report from gbgh operational review

7/25/2019 Report from GBGH operational review

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GEYER &ASSOCIATES INC.

Georgian Bay General Hospital

Operational Review

Final Report

December 9, 2015


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EXECUTIVE SUMMARY

GBGHOPERATIONAL REVIEW OBJECTIVESFunded by the NSM LHIN, the Operational Review of GBGH sought to:

!Examine and report on the factors that have contributed to the hospitals financial challenges;

!Review the hospitals draft improvement plan; and

!Identify other opportunities for the hospital to establish a sustainable balanced financial operating positionwithin approved funding.

The RFP specifically required:

!An assessment of GBGHs current and future clinical service profile and service sustainability; and

!Findings and recommendations that apply to GBGH as a singular organization and to the wider localhealth system of which it is a part.

PROCESS AND TIMELINES FOR THE REVIEW

A consulting team from Geyer & Associates Inc. was guided by a Steering Committee that included:

!GBGHs Board Leadership;

!GBGH Chief of Staff;

!GBGH Executive Management Team;

!Representation from the local community; and

!North-Simcoe Muskoka LHIN Chief Operating Officer.

GBGH and the LHIN

sought a review of

opportunities to

establish a

sustainable financial

operating position

within approved

funding.


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The Operational review was initiated in early September and the final report was submitted to the project

Steering Committee on November 25, 2015.

Reporting to the GBGH Operational Review Steering Committee, the review team synthesized information

from:

!Extensive review of documentation provided by the hospital;

!Quantitative analysis of clinical and administrative data sets;

!Focused review of hospital finances and corporate departments;

!On site tours in all clinical areas and departments at both sites;

!

Extensive consultation with:

"The GBGH Board and Board Committee Chairs;

"GBGH Executive Management;

"GBGH Medical Advisory Committee, Physicians leaders and past leaders;

"Clinical and non-clinical managers;

"Front line staff physicians;

"Front line staff in clinical and corporate departments;

"Stakeholders in the community; and

"Key partners in the LHIN.

!Confidential email submissions received from front line staff.

The operational

review team

synthesized analytical

findings with

perspectives shared

during extensive

consultation withinternal and external

stakeholders.


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KEY FINDINGS

Key findings of the operation review include:

!GBGH culture is a matter of significant concern and requires immediate and focused attention. The

GBGH culture is one of fear, intimidation, and a lack of respect for hospital policies, as evidenced by:"The GBGH 2015 Safety Culture Survey completed for the accreditation process, and

"Interviews, focus groups and confidential email submissions.

!The Draft Hospital Improvement Plan (HIP) was too optimistic and insufficient to ensure that GBGHachieved a balanced financial operating position within three years.

!The Board does not have a robust strategic plan in place and does not benefit from the use of a strategicmanagement system to plan and monitor operations at the appropriate level.

!

The quality focus expected of governance appears to be muted due in part to the lack of strategy but alsothe significant attention directed towards the financial condition of the hospital.

!The Board has not assumed a proactive governance role in appropriately positioning the hospital to meetthe needs of the populations it serves within directions set by the LHIN.

!The current organizational structure does not promote clear lines of accountability or effective decision-making.

!Physician leaders are not effectively integrated into the organizational structure and do not play ameaningful and collaborative role in decisions affecting hospital operations.

!Many managers and directors lack the skills and tools to fulfill their roles and responsibilities.

!There is ample room to improve workplace engagement and staff satisfaction with GBGH as anemployer.

!There is a need to enhance the role of MAC, reduce the number of Department Chiefs, and enhance theirroles and compensation.


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!There is a need to strengthen the role of the Chief of Staff, particularly with respect to the quality ofmedical care.

!There are significant issues that need to be addressed to ensure consistent quality of medical care.

!The hospitalist role and hospitalist expectations at GBGH are poorly defined and understood.

!Corporate services expenditures are close to other comparably sized hospitals and corporate servicesimprovements have been implemented in the past several years; there are still opportunities for furtherimprovements. One of the most significant remaining opportunities to reduce overhead expenditures anddirect more funding to patient care is through the closure of the Penetanguishene site.

!The communities GBGH serves have actual utilization rates for hospital based services that are close tothe rates that would be expected given community demographics and established measures of relativeneed.

!

Market share of GBGH for the primary catchment population has been declining and is of some concernsince population based funding follows the patient.

!With respect to unit costs, GBGH is:

"Of average relative efficient in the delivery of acute, day surgery, emergency and dialysis services.

"Relatively inefficient in the delivery of inpatient rehabilitation and complex continuing care due toexcessively long lengths of stay, and the use of these programs to augment services that should beprovided in the community.

!GBGH acute programs have become less clinically efficient over the past five years: the hospital uses thesame number of beds to provide care to fewer patients.

!Emergency Department (ED) performance has been among the best in the province in terms of PhysicianInitial Assessment (PIA), and has focused successfully on reducing ED length of stay for admittedpatients in 2015.

!There are clear opportunities to improve clinical utilization on acute inpatient units including the ICU andOperating Rooms.


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RECOMMENDATIONS TO IMPROVE GBGHCULTURE

Recommendation 1: GBGH should immediately reinvigorate the Code of Conduct.

Recommendation 2: All GBGH physicians should be required to sign the Code of Conduct as part of annual

credentialing.

Recommendation 3: GBGH should consistently apply the expectations of the Code of Conduct to all staff

and physicians.

Recommendation 4: GBGH should include staff satisfaction metrics into regular Balanced Scorecard

reporting.

Recommendation 5: All GBGH position descriptions should include expectations with respect to employeeand physician roles to contribute to a positive work environment.

Recommendation 6: GBGH should establish a broad based Advisory Committee to oversee the promotion

of a positive work environment. This Committee should be accountable to the Board Quality & Safety

Committee.

Recommendation 7: Appropriate whistle blower protection policies should be developed and

implemented within 6 months.


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RECOMMENDATIONS TO IMPROVE GBGHGOVERNANCE

Recommendation 8: The Board should direct senior leadership to develop a new Strategic Plan for GBGH

that is comprehensive and includes Vision, Mission, Values, Strategic Directions, Tactics and Metrics.

Recommendation 9: The Board should direct senior leadership to develop a new balanced scorecard at thegovernance level that will serve as the foundation for reporting across the organization.

Recommendation 10: A consistent approach for reporting to the Board on tactics identified in the strategicplan should be developed and implemented.

Recommendation 11: The Board should review best practices with respect to meeting processes.Specifically, the frequency of meetings and how material is reviewed at the Board level should be examined,

and necessary changes implemented.

Recommendation 12: The Board should consider engaging a Coach to provide mentorship and supportthrough the implementation of the recommendations in this report.

Recommendation 13: The Board should link the evaluation of CEO and COS performance to the keystrategic directions, tactics and metrics identified in the strategic plan discussed in Recommendation 8.

Recommendation 14: The Board should define its expectations of the Chief of Staff with greater clarity,

particularly in respect to the quality of medical care.Recommendation 15: Critical incidents leading to death or harm need to be reported to the Board andQuality & Safety Committee in a timely fashion.

Recommendation 16: The Board should direct staff to develop a quarterly written critical incident report forreview at the Quality & Safety Committee that identifies incidents, key investigative findings, improvementactions, target dates and accountability.


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Recommendation 17: The revised balanced scorecard that builds upon a new strategic plan needs to includequality metrics, and those metrics should be included in the evaluation of the CEO and Chief of Staff.

Recommendation 18: Develop a Board education plan that includes a Board education session related toquality at the majority of Board meetings.

Recommendation 19: The Board should include a patient story at each meeting of the Quality & SafetyCommittee.

Recommendation 20: Create a joint medical/management committee focused on quality and safety as theoperational counterpart to the Board Quality & Safety Committee.

Recommendation 21: The Board should revise and strengthen the terms of reference for the MAC to ensurethe appropriate focus on medical quality and credentialing issues.

Recommendation 22: The Board should direct GBGH staff to move towards a revenue-based approach tobudgeting.

Recommendation 23: The Board should only accept and/or approve proposals when there is a crediblefinancial plan showing sources of necessary funds.

Recommendation 24: The Board should also develop a policy requiring that proposals will only beconsidered when a robust sustainability plan is included.

Recommendation 25: The Board should increase the amount of time it dedicates to relationship building.

Recommendation 26: The Board should regularly consider Collaboration and Partnership as a potentialtactic to achieve strategic directions.

Recommendation 27: Terms of Reference for The GBGH Community Health Care Partners Forum shouldbe developed.


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RECOMMENDATIONS TO IMPROVE MANAGEMENT EFFECTIVENESS

Recommendation 28: The CEO should lead an organizational re-design process to develop a new structure

that will better enable strategy, integrate physician leadership into the design, and ensure greater clarity withrespect to accountability and reporting.

Recommendation 29: The organizational redesign should seek to reduce the number of internal committeesand streamline the terms of reference to minimize duplication of work effort.

Recommendation 30: The new organizational structure should enhance the accountabilities of the two VicePresidents in their respective areas to include all aspects of the departments that report to them quality,financial, strategic, operational, etc.

Recommendation 31: Key corporate departments such as Finance, Decision Support and Human Resourcesshould play a supporting role to all clinical and clinical support departments and programs.

Recommendation 32: The new organizational structure should promote, where possible, a managementdiad in which physicians and administrators jointly oversee the operational and financial performance ofclinical programs.

Recommendation 33: A leadership development plan for administrative leaders should be developedfocusing on the skills required to lead and manage in todays ever changing environment.

Recommendation 34: Senior leadership should identify a staff engagement survey instrument to beadministered to a sample of staff on at least a biannual basis.

Recommendation 35: GBGH leadership should develop further skill and competency in financialmanagement.

Recommendation 36: GBGH should continue to incorporate annual benchmarking as part of the financialmanagement process.


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Recommendation 37: The Finance Department should introduce a business case standard template for allmajor financial decisions including program changes, capital requests and physician impact analysis with asign-off protocol.

RECOMMENDATIONS TO IMPROVE MEDICAL LEADERSHIP AND QUALITY OF CARE

Recommendation 38: Restructure the number of Chiefs to 4

Recommendation 39: Revise and/or develop position description for Departmental Chiefs to enhance thefocus on quality of medical care, as well as increased responsibility for the administrative and operationalaspects of their respective clinical areas.

Recommendation 40: Increase the stipend paid to Chiefs and define the time to be dedicated to this role (.5days/week).

Recommendation 41: Revise and strengthen the role of the Chief of Staff to increase his/her role to overseethe quality of medical care.

Recommendation 42: Consider the possibility of providing the Chief of Staff with a mentor/coach for a 6-month period.

Recommendation 43: Invigorate the MAC with the goal of increasing focus on quality and accountabilityfor all medical staff at GBGH.

Recommendation 44: The Board Chair or Vice Chair should attend MAC meetings on a regular basis.

Recommendation 45: Consider developing an in house medical leader boot camp program to become aregular item on the MAC agenda.


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Recommendation 46: Integrate selected medical leadership development sessions with AdministrativeLeadership to facilitate team development.

Recommendation 47: The Board must play a strong role in providing the necessary support to the Chief ofStaff and the senior leadership of GBGH to ensure that unacceptable behaviours are not tolerated.

Recommendation 48: GBGH should develop written contractual agreements with the hospitalists thatoutline the expectations and roles and responsibilities for both parties.

Recommendation 49: In order to be competitive in the market, GBGH should explore the opportunity toenhance hospitalist remuneration and review alternative compensation models that are team based.

Recommendation 50: GBGH should make efforts to enhance communication with local primary carephysicians, and should increase the degree of involvement in LHIN planning and with other potential

partners in the region.

RECOMMENDATIONS TO IMPROVE CORPORATE PERFORMANCE AND INCREASE THE SHARE OF GBGH

FUNDING DEDICATED TO PATIENT CARE

Recommendation 51: It is recommended that a formal tracking program be implemented to ensure costsrelated to food wastage are captured accurately and are captured accurately in the cost per patient day.

Recommendation 52: Target further savings related to food wastage of $20K.

Recommendation 53: Close the cafeteria.

Recommendation 54: GBGH to explore a shared service agreement with Central North Corrections Centre,and recover costs for security services that are directly related to the clients of this facility.

Recommendation 55: GBGH should aim to close the Penetang Site by 2016/17.


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Recommendation 56: GBGH should not be the landlord of the proposed health hub at the Penetang Site.

Recommendation 57: GBGH should aim to sell or lease-to-own the building.

Recommendation 58: It is recommended that GBGH review the contract with Shared Service West to

ensure that there are annual savings targets in the contract and clear deliverables to be met.

Recommendation 59: Current budget tool (BUDMAN) should be upgraded to the most recent version andthe Executive Support Manager (ESM) tool be purchased and implemented.

Recommendation 60: GBGH should develop and implement a formal Position Control Process for thereplacement of staff, or hiring of new staff to ensure that budgetary dollars exist for any new positions,replacement of positions or additional part time hours.

Recommendation 61: GBGH should ensure that all purchase of goods and services are done through a

formal approved contract, and a purchase order created to ensure that the organization is aware of allcommitments.

Recommendation 62: All rental agreements should be reviewed and compared against current market valuerates to ensure that all costs of GBGH are fully recovered.

Recommendation 63: GBGH should explore opportunities to enhance HR functionality through partnershipwith another organization in the LHIN.

RECOMMENDATIONS RELATED TO CLINICAL OPERATIONS

EMERGENCY DEPARTMENT

Recommendation 64: Consider using the management model that has worked effectively in the ED as thebasis for the new organizational model throughout GBGH.


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Recommendation 65: Review CDU utilization and staffing. Develop clear criteria for admission anddischarge to this area, and monitor performance to ensure that the right types of ED patients are admitted tothese beds.

Recommendation 66: Adjust nursing staffing patterns to reduce the numbers of RNs who start at 07.30

hours, and stagger shift start times to 09.00/10.00/11.00 hours.

Recommendation 67: Review triage process with the goal of reducing triage time by 50%.

Recommendation 68: Within the current ED budget, add in a Pharmacy Technician to conduct MedicationReconciliations 12 hours/day.

Recommendation 69: Review current state with respect to utilization of CT for diagnostic purposes.

ACUTE INPATIENT UNITS

Recommendation 70: Explore the opportunity to establish a 4 bed higher acuity room to accommodatethose patients that require a higher level of monitoring/oversight.

Recommendation 71: Provide additional support to Managers of Clinical Services to deal with aberrantbehaviours, and adhere to the collective agreement re: disciplinary actions that may be required.

Recommendation 72: Review educational needs of nurses on all nursing units, and develop a structured

program to enhance their level of competency.

Recommendation 73: Recover all day surgical cases in the PACU.

Recommendation 74: Establish guidelines for hospitalist practices ensure rounding is done earlier in theday.


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Recommendation 75: GBGH should develop a utilization management program to identify opportunities toimprove clinical utilization of hospital resources. The Joint Medical/Management Committee shouldoversee the work.

Recommendation 76: Aim to improve utilization of beds by decreasing LOS and reducing conservable

days. The goal is to reduce the number of beds by 5 by 2017/18.

Recommendation 77: Improve efficacy of daily discharge rounds by support the engagement of hospitalistsand family physicians in these rounds.

Recommendation 78: Enhance partnership with CCAC personnel and engage them more effectively indischarge planning.

Recommendation 79: Consistently adhere to Expected Date of Discharge (EDD) Guidelines.

Recommendation 80: Explore the possibility of providing a Discharge Clinic for discharged medicalpatients run by the hospitalists out of Ambulatory Care.

Recommendation 81: Document response times and incidents in which physicians on call direct staff to notcall them.

Recommendation 82: Partner with RVHC to ensure that higher acuity patients are transferred in a timelymanner to a critical care environment that can better meet their needs.

Recommendation 83: Re-designate the GBGH ICU as a level 2 unit and explore opportunities to partnermore effectively with RVHCs critical care program to improve the quality of care.

Recommendation 84: Reduce number of beds to 4.

Recommendation 85: Enhance admission, transfer and discharge criteria, and implement the revised criteriaconsistently.


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REHABILIATION AND COMPLEX CONTINUING CARE

Recommendation 86: Add 1 full shift of physiotherapy coverage on weekends.

Recommendation 87: Initiate assessments immediately upon admission to the unit.

Recommendation 88: Eliminate the practice of providing ambulatory rehabilitation on an inpatient basiswith weekend passes.

Recommendation 89: Conduct a review of clinical information practices and develop a new model thatintegrates the use of assessments into care planning and delivery.

