentations Charter Section #4

Charter Item Action (Italics-comments) Committee Responsible

j-i-A Communication and Community Relationships

Establish processes for community engagement to receive public input on material issues

Board oversight Led by CEO

j-i-B Communication and Community Relationships

Promote effective collaboration and engagement between the Corporation and its community, particularly as it relates to organizational planning, mission and vision

Board oversight Led by CEO/COS and Chair

j-i-C Communication and Community Relationships

Work collaboratively with other community agencies and institutions in meeting the healthcare needs of the community

Board oversight Led by CEO/COS Quality

j-i-D Communication and Community Relationships

Maintain information on the website Board oversight Led by CEO

j-i-E Communication and Community Relationships

Establish a communication policy for the Corporation; review periodically (2-D-11 – reviewed April 2019, next review 2022)


m Communications Policy Oversee the maintenance of effective stakeholder relations through the Corporation’s communications policy and programs (updated communication plan (2020-2023) to be approved by Board in 2021)


18

Priority Prior YTD

41.6 Dec-20

22.4 Dec-20

16.4 Dec-20

--- ---

--- ---

--- ---

476.5 Dec-20

--- ---

1,599.8 Jan-21

2,092.0 Jan-21

16.0 Jan-21

Meet evolv ing needs of our community through

--- ---

Prepare for digital transformaiton through re-

--- ---

137Days since last incident of workplace violence At Risk

Forecasted Not to Achieve*Includes Closed,In-Progress and New Cases*

---

Forecasted to AchieveDays since last critical patient safety event (Severity level 5/6)

*CRP phase 3* Driver --- ---Lead Boldly*Digital Trasnformation(HIS)* Driver ---

1,752.0Workplace Violence Reported Incidents QIP % 5.5 15.0

Keep staff and physicians safe and engaged *Diversity and inclusion awareness* Driver --- ---Overtime Hours (average per pay period) Driver hours 2,083.8 1,129.0Sick Hours (average per pay period)

Increase Joy in Work

Resources month 2,138.0

---Weighted Cases (IP Surgery + Day Surgery) (average) Driver HIG weight 344.1 463.0

---Quality Based Procedures – Cancer Care Ontario Volumes Resources --- ---

12.0Percent ALC Days (closed cases) Driver % 25.2 15.0

Accelerate access to care for our patients by achiev ing planned PCOP growth

Conservable Bed Days (MEDA,MEDB,MEDC) Driver % 42.4 38.0PatientFlow - Time To IP bed 90th% tile

Prove Patients Matter Most

QIP hours 13.9

Quality Based Procedures - Bundled Care Volumes Resources ---

Quality Based Procedures – Ministry of Health Volumes Resources ---

CMH Corporate Scorecard, FY2020/20212-8-2021 1:17:54 PM

Direction Measures of Success Alignment Unit YTD Target Year-End

19

Conservable Bed Days (MEDA,MEDB,MEDC)

Last Updated: 2/8/2021 10:41:47 AM20

ED - Time To Bed, 90th percentile

Last Updated: 2/4/2021 11:32:03 AM21

Percent ALC Days (closed cases)

Last Updated: 1/15/2021 7:43:26 AM22

Quality Based Procedures – Cancer Care Ontario Volumes

Edit Commentary

YTD Period: 2020-11-01 Indicators Details/Components Action Plan Updated: 2021-01-06 01:57

24

http://cmhapp97/commentary/select-style_v2.asp

Quality Based Procedures – Ministry of Health Volumes

YTD Period: 2020-11-01 Indicators Details/Components Action Plan Updated: 2021-02-08 12:17

25

Edit Commentary

26

http://cmhapp97/commentary/select-style_v2.asp

Weighted Cases (IP Surgery + Day Surgery) (average)

Last Updated: 2/5/2021 4:09:21 PM

27

Overtime Hours (average per pay period)

28

Sick Hours (average per pay period)

Last Updated: 1/15/2021 7:40:23 AM

29

Workplace Violence Reported Incidents

Last Updated: 2/8/2021 9:52:01 AM30

Agenda Item 1.3.5

31

Agenda Item 3.1.1

Page 1 of 2

Date: February 24, 2021 Issue: Board Chair Report Prepared for: Board of Directors Purpose: ☐ Approval ☐ Discussion ☒ Information Prepared by: David Pyper Summary Kudos to

• Ellen Otterbein and Hayley Hamilton for representing CMH so well in the Waterloo Record article on Pandemic Protocol

• Dr. Asim Masood for representing CMH so well in a Waterloo Record article on Covid • Dr. W. Lee for being the key note speaker at Chamber of Commerce Women Leaders

Breakfast • Med B Staff for managing through a recent Covid outbreak • Stephan Beckhoff for his regular Covid-19/CMH updates • CMH Foundation for their new 50/50 fundraising efforts • Trevor Clark and the financial team for working towards a 2021 balanced budget

Learning

• Research/investigation of studies and literature pertaining to the role of Board’s in corporate wellness programs.

• Advisory Board weekly article reviews. • Review of professional article on Burnout.

Concerning

• Continued high capacity of ICU • Staff burnout & wellness • Potential for significant wave 3 and need for caution & awareness • Continuing delay of vaccines • Rapid removal of provincial Covid restrictions • Growing number of Covid variant cases

Chair’s Activity

• Zoom meetings with: o Patrick Gaskin - 5 o Asim Masood - 3 o Nicola Melcher -1

• Attended MAC meeting

BRIEFING NOTE

32

Agenda Item 3.1.1

Page 2 of 2

• 2 reports and generative discussion plan prepared for Board Mtg • Researched articles focused on corporate wellness • Attended monthly OHT mtg • Thank you emails send to two staff for Waterloo Record article

What’s Ahead for March

• Review of Patrick Gaskin’s goal pkg • Review of Dr. Asim Masood’s goal pkg • Review of Dr. Asim Masood’s 6-month probationary review • Sub-committee report to Board re: Board Culture discussion follow-up • Nominations assessment of applicants for Board positions • Ramp up of Phase 3 construction activities • Year-end financials and budget preparations finalized • Regular series of monthly meetings

33

Agenda Item 3.1.2 19 February 2021 Events Calendar 2020-2021

Page 1 of 2 19 February 2021

Board/Committee Meeting and Event Dates Sep Oct Nov Dec Jan Feb Mar Apr May Jun Sep (2021)

Board of Directors 5:00pm – 8:00pm – A.0.218

30 28 25 27 24 28 26 30

29

Meeting with City Council and CMH Board of Directors - TBD 6:00pm – 8:00pm - City Hall

Joint CMH/CMHF/CMHVA Board Meeting - TBD

Quality Committee 7:00 am – 9:00am

16 21 18 20 17 17 21 19 16

Quality Committee QIP Meeting - cancelled 7:00 am – 9:00 am

Quality/Resources Joint Meeting 5:30pm – 7:00pm

22

Resources Committee 5:30pm – 7:30pm

28 23 25 22 26 25 28

Capital Projects Sub - Committee 4:00pm – 5:30pm

28 23 25 22 26 25 28

Governance Committee 4:30pm – 6:30pm

10 8 12 14 18 11 13

Audit Committee 5:00pm-6:30pm

18 26 25

Executive Committee 5:00pm – 6:30pm

16 17 31

Waterloo Hospitals Collaborative Committee - TBD Waterloo Wellington Collaborative Council (Hospital Chairs and Vice Chairs) TBD OHT Joint Board Committee

5:00pm – 7:00pm – Virtual Zoom meeting 14 26 23 14 25 22 22

2020-21 Events

Staff Holiday Lunch – cancelled for 2020 Career Achievement 2:00pm – 4:00pm – A.0.218 – cancelled 24

