Report From GBGH Operational Review

GEYER & ASSOCIATES INC.
Georgian Bay General Hospital

Operational Review
Final Report
December 9, 2015
Geyer & Associates Inc.
EXECUTIVE SUMMARY
GBGH OPERATIONAL REVIEW OBJECTIVES
GBGH and the LHIN
sought a review of
opportunities to
establish a
sustainable financial
operating position
within approved
funding.
Funded 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 position
within 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 local
health 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.
ii
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:
The operational
review team
synthesized analytical
findings with
perspectives shared
during extensive
consultation with
internal and external
stakeholders.
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.
iii
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 GBGH
achieved 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 strategic
management 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 also
the 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 meet
the 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 decisionmaking.
Physician leaders are not effectively integrated into the organizational structure and do not play a
meaningful 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 an
employer.
There is a need to enhance the role of MAC, reduce the number of Department Chiefs, and enhance their
roles and compensation.
iv
There is a need to strengthen the role of the Chief of Staff, particularly with respect to the quality of
medical 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 services
improvements have been implemented in the past several years; there are still opportunities for further
improvements. One of the most significant remaining opportunities to reduce overhead expenditures and
direct 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 to
the rates that would be expected given community demographics and established measures of relative
need.
Market share of GBGH for the primary catchment population has been declining and is of some concern
since 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 to
excessively long lengths of stay, and the use of these programs to augment services that should be
provided in the community.
GBGH acute programs have become less clinically efficient over the past five years: the hospital uses the
same number of beds to provide care to fewer patients.
Emergency Department (ED) performance has been among the best in the province in terms of Physician
Initial Assessment (PIA), and has focused successfully on reducing ED length of stay for admitted
patients in 2015.
There are clear opportunities to improve clinical utilization on acute inpatient units including the ICU and
Operating Rooms.
RECOMMENDATIONS TO IMPROVE GBGH CULTURE

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 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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RECOMMENDATIONS TO IMPROVE GBGH GOVERNANCE
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 the
governance 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 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.
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.
Recommendation 15: Critical incidents leading to death or harm need to be reported to the Board and
Quality & Safety Committee in a timely fashion.
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.
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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.
Recommendation 18: Develop a Board education plan that includes a Board education session related to
quality at the majority of Board meetings.
Recommendation 19: The Board should include a patient story at each meeting 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.
Recommendation 21: The Board should revise and strengthen the terms of reference for the MAC to ensure
the appropriate focus on medical quality and credentialing issues.
Recommendation 22: The Board should direct GBGH staff to move towards a revenue-based approach to
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.
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 potential
tactic to achieve strategic directions.
Recommendation 27: Terms of Reference for The GBGH Community Health Care Partners Forum should
be 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 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 a supporting 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.
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.
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.
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.
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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.
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 the
focus on quality of medical care, as well as increased responsibility for the administrative and operational
aspects of their respective clinical areas.
Recommendation 40: Increase the stipend paid to Chiefs and define the time to be dedicated to this role (.5
days/week).
Recommendation 41: Revise and strengthen the role of the Chief of Staff to increase his/her role to oversee
the quality of medical care.
Recommendation 42: Consider the possibility of providing the Chief of Staff with a mentor/coach for a 6month period.
Recommendation 43: Invigorate the MAC with the goal of increasing focus on quality and accountability
for 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 a
regular item on the MAC agenda.
Recommendation 46: Integrate selected medical leadership development sessions with Administrative
Leadership to facilitate team development.
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.
Recommendation 48: GBGH should develop written contractual agreements with the hospitalists that
outline the expectations 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.
Recommendation 50: GBGH should make efforts to enhance communication with local primary care
physicians, 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 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.
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.
xi
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 and
the Executive Support Manager (ESM) tool be purchased and implemented.
Recommendation 60: GBGH should develop and implement a formal Position Control Process for the
replacement 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 all
commitments.
Recommendation 62: All rental agreements should be reviewed and compared against current market value
rates to ensure that all costs of GBGH are fully recovered.
Recommendation 63: GBGH should explore opportunities to enhance HR functionality through partnership
with 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 the
basis for the new organizational model throughout GBGH.
xii
Recommendation 65: Review CDU utilization and staffing. Develop clear criteria for admission and
discharge to this area, and monitor performance to ensure that the right types of ED patients are admitted to
these 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 Medication
Reconciliations 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 accommodate
those patients that require a higher level of monitoring/oversight.
Recommendation 71: Provide additional support to Managers of Clinical Services to deal with aberrant
behaviours, 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 the
day.
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Recommendation 75: GBGH should develop a utilization management program to identify opportunities to
improve clinical utilization of hospital resources. The Joint Medical/Management Committee should
oversee 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 hospitalists
and family physicians in these rounds.
Recommendation 78: Enhance partnership with CCAC personnel and engage them more effectively in
discharge planning.
Recommendation 79: Consistently adhere to Expected Date of Discharge (EDD) Guidelines.
Recommendation 80: Explore the possibility of providing a Discharge Clinic for discharged medical
patients run by the hospitalists out of Ambulatory Care.
Recommendation 81: Document response times and incidents in which physicians on call direct staff to not
call them.
Recommendation 82: Partner with RVHC to ensure that higher acuity patients are transferred in a timely
manner 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 partner
more 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 criteria
consistently.
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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 basis
with weekend passes.
Recommendation 89: Conduct a review of clinical information practices and develop a new model that
integrates 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; Ordering
Physician; 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 increase
the numbers of full time staff.
Recommendation 95: Establish a DI/ED Council to meet on a quarterly basis to discuss issues affecting
service in each department. This council should include representation from Georgian Bay Radiology.
Recommendation 96: Conduct a focused review of Pharmacy operations by an experienced Pharmacy
Leader.
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THE ROLE OF GBGH IN 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 timely
emergency 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-organ
failure 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 effective
rehabilitation 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 appropriate
GBGH based ambulatory mental health care services. The model should share medical staff and
program management.
xvi
RECOMMENDATIONS REGARDING GBGHS APPROPRIATE 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 mental
health 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 for
acute mental health and $0.766 million for ambulatory care.
Recommendation 100: Close the obstetrical program and pursue a partnership with OSMH for all
obstetrical, 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 surgical
procedures after regular hours. These criteria should be applied consistently in all situations in which a
request 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.
xvii
PROJECTED GBGH BEDS

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
Medical & Surgical
Obstetrics
ICU
CCC
Rehab
Mental Health
Total Beds
2015/16
60
3
6
21
15
0
105
2016/17
60
0
4
21
15
0
100
2017/18
2018/19
55
0
4
21
15
0
95
2019/20
55
0
4
21
15
0
95
55
0
4
21
15
20
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 onetime 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 be
critical 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
Ongoing Savings
Ongoing Reinvestments
Ongoing Recoveries Increase
New Program Funding
New Program Expenses
One Time Revenue Increase
One Time Investment
Total Revenue & Recoveries Increase
Total Expense Decrease
Total
2015/16
$550,000
$$$$$1,500,000
$395,000
$1,500,000
$155,000
$1,655,000
2016/17
$2,170,333
$280,000
$100,000
$$$29,333
$0
$129,333
$1,890,333
$2,019,667
2017/18
$4,858,025
$230,000
$100,000
$$$0
$0
$100,000
$4,628,025
$4,728,025
2018/19
$5,108,025
$230,000
$100,000
$$$0
$0
$100,000
$4,878,025
$4,978,025
2019/20
$5,108,025
$230,000
$100,000
$6,000,000
$6,000,000
$$$6,100,000
-$1,121,975
$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 base
funding 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-time
revenues. It is assumed that any proceeds from the sale of the building will be used to reduce hospital
debt.
Projected Financial Performance
PROJECTED FINANCIAL PERFORMANCE
Total Revenue
Total Expenses
Surplus/Deficit from Operations
Amortization
Surplus/Deficit
2014/15
2015/16
2016/17
2017/18
2018/19
$56,726,909 $56,705,957 $55,346,187 $55,316,854 $55,316,854
$56,950,688 $57,096,780 $56,595,558 $55,077,523 $56,017,265
($223,779)
($390,823) ($1,249,370)
$239,331
($700,411)
($1,045,538)
($943,996)
($943,996)
($943,996)
($943,996)
($1,269,317) ($1,334,819) ($2,193,366)
($704,665) ($1,644,407)
2019/20
$61,316,854
$63,231,460
($1,914,606)
($943,996)
($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 lags
behind 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 this
report. Board Leadership is responsible for monitoring performance with respect to the successful
implementations of the recommendations of this report.
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CONTENTS
EXECUTIVE SUMMARY
II
INTRODUCTION AND CONTEXT

Operational Review Objectives and Scope
Review Methodology and Timelines
Assessment of the Draft Hospital Improvement Plan
1
1
2
3
ORGANIZATIONAL FINDINGS & RECOMMENDATIONS

Organizational Culture
Governance
Management and Leadership
Medical Staff
6
6
9
18
26
CORPORATE SERVICES FINDINGS AND RECOMMENDATIONS

GBGH Overhead Expenditures
Corporate Departments
33
33
35
CLINICAL SERVICES FINDINGS AND RECOMMENDATIONS

Overview of Clinical Utilization and Unit Costs by Broad Program
Emergency Department
Acute Inpatient Services
Rehabilitation and Complex Continuing Care
Ambulatory Care
Clinical Support Services
44
44
46
53
65
76
80
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CLINICAL SERVICES SUSTAINABILITY AND THE ROLE OF GBGH IN THE LHIN

Context
Mental Health
Obstetrics and Neonatology
Surgical Services
The Role of GBGH in the LHIN
85
85
86
89
96
98
FINANCIAL IMPACT OF RECOMMENDATIONS

Summary of Recommended Savings and Reinvestments
Impact of Recommendations on Key Measures of Financial Performance
Requirements for Success
100
100
105
106
APPENDIX 1 INTERVIEWS AND FOCUS GROUPS
107
APPENDIX 2 IMPLEMENTATION 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 balanced
financial operating position within three years; and
Identify other opportunities for the hospital to establish a sustainable balanced financial operating position
within 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 wider
local health system of which it is a part.
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.
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 other
hospitals 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.
Figure 1: Conservative Inflation Assumptions

E XPENSE C ATEGORY
SALARIES
SUPPLIES
MEDICAL/SURGICAL
DRUGS
OTHER EQUIPMENT
CONTRACTED OUT
GROUNDS EXPENSE/OTHER
A NNUAL I NFLATION
2%
3%
3.50%
5%
2%
2%
2%
Figure 2: Estimated Impact of Inflation for GBGH

ESTIMATED INFLATION BY EXPENSE TYPE
SALARIES AND WAGES
EMPLOYEE BENEFIT CONTRIBUTIONS
SUPPLIES & OTHER EXPENSE
MEDICAL/SURGICAL SUPPLIES
DRUGS & MEDICAL GASES
RENTAL/LEASE OF EQUIPMENT
OTHER EQUIPMENT EXPENSE
CONTRACTED OUT SERVICES
BUILDINGS & GROUND EXPENSE
TOTAL
2016/2017 2017/2018
$586,443
$598,172
$43,369
$164,497
$178,688
$176,549
$69,760
$72,202
$164,102
$172,307
$2,555
$2,606
$29,220
$29,804
$26,218
$26,742
$3,066
$3,127
$1,103,420
$1,246,006
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
CURRENT STATE
Total Revenue
Total Expenses
Amortization
Surplus/Deficit
2014/15
$56,726,909
$56,950,688
($223,779)
($1,045,538)
($1,269,317)
($8,144,159)
PROJECTED
2015/16
$55,205,957
$56,849,116
($1,643,159)
($943,996)
($2,587,155)
($9,596,780)
PROJECTED
2016/17
$55,179,906
$57,690,150
($2,510,244)
($944,000)
($3,454,244)
($11,539,078)
PROJECTED
2017/18
$55,179,906
$58,686,156
($3,506,250)
($944,000)
($4,450,250)
($15,805,549)
ORGANIZATIONAL FINDINGS & RECOMMENDATIONS

Organizational Culture
The culture at GBGH is a matter of great concern, and will significantly influence the ability of the hospital
to 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 traumatic
patient death that was widely reported in the press.
Many staff and physicians expressed concern over the actions taken by the hospital, and the lack of
transparency;
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, reasoned
discussion as to what contributed to the situation, what could have mitigated the consequences, and what
systems and processes need to be enhanced/changed/developed.
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.
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.
Governance
Strategy
A strategic plan and management system provides the foundation for continuous improvement and the basis
for 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 strategic
management 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 be
operational rather than governance oriented.
The Finance and Audit Committee has been very focussed on monthly budget variance and not on the
strategic 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.
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 and
accountability.
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 from
execution of change and innovation.
10
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.
11
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 ill
defined, 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.
12
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 GBGH
the answers were more descriptive and not grounded in measurable statistical performance;
Financial and quality elements are almost disembodied, rather than being strategically linked at every
level of the organization, but particularly at the Board;
It is concerning that the Board appears to have not been made aware of critical incidents involving
significant negative consequences to patients; and
Formal reporting of critical incidents is not pursued because those that take the time to report the
incidents never hear back.
13
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 to
demonstrate 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 type
system. 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 per
year 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.
14
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 appropriate
focus 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.
15
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 scenario
might look like for the organization;
In addition, there does not appear to be regular Board level reporting and discussion of the status of the
Hospital Improvement Plan as a package;
The Board has endorsed program decisions when the financial analysis prepared by staff suggests that
there 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 and
uses 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 revenue
envelope while maintaining volumes and maintaining or improving quality.
16
This approach tends to encourage creative re-designs of workflow, staffing and reduction in no-value
add steps and practices. It also helps to clarify the organizations overall direction that operating at a
deficit 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 support
revenue 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 community
partners. 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 semiquarterly basis. There is a need to better define the role and objectives of this group in order for it to be
successful.
Effective collaboration with partners is key to improving system integration. This is especially important
for smaller hospitals.
17
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 decisionmaking. 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.
18
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.
19
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 a
supporting 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.
20
Effectiveness of Management Decision Making

GBGH Managers frequently struggle to make effective decisions. One specific example is the recent
decision to designate revised commode cleaning functions to Registered Nurses.
In the discussion between 2 departments (Housekeeping and Nursing), it was made clear that
Housekeeping did not have the resources to provide this service.
The decision was subsequently made to assign this task (which requires 10 minutes of time) to the
hospitals most expensive clinical resource Registered Nurses.
There appears to have been little flexibility to reassign dollars to housekeeping to enable the most
appropriate personnel to provide cleaning, thus allowing registered nursing staff to do what they should be
doing providing high quality, focused patient care. This is sub-optimal from a cost and quality
perspective.
Too often, sub-optimal decisions have been justified with We dont have the resources.
In the future, resources may need to be re-allocated between departments to ensure that staff is utilized
appropriately and that decisions are in alignment with strategic and operational objectives.
21
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 there
ongoing programs that cover all levels of management to enhance skills. Onboarding is the process by
which new hires learn the social and performance aspects of their jobs quickly and smoothly, and learn
the 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 many
interviews, it was apparent that Managers and Directors did not fully recognize their roles and
responsibilities.
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-time
monies has been allocated to this recommendation.
22
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 survey
annually.
Staff satisfaction scores derived from this instrument should be part of the balanced scorecard.
23
Financial Management
A traditional budgeting approach is used driven by the Finance Department. This process uses the
previous years spend as the basis for developing the next years budget. The challenge with this
traditional approach is that:
It usually results in a budget that is additive, that is, last years spend is increased by inflation and other
pressures 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 that
appears after the first phase of the budget process.
Budget and planning assumptions appear to have been overly optimistic leading to added pressures when
costs emerge as higher or revenues less than expected. Pubic organizations like hospitals should budget
in a cautious way in terms of assumptions.
The finance department appears to be strong in terms of reporting and support for managers. However, it
also 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 budget
process; and
There is variability in the level of financial management knowledge and a lack of ongoing leadership
development 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 to
identify opportunities for fiscal improvement.
In todays funding environment, it is crucial that organizations see their financial performance in terms
of the rest of the industry as improving faster than ones peers is the only way to improve positioning
under the new formulaic funding system.
It is recognized that GBGH has begun incorporating benchmarking data. The challenge now is to
effectively utilize the data they are collecting to improve program and departmental performance.
24
A robust standardized business case process does not appear to be in place in terms of major changes
including 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.
25
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 overseeing
quality of care in their respective divisions. One Chief acknowledged that they did not know what their
divisional colleagues did. In general, they viewed their role to be doing the call schedule and fire
fighting issues when necessary.
The selection process for Department Chiefs does not appear to be competency based. A number of
medical 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 increased
if 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 hospital
such as the budgeting process.
There is lack of clarity around the Chief of Staff role. While he fully understands his role to monitor
matters such as chart completion, he acknowledges that improvement is required with respect to his
relationship with the Board, and around credentialing.
26
The efficacy of the MAC is questionable, and as with the Board, this group tends to focus on details as
opposed to overall quality of medical care within GBGH.
RECOMMENDATