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LEADING

FOR PATIENTS

Community Agencies Roundtable: Joint Friends Meeting

Community Agencies Roundtable: Joint Friends Meeting
November 19, 2013
6:30 pm to 8:00 pm
TSH Birchmount Site
Facilitators:
Robert Biron, President and CEO, The Scarborough Hospital (TSH)
Dr. Romas Stas, Associate Chief of Staff, Rouge Valley Health System (RVHS)
Staff: David Brazeau, Holly‐Ann Campbell

10 community members present from the Friends of The Scarborough Hospital and the Friends of Ajax
and Pickering Hospital
Themes
Benefits

  • Improved facility services
  • Consolidation of administration function
  • Purchasing power
  • Attraction of more specialist physicians
  • Repatriation of patients
  • Potential funding increases
  • Centres of excellence/regional services

Risks

  • Continued financial pressure (re: debt)
  • New Board not upholding commitments
  • Current lack of vision for merged hospital
  • Selection of strong leadership for governance and CEO

Presentation

A presentation slide deck was distributed to the participants. The presentation was the same one presented to the TSH Board of Directors at their open public meeting on November 12, 2013. The meeting started with Robert Biron presenting the information. The presentation summarized the content of the Preferred Integration Report, including the current environment, short and long‐term benefits of the merger, the value proposition, anticipated timelines, and the hospitals’ Boards resolution. The meeting was then opened for discussion, questions and answers.

Slide 11:

Community Participant:

What are chances of the new Board saying that TSH Birchmount facility is so behind in terms of upgrades, why don’t we shut it down and spend the money on the other hospital sites instead?

Facilitator:

I don’t think that’s a risk. Looking at the population served in northern Scarborough, there’s a high reliance by the immediate community on this facility. You can’t pick up and close a hospital like that. The Emergency Department is a good example, as the capacity in other facilities is not adequate to deal with the additional volume. My take on the Scarborough community in particular, is that the leadership has been divided, including the Board, and this poor integration has impaired the Scarborough community for positioning itself for operating dollars and capital investments. How do you reposition these communities to get their fair share for both capital and operating dollars? The first step is to create a single accountability structure to develop one strategic plan, one voice that will advocate for our communities.

Facilitator 2

No one hospital campus could take the patient volumes of another hospital campus if one were close. We just don’t have the capacity in other facilities. Demand in terms of patient demand and population growth is taking off.

Slide 16:

Community Participant

Which three years are being identified up there?

Facilitator

This would be the immediate three years; establishing the corporation during the “Implementation Phase.” It takes time to establish a merged organization. The initial work will be focused on the integration of back‐office / administrative functions such as information technology, finance, payroll, etc.

Community Participant

In the motion itself, were you speaking about Durham growth, why would that not be included in the feasibility study?

Facilitator

It most certainly is. The motions from both hospital Boards include a request for a capital planning grants (planning, feasibility, design) for each community – one for west Durham, and one for Scarborough.

Facilitator

We recognize that in the Scarborough cluster there is an issue of aging facilities. In west Durham there is an issue of capacity to adequately serve the growing community. The two projects being requested are for each of the communities.

Community Participant

Is the motion presented different from RVHS?

Facilitator

The motions are exactly the same.

Community Participant

In 2008, there was money borrowed based on a commitment by the fundraising group [TSH Foundation] that fell through. So TSH is still carrying that debt. There was a huge failure to deliver on the part of the fundraising group. Interest on that is pretty low.

Facilitator

Yes, TSH is still carrying that debt. The request for financial support does not address past issues.

Community Participant

This will continue to be part of the problem

Facilitator

There is existing funding program from the province to help hospitals address their negative working capital. The program helps reduce short‐term debt, but the hospital must provide a contributing share. Both hospitals have been unable to participate due to the need to invest in our aging facilities and equipment. Merger does not relieve us of our collective debt load.

Community Participant

How do you address that issue?

Facilitator

Pay it off as you usually do, as part of your operating plan and budget. The operating challenges that the hospital currently have don’t go away should we proceed with a merger. However, we believe we will have more options in finding solutions by coming together.

Community Participant

We have four hospitals, three of which are in sad state of repair, two with high debt ratio. I guess what prompts my concern is how did we get to that state?