34

Agenda Item 3.1.2 19 February 2021 Events Calendar 2020-2021

Page 2 of 2 19 February 2021

Board/Committee Meeting and Event Dates Sep Oct Nov Dec Jan Feb Mar Apr May Jun Sep (2021)

Embrace Winter Walk: CMH Staff & Family 11:00am-2:00pm Galt Country Club https://cmhfoundation.ca/event/embrace-winter-walk-cmh-staff-family/

28

CMH Foundation Golf Tournament 11:30am – Galt Country Club – Ian Miles 24

Chamber Business Awards – David Pyper 24

Langdon Hall Picnic for CMH – David Pyper, Nicola Melchers, Sara Alvarado 27

CMHF Diversity Dinner TBD

Board Education Opportunities Governors Education Sessions

• Governance Essentials for New Directors (Nov 3 & 18) – Diane Wilkinson 26 3/18

• Governance Master Class: Advancing Diversity and Inclusion – David Pyper, Lynn Woeller

12

35

https://cmhfoundation.ca/event/embrace-winter-walk-cmh-staff-family/

Agenda Item 3.2.1

Page 1 of 7

Date: February 17, 2021 Issue: January 2021 Financial Statements Prepared for: Resources Committee Purpose: ☐ Approval ☐ Discussion ☒ Information Prepared by: Ernie Sersen, Director of Finance Approved by: Trevor Clark, Vice President Finance & Corporate Services, CFO Attachments/Related Documents: Financial Statements, Sick & Overtime Charts Alignment with CMH Priorities

2019-2021 Strategic Plan

No ☐

2020/21 Integrated Risk Management Priorities

No ☐

2020/2021 Priorities

No ☐ ☐ Prove Patients Matter Most ☐ Patient Experience ☒ Accelerating Access to Care ☐ Increase Joy in Work ☐ Length of Stay ☐ Keeping Staff and Physicians Safe and Engaged ☒ Lead Boldly ☐ CRP Phase 3 ☐ Executing CRP Phase 3 ☒ Multi-year Fiscal/Capital Strategy ☐ Completing our HIS Evaluation

Recommendation/Motion The Resources Committee receives the January financial statements as presented by management. Executive Summary Cambridge Memorial Hospital (CMH) has a January year-to-date operating deficit of $1.3M after building amortization and related capital grants which represents a $4.4M negative variance from budget. The forecasted deficit for the year is $2.3M. The major driver of the deficit is unearned Post Construction Operating Plan (PCOP) funding ($5M) and urgent Quality Based Procedures (QBP) revenue ($1.7M). These losses in revenue are partially offset by savings in the Perioperative program during wave 1 of the pandemic ($1.9M), additional COVID revenue for 10 additional beds of $1.8M, additional COVID revenue of $259K for 2 additional ICU beds and savings in supplies ($680K). Risks • As a result of wave 2 of the pandemic, there was a decline in PCOP revenue in the month of

January due to a slowdown in surgical services. Volumes are beginning to ramp up in February but it is uncertain whether year end targets will be achieved.

• Elective QBPs declined more than expected in the month of January. A $380K adjustment has been made to the forecast due to the loss of this revenue. If the current trend continues, the loss could increase by another $800K which has not been forecasted.

BRIEFING NOTE

36

Agenda Item 3.2.1

Page 2 of 7

Opportunities • There is an opportunity that the Ministry of Health (MOH) may allow hospitals to keep all of

their QBP revenue despite targets not being reached. This would potentially result in a balanced budget for the hospital.

• The hospital is negotiating with the MOH to keep unearned PCOP revenue in the year as a result of the impact of COVID.

Summary CMH has a January year-to-date operating deficit of $1.3M after building amortization and related capital grants which represents a $4.4M negative variance from budget. The YTD variance is driven by:

• A shortfall of PCOP revenue of $5.0M; • A shortfall of elective and urgent QBPs revenue of $2.4M; • A reduction of revenue from parking, technical fees and preferred accommodation of

$2.5M.

The negative variance has been partially offset by: • A $3.0M positive variance in the Perioperative program – $2.1M for medical and surgical

supplies, $714K for salaries and benefits, and $212K for drugs. The positive variance is the result of the cancellation of elective surgeries during wave 1 of COVID;

• An $815K positive variance in supplies mainly due to savings in bundled care (due to a reduction in the number of joint surgeries), favourable spending on utility costs and the timing of IT software expenditures;

• A $277K positive variances in salaries due to unfilled positions; • $146K in benefit savings as a result of less than expected maternity payments; • $991K of new COVID funding for staggering the operationalization of 10 additional

medical beds beginning November 1; • $346K in COVID incremental expense funding for the month of March which was not

accrued at year end due to the uncertainty of collection; • $307K of Ministry of Health (MOH) funding to compensate for uninsured patients.

Activity Volumes • The total incremental weighted cases for acute inpatient and day surgery is 10,524 YTD.

The base YTD target is 10,030. Weighted cases in excess of the base target generate $4,517 per weighted case. The PCOP revenue recognized is $2.2M YTD.

• The medicine floors have averaged 70 patients per day YTD, 15% higher than last year. The budget was based on 65 beds and by the end of January there were 89 beds staffed and in operation.

• The Medicine/Rehab unit surged six additional beds in January. YTD volumes are 25% higher than last year.

• The surgical floor has had an average of 21 patients per day YTD, 16% less than last year. This is primarily due to the effects of the pandemic and cancellation of elective surgeries during wave 1 of COVID. Surgical beds were used as medical beds for the months of April, May and June and were converted back to surgical beds in July. It has taken time to ramp up the surgical program.

• The Mental Health unit has had an average of 17 patients per day YTD, 6% lower than prior year volumes.

• The average number of YTD visits in the Emergency Department (ED) are 115 per day, 20% lower than last year. On average there have been 3 admitted patients per day from the ED, 40% lower than in fiscal 2019-20.

37

Agenda Item 3.2.1

Page 3 of 7

Revenue MOH Funding Budgeted revenue includes a 1% increase in MOH funding plus approximately an additional 1% increase as a result of CMH’s medium hospital status. QBP budgeted revenue increased by $220K in fiscal 2020-21 due to an increase in Case Mix Index (CMI). The largest increases in weights came in congestive heart failure (CHF), pneumonia and cataract cases which were partially offset by decreases in weights for chronic obstructive pulmonary disease (COPD) and hip fractures. In addition, there was an $111K increase in the QBP allocation for growth. The growth primarily came in COPD, CHF and pneumonia cases. The pandemic has significantly impacted the hospital’s ability to achieve QBP volume targets. QBP funding can only be recognized as volumes are achieved. The hospital is eligible to receive $10.8M in PCOP funding in fiscal 2020-21 (50% of the maximum PCOP funding allocation) tied to meeting identified volume targets. The budget was built to achieve 40% ($8.6M) of the hospital’s PCOP entitlement. $2.2M of the available PCOP funding was not budgeted and is available to support growth pressures. Year to date, $2.2M of PCOP revenue has been recognized and the YTD shortfall is attributed to the decline in surgical volumes resulting from the reallocation of resources due to COVID. The MOH has developed a process to report on COVID related expenditures. Since March the hospital has remitted $9.2M for incremental operating expenditures and $1.5M for capital costs. To date the hospital has received $6.8M of funding from the Ministry for operating expenses and $1.4M for capital. There are two other sources of revenue the hospital receives from the MOH for COVID related costs. The MOH has been funding the Assessment Centre based on $38 per test since October. The breakeven point of the Assessment Centre is 157 tests per day and YTD the Centre has been averaging 182 tests per day. The hospital has generated $ 807K of revenue from the Assessment Centre year to date. The other source of revenue from the MOH is $1,300 per day for 10 additional beds operated on the surgical floor since November 1. CMH initially ramped up the services with 5 beds in November and then 5 additional beds were added in December. $991K of revenue has been recognized YTD. A summary of the major year to date revenue variances are as follows: • As a result of acute and day surgery weighted case growth targets not met there is a

negative PCOP revenue variance of $5.0M; • Due to the cancellation elective surgeries during wave 1 of the pandemic and gradual ramp up

of elective surgeries, there has been a decline in revenue recognized for elective QBPs. (hip, knee, shoulders, cataract and tonsillectomy). The result is a negative $847K variance. With the onset of phase 2 of COVID the ramp up of surgical services was delayed resulting in elective procedures not achieving the target for January;

• Volumes for urgent QBPs (CHF, COPD, pneumonia and hip fractures) are lower than budget creating a $1.5M negative variance;

38

Agenda Item 3.2.1

Page 4 of 7

• Cancer Care Ontario (CCO) QBP revenue for colorectal, prostate and thyroid surgeries are lower than budget YTD creating a $286K negative variance;

• CMH has received $4.6M in temporary one-time funding for physician related pandemic costs. 100% of this funding has been paid out to physicians in medical remuneration.

Billable Patient Services • The $1.5M YTD negative variance is primarily due to unfavourable variances in professional

fees ($247K), technical fees ($764K) and preferred accommodation ($566K). The reduction in revenue is due to the cancellation of elective procedures. It is not expected that the hospital will be reimbursed for lost technical fees and preferred accommodation revenue.

Recoveries and Other Revenues • The year-to-date $1.0M positive variance is primarily due to pandemic pay recovery ($2.4M)

as prescribed by the MOH, which has partially been offset by the elimination of parking revenue ($1.2M) and higher than expected drugs costs for medical day care ($431K). As part of the hospital’s pandemic response, a decision was made to not charge for parking for both visitors and staff for the months of April, May and June.

Expenses Salaries and Wages • The financial statements reflect a YTD $9.1M negative variance. The major source of the

negative variance is COVID related costs including pandemic pay to frontline staff and higher overtime than budget.

• Overtime was higher than budget in the month of January by $165K. Overtime is over budget by $1M YTD. This unfavourable variance for sick time increased by $34K in the month. The table below provides a summary in hours for sick and overtime.

A brief overview of the YTD overtime variance is as follows: • 34% of the overtime variance is attributed to ED (including clinical and clerical staff) of which

most of the variance is as a result of vacant positions and sick time; • Medicine units contributed 14% of the variance which was caused by the number of

vacancies in the program and the staffing pressures resulting from the 25 additional beds; • The Rehabilitation and Surgical units contributed 13% of the variance resulting from a

shortage of available staff; • The Mental Health program contributed 8% of the variance resulting from one-to-one level of

care.

Other variances in salaries and wages are: • $2.4M of pandemic pay was paid out to front line staff as prescribed by the MOH.

Approximately $2.0M of the payment has been funded by the MOH to date. The remainder of the recovery has been accrued and is expected to be paid by the MOH before the end of the fiscal year;

January 2021 YTD 2020-21 HOURS Actual Budget 2020 Actual Budget 2020 Overtime 5,612 2,504 4084 46,554 24,684 31,838

Sick 5,665 3,876 4,530 46,345 38,212 45,610

39

Agenda Item 3.2.1

Page 5 of 7

• The COVID cost centre has a $2.0M negative variance YTD which is a result of additional staff for screening, environmental services and other support areas. These costs are 100% offset by incremental funding;

• A 20 bed Medicine unit was created in response to COVID. The beds were unbudgeted and have contributed $1.7M to the overall negative variance. These costs are offset by PCOP funding;

• The Assessment Centre was created in response to COVID. Salaries incurred to date are $850K. Through September, 100% of these costs were reimbursed. Beginning in October, funding for the Assessment Centre is tied to the number of tests completed;

• Six additional beds were added to the Medicine/Rehab unit in response to surge pressures resulting in a $574K negative variance YTD;

• The Surgical unit, which was converted to a Medicine unit during wave 1 of the pandemic, has generated a $423K negative variance. The cost drivers were sick time, overtime and unit staffing;

• There was a $508k negative variance in the Medicine units as a result of training of redeployed staff and additional staff hired to prepare for the pandemic;

• The above negative variances were partially offset by a $567K positive YTD variance in the Perioperative program. The variance resulted from the redeployment of staff to other areas of the hospital due to the cancellation of elective surgery.

Benefits • The YTD variance in benefits is primarily due to the payout of the pandemic pay to frontline

staff. 100% of these are offset by incremental funding. There is a partial offset of the negative variance by a positive variance in maternity leave benefits due to fewer maternity leaves than budgeted. When a person goes on maternity leave, the entire amount of the maternity leave supplement is expensed in the month their leave begins.

Medical Remuneration • The negative YTD variance is mainly attributed to COVID related costs for hospitalists

($3.6M) and Infection Prevention and Control (IPAC) ($554K). Revenue has been received to offset both variances.

• The negative variances above have been offset by positive variances in MRI ($186K) and pathology ($197K) professional fees. The positive variances are a result of the elimination of elective procedures due to COVID during wave 1. These areas began ramping up in Q2 and the size of the positive variance is expected to decrease by the end of the fiscal year.

Medical and Surgical Supplies • The positive YTD variance is attributed to a large positive variance in the Perioperative

program of $2.1M, partially offset by a negative variance of $1.4M in IPAC. The variance in the Perioperative program is due to the cancellation of elective surgeries, and the variance in IPAC is due to the cost of procuring masks and gloves at a significantly higher cost and volume from non-contracted vendors.

Drug Expense • The negative variance is primarily attributed to an increase in utilization of oncology drugs in

medical day care. There are new drugs and protocols which have increased the utilization of high end drugs. Approximately 95% of the variance is recovered from funding from Cancer Care Ontario.

40

Agenda Item 3.2.1

Page 6 of 7

Other Supplies and Expenses • With the cancellation of elective surgical procedures, hip and knee procedures have not been

performed resulting in a $457K positive variance in bundled care costs. These costs are associated with patients receiving outpatient treatment in the community after their procedure has been completed in the hospital. It is expected that these costs will be incurred during the year as services ramp up.

• CEO/HR contribute $163K of the positive variance. As in prior years spending will vary in these cost centres based on the need to engage professional services and contingencies.

• The IT department has a YTD positive $195K variance due to the timing of expenditures.

Balance Sheet and Statement of Cash • CMH’s current cash position is $53.1M consisting of restricted cash of $21.5M and

unrestricted cash of $31.6M. • The working capital ratio meets the requirements of the Hospital Service Accountability

Agreement (H-SAA) target after adjusting for the vacation accrual. Forecast

The forecasted deficit for the year is $2.3M. The major driver of the deficit is unearned PCOP ($5M) and urgent QBP revenue ($1.7M). These losses in revenue are partially offset by savings in the Perioperative program during wave 1 of the pandemic ($1.9M), additional COVID revenue of $1.8M for 10 additional beds, additional COVID revenue of $259K for 2 additional ICU beds and savings in supplies ($680K). The forecast is based on the following key assumptions:

• PCOP volume targets will be achieved each month beginning in November; • Wave 2 of the pandemic will not adversely affect Perioperative service volumes or the

number of Medical beds available; • The MOH will continue to fund all COVID related operating and capital costs; • The Assessment Centre will reach daily volume targets to maximize funding.

Key assumptions by revenue/expense category are as follows: MOH Funding • $12.4M of COVID funding has been included in the forecast, 100% offset by incremental

expenses. • $3.9M of temporary physician funding due to COVID has been included in the forecast, 100%

offset by incremental expenses. • $1.8M of funding for 10 tier 2 medical beds for additional COVID beds to be in operation from

November 1 to March 31 has been included in the forecast. • Elective QBP volume targets for hips, knees and shoulders will be achieved resulting in an

additional $305K in funding. In recognition of the extra costs associated which meeting volume targets in a condensed period of time, the MOH is providing a 20% premium on elective QBPs on any volumes higher than 50% of the approved volume.

• $259K of revenue from the MOH to fund 2 additional ICU beds Billable Patient Services • Professional fees, technical fees, preferred accommodation and WSIB revenue are forecast

to be $1.8M less than budget to account for the decline in volume during the first wave of the pandemic.

41

Agenda Item 3.2.1

Page 7 of 7

• The MOH will continue to fund all uninsured patients resulting in a surplus of $470K.

Recoveries & Other Income • $2.4M of temporary pandemic pay is included in the forecast, 100% offset by expenses. • $650K of the increase in revenue is due to the increase demand for systemic drugs which

cost $684K. • Due to free parking during wave 1 of the pandemic and a decrease in visitor parking, it is

assumed there will be a $1.2M shortfall in parking revenue for the year. Salaries and Wages • $8M increase in salaries and wages due to the operation of 41 additional Medical beds, the

Assessment Centre, screening function and addition support services. These costs are fully offset by MOH funding.

• $2.4M of the variance is due to the payment of pandemic pay. These costs are also fully offset by MOH funding. The forecast for overtime was increased by $1.2M to reflect the current run rate.

• $578K of savings in the Perioperative program due to the redeployment of staff during wave 1 of the pandemic when there were no elective surgeries.

Benefits • Benefits were reduced by $1.5M to reflect an adjustment to budget and due to the fact that

some of the one time pandemic payments were not eligible for full benefit costs. Medical Remuneration • The increase in medical remuneration is a result of COVID payments to physicians of $3.9M.

These payments are fully funded.

Medical Surgical Supplies • A $1.5M increase in cost of personal protective equipment due to decreased availability of

supplies. There is offsetting revenue for this increase cost. • A $1.6M decrease in medical and surgical supplies due to a reduction in the number of

procedures during wave 1 of the pandemic. Drugs • As a result of an increase in demand for systemic drugs the budget has been increased by

$684K. Over 95% of the expenditure is recovered by revenue recoveries. Supplies • The supplies forecast was increased by $800K for COVID related costs. There is offsetting

revenue for these costs. • $480K in saving opportunities have been identified in a number of departments on budgeted

supplies that are not expected to be spent this fiscal year.

42

Agenda Item 3.2.1

CAMBRIDGE MEMORIAL HOSPITALCOMPARATIVE BALANCE SHEET

JAN MARCH

2021 2020

ASSETS

Current Assets

Cash and short-term investments 31,600,616$ 30,584,382$

Due from Ministry of Health/LHIN 1,252,493 1,114,028

Other receivables 3,071,649 2,241,460

Inventories 2,751,531 2,641,192

Prepaid expenses 1,745,433 1,442,764

40,421,722 38,023,826

Non-Current Assets

Due from Ministry of Health - Capital Redevelopment 3,165,169 67,887,210

Due from CMH Foundation 388,554 6,561,260

Cash and investments restricted - Capital 21,541,964 24,911,264

Endowment and special purpose fund cash & investments 187,427 187,427

Capital Assets 240,971,327 237,749,118

TOTAL ASSETS 306,676,163$ 375,320,105$

LIABILITIES & EQUITY

Current Liabilities

Due to Ministry of Health/LHIN 5,395,139$ 1,016,554$

Accounts payable and accrued liabilities 32,216,206 32,633,730

37,611,345 33,650,284 Long Term Liabilities

Employee future benefits 4,011,828 3,950,400

Capital Redevelopment Construction Payable - 69,924,914

Deferred Capital Grants and Donations 236,445,223 237,918,769

240,457,051 311,794,083

Net Assets:

Unrestricted 2,352,272 4,946,698

Externally restricted special purpose funds 187,427 187,427

Invested in Capital Assets 26,068,068 24,741,613

28,607,767 29,875,738

TOTAL LIABILITIES & EQUITY 306,676,163$ 375,320,105$

Working Capital Balance 2,810,377 4,373,542

Working Capital Ratio (Current Ratio) 1.07 1.13

43

Agenda Item 3.2.1

15-Feb-21

CAMBRIDGE MEMORIAL HOSPITAL

STATEMENT OF INCOME AND EXPENSE

20/21 20/21

Actual Plan Variance % var YTD Actual YTD Plan YTD Variance % var Plan Forecast JAN20 YTD JAN20 19/20 YE

Operating Income

MoH Funding

4,314,741$ 4,314,741$ -$ 0.0% MoH Base $ 42,590,673 42,590,673$ -$ 0.0% 50,802,603$ 50,802,603$ 4,092,410$ 39,874,144$ $ 46,882,908

2,490,417 2,490,417 - 0.0% MoH HBAM 24,582,826 24,582,826 - 0.0% 29,322,655 29,322,655 2,405,329 23,742,928 29,322,655

1,897,169 1,979,310 (82,141) (4.1%) MoH QBP 14,524,164 16,909,715 (2,385,551) (14.1%) 19,914,988 17,901,321 1,730,813 15,828,048 18,259,510

3,439,754 1,660,802 1,778,952 107.1% MoH Onetime / Other 27,585,311 16,393,728 11,191,583 68.3% 19,554,604 31,627,369 1,447,219 12,166,267 15,198,040

12,142,081 10,445,270 1,696,811 16.2% Total MoH Funding 109,282,974 100,476,942 8,806,032 8.8% 119,594,850 129,653,948 9,675,771 91,611,387 109,663,113

1,107,133 1,202,477 (95,344) (7.9%) Billable Patient Services 10,322,699 11,869,638 (1,546,939) (13.0%) 14,158,230 13,388,230 1,279,040 12,597,924 15,014,909

1,098,743 1,085,101 13,642 1.3% Recoveries and Other Revenue 11,693,403 10,712,918 980,485 9.2% 12,839,539 14,246,452 1,356,131 13,449,084 17,995,256

177,752 183,730 (5,978) (3.3%) Amort'n of Deferred Equip Capital Grants 1,838,760 1,813,592 25,168 1.4% 2,163,254 2,163,254 65,656 711,391 1,468,943

306,600 299,454 7,146 2.4% MoH Special Votes Revenue 2,967,733 2,985,300 (17,567) (0.6%) 3,555,212 3,555,212 275,906 2,871,047 3,586,728

14,832,309 13,216,032 1,616,277 12.2% Total 136,105,569 127,858,390 8,247,179 6.5% 152,311,085 163,007,096 12,652,504 121,240,833 147,728,949

Operating Expense

6,701,733 5,637,743 (1,063,990) (18.9%) Salaries & Wages 64,653,638 55,578,448 (9,075,190) (16.3%) 66,340,929 76,673,721 5,693,341 53,673,421 66,351,376

1,823,858 1,703,922 (119,936) (7.0%) Employee Benefits 16,415,990 15,652,741 (763,249) (4.9%) 18,888,168 20,074,767 1,517,855 13,930,168 17,359,975

2,178,749 1,607,072 (571,677) (35.6%) Medical Remuneration 19,128,718 15,532,605 (3,596,113) (23.2%) 18,590,269 21,617,678 1,714,965 16,518,168 19,857,104

627,880 973,237 345,357 35.5% Medical & Surgical Supplies 8,743,253 9,606,762 863,509 9.0% 11,459,122 11,359,122 1,002,040 8,735,481 10,449,198

706,938 692,910 (14,028) (2.0%) Drug Expense 7,242,882 6,839,740 (403,142) (5.9%) 8,158,505 8,842,716 762,422 6,981,228 8,186,995

1,838,031 1,377,796 (460,235) (33.4%) Other Supplies & Expenses 13,724,014 13,551,231 (172,783) (1.3%) 18,892,169 17,022,871 1,264,613 11,984,432 15,384,484

395,383 425,798 30,415 7.1% Equipment Depreciation 3,994,817 4,203,032 208,215 5.0% 5,013,408 5,013,408 237,992 2,256,405 3,487,195

306,600 305,723 (877) (0.3%) MoH Special Votes Expense 2,967,733 2,973,424 5,691 0.2% 3,555,212 3,555,212 290,384 2,871,047 3,586,728

14,579,172 12,724,201 (1,854,971) (14.6%) Total 136,871,045 123,937,983 (12,933,062) (10.4%) 150,897,782 164,159,495 12,483,612 116,950,350 144,663,055

253,137 491,831 (238,694) (48.5%) MOH Surplus (Deficit) (765,476) 3,920,407 (4,685,883) (119.5%) 1,413,303 (1,152,399) 168,892 4,290,483 3,065,894

Other income (expense):

(517,498) (553,089) 35,591 (6.4%) Building Depreciation (5,182,044) (5,459,522) 277,478 (5.1%) (7,012,171) (6,712,171) (145,366) (1,452,699) (3,522,440)

467,763 475,521 (7,758) (1.6%) Amortization of Deferred Build Capital Grants 4,679,549 4,693,850 (14,301) (0.3%) 5,598,868 5,598,868 96,569 963,609 2,933,842

203,402$ 414,263$ (210,861)$ (50.9%) Net Surplus (Deficit) for the period (1,267,971)$ 3,154,735$ (4,422,706)$ (140.2%) -$ (2,265,702)$ 120,095$ 3,801,393$ 2,477,296$

CONFIDENTIAL

Month of January 2021 Year to date ending January 31, 2021 19/20 prior year actuals

44

Agenda Item 3.2.1

CAMBRIDGE MEMORIAL HOSPITAL 15-Feb-21

STATEMENT OF CHANGES IN FINANCIAL POSITION

For the Month Ending January 31, 2021

Cash Provided By (used in) Operations: YTD JAN21 FY 2019/20

Excess (deficiency) of revenue over expenses (1,267,971)$ 2,477,296$

Items not involving cash:

-Amortization 9,176,861 7,009,635

-Loss on Disposal of Assets - -

-Amortization of deferred grants and donations (6,518,309) (4,402,785)

Change in non-cash operating working capital 73,474,146 (125,107,174)

Change in employee future benefits 61,428 (50,800)

74,926,155 (120,073,828)

Investing:

Acquisition of capital assets & CRP (12,399,070) (13,353,064)

(12,399,070) (13,353,064)

Financing:

Capital donations and grants & CRP 5,044,763 88,301,391

Construction payable (69,924,914) (20,000)

64,880,151- 88,281,391

Increase (Decrease) In Cash for the period (2,353,066) (45,145,501)

Cash & Investments - Beginning of Year 55,495,646 100,641,147

Cash & Investments - End Of Period 53,142,580$ 55,495,646$

Cash & Investments Consist of:

Unrestricted Endowment and Special Purpose Investments 29,668$ 29,668$

Cash & Investments Operating 31,570,948 30,554,714

Cash & Investments Restricted 21,541,964 24,911,264

Total 53,142,580$ 55,495,646$ 45

Agenda Item 3.4.1

Page 1 of 2

Date: February 18, 2021 Issue: Quality Committee, February 17, 2021 Prepared for: Board of Directors – OPEN Purpose: ☐ Approval ☐ Discussion ☒ Information Prepared by: Iris Anderson, Administrative Assistant, Clinical Programs Approved by: Sandra Hett, Vice President of Clinical Programs & CNE Attachments/Related Documents:

QIP Target Recommendations Refer to Quality Committee agenda package of February 17,

2021 for all other noted attachments Alignment with CMH Priorities


No ☐


No ☐


No ☐ ☒ Prove Patients Matter Most ☒ Patient Experience ☒ Accelerating Access to Care ☐ Increase Joy in Work ☒ Length of Stay ☐ Keeping Staff and Physicians Safe and Engaged ☒ Lead Boldly ☐ CRP Phase 3 ☐ Executing CRP Phase 3 ☐ Multi-year Fiscal/Capital Strategy ☐ Completing our HIS Evaluation

Quality Improvement Plan (QIP) 2021/22 – update Ms. Barefoot directed the Committee members to the previously circulated briefing note. In the absence of further direction from Health Quality Ontario (HQO) and/or Ontario Health (OH), Management proposed a roll-over of the 2020-21 QIP metrics for the 2021-22 fiscal year to members of the Quality Committee which was conceptually supported. Also, Management proposed omitting the creation of the QIP Narrative until such time as there is clear direction from HQO and/or OH on the content which was also supported by QC members. Ms. Barefoot provided the data and recommendations for targets for the two (2) roll-over QIP metrics for the 2021-22 QIP. Ms. Barefoot requested the Committee members for any comments or feedback. It was requested of Management to proceed with suggested targets, however with respect to workplace violence, for implore Management to revisit with staff to ensure capture of incidents.

MOTION: (Stecho/Adair) that, 1. The Quality Committee approve a target of 19.0 hours (90th Percentile) for

Time to Inpatient Bed for fiscal year 2021-22 to the Board. CARRIED

BRIEFING NOTE

46

Agenda Item 3.4.1

Page 2 of 2

2. The Quality Committee approve a target of 155 workplace violence incidents (as defined under the Occupational Health & Safety Act) for fiscal year 2021-22 to the Board. CARRIED

Should OH provide additional direction before March 31, 2021 or thereafter, Management will modify the QIP accordingly. Quality Update Service Resumption The Committee members were directed to the previously circulated briefing note. Ms. Iromoto provided a detailed summary of the internal and external risks as it pertains to ramping up service volumes at CMH. A discussion ensued regarding CMH’s response or role should further outbreaks in the community evolve. CMH will assist as required, and role to be determined depending on needs. Annual Review of ED Return Visit Quality Program Ms. Hett referred to the previously circulated narrative and provided context of the report. In recognition of the pandemic, HQO did not require an audit. It was a testament to Dr. A. Eugenio, Chief of Emergency Department, and the ED team that they choose to proceed and conduct a quality chart review audit. Chief Nursing Executive (CNE) Report Update The Chair asked Ms. Hett to provide a brief update. The following was highlighted:

− Surgery resumption plan continues in a measured approach, monitoring wait times for cancer surgeries and capacity to support COVID patients. Surgical volumes are being monitored system wide to ensure this balanced approach is consistent across the province. The Surgery program is presenting to QC in March and will discuss this plan in more detail

− The Medicine program which includes ICU continues to surge to support the volume of patients

− The Mental Health program has requested a review of the Outpatient Department related to persistent issues that threaten this part of the program. An external consultant will conduct an assessment based on general principles and staff concerns. A further update will be given at the March Quality Committee meeting

− The Women’s & Children’s program was working with the Maternal Newborn Network on a program review to confirm quality outcomes in the new CRP space as growth occurs, but was delayed due to the pandemic. A new target date of March 2021 has been set and the review will be subject to any public health restrictions as there is an on -site component.

COVID-19 Dashboard Ms. Iromoto provided a summary of the current status and progress, and also highlighted the thresholds used in this tool.

47

Agenda Item 3.4.1 (QIP)

Page 1 of 4

Date: February 4, 2021 Issue: Quality Improvement Plan QIP – Target Recommendations Prepared for: Quality Committee Purpose: ☐ Approval ☒ Discussion ☐ Information Prepared by: Liane Barefoot, Director Patient Experience, Quality& Risk Kyle Leslie, Manager Transformation Office Approved by: Mari Iromoto, Senior Director Strategy, Performance & CIO Sandra Hett, VP Clinical Services & CNE Attachments/Related Documents: None Alignment with CMH Priorities


No ☐


No ☐


No ☐ ☒ Prove Patients Matter Most ☒ Patient Experience ☒ Accelerating Access to Care ☐ Increase Joy in Work ☐ Length of Stay ☐ Keeping Staff and Physicians Safe and Engaged ☐ Lead Boldly ☐ CRP Phase 3 ☐ Executing CRP Phase 3 ☐ Multi-year Fiscal/Capital Strategy ☐ Completing our HIS Evaluation

Recommendation/Motion

MOTION: 1. That, Quality Committee approve a target of 19.0 hours (90th Percentile) for Time

to Inpatient Bed for fiscal year 2021-22 to the Board 2. That, Quality Committee approve a target of 155 workplace violence incidents

(as defined under the Occupational Health & Safety Act) for fiscal year 2021-22 to the Board

Background All healthcare organizations are required under the Excellent Care for All Act, 2010 (ECFAA) to develop and submit a Quality Improvement Plan (QIP) annually to Health Quality Ontario (HQO) by April 1st of each year. In the absence of further direction from Health Quality Ontario (HQO) and/or Ontario Health (OH), management proposed a roll-over of the 2020-21 QIP metrics for the 2021-22 fiscal year to members of the Quality Committee which was conceptually supported. In addition, management proposed omitting the creation of the QIP Narrative until such time as there is clear direction from HQO and/or OH on the content which was also supported by QC members. This briefing note will provide the data analysis modelling and management recommendations for targets for the two (2) roll over QIP metrics for the 2021-22 QIP:

BRIEFING NOTE

48


Page 2 of 4

1. Time to inpatient bed (time from decision to admit to admitted to bed time) – 90th Percentile

2. Total number of workplace violence incidents (as defined under the Occupational Health & Safety Act) in a 12-month period

Data Analysis Modeling & Recommendations: 1. Time to Inpatient Bed, 90th Percentile Time to inpatient bed is reported as an ED metric but in reality is a proxy measure for flow throughout the organization. Recall, that the QIP target approved by the Board for fiscal year 2020-21 was set at 19.0 hours (90th Percentile). Subsequent to setting the QIP target and based on Q1 performance, the Patient Flow Committee decided in August 2020 to reduce the internal CMH stretch target to 12.0 hours (90th Percentile). YTD to November 2020 we were tracking at 10.6 hours (90th Percentile), on point with the revised target, however, a trend line applied to the entire fiscal year shows a steep incline close to the original QIP target based on performance from August onwards.

A regression analysis was used to predict Time to Inpatient Bed for 2021-22. The variables tested included: number of admissions per day, number of ED visits per day, and % medical bed occupancy (previously demonstrated to be the only types of admissions to statistically impact this metric). Each of these three (3) variables are independently statistically significant but when combined into the regression analysis, only % medical bed occupancy is a predictor of time to inpatient bed. Combined with above it should be noted that performance in 2020-21 while exemplary, is not necessarily reflective due to ED volumes being down ~ 15% and admissions being down ~ 7% for the first two (2) quarters of fiscal 2020-21. Throughout the pandemic we have opened additional medical beds with occupancy at ~83% for the majority of the fiscal year compared to 97% occupancy for fiscal 2019-20. The pandemic bed flow for medicine has evolved through this pandemic however establishing MEDA (majority private rooms and close proximity to ICU) has challenged patient flow to inpatient beds in new ways. The turnaround time for COVID tests and the increased

0

5

10

15

20

25

30

35

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

Hou

rs

Time to IP Bed 90th%tile Hours

20/21

19/20

Linear (20/21)

49


Page 3 of 4

requirement for isolation has, at times, restricted the availability of inpatient capacity. The mid-November and December performance will reflect two sequential COVID outbreaks on two medical units. Using the assumption that we will be closing medical beds in fiscal year 2021-22 due to Phase 3 of the CRP through concerted work on reducing conservable bed days (fiscal strategy + 2020-21 IRM organizational priority) there will be less medical beds available to admit to which will have an impact on time to inpatient bed. Recommendation – based on above, management is recommending a 2021-22 QIP target for Time to Inpatient Bed of 19.0 hours (90th Percentile) which is the same as the original 2020-21 QIP target. 2. Number of Workplace Violence Incidents The target for this indicator was set at 175 for the 2020-21 fiscal year QIP. As with every year that this has been included as a QIP metric, setting a ‘target’ seems ethically counter intuitive. It is a balancing act between implementing initiatives aimed at decreasing the number of incidents while simultaneously promoting culture of reporting. As reported in January 2021, the move into the A Wing while not a ‘tactic’ per se has been a big influence as the spaces in ED, Mental Health, and one Medicine unit are larger, brighter and generally more calming. In addition, Mental Health and ED both have dedicated spaces for patients who require more intensive monitoring compared to old spaces in B Wing. A hybrid online/in-person version of Code White training has recently resumed in late Fall 2020 with plans in place to certify all newly hired staff and re-certify those requiring it over the next year. Staff duress alarm work is underway and will be implemented in fiscal year 2021-22. Performance from 2019-20 and 2020-21 YTD are included in the graph below including trend line for 2020-21. Despite a steep downward trend, the recommendation being brought forward balances initiatives with continuing to support and foster a reporting culture.

0

5

10

15

20

25

30

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

Inci

dent

s

Workplace Violence Reported Incidents

20/21

19/20

Linear (20/21)

50


Page 4 of 4

Recommendation – based on above management is recommending an ~11% reduction in this target to 155 workplace violence incidents (as defined under the Occupational Health & Safety Act) annually. Next Steps The revised targets for the two (2) QIP metrics will continue to be reported on the Corporate Scorecard. Should OH provide additional direction either before March 31, 2021, or beyond, plans will be modified accordingly.

51

Agenda Item 3.6.1

Date: February 11, 2021 Issue: Medical Advisory Committee - OPEN Prepared for: Board of Directors Purpose: ☐ Approval ☐ Discussion ☒ Information Prepared by: Dr. Asim Masood, Chief of Staff, VP Medical Affairs Approved by: Mr. Patrick Gaskin, CEO Attachments/Related Documents: HSMR Briefing Note Alignment with CMH Priorities


No ☐


No ☐


No ☐ ☒ Prove Patients Matter Most ☒ Patient Experience ☒ Accelerating Access to Care ☐ Increase Joy in Work ☒ Length of Stay ☒ Keeping Staff and Physicians Safe and Engaged ☒ Lead Boldly ☒ CRP Phase 3 ☒ Executing CRP Phase 3 ☐ Multi-year Fiscal/Capital Strategy ☒ Completing our HIS Evaluation

Items for Board Information The following medical directives were approved: Medical Directive: Application of Ultrasound for Guided Arterial Line Insertion This new Medical Directive for registered respiratory therapists supports the use of point of care ultrasound (POCUS) for real-time imaging and direct visualization of anatomical landmarks for arterial line insertion which is the standard of care now. Medical Directive: 385 Newborn Hypoglycemia There were no significant changes to the Medical Directive, the only changes are according to Canadian Pediatric Guidelines that if the blood glucose (BG) of a Newborn is less than 2.6 mmol/L, they will be treated according to the Algorithm for Newborn Hypoglycemia and rechecked in 30 minutes instead of 60 minutes. CRRT Update CRRT implementation was targeted for spring of 2020 implementation and was delayed due to COVID-10. Despite the pandemic, the ICU team achieved key milestones for capital purchase, order sets, protocols, staff and physician training, supply readiness and liaising with the Regional Renal Program by December 2020. Implementation planned for January 2021 was delayed due to medical human resource concerns for coverage during the second COVID-19 wave. In addition, CRRT intervention was not utilized during the first COVID-19 wave with the COVID population, with observation that proning caused thrombus therefore acute hemodialysis was more of the demand.

BRIEFING NOTE

52

Agenda Item 3.6.1

CRRT remains a priority procedure for CMH, however, due to the pandemic, the implementation has been adjusted from Spring 2020 to Spring 2021. The ICU team and nephrology-trained general internists are developing a plan to provide 24/7 coverage for the CRRT program. The following policies were approved:

• Policy Review: 14-192 Transfusion Medicine (Administration Guidelines) Fibrinogen Concentrate (RiaSTAP)

There were no significant changes to the policy. Additions include a section about transfusion reactions and the parameters for the nursing staff to monitor.

• Policy Review: 14-191 Transfusion Medicine (Administration Guidelines C1 Esterase Inhibitor

There were no significant changes to the policy. A section on adverse reactions and monitoring was added. The Emergency Department Return Visit Quality Program The Emergency Department (ED) Return Visit Quality Program has been in operation since 2016 and focuses on the quality of care in emergency departments. Each January, participating hospitals answer a set of questions as part of their annual submission of results to Ontario Health. Audits are focused on the data reports received in the 2020 calendar year, which present return visits occurring between July 1, 2019, and June 30, 2020.

The requirement is to complete 50 audits per year. Due to the pandemic, this requirement was waived for this year. However, CMH ED did conduct the audits. Additionally, HQO asked hospitals to identify opportunities and quality improvements related to COVID-19. COVID-19 Update Dr. K. Nuri provided the following update on February 10, 2021 numbers:

Global Update National Update Total Confirmed Cases: 106,555,206 Total Confirmed Cases in Canada: 810,797 Total Deaths: 2,333,446 Total Deaths in Canada: 20,908 CF: 2.2% CF: 2.6% Provincial Update Regional Update Total Confirmed Cases in Ontario: 281,566 New Cases: 34 New Cases: 1,072 Total Confirmed Cases in Local Region: 9,886 Total Deaths in Ontario: 6,596 Active: 380 CF: 2.3% Total Deaths in Local Region: 211 LTC Outbreaks: 200 CF: 2.1% Hospitalizations: 948 LTC/RH Outbreaks: 18 ICU on a ventilator: 313/226 Hospitalizations / ICU: 31/9

CMH Update Available Swabs at CMH: 339 Number of Positive patients: ICU: 2 intubated on ventilator Med A: 4

53

Agenda Item 3.6.1

Critical Care Update The biggest challenge we have had with the COVID patients is there incredible complexity and the long length of stay. There are currently 2 active cases in the ICU, and 3 resolved yet remain intubated and quite unwell clinically. Covid ICU patients have much longer periods of ventilation and use a lot of nursing resources. ICU numbers have stabilized and improved after a busy December and January. We have received temporary funding to staff additional beds which brings us to 14 beds. CMH Adult Critical Care ESOC Policy This policy supports the implementation of an Adult Critical Care Emergency Standards of Care (CC ESOC) for Major Critical Care Surge if so declared and mandated by the Government of Ontario, the Ministry of Health, Ontario Health, or Ontario Health West. This protocol was developed for specific application to a pandemic, resulting in a significant surge in the need for critical care, with inadequate resources to meet the demand; this is an option of last resort. HSMR – see attached BN PFAC Update Ms. Corey Kimpson provided the following update from Feb meeting of PFAC: • Expressed their appreciation for CMH staff for continuing to support the community. • Attended the recent Advisory Board Diversity and Inclusivity workshop which prompted a

fulsome discussion and one of the questions that came up was ‘does CMH reflect our community as a whole’?

• Discussion of reinstating in person visits for Care Partners and if this can be offered in a safe capacity.

• Patient Experience Conference coming up at the end of April hosted by the Beryl Institute. This year it will be held virtually – hoping to open it up to all staff at CMH.

54

Agenda Item 3.6.1 (HSMR)

Page 1 of 4

Date: January 29, 2020 Issue: HSMR 2019 Results Prepared for: Senior Executive Committee Purpose: ☐ Approval ☒ Discussion ☐ Information Prepared by: Kyle Leslie, Manager, Transformation Office Approved by: Dr. Asim Masood, Chief of Staff, VP Medical Affairs Attachments/Related Documents:

Alignment with CMH Priorities


No ☐


No ☐


No ☐ ☒ Prove Patients Matter Most ☐ Patient Experience ☐ Accelerating Access to Care ☐ Increase Joy in Work ☐ Length of Stay ☐ Keeping Staff and Physicians Safe and Engaged ☐ Lead Boldly ☐ CRP Phase 3 ☐ Executing CRP Phase 3

☐ Multi-year Fiscal/Capital Strategy ☐ Completing our HIS Evaluation

Recommendation/Motion 1) Continue to investigate palliative care coding and documentation to ensure HSMR

counts are not overstated2) Establish coding and documentation chart review process monthly, leveraging existing 3

Terra coding discrepancy tool to assist with flagging cases for review3) Identify all 2020/2021 cases that need to be re-coded and corrected prior to May 31st,

2021 and measure impact on HSMR results and establish lessons learned for codingand documentation

4) Explore the potential for a palliative care program at CMH and the impact to patient andfamily experience

Executive Summary Updated HSMR results were posted publicly in December2020; CMH’s results were below average. Initial data and chart reviews identified the following contributors to the 2019 HSMR results:

1) Coding and documentation for palliative care2) Palliative care conversations happening late in the course of care, resulting in palliative

care not being coded as main diagnosis and the case not being excluded from HSMRcounts

3) Need for better documentation of reason for admission, cause of death and goals of careto ensure coding best reflect patient care

Background Hospital Standardized Mortality Ratio (HSMR) is the ratio of the actual number of acute in-hospital deaths to the expected number of deaths, for conditions accounting for 80% of inpatient

BRIEFING NOTE

55

Agenda Item XX

Page 2 of 4

mortality. This indicator is used by the Canadian Institute for Health Information (CIHI) to measure whether the number of deaths at a hospital is higher than expected based on the average experience of Canadian Hospitals. In December of 2019 CIHI posted updated HSMR results for all Canadian hospitals. The graph below displays the 2019 HSMR results published for Waterloo Wellington LHIN and totals for Canada and Ontario:

Analysis A deep dive into the HSMR data was conducted to understand drivers to HSMR. Below is a summary of CMH’s five-year trend in HSMR performance:

In 2018 CMH’s HSMR was over 100, however was still considered to be on par with average performance. The chart above illustrates an upward trend over the last two years which is continuing into FY 2020-2021. Our data analysis identified that HSMR was increasing within certain diagnosis groups over the 2015-2020 timeframe. The chart below highlights the top five diagnosis groups with highest deaths that had the largest increases in HSMR results from 2018 to 2019.

0

20

40

60

80

100

120

140

2015 2016 2017 2018 2019 2020 (YTD Nov)

CMH HSMR Trend

Series1

Series2

CMH HSMR

Target <100

56

Agenda Item XX

Page 3 of 4

Chart reviews were performed focusing on the above diagnosis groups to determine contributing factors to the increase in HSMR. The chart reviews revealed the following:

1) Palliative care conversations are happening late in a patient’s stay, which has led to palliative care cases not being excluded from HSMR counts. Palliative care must account for the majority of the stay and for at least 24 hours to qualify as the main diagnosis. This indicates that we may be failing to give patients and families time to prepare for end of life. In addition, it was identified that a limited number of physicians are having conversations around palliative care

2) There were a number of cases where palliative care was missed in the coding which resulted in these cases not being excluded from HSMR counts. These cases will be included in our re-coding process.

3) From a documentation perspective, face sheets do not capture the information needed to attribute reason for admission, cause of death and goals of care. In many cases the face sheets are incorrect or incomplete, which can contribute to charts being coded incorrectly.

Consultation An initial HSMR working / strategy group began meeting in December which included the following people:

Dr. Masood Sandra Hett Mari Iromoto Dr. Legassie Dr. Nguyen Kyle Leslie

0.00

50.00

100.00

150.00

200.00

250.00

300.00

350.00

J18:Pneumonia,organism unspecified

N17:Acute renalfailure

I50:Heart failure I21:Acute myocardialinfarction

J96:Resp failure, notelsewhere classified

HSM

RCMH Top 5 Diagnosis Groups With Increases in HSMR

FY 2018 vs FY 2019

2018

2019

57

Agenda Item 3.6.2

Page 1 of 6

Date: February 11, 2021 Issue: Medical Advisory Committee Privileges & Credentialing

(January Credentialing Committee) Prepared for: Board of Directors Purpose: ☒ Approval ☐ Discussion ☐ Information Prepared by: Dr. Asim Masood, Chief of Staff, VP Medical Affairs Approved by: Mr. Patrick Gaskin, CEO Attachments/Related Documents: Alignment with CMH Priorities


No ☒


No ☒


No ☒ ☐ Prove Patients Matter Most ☐ Patient Experience ☐ Accelerating Access to Care ☐ Increase Joy in Work ☐ Length of Stay ☐ Keeping Staff and Physicians Safe and Engaged ☐ Lead Boldly ☐ CRP Phase 3 ☐ Executing CRP Phase 3 ☐ Multi-year Fiscal/Capital Strategy ☐ Completing our HIS Evaluation

Recommendation/Motion Proposed Board Motion: That the recommended privileges for ratification and granting be approved as presented to the Board. Committee motion: Applications for privileges as displayed be approved

BRIEFING NOTE

58

Agenda Item 3.6.2

Page 2 of 6

Credentialing Files for Review (January 2021 Credentials Committee): Name Program Specialty Appointment Reason Supervisor Recommended/

Not Recommended

Comments

Dr. Venus Valbuena

Oncology GPO Associate Resigning effective Dec 31, 2020

Dr. Lyndsay Evans/ Dr. Helen Lin

☒ Recommended ☐ Not Recommended

Working on replacement

Dr. Stephanie Ma

Surgery Plastics Active Requesting 6 months parental leave starting mid Jan 2021 is looking for a locum

Dr. Ingrid Whitehead


There is some activity around coverage for at least the call piece and fracture clinic, working on elective

Krista Barclay

Midwifery Midwife Associate – overdue to transition to active

Requesting parental leave from Dec 24, 2020 – September 1, 2021

Corine Witteveen


No concerns will address transition to active upon return

Dr. Mandeep Gill

Surgery ENT Associate – overdue to transition to active

Requesting parental leave from Jan 4 – March 15, 2021 is looking for a locum



Still looking for locum, will address transition to active upon return

59

Agenda Item 3.6.2

Page 3 of 6

Name Program Specialty Appointment Reason Supervisor Recommended/ Not

Recommended

Comments

Dr. Patrick Lindsay

Medicine Internal Medicine

Locum Requesting locum privileges from Jan 25 – June 30, 2021

Dr. Augustin Nguyen


No concerns

Dr. Andrew Worster

Surgery Surgical Assist

Locum Requesting locum privileges from Dec 1, 2020 – April 1, 2021



No concerns

Dr. Asim Masood

Emergency Emergency Medicine

Associate New hire Dr. Arthur Eugenio

☐ Recommended ☒ Not Recommended

Deferred – file incomplete

Dr. Hafez Shuhaibar

Pathology Pathologist Locum Requesting extension of locum privileges until Feb 28, 2021

Dr. Anita Bane


Awaiting new hire to start March 1, 2020

Dr. Abdulrhman Abulaban


Locum Requesting extension of locum privileges until March 31, 2021

Dr. Augustin Nguyen


No concerns

60

Agenda Item 3.6.2

Page 4 of 6


Recommended

Comments

Dr. Tin Leung

Family Medicine

Affiliate Relinquishing privileges Dec 31, 2020 – retiring

Dr. Mekalai Kumanan


Letter of thanks from Board/COS/CEO/MSPA will be sent

Dr. Adnan Qureshi

Surgery General Surgery

Locum Requesting locum privileges to cover call for Dr. Roth-Albin Dec 28 & 29, 2020

Dr. Ingrid Whitehead Dr. Roth-Albin


No concerns

Dr. Ashley Kim

Surgery Plastics Locum Requesting locum privileges from Dec 9, 2020 – March 9, 2021 to assist Dr. Sawa

Dr. Ingrid Whitehead Dr. Katie Sawa


Acting as surgical assist with Dr. Sawa in plastics Dr. MacLeod said that it’s a very specialized role and you need some one to look under the microscope while performing the micro cases

Dr. Zahira Khalid


Locum Requesting extension of locum privileges to assist Dr. Legassie with staffing

Dr. Augustine Nguyen Dr. Jenny Legassie


No concerns

61

Agenda Item 3.6.2

Page 5 of 6


Recommended

Comments

coverage until March 31, 2021

Dr. Christine Herrera

Family Medicine

Associate – overdue to transition to active

Requesting parental leave from March , 2021 – March, 2022

Dr. Mekalai Kumanan


Will address transition to active upon return

Julia Heyens

Midwifery Midwife Associate – overdue to transition to active

Requesting parental leave from May 1, 2021 – May 1, 2022

Corine Witteveen


Will address transition to active upon return. Coverage plan in place

Cathy Gong

Family Medicine – COVID assessment centre

NP Locum Resigning locum privileges

Dr. Meikalai Kumanan Paula Carere


No concerns

Dr. Michelle Kuang

Emergency Locum Requesting extension of locum privileges from July 1, 2020 – Jan 31, 2021 also Dr. Eugenio would like to

Dr. Arthur Eugenio


Need to interview as sole hire, will work with Dr. Eugenio to have done in New Year

62

Agenda Item 3.6.2

Page 6 of 6


Recommended

Comments

offer her associate staff

63

Indicator Current Value

WR Weekly Incidence Rate per 1000 47.5 <19 per 100,000 10 to 24.9 per 100,000 24 to 39.9 per 100,000 >= 40 per 100,000WR (R- 0) 0.9 < 1 1 1 - 1.1 > 1.2 WR % Positivity 2% <0.5% >0.5 < =1.2% >1.3% <= 2.4% > 2.5%CMH ICU Capacity 78% <80% 80% - 90% 90% -99% >99%CMH Med Capacity 84% <90% 90% - 95% 95% - 99% >99%CMH Positive IP cases 7 <2 cases 2-5 cases 5 - 10 cases >10 Cases

New Cases7 Day

Rolling Avg Total Cases Hospitalized

ICU COVID Cases / Vented

CriticalCare

Census

Critical Care Vented Census

Total Critical Care Occupancy %

Total Critical Care Occupancy % (rolling 7 day

average)

Critical Care Vented Occupancy

%

Critical Care Vented Occupancy % (rolling 7

day average)Ontario 1,150 1,026 290,621 689 322/ 210 1,778 698 78% 73% 45% 42%

WR 38 38 10,220 24 16/8 82 29 77% 80% 46% 49%

5

CMH COVID-19 Dashboard – Feb 19

Waterloo Region ICU Capacity

ICU (Total COVID

Cases)

ICU Vented (COVID Cases) Total % Occupancy

CMH 3 0 64%

GRH 7 6 65%

GGH 3 1 82%

SMGH 3 1 75%

CMH Staff

Staff who have tested positive 46 (+3 student)+(1 LHIN) + (1Security)

Staff who have tested positive- cleared to return to work 43(+2 student)

Staff waiting for results isolation 4

Staff waiting for results working 0

Staff in self isolation7 + 2 Security + 2 work iso

+ 3 contact of contact isolation64