DIAGNOSTIC AND THERAPEUTIC SERVICES

Recommendation 90: Adjust the outpatient lab target savings estimate to $300,000 this fiscal year, and

$600,000 annually on a go forward basis.Recommendation 91: Conduct an audit of all CTs that are conducted on an unscheduled urgent basis.Collect information such as: Time of procedure; Technologist assigned to the procedure; OrderingPhysician; reason for request; etc.

Recommendation 92: Encourage and support staff to become certified in CT testing.

Recommendation 93:Require that Technologists being hired into the department are CT certified.

Recommendation 94: Review current complement of full time and part time staff, and set a goal to increasethe numbers of full time staff.

Recommendation 95: Establish a DI/ED Council to meet on a quarterly basis to discuss issues affectingservice in each department. This council should include representation from Georgian Bay Radiology.

Recommendation 96: Conduct a focused review of Pharmacy operations by an experienced PharmacyLeader.


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THE ROLE OF GBGHIN THE LHIN

GBGH has an important role to play in the provision of care in the LHIN.

Specifically:

!Emergency Department GBGH should remain the primary provider of high quality and timelyemergency services to residents of the communities that it serves.

!Acute Medicine GBGH should provide high quality medical services

"GBGH should have a level 2 ICU.

"GBGH should have linkages to RVHC for seamless and timely transfer of critically ill multi-organfailure patients.

!Inpatient and Day Surgical Services GBGH should focus on primary elective surgical procedures

"Elective general surgery,

"Day surgery and endoscopy,

"Ophthalmology, and

"Services that can be safely and economically provided by itinerant surgeons.

!Complex Continuing Care and Rehabilitation GBGH should provide clinically efficient and effectiverehabilitation and CCC services using multidisciplinary teams.

!Program Partnerships with OSMH GBGH should create clinical program partnerships:

"For the provision of high quality obstetrical, gynaecological, neonatal and paediatric care.

"For a shared mental health program that has 20 acute beds sited at GBGH along with the appropriateGBGH based ambulatory mental health care services. The model should share medical staff andprogram management.


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RECOMMENDATIONS REGARDING GBGHSAPPROPRIATE FUTURE ROLE IN THE LHIN

Recommendation 97: GBGH should aggressively pursue adding 20 acute mental health beds to the

complement of beds.

Recommendation 98: GBGH should explore opportunities to partner with OSMH in the provision of mentalhealth services with a shared medical staff and senior leadership for the program.

Recommendation 99: GBGH should target and seek to negotiate a total operating budget of $5.2 million foracute mental health and $0.766 million for ambulatory care.

Recommendation 100: Close the obstetrical program and pursue a partnership with OSMH for allobstetrical, gynecological and pediatric care.

Recommendation 101: Reconfigure the OR schedule to operate 3 days/week with 13 blocks per month.

Recommendation 102: Reallocate ophthalmology procedures to a designated space in Ambulatory Care(consistent with best practice), and recover patients in the same area.

Recommendation 103: Reallocate pregnancy terminations to Ambulatory Care.

Recommendation 104: Immediately cease the Scope On Call.

Recommendation 105: GBGH should develop clear criteria to guide the decision to conduct surgicalprocedures after regular hours. These criteria should be applied consistently in all situations in which arequest is made to conduct a case after hours and is a joint administrative and medical decision.

Recommendation 106: Focus on elective procedures.

Recommendation 107: Stop providing paediatric surgery.

Recommendation 108: Reduce the dental blocks by 1/month.


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PROJECTED GBGHBEDS

Implementation of the recommendations of this report will result in:

!A short term reduction of GBGH beds staffed and in operation through 2018/19, and

!

A net increase in the number of beds by 2019/20 with the additional of mental health.

GBGH Bed Projections

BEDS 2015/16 2016/17 2017/18 2018/19 2019/20

Medical & Surgical 60 60 55 55 55

Obstetrics 3 0 0 0 0

ICU 6 4 4 4 4

CCC 21 21 21 21 21Rehab 15 15 15 15 15

Mental Health 0 0 0 0 20

Total Beds 105 100 95 95 115


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SUMMARY OF THE RECOMMENDED SAVINGS AND REINVESTMENTS

The recovery plan recognizes one-time and ongoing savings, increases in revenues and recoveries, and one-

time and ongoing reinvestments. The plan includes:

!

$5.2 million reduction in net expenses by 2018/19 excluding reinvestments;

!$395K in one time current year reinvestments and $230K in ongoing reinvestments that are thought to becritical to GBGHs ability to implement the recovery plan;

!$1.5 million in one-time LHIN funding to be received in fiscal 2015/16; and

!A target $6 million for 20 GBGH based mental health beds with ambulatory mental health in 2019.

Cumulative Impact of Recommendations

IMPACT OF RECOMMENDATIONS 2015/16 2016/17 2017/18 2018/19 2019/20

Ongoing Savings $550,000 $2,170,333 $4,858,025 $5,108,025 $5,108,025

Ongoing Reinvestments $- $280,000 $230,000 $230,000 $230,000

Ongoing Recoveries Increase $- $100,000 $100,000 $100,000 $100,000

New Program Funding $- $- $- $- $6,000,000

New Program Expenses $- $- $- $- $6,000,000

One Time Revenue Increase $1,500,000 $29,333 $0 $0 $-

One Time Investment $395,000 $0 $0 $0 $-

Total Revenue & Recoveries Increase $1,500,000 $129,333 $100,000 $100,000 $6,100,000

Total Expense Decrease $155,000 $1,890,333 $4,628,025 $4,878,025 -$1,121,975

Total $1,655,000 $2,019,667 $4,728,025 $4,978,025 $4,978,025


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IMPACT OF RECOMMENDATIONS ON KEY MEASURES OF FINANCIAL PERFORMANCE

Implementation of the recommendations of this operational review will allow the hospital to achieve a

balanced operating budget in 2017/18.

!

Inflationary pressures will require GBGH to implement further improvements or receive additional basefunding to sustain a balanced operating budget in 2018/19 and beyond.

!The recommendations of this report will not address the significant working capital deficit.

!The sale of the Penetanguishene facility following closure in 2017/18 has not been included in one-timerevenues. It is assumed that any proceeds from the sale of the building will be used to reduce hospitaldebt.

Projected Financial PerformancePROJECTED FINANCIAL PERFORMANCE 2014/15 2015/16 2016/17 2017/18 2018/19 2019/20

Total Revenue $56,726,909 $56,705,957 $55,346,187 $55,316,854 $55,316,854 $61,316,854

Total Expenses $56,950,688 $57,096,780 $56,595,558 $55,077,523 $56,017,265 $63,231,460

Surplus/Deficit from Operations ($223,779) ($390,823) ($1,249,370) $239,331 ($700,411) ($1,914,606)

Amortization ($1,045,538) ($943,996) ($943,996) ($943,996) ($943,996) ($943,996)

Surplus/Deficit ($1,269,317) ($1,334,819) ($2,193,366) ($704,665) ($1,644,407) ($2,858,602)

Working Capital Deficit ($8,144,159) ($8,094,444) ($8,143,941) ($8,032,906) ($9,427,313) ($12,035,914)

!Note that the financial projections do not include:

"One-time severance costs that may be incurred, and

"Impact of recovery plan on MoHLTC Health Based Allocation Methodology performance, which lagsbehind performance by two years.


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REQUIREMENTS FOR SUCCESS

GBGH is a valued partner in the NSM LHIN and should continue to play a strong role as an acute care

hospital and hub in the region. To be successful, GBGH needs to improve its financial performance, address

long-standing cultural issues that affect quality of care, staff morale, and limit opportunities to improve.It is important that GBGH and the LHIN accept the recommendations of this report as a package and

roadmap to achieving:

!Financial sustainability;

!Consistently high quality care in all programs and services;

!A more rewarding and satisfying work environment for staff and physicians;

!Stronger partnerships and alliances in the LHIN; and

!A consistently positive reputation in the community and in the region.

GBGH will not be successful if it focuses on selected recommendations that are thought to be easier to

implement.

Successful implementation of the recommendations of this report will require the commitment of the CEO,

Chief of Staff, and the entire Board. The hospital will in turn require the unwavering support of the LHIN.

It will also be imperative that the hospital moves quickly to begin implementing the recommendations. A

detailed implementation plan with responsibilities and timelines for each recommendation is included in thisreport. Board Leadership is responsible for monitoring performance with respect to the successful

implementations of the recommendations of this report.


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CONTENTSEXECUTIVE SUMMARY II

INTRODUCTION AND CONTEXT 1

Operational Review Objectives and Scope 1

Review Methodology and Timelines 2

Assessment of the Draft Hospital Improvement Plan 3

ORGANIZATIONAL FINDINGS &RECOMMENDATIONS 6

Organizational Culture 6

Governance 9

Management and Leadership 18

Medical Staff 26

CORPORATE SERVICES FINDINGS AND RECOMMENDATIONS 33

GBGH Overhead Expenditures 33

Corporate Departments 35

CLINICAL SERVICES FINDINGS AND RECOMMENDATIONS 44

Overview of Clinical Utilization and Unit Costs by Broad Program 44

Emergency Department 46

Acute Inpatient Services 53

Rehabilitation and Complex Continuing Care 65Ambulatory Care 76

Clinical Support Services 80


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CLINICAL SERVICES SUSTAINABILITY AND THE ROLE OF GBGHIN THE LHIN 85

Context 85

Mental Health 86

Obstetrics and Neonatology 89

Surgical Services 96The Role of GBGH in the LHIN 98

FINANCIAL IMPACT OF RECOMMENDATIONS 100

Summary of Recommended Savings and Reinvestments 100

Impact of Recommendations on Key Measures of Financial Performance 105

Requirements for Success 106

APPENDIX 1INTERVIEWS AND FOCUS GROUPS 107

APPENDIX 2IMPLEMENTATION RESPONSIBILITY AND TIMELINES 114


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INTRODUCTION AND CONTEXT

Operational Review Objectives and Scope

The objectives are to:

!

Examine and report on the factors that contributed to the hospitals financial challenges;

!Review the draft hospital improvement plan and analyze whether or not it will get GBGH to a balancedfinancial operating position within three years; and

!Identify other opportunities for the hospital to establish a sustainable balanced financial operating positionwithin approved funding.

The RFP specifically requires that the external review:

!Includes an assessment of GBGHs current and future clinical service profile and service sustainability;and

!Yield findings and recommendations that apply to GBGH as a singular organization and to the widerlocal health system of which it is a part.


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Review Methodology and Timelines

The review was guided and overseen by a Steering Committee that included representation from the hospital

Board, Senior Management, the Chief of Staff, and the LHIN Chief Operating Officer. Reporting to the

GBGH Operational Review Steering Committee, the review team engaged in the following activities to

complete this assignment:

!Extensive review of documentation provided by the hospital;

!Quantitative analysis of clinical and administrative data sets;

!Focused review of hospital finances and corporate departments;

!On site tours in all clinical areas and departments at both sites;

!

Extensive consultation with:"The GBGH Board and Board Committee Chairs;

"GBGH Executive Management;

"GBGH Medical Advisory Committee, Physicians leaders and past leaders;

"Clinical and non-clinical managers;

"Front line staff physicians, and clinical and non-clinical staff; and

"Stakeholders in the community and key partners in the LHIN.

!

Confidential email submissions received from front line staff.A full list of stakeholder interviews and focus groups is provided in Appendix 1.


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Assessment of the Draft Hospital Improvement Plan

A hospital improvement plan should plan for the worst and hope for the best. The consultants assessment

is that the draft HIP is optimistic and insufficient to ensure that GBGH achieves a balanced financial

operating position within three years.

Funding Model Performance

The Draft HIP includes revenue increases of more than $1M in 2017/18 due to funding formula performance

that will be achieved through improved documentation and coding of clinical data. Improved reporting of

financial statistical and clinical data should be pursued but not included as a bankable element of the

recovery plan. Many hospitals are striving to achieve this objective and, since the funding model is a zero

sum game, the success of this strategy requires that GBGH exceeds the improvements in reporting that otherhospitals achieve.

Inflation Assumptions

The Draft HIP did not estimate or otherwise acknowledge non-labour inflation. Non-labour inflation is a

material pressure that all hospitals should include in a conservative financial plan.

!Suggested annual inflation assumptions are provided in Figure 1.

!

The impact of inflation on GBGH operations is provided in Figure 2.


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Figure 1: Conservative Inflation Assumptions

EXPENSE CATEGORY ANNUAL INFLATION

SALARIES 2%

SUPPLIES 3%

MEDICAL/SURGICAL 3.50%

DRUGS 5%

OTHER EQUIPMENT 2%

CONTRACTED OUT 2%

GROUNDS EXPENSE/OTHER 2%

Figure 2: Estimated Impact of Inflation for GBGH

ESTIMATEDINFLATIONBYEXPENSETYPE 2016/2017 2017/2018

SALARIES AND WAGES $586,443 $598,172

EMPLOYEE BENEFIT CONTRIBUTIONS $43,369 $164,497

SUPPLIES & OTHER EXPENSE $178,688 $176,549

MEDICAL/SURGICAL SUPPLIES $69,760 $72,202

DRUGS & MEDICAL GASES $164,102 $172,307

RENTAL/LEASE OF EQUIPMENT $2,555 $2,606

OTHER EQUIPMENT EXPENSE $29,220 $29,804

CONTRACTED OUT SERVICES $26,218 $26,742

BUILDINGS & GROUND EXPENSE $3,066 $3,127

TOTAL $1,103,420 $1,246,006


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Current Financial Condition

GBGH finished 2014/15 with:

!A deficit from operations of $224K,

!

An overall deficit of $1.2 million, and

!A significant $8.1 million working capital deficit.

Based on the current spend and operating line of credit GBGH will have depleted all cash at the beginning

of fiscal 2016/17.

Currently the bank is allowing the hospital to net restricted funds to determine cash position so that

restricted funds are effectively being used to fund operations. It is recognized that this was intended as a

temporary practice.

Figure 3: Key Financial Metrics

CURRENTSTATE 2014/15

PROJECTED

2015/16

PROJECTED

2016/17

PROJECTED

2017/18

Total Revenue $56,726,909 $55,205,957 $55,179,906 $55,179,906

Total Expenses $56,950,688 $56,849,116 $57,690,150 $58,686,156

Surplus/Deficit from Operations ($223,779) ($1,643,159) ($2,510,244) ($3,506,250)

Amortization ($1,045,538) ($943,996) ($944,000) ($944,000)

Surplus/Deficit ($1,269,317) ($2,587,155) ($3,454,244) ($4,450,250)

Working Capital Deficit ($8,144,159) ($9,596,780) ($11,539,078) ($15,805,549)


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ORGANIZATIONAL FINDINGS &RECOMMENDATIONS

Organizational Culture

The culture at GBGH is a matter of great concern, and will significantly influence the ability of the hospitalto successfully address fiscal and quality concerns identified during this review. It is an unhealthy

environment driven by fear, intimidation, and a lack of respect.

The consultants heard and observed the following in interviews, focus groups and written submissions:

!The environment is disrespectful;

!There are frequent examples of vertical and horizontal bullying and intimidation;

!

Staff feel unsafe and unsupported when they bring up issues to colleagues and management;!There is tremendous fear of negative outcomes if one reports an incident.

"This has been exacerbated by the manner in which GBGH handled a recent event involving a traumaticpatient death that was widely reported in the press.

"Many staff and physicians expressed concern over the actions taken by the hospital, and the lack oftransparency;

!When incidents are reported they are not effectively dealt with;

!

Physicians and staff have given up filing incident reports, because nothing ever gets done;!Stress levels are high;

!The perception is that bad behaviours are allowed because there are no consequences of such; and

!When issues do arise, there is a run for the hills mentality that does not promote the objective, reasoneddiscussion as to what contributed to the situation, what could have mitigated the consequences, and whatsystems and processes need to be enhanced/changed/developed.


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In addition to these comments and observations, it is noted that GBGH scored poorly in the following areas

of the 2015 Safety Culture Survey completed for accreditation:

!Making a serious error may cause staff members to lose their jobs;

!

Staff feel like a failure when they make an error;!Lack of feedback about changes put in place based on incident reports;

!Fear that staff would face disciplinary action from management if they make a serious error; and

!Fear that making a serious error would limit career opportunities at GBGH.

The Safety Culture Survey, the interviews, focus groups and email submissions from staff all support the

conclusion that the organizational culture needs immediate and focused attention.


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RECOMMENDATIONS

Recommendation 1: GBGH should immediately reinvigorate the Code of Conduct.

The Board should assume a key role in this initiative.

Recommendation 2: All GBGH physicians should be required to sign the Code of Conduct as part of annual credentialing.

Recommendation 3: GBGH should consistently apply the expectations of the Code of Conduct to all staff and physicians.

Recommendation 4: GBGH should include staff satisfaction metrics into regular Balanced Scorecard reporting.

Recommendation 5: All GBGH position descriptions should include expectations with respect to employee and physician

roles to contribute to a positive work environment.

Recommendation 6: GBGH should establish a broad based Advisory Committee to oversee the promotion of a positive work

environment. This Committee should be accountable to the Board Quality & Safety Committee.

Recommendation 7: Appropriate whistle blower protection policies should be developed and implemented within 6

months.


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Governance

Strategy

A strategic plan and management system provides the foundation for continuous improvement and the basisfor the Boards monitoring of the organization, the CEO and Chief of Staff.

!The organization lacks a robust strategic plan and thus does not benefit from the use of a strategicmanagement system to plan and monitor operations.

!This gap leads to a lack of long-range direction and a focus on short-term pressures.

"While we understand the reasons for this, it has resulted in a level of oversight that appears to beoperational rather than governance oriented.

"The Finance and Audit Committee has been very focussed on monthly budget variance and not on thestrategic initiatives needed to return the hospital to fiscal stability.

!Strategy should drive everything from structure to performance management. Without clear strategy,organizations flounder and ultimately fail.

RECOMMENDATION

Recommendation 8: The Board should direct senior leadership to develop a new Strategic Plan for GBGH that is

comprehensive and includes Vision, Mission, Values, Strategic Directions, Tactics and Metrics.

It will be possible to build on some of the work completed to date with respect to Vision and Mission,

however there is a need to further focus on the strategic perspective. Examples from other smaller Ontario

hospitals that may be used as reference points include Arnprior Regional Hospital and Muskoka Algonquin

Health Care.


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Oversight

The Board and its Committees receive numerous statistical monitoring reports e.g. financial variance

reporting, scorecard etc. Board members are well versed in some of the detail of the statistical reporting

however the volume of reporting may make it hard for them to see the larger picture necessary to be

effective governors.

!Many of the indicators are not linked together.

!The Balanced Scorecard does not provide action plans with deliverables, specific tactics, due dates andaccountability.

A Board approved strategic plan with metrics embedded in the plan could serve as the basis for an effective

balanced scorecard, to strengthen governance oversight and allow for the elimination of some of the more

detailed reports.

The Board and Committees meet monthly with the exception of some of the summer months. This

frequency reflects the commitment of the Board members to the organization. A focus on the quality of

meetings over the quantity might be helpful. Too frequent meetings at the governance level can

unintentionally increase the Boards focus on operational matters.

!The high frequency of meetings may create an administrative burden for staff taking them away fromexecution of change and innovation.


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RECOMMENDATIONS

Recommendation 9: The Board should direct senior leadership to develop a new balanced scorecard at the governance level

that will serve as the foundation for reporting across the organization.

A robust scorecard should be informed by departmental report cards that are oriented to related indicators.

Recommendation 10: A consistent approach for reporting to the Board on tactics identified in the strategic plan should be

developed and implemented.

Recommendation 11: The Board should review best practices with respect to meeting processes. Specifically, the frequency

of meetings and how material is reviewed at the Board level should be examined, and necessary changes implemented.

Recommendation 12: The Board should consider engaging a Coach to provide mentorship and support through the

implementation of the recommendations in this report.

A Coach could also assist the Board in the initial evaluation of the effectiveness of the implementation plan

and process.


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CEO/COS Evaluation and Relationship to Board

There is a perception that there are specific quantitative measures that are used to evaluate the performance

of the CEO and Chief of Staff. However, it was unclear to the consultants as to what goals and performance

metrics were used to evaluate these two direct reports to the Board.

!It was also acknowledged in some interviews that the relationship between the COS and the Board was illdefined, and lacked clarity.

The Board plays a key role in supporting the Chief of Staff in all matters, particularly when it comes to

difficult issues related to physician discipline. At GBGH, when performance issues have arisen with

physicians, these matters have been discussed at MAC, where it may be difficult for a large group of

colleagues to understand the need for tough but necessary actions.

!

The hospital has been largely unable to deal with chronic bad behaviours on the part of a few physicians.

RECOMMENDATIONS

Recommendation 13: The Board should link the evaluation of CEO and COS performance to the key strategic directions,

tactics and metrics identified in the strategic plan discussed in Recommendation 8.

Recommendation 14: The Board should define its expectations of the Chief of Staff with greater clarity, particularly in respect

to the quality of medical care.

The Board should assert that where there are issues of substandard care and/or disregard for the General

Rules and Regulations for GBGH physicians, there must be a clear and timely plan of action to address

such.

The Board should also ensure that linkages are clear between the Balanced Scorecard and the Quality Plan.


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Quality

The quality focus expected of governance appears to be muted due in part to the lack of strategy but also the

obsession with financial issues. Key findings include:

!

When trustees were asked in interviews how they would briefly explain that quality was good at GBGHthe answers were more descriptive and not grounded in measurable statistical performance;

!Financial and quality elements are almost disembodied, rather than being strategically linked at everylevel of the organization, but particularly at the Board;

!It is concerning that the Board appears to have not been made aware of critical incidents involvingsignificant negative consequences to patients; and

!Formal reporting of critical incidents is not pursued because those that take the time to report theincidents never hear back.


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RECOMMENDATIONS

Recommendation 15: Critical incidents leading to death or harm need to be reported to the Board and Quality & Safety

Committee in a timely fashion.

A protocol that documents the timing of the escalation of reporting should be developed so as todemonstrate the timely reporting of serious incidents.

Recommendation 16: The Board should direct staff to develop a quarterly written critical incident report for review at the

Quality & Safety Committee that identifies incidents, key investigative findings, improvement actions, target dates and

accountability.

!

The current status of improvement actions should be categorized using a red/yellow/green or similar typesystem. At a minimum, this report must include incidents leading to death or harm.

!Less severe incidents should also be reported to the Committee although the frequency could be twice peryear rather than quarterly.

Recommendation 17: The revised balanced scorecard that builds upon a new strategic plan needs to include quality metrics,

and those metrics should be included in the evaluation of the CEO and Chief of Staff.

It is recognized that, during the operational review, GBGH developed specific timelines that support more

effective monitoring of key quality metrics.

Recommendation 18: Develop a Board education plan that includes a Board education session related to quality at the

majority of Board meetings.


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Recommendation 19: The Board should include a patient story at each meeting of the Quality & Safety Committee.

!These stories can be found by looking at data such as patient complaints and compliments.

!After presenting a patient story, management can then present to the committee improvement initiatives

that have been started as a result of the story.It is recognized that this has recently become a standing item on the agenda of the Quality & Safety

Committee.

Recommendation 20: Create a joint medical/management committee focused on quality and safety as the operational

counterpart to the Board Quality & Safety Committee.

This Committee should be co-chaired by the CEO and the Chief of Staff.

Recommendation 21: The Board should revise and strengthen the terms of reference for the MAC to ensure the appropriatefocus on medical quality and credentialing issues.

Further elaboration on the appropriate focus of the MAC is provided in the later discussion pertaining to

Medical Staff.


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Financial Oversight

The Board of an organization sets the tone for the rest of the organization in terms of fiscal responsibility.

!A culture of accepting deficits and working fund pressures appears to have developed;

!

There appears to have been little discussion at a governance level about what a balanced budget scenariomight look like for the organization;

!In addition, there does not appear to be regular Board level reporting and discussion of the status of theHospital Improvement Plan as a package;

!The Board has endorsed program decisions when the financial analysis prepared by staff suggests thatthere will be a funding shortfall;

!While the Board has been focused on detailed variance reporting, this has not filtered to the rest of the

organization; and!Budget overages and deficits are generally not well understood.

RECOMMENDATIONS

Recommendation 22: The Board should direct GBGH staff to move towards a revenue-based approach to budgeting.

!The Board should also define major budget assumptions such as:

"

No deficit,"No erosion of volumes or quality etc.

!Revenue based budgeting starts by estimating how much revenue the organization is likely to receive anduses this as the basis for budgeting in each department/program.

"The department/program leaders are challenged to develop a plan that will fit within their revenueenvelope while maintaining volumes and maintaining or improving quality.


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"This approach tends to encourage creative re-designs of workflow, staffing and reduction in no-valueadd steps and practices. It also helps to clarify the organizations overall direction that operating at adeficit is not an option.

!It is recognized that current GBGH managers and systems may not be ready for this method of budgeting.

The goal should be to develop GBGH management skills and competency in budgeting to supportrevenue based budgeting.

Recommendation 23: The Board should only accept and/or approve proposals when there is a credible financial plan

showing sources of necessary funds.

Recommendation 24: The Board should also develop a policy requiring that proposals will only be considered when a robust

sustainability plan is included.

Collaboration and Partnerships

The Board has not assumed a proactive governance role in appropriately positioning the hospital to meet the

needs of the population it serves within the direction set by the LHIN.

!There is a strong anti-RVHC view among many at all levels within the hospital and among communitypartners. Perception of those interviewed is that GBGH has tried to collaborate but that others do not.

There are limited regional Board-to-Board discussions except at events planned by the LHIN.!GBGH local partners do not view the hospital to be effective communicators, despite the fact that efforts

have been made to establish a GBGH Community Health Care Partners Forum that meets on a semi-quarterly basis. There is a need to better define the role and objectives of this group in order for it to besuccessful.

!Effective collaboration with partners is key to improving system integration. This is especially importantfor smaller hospitals.


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RECOMMENDATIONS

Recommendation 25: The Board should increase the amount of time it dedicates to relationship building.

A reduction in Board and Committee meetings would allow for an increase of attention to this activity.

Recommendation 26: The Board should regularly consider Collaboration and Partnership as a potential tactic to achieve

strategic directions.

Recommendation 27: Terms of Reference for The GBGH Community Health Care Partners Forum should be developed.

Management and Leadership

Structure and Accountability

The organizational structure does not enable clear lines of accountability or promote effective decision-

making. In the interview process it was revealed that there was confusion as to who was ultimately

accountable for the successful achievement of savings targets.

For example, with respect to the outpatient lab closure, the accountability for achieving savings targets was

not clear:

!The savings targets were identified by the Director of Human Resources;

!The CFO is accountable for the successful achievement of the savings target; yet

!Laboratory operations report to the Clinical VP;

!The supervisor was not sure there would be any savings, perhaps a reduction in part time staff; and

!Concern was expressed that savings projections were unrealistic.


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Organization structure must follow strategy with expectations and accountability being very clear. Within

GBGH, the current management model is siloed with respect to budget allocations and operational

oversight. It is understood that the current organizational structure has been shaped by the impact of staff

leaving the organization, and others filling in for short, medium and longer terms.

Physician leaders are not effectively integrated into the organization chart. Programmatic approaches to

organizational design have been commonplace in Ontario hospitals for some time. Although harder to

develop in a smaller rural hospital, this approach to design is crucial to ensure continuous quality

improvement and fiscal responsibility in times of major change. The collaboration of medical and

administrative leaders results in more effective decision-making and an increased likelihood that clinical

quality and efficiency are enhanced.

It also appears that there are numerous committees that require a significant amount of time on the part of

Managers, Directors, Senior Leaders, and clerical support.


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RECOMMENDATIONS

Recommendation 28: The CEO should lead an organizational re-design process to develop a new structure that will better

enable strategy, integrate physician leadership into the design, and ensure greater clarity with respect to accountability and

reporting.

Recommendation 29: The organizational redesign should seek to reduce the number of internal committees and streamline

the terms of reference to minimize duplication of work effort.

Recommendation 30: The new organizational structure should enhance the accountabilities of the two Vice Presidents in

their respective areas to include all aspects of the departments that report to them quality, financial, strategic, operational,

etc.

Recommendation 31: Key corporate departments such as Finance, Decision Support and Human Resources should play asupporting role to all clinical and clinical support departments and programs.

Recommendation 32: The new organizational structure should promote, where possible, a management diad in which

physicians and administrators jointly oversee the operational and financial performance of clinical programs.


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Leadership Development

In challenging times leadership skill at all levels is crucial for success. There is a perception that there are

few resources for leadership skill development as reflected in the Work Life Pulse survey results.

!

Onboarding of new leaders does not come with a bundle of education and skill development nor are thereongoing programs that cover all levels of management to enhance skills. Onboarding is the process bywhich new hires learn the social and performance aspects of their jobs quickly and smoothly, and learnthe attitudes, knowledge, skills, and behaviours required to function effectively within an organization.

!

There is a need to invest in skills development for leaders at all levels in the organization. In manyinterviews, it was apparent that Managers and Directors did not fully recognize their roles andresponsibilities.

RECOMMENDATION

Recommendation 33: A leadership development plan for administrative leaders should be developed focusing on the skills

required to lead and manage in todays ever changing environment.

!This should include topics such as:

"Financial management;

"Quality measurement;

"

Performance management;"Emotional intelligence;

"Lean principles; and

"Incident investigation and review.

!Other hospitals may be interested in sharing their programs that would reduce cost. $200,000 of one-timemonies has been allocated to this recommendation.


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Staff Engagement

The 2015 Workplace Pulse survey and the Safety Culture surveys suggest there is ample room to improve

workplace engagement. GBGH received a poor rating in the following categories:

!

Opportunities to develop my career;!Senior managers effectively communicate the organizations goals;

!Senior managers are committed to providing high quality care;

!Senior managers act on staff feedback; and

!Overall rating of the organization as a place to work.

Workforce engagement is a necessary prerequisite for the development of a culture focussed on continuous

improvement and value. Some committee work has started in response to the Workplace Pulse.

The organization has used different staff engagement instruments over the years with the most recent survey

being the Workplace Pulse survey in advance of accreditation. There needs to be more frequent staff

engagement surveying using a consistent tool so that interventions can be implemented and then measured

to ensure progress towards a stronger organizational culture.

RECOMMENDATION

Recommendation 34: Senior leadership should identify a staff engagement survey instrument to be administered to a

sample of staff on at least a biannual basis.

!The GBGH workforce can be stratified for survey distribution so that each employee receives one surveyannually.

!Staff satisfaction scores derived from this instrument should be part of the balanced scorecard.


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Financial Management

!A traditional budgeting approach is used driven by the Finance Department. This process uses theprevious years spend as the basis for developing the next years budget. The challenge with thistraditional approach is that:

"

It usually results in a budget that is additive, that is, last years spend is increased by inflation and otherpressures but fundamental process transformation does not get identified through the budget process.

"The budget process becomes a series of back and forth discussions to pare down the large shortfall thatappears after the first phase of the budget process.

!

Budget and planning assumptions appear to have been overly optimistic leading to added pressures whencosts emerge as higher or revenues less than expected. Pubic organizations like hospitals should budgetin a cautious way in terms of assumptions.

!The finance department appears to be strong in terms of reporting and support for managers. However, italso appears that:

"There is an over-dependence of managers on Finance and Decision Support;

"There is a need for greater engagement of front line leadership and physician leaders in the budgetprocess; and

"There is variability in the level of financial management knowledge and a lack of ongoing leadershipdevelopment in this area for leaders, both administrative and medical.

!Regular annual benchmarking does not appear to be part of the budgeting process.

"

A detailed annual benchmarking study in advance of the budget process is an important tool in order toidentify opportunities for fiscal improvement.

"In todays funding environment, it is crucial that organizations see their financial performance in termsof the rest of the industry as improving faster than ones peers is the only way to improve positioningunder the new formulaic funding system.

"It is recognized that GBGH has begun incorporating benchmarking data. The challenge now is toeffectively utilize the data they are collecting to improve program and departmental performance.


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!A robust standardized business case process does not appear to be in place in terms of major changesincluding program changes and physician impact analysis.

RECOMMENDATIONS

Recommendation 35: GBGH leadership should develop further skill and competency in financial management.

Recommendation 36: GBGH should continue to incorporate annual benchmarking as part of the financial management

process.

Recommendation 37: The Finance Department should introduce a business case standard template for all major financial

decisions including program changes, capital requests and physician impact analysis with a sign-off protocol.


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Medical Staff

Physician leaders want to do right by the community and expressed a desire to maintain services for the

community. The majority of physicians expressed and demonstrated a willingness to participate in

improvements that may be required.

Structure

The medical structure has a large number of small departments. There are opportunities to streamline the

structure. The consultants met with 8 internal Chiefs. The hospital also engages a Chief of Dentistry. For a

hospital the size of GBGH, this seems excessive. As well, GBGH remunerates external Chiefs for

Radiology and Laboratory as part of established agreements with RVH and Georgian Radiology.

!

The majority of the Chiefs did not fully appreciate their roles with respect to credentialing and overseeingquality of care in their respective divisions. One Chief acknowledged that they did not know what theirdivisional colleagues did. In general, they viewed their role to be doing the call schedule and firefighting issues when necessary.

!The selection process for Department Chiefs does not appear to be competency based. A number ofmedical Chiefs indicated they got the role as it was their turn or no one else stepped up etc.

!There are no limits on Chief tenure.

!Stipends for Chiefs are relatively small for some chiefs ($5,000 per annum) and may need to be increasedif the expectations and/or the scope of the roles are enhanced.

!Chiefs and MAC do not appear to be actively involved in the Business decision making of the hospitalsuch as the budgeting process.

!There is lack of clarity around the Chief of Staff role. While he fully understands his role to monitormatters such as chart completion, he acknowledges that improvement is required with respect to hisrelationship with the Board, and around credentialing.


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!The efficacy of the MAC is questionable, and as with the Board, this group tends to focus on details asopposed to overall quality of medical care within GBGH.

RECOMMENDATIONS

Recommendation 38: Restructure the number of Chiefs to 4

!Emergency;

!Medicine, including: Internal Medicine, Hospitalist Care, and Family Medicine;

!Surgery, including: Surgical Services, Anaesthesia, and Ambulatory Care; and

!Non-Acute Care including: Rehabilitation, Complex Continuing Care, and Palliative Care.

In order to address the concern that a reduced number of Chiefs will limit the opportunities for input fromsome sub specialties or groups, the Chiefs may wish to establish Sub Committees for physicians with

specific interests in their clinical areas.

Recommendation 39: Revise and/or develop position description for Departmental Chiefs to enhance the focus on quality of

medical care, as well as increased responsibility for the administrative and operational aspects of their respective clinical

areas.

The need for additional input from physicians will be a critical success factor to the successful

implementation of the recommendations in this report.

Recommendation 40: Increase the stipend paid to Chiefs and define the time to be dedicated to this role (.5 days/week).

The reduced number of chiefs will provide more funding to support each of the Chiefs. Additional

investment in physician leadership remuneration has been added to the recovery plan to increase the pool of

funds available for medical leadership stipends.


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Recommendation 41: Revise and strengthen the role of the Chief of Staff to increase his/her role to oversee the quality of

medical care.

The goal should be to ensure 1 day/week dedicated to this function. However, in the immediate short term,

2 days/week may be required to deal with some of the complex behavioural/discipline issues that are

currently influencing the culture and operations at GBGH.

Recommendation 42: Consider the possibility of providing the Chief of Staff with a mentor/coach for a 6-month period.

An existing Chief of Staff or Vice President, Medical Staff may be interested in providing this support.

Recommendation 43: Invigorate the MAC with the goal of increasing focus on quality and accountability for all medical staff

at GBGH.

Terms of reference should be revised to reflect this necessary change. The hospital should also considerengaging legal counsel to attend an MAC meeting on an annual basis to increase the level of awareness

regarding the MACs fiduciary responsibility.

Recommendation 44: The Board Chair or Vice Chair should attend MAC meetings on a regular basis.


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Leadership Development

In hospitals, Department Chiefs have important roles related to medical quality and safety, complaint

resolution, program planning etc. It is important that organizations offer opportunities for medical leaders to

advance their knowledge and skills in these areas to ensure their effectiveness.

!GBGH medical leaders receive no training for their roles.

!There does not appear to be any sort of formal succession planning process for medical leaders includingthe Chiefs of Departments and the Chief of Staff.

RECOMMENDATIONS

Recommendation 45: Consider developing an in house medical leader boot camp program to become a regular item on

the MAC agenda.

Topics covered at these sessions could include

!Dealing with Patient Complaints,

!Current Health Policy Directions in Ontario,

!Quality/Safety investigations, and

!Budgeting.

Recommendation 46: Integrate selected medical leadership development sessions with Administrative Leadership to

facilitate team development.

Learning is a powerful tool to develop a sense of team.


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Quality of Medical Care

There is a noticeable divide between the physicians who have served GBGH for a long time and those who

are more junior. While the contributions of some physicians are undoubtedly valued, the days of being on

call 365 days/52 weeks are over.

Some physicians have clearly rejected hospital policies and, according to some allegations, have even

sabotaged efforts by the hospital to hire new physicians in some areas. There is limited evidence that

physicians are held accountable for their behaviour and performance.

!It was widely reported to the consultants that one GBGH physician will frequently ask staff not to call inoff-hours, despite the fact this physician is on call. According to staff in multiple interviews and focusgroups, this request is made approximately 30% of the time that this physician is on call. As a result, staffresorts to calling on physicians in the ED or other GBGH physicians who are not on call. This places

considerable stress on GBGH nurses, and puts patients at significant risk.

RECOMMENDATIONS

Recommendation 47: The Board must play a strong role in providing the necessary support to the Chief of Staff and the

senior leadership of GBGH to ensure that unacceptable behaviours are not tolerated.

Incidents in which patient and/or staff safety is placed at risk must be dealt with in a swift and timely

fashion according to the appropriate protocols and rules. Repeated violations of health system and hospitalpolicies cannot be tolerated.


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The Hospitalist Model

The hospitalists play a vital role in the provision of medical care at GBGH. They are a committed group of

physicians who support a significant number of admitted inpatients in acute and non-acute beds. In general,

hospitalists work in pairs, one acting as an admissionist and the other following inpatients.

!GBGH pays for two hospitalists per day although there are several on the roster who all rotate throughthis A/B arrangement.

!In the A/B rotation, Hospitalist A would do the HOCC on-call coverage from 5pm-7am and is covered byspecial funding for HOCC. S/he would then transition to Hospitalist B the next day and continue tofollow patients and be paid out of the hospitals base budget for that day.

!At the end of each day, care is transitioned to the next hospitalist assigned to the A role.

!Both the A&B roles also bill fee for service.

!GBGH does not have written contracts that outline specific requirements and roles and responsibilitieswith its hospitalists.

Hospitalist practices can negatively impact departmental efficiency. Currently, hospitalists will frequently

write orders late in the evening which significantly increases the workload for nursing staff at times when

staffing levels are reduced, ward clerks are not on staff to transcribe orders, and support services such as

pharmacy, laboratory or DI are either closed or staffed at minimal levels.

Recommendation 48: GBGH should develop written contractual agreements with the hospitalists that outline theexpectations and roles and responsibilities for both parties.

Recommendation 49: In order to be competitive in the market, GBGH should explore the opportunity to enhance hospitalist

remuneration and review alternative compensation models that are team based.

The proposed improvement plan has allocated funds to support this recommendation.


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Physician engagement with primary care

GBGH physicians are not as engaged as they could be with primary care physicians in the community or on

LHIN planning efforts.

Recommendation 50: GBGH should make efforts to enhance communication with local primary care physicians, and shouldincrease the degree of involvement in LHIN planning and with other potential partners in the region.


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Geyer & Associates Inc.33

CORPORATE SERVICES FINDINGS AND RECOMMENDATIONS

GBGH Overhead Expenditures

Net overhead costs were $14.1 million in 2014/15, approximately 37.3% of direct patient care net expenses.

!

GBGH overhead per patient care net expense is 1.9% higher than similarly sized hospitals in Ontario.

!This small difference amounts to approximately $300K and is easily accounted for by the currentoperation of two sites.

Figure 4: OCDM Overhead Expenditure Trends

Fiscal YearOverhead per Direct Care Net Expense

GBGH COHORT GBGH RELATIVE

2010-2011 37.1% 36.1% 102.6%

2011-2012 39.1% 36.8% 106.3%

2012-2013 36.1% 36.0% 100.3%

2013-2014 37.2% 36.6% 101.6%

2014-2015 37.3% 36.6% 101.9%

The three major components of overhead (Education, Undistributed and Administration and Support

Services) are all slightly higher on this metric than comparably sized organizations. Per patient care dollar,

administration and support net expenses are only 0.7% higher than similarly sized organizations.


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Figure 5: Components of Overhead at GBGH

Fiscal Year

Education Per

Direct Care Net Expense

Undistributed Per


Administration & Support Per


GBGH COHORT GBGHRELATIVE



2010-2011 1.2% 0.6% 180.0% 1.3% 0.8% 167.9% 34.6% 34.7% 99.7%

2011-2012 0.9% 0.6% 144.6% 1.3% 1.0% 126.0% 36.9% 35.1% 105.0%

2012-2013 0.8% 0.6% 133.5% 1.0% 1.1% 84.7% 34.3% 34.3% 100.2%

2013-2014 0.8% 0.7% 106.6% 0.9% 1.2% 78.4% 35.5% 34.6% 102.6%

2014-2015 0.7% 0.6% 116.5% 1.0% 0.7% 152.3% 35.6% 35.3% 100.7%


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Corporate Departments

Food Services and Nutrition

Food services were outsourced to Aramark in 2013. Savings, identified in the prior operational

review for FY12/13, were not achieved by $286K. Savings for FY 13/14 and FY 14/15 were

achieved and surpassed the original estimated savings by $675K. Part of this is due to a reduction in

patient food services expenditures resulting from the closure of CCC beds. Aramark is continuing to

look for efficiencies and is currently assessing measurement of food wastage.

RECOMMENDATIONS

Recommendation 51: It is recommended that a formal tracking program be implemented to ensure costs related to food

wastage are captured accurately and are captured accurately in the cost per patient day.

Recommendation 52: Target further savings related to food wastage of $20K.

Cafeteria

The prior operational review had recommended reviewing the on-going operations of the cafeteria.

There has been an improvement in the deficit position of the cafeteria but the cafeteria continues to

operate in a deficit position.

Recommendation 53: Close the cafeteria.

GBGH should continue to provide a location for employees to eat during breaks but should explore

alternative models including, for example, vending machines and/or delivery from local restaurants that are

within walking distance.


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Figure 6: Cafeteria Financial Performance

RECOVERIES

AND EXPENSES

A

CTUAL

A

CTUAL

A

CTUAL

A

CTUAL

P

RO

-

RATE

2011/2012 2012/2013 2013/2014 2014/2015 2015/2016

Recoveries

Cafeteria $117,455 $88,901 $62,538 $47,528 $45,615

Meals on Wheels $21,008 $34,529 $34,051 $33,078 $44,727

Total Recoveries $138,463 $123,430 $96,589 $80,606 $90,342

Expenses

Catering Expenses $44,257 $53,729 $35,972 $34,427 $31,236

Food Costs** $69,232 $61,715 $48,295 $40,303 $45,171

Salaries $82,581 $88,544 $81,429 $69,093 $33,224

Benefits $23,789 $46,046 $20,769 $8,631 $8,170

Depreciation Expense $3,629 $5,815 $6,079 $6,195 $7,389Total Expenses $(223,487) $(255,849) $(192,543) $(158,649) $(125,189)

Surplus/(Deficit) $(85,024) $(132,419) $(95,954) $(78,043) $(34,847)


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Laundry and Linen

Laundry and Linen has been outsourced since the last operational review.

!Revenues have decreased significantly from FY 12/13.

!

Actual revenues in FY 12/13 were $161K and projected FY 15/16 is less than $1K. This is due to thelaundry services being discontinued for Waypoint.

!Expenses for the same time period have also reduced. Total expenses for FY 12/13 before utility costswere $667K and projected FY15/16 are $526K.

Figure 7: Laundry and Linen Financial Results

RECOVERIES AND EXPENSES ACTUAL ACTUAL ACTUAL ACTUAL PRO-RATED

2011/2012 2012/2013 2013/2014 2014/2015 2015/2016

Recoveries $4,693 $161,204 $6,589 $1,058 $1,059

Salaries $289,065 $167,337 $80,605 $81,077 $86,856

Benefits $124,902 $80,166 $32,832 $32,949 $27,246

Supplies $85,299 $132,959 $2,402 $1,552 $1,569

Equipment Maintenance $8,249 $58,072 $(24,100) $ - $2,397

Referred-Out Expense $ - $261,035 $469,733 $422,029 $407,655

Depreciation Expense $16,045 $19,593 $3,373 $1,253 $1,254

Total - Without Utilities $523,560 $719,162 $564,845 $538,860 $526,977Utilities Allocation $177,429 $182,752 $188,234 $193,881 $199,698

Total Expenses - With Utilities $700,989 $901,914 $753,079 $732,741 $726,675

TOTAL Surplus/(Deficit) $(696,296) $(740,710) $(746,490) $(731,683) $(725,616)


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Security

It had been identified in a prior operational review that there had been an increased pressure on security

services due to the increased patients sent from Waypoint. There were 5.96 FTEs in security. It has been

further identified that pressure from Central North Corrections Centre on security services has resulted in an

increase in staffing. FY 15/16 there are 6.87 FTEs for a total salary and benefit cost of $426K.

Figure 8: Security Expenditures

RECOVERIES AND EXPENSES ACTUAL ACTUAL ACTUAL PRO -RATE

2012/2013 2013/2014 2014/2015 2015/2016

Recoveries $0 $0 $0 $0

Salaries $421,256 $426,763 $438,665 $454,801

Benefits $121,309 $129,632 $139,992 $131,273Supplies & Sundry $16,186 $8,965 $13,993 $30,253

Equip't Maint $- $100 $3,601 $-

Total Expenses $(558,750) $(565,460) $(596,250) $(616,327)

Surplus/(Deficit) $(558,750) $(565,460) $(596,250) $(616,327)

RECOMMENDATION

Recommendation 54: GBGH to explore a shared service agreement with Central North Corrections Centre, and recover costsfor security services that are directly related to the clients of this facility.

The hospital should target $75K to $125K.


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Facilities

Housekeeping and Facilities staff supports both the Midland and Penetang sites. Increased salary and

supply costs due to the Penetang site have resulted in higher indirect costs for GBGH. GBGH has had

to carry these additional expenses in their budget and current run rate until a decision is made in

relation to the future of the Penetang site.

The cost projection related to indirect costs at the Penetang site is $459K as detailed below in Figure 9.

Figure 9: Pentetanguishene Site Costs

D

ESCRIPTION

Q

UANTITY

Salaries $132,103

Benefits $45,150

Total Salaries & Benefits $177,253Supplies $13,749Utilities $183,788Insurance, Fees and Service Contracts $7,140

Equipment maintenance $76,243

Total Supplies & Sundry $280,920Depreciation - Major Equipment $1,672

Total Expense $459,845

RECOMMENDATIONS

Recommendation 55: GBGH should aim to close the Penetang Site by 2016/17.

Recommendation 56: GBGH should not be the landlord of the proposed health hub at the Penetang Site.

Recommendation 57: GBGH should aim to sell or lease-to-own the building.


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Energy Retrofit Initiative

GBGH embarked on an energy retrofit project and the retrofits were fully completed and operational as of

August 2013. The project had a payback of 10 years and total savings were estimated at $362K per year

(over the 2010 base costs). Total actual annual savings have been $286K, $76K unfavorable as compared

to the original estimate.

Financial Practices - Budgeting Tools

The current budgeting tool needs to be upgraded for additional functionality and efficiency.

RECOMMENDATION

Recommendation 59: Current budget tool (BUDMAN) should be upgraded to the most recent version and the Executive

Support Manager (ESM) tool be purchased and implemented.

An ESM tool will integrate the following internal reporting tools and modules:

!General Ledger

!Payroll

!Human Resources

!Accounts Receivable and Accounts Payable

!

Materiel Management!Budgeting

!Statistics

Additionally, ESM has the ability to create Key Performance Indicators and Program Scorecards, enabling

managers to link financial and clinical data, and measure outcomes on a monthly basis. ESM tool costs to

GBGH are approximately $65K.


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Financial Practices - Approval of Expenditures Outside of the Budget

There is not a clear process for the approval of operational expenditures that are not part of an approved

budget. It was noted that:

!

The CEO presents expenses outside of the final budget to the Finance and Audit Committee for approval.A formal approval framework needs to be established within the management structure for any additionalproposed investments or resources.

!There was not an approved signing authority matrix used consistently across the organization for theapproval of expenditures and purchase requisitions. Procurement is not clear on the established signingauthority and delegation policy, and ensuring that all purchase requisitions are approved by theappropriate signing authority for the respective department.

It is acknowledged that, during the course of this review:

!The Board approved the delegation and schedule of authority policy and matrix October 22, 2015.

!An education session was planned for the November Management and Quality meeting as part of the roleout of this policy.

!Shared Services West will be using this matrix in their processes and implementing with eS

report from gbgh operational review

Documents