Facilitator

Some hospitals have been well managed, and others historically have not. This is also related to how successful the hospital has been in negotiating for funding, long‐term positioning, socio‐economic factors, those kinds of factors.

Community Participant

There should be a way to transfer funding from richer communities to poorer. It is not our fault the demographics have changed over the 40 years.

Facilitator

We should see improvements in the years ahead, but it will take time. This relates to patient‐based funding. Hospitals that get the activity (volume of patients), will get the funding. This goes back to how we strategically position ourselves as a group of hospitals. Right now we serve the same community, but are competing against ourselves for those dollars. By merging, our hospitals will be better positioned to create joint strategies to repatriate patients that live in our communities. The new funding formula creates a level of competition, and by combining we are in a much better position to gain our equitable share. Some opportunities we envision in that report reflect that both hospitals are much stronger to do that together than separate.

Facilitator 2

We’ve talked about risks. Do you see any potential benefits in the merger?

Community Participant

Reducing duplication of back‐office functions, administrative staff, that kind of thing.

Community Participant 2

Purchasing power.

Community Participant 3

When I looked at the report appendices for infrastructure and study what was done on that and the financial section, I couldn’t find any comparative information related to mergers in the province of Ontario and what the global benefits were from them that this study group/task group could say to this organization. “If you do this, this is what you might be able to expect”. The templates being used were extracted from the UK, where they had, by far, millions of square feet than any organization offering health care services. What I was looking to see was if there was something closer to home. Sudbury is a classic example, as is Wellington County, Cornwall. Where is that information that informs us?

Facilitator

We know that there are some mergers that have been handled very well, and others that have been lessthan ideal. Those risks and benefits are identified throughout the report. No one said there wouldn’t be any risks. There is also a risk of not doing anything. On the facilities piece, the whole purpose of planning grants is to do a deep dive as it relates to facilities, capacities, design, among other things. Until we have one master plan and one voice, it is difficult to get government to invest in large‐scale changes to our infrastructure.

Facilitator 2

We can also attract a lot more physician specialists with a merged corporation. This appeals to doctors as there would be a lot more practice for them, a lot more service for them to provide. A merged hospital presents some opportunities to doctors and can bring more services to patients.

Community Participant

People want something more concrete; they want a more concrete vision of what the whole process is going to look like, what it will look like after the merger. The feasibility study and planning is something that could actually start to occur if you got funding from government. One way to get funding to government is to lobby your MPPs. Gives people a much better idea of what you’re getting into. If feasibility study could be done in 6‐9 months; could be done before final merger takes place.

Facilitator

Look at the Windsor example. Two hospitals, separately governed, the hospitals were similar to us, they didn’t collaborate, and government said “we are not investing in your capital infrastructure until you get your governance in order and programs and services in order”. We have to get to a single accountability structure to put that level of detail planning in place. It is a significant feasibility review with extensive consultation about how we renew the facilities to meet needs of community. This is a significant undertaking that cannot be done under two separate authority structures. In order for us to get to a better place for both communities, those planning grants are needed to successfully achieve the longerterm value proposition contemplated in the report. The community also has reassurance therefore that this is going to be a strategic priority for the new organization moving forward.

Community Participant

I’m looking at the resolution – seems we can’t move forward without x million dollars. I have a concern that we don’t get any money from LHIN and are still forced to move ahead.

Facilitator

At the end of the day this is not a forced merger, even though we were directed by the LHIN through a facilitated integration. We do believe there are clear benefits of a merger, particularly in the longerterm. Mergers take time and money, and we need financial support to be successful. We don’t know what LHIN and Ministry response will be, and we have put forward the best case, and if we get partial response the Boards are going to reconvene and reconsider if it’s still right to move forward. We are asking to be reimbursed for the study they asked us to do, as well as additional costs. The primary reasons for the merger are not financial; instead, it is strategic positioning the hospitals to better serve our communities and providing better access and scope of services. For example, we can work better together to take advantage of the new funding formula. At this point in time, the Boards have not deliberated the “what‐ifs” should the financial support not materialize. We hope you can trust your Boards that they will check‐in and do the due diligence. The Boards may decide it’s not worth pursuing based on decision of the LHIN.

Community Participant

I’m interested in patient‐based funding based on patients staying in catchment areas for their services. However, patients go to where they think the best specialists are. You mentioned as a larger corporation we are going to be able to attract physicians, specialists, etc. Will this resolve patients going outside our areas?

Facilitator

We have also talked about strengthening our relationships with the medical schools. This is a potential for us to expand. In terms of repatriation, referral patterns are an interesting thing. It is very dependent on the primary care (family doctors). We know we can influence referral decisions by working with our GPs. This is also based on availability and expertise locally; we need to establish a strong business case. Hospitals are motivated now because the funding follows the patient. We need to retool our hospital to capture this funding. Parts of the strategy are to be more efficient, provide good quality care so patients return, and lastly, repatriating patients.

Community Participant

We know you want to create centres of excellence, know that government funding is based on patients served. How do you have a fair share of resources amongst the hospitals? How will you allocate resources among the four sites?

Facilitator

Some of it is historical; programs and services that are in place and with budgets to support those activities. Decisions must be made regarding how we can be more effective working together and what the opportunities are. I don’t know answer to that, but I think the risks that I keep hearing is compromising one site over another. We have made commitments that all four hospital sites will remain open with 24/7 emergency departments. Therefore we have to have a number of services that support the emergency department. Those are strong commitments; however there are other services that could be consolidated to ensure local access is maintained.

Community Participant

Do you anticipate a regional program at each of the sites?

Facilitator

To some extent that’s already happening. There does exist enough capacity in our system to allow for that. This would occur out of detailed conversation in the future with doctors and our community. Establishing a signature program for each of the sites is a good idea.

Community Participant

We talk about concrete facts about what is going to happen, have our guarantees. I think this is very important. Then we talk about other what‐ifs: centres of excellence, regional services. My question is, have you ever tried to do an inventory of the services that we have in Scarborough and in west Durham, and then look at our resources, and then think of what centres of excellence we could have?

Facilitator

This is a large part of our Preferred Integration Plan. As you know, we had 11 clinical working groups prepare workbooks to identify possible opportunities. Many ideas have come out of this process. It will be left to the new hospital Board to identify the priorities through a planning process, in consultation with the stakeholders and community.

Community Participant

I want to know more of what it’s going to look like in the end. What challenges we will face, factors such as demographic issues are going to continue, with or without a merger.

Facilitator

We don’t want to be paralyzed in planning, which can take years for larger scale changes. In the interim, and if the hospitals remain separate, they could become weaker due to the ongoing pressures. Facility renewal, regional programs, these are long term visions. This is only going to happen if everyone is on board, one strategic plan, etc. Our first objective would be to secure dollars in order to ensure appropriate planning. Facility planning is paramount for the longer term to ensure we’re meeting the needs of our communities, but this can’t be done in just a few weeks or months.

Community Participant

I wanted to inquire about the submission from the Friends of Scarborough to the Board, regarding a request to slow down the process.

Facilitator

The hospitals can’t slow down the process; the LHIN established the timelines. As a reminder the LHIN did extend the initial timeline by 30 days to allow for additional time to consult our stakeholders. . My question for you is what specifically needs to be slowed down? We thought the due diligence was going to take a few months, but it may take longer than that. We will also continue dialogue with stakeholders during that process. We are talking about multi‐year planning once the merger takes place. When you say you want to slow down the process; for how long, and for what purpose?

Community Participant 2

When the Friends submitted their deputation, we weren’t given the timelines as you have presented here. Now that we have this, we understand it better. We were talking about giving us the timelines, how long it will take; now we have this information and it addresses the question.

Community Participant 1

Part of it deals with what I read in the appendices of the report. Would like to see more information about where do we really want to be. Response in report is we can’t decide that until we see the feasibility study, and until LHIN releases the funds to give us a go‐ahead.

Facilitator

We can be paralyzed in planning and never move forward. Remember that a single accountability structure with the hospitals is an effective way to ensure the process moves along and a single plan is developed. The hospitals have included funding support in our proposed recommendation to move forward. In my mind that’s the starting point for conversation. Much of this planning takes a lot of time, it involves large studies and we need to consult with a lot of people, plus bureaucracy is involvedin it as well. These things take time and effort. We’re not going to get to the ideal state in year one, that is not realistic. Plus remember that we still have to address the real time, on‐going financial and demographic pressures.

Community Participant

In terms of establishing a base line, we now have a good understanding of where things are now between four sites. How much effort has gone into determining where you would like to go?

Facilitator

This is not an operating plan or a budget. We are looking at risks and potential values of a merger. As noted earlier, we need to complete more rigorous planning exercises and consult with our stakeholders about these opportunities.

Community Participant

Risk review is a huge part of the process, including risk identification and risk mitigation. If you don’t do it right you will go into a hole. My concern is that if you haven’t done that assessment properly and you get down road to where you can’t come back, what is going to be the mitigation strategy for that? We look after well over a million people.

Facilitator

These concerns are discussed in the report. We acknowledge that there are many risks – but the there are many potential benefits that out weight those risks. There are clear lessons learned that we have applied. We have learned forced mergers don’t work; there is a true sense among boards and physicians and community that this is a relatively good value proposition, especially in the long‐term. The cultures of hospital are similar, which is a good foundation to build on. We are concerned with providing superior services for our patients. There exists a strong sense of collaboration and willingness to work together – that’s an important first step to finding solutions.

Community Participant

When/if the LHIN comes forward with investments, and Board comes together for next steps, are you planning to have same sort of facilitations being done to keep community informed and involved? If we don’t do this, we are in trouble. We have to be smarter about our health care. The hospitals need to maintain the same open relationship and communications.

Facilitator

Absolutely. We discuss this commitment in Section 8.2 of the report. The Boards are committed to continued community engagement throughout the next phases. Part of this due diligence is setting up the governance structure. Best practices will be applied; it has to be skills‐based board, but there are mechanisms that can be considered to ensure community engagement remains a commitment for the new organization.

Community Participant

Right now there are two separate corporations, two different Boards. Those Boards are making these commitments to us. When you merge those two Boards, it is a new entity. This new Board of Directors did not make these commitments to us.

Facilitator

It is likely that the new Board will be made up of a composition of the existing Boards, in whole or in part. There will exist some continuity of individuals. Both existing Boards have demonstrated a strong commitment to community engagement throughout this process. I don’t see this changing as we move forward.

What I would suggest: Here is a good way to work with the two Boards as we move forward with this process. Write a correspondence and make some suggestions about how it might be more effective to do x, or x. If you want to make a suggestion that you want community representation on the Board orCEO selection, then make that suggestion. I don’t think it’s an unreasonable suggestion, because it’s been done before.

Community Participant

How do you feel about the depth of current resources to manage this large‐scale project?

Facilitator

I have been incredibly impressed with the executive and the management teams of both hospitals. Many directors at TSH that have been here for some time and understand systems of Scarborough; I imagine this is the same as RVHS as well. The Transformation Office focuses on change management. They are cited about leading transformation. We would elevate and invest in that transformation office as they have expertise and know‐how. There is existing management structure we can leverage in the new organization.

 

Community Participant

What is the position of doctors from TSH and RVHS with regards to the recommendation?

Facilitator

Both hospitals have had meetings with their medical administrative leaders, who are supportive unanimously. Medical staff association meetings have also taken place and the physicians in those meetings are also generally supportive. A lot of it is contingent on the planning, feasibility study for facilities renewal. They are trying to provide a health care system which we don’t have currently. They want to develop this so that patients can go to any hospitals and be able to get the same care wherever they go. All services can be provided within our geographical areas. From that perspective, they are supportive and physicians are looking at access for patients, and not looking at their own needs. If looking at it from point of view of patients, this is the way to go.

The Medical Advisory Committees recommended moving forward unanimously at TSH and RVHS; The Medical Staff Association had a strong turnout and were behind it. The medical leadership will be formally sharing its perspective with the community in the days ahead.

Community Participant

Scarborough has a fundraising foundation. Does the RVHS have a foundation that raises funds? Will they be amalgamated?

 

Facilitator

That’s their decisions. They are separate legal corporations. This is something for them to sort out. They recognize that they will need to work together, and will likely come up with a satisfactory solution that will not interfere with our ability to raise funds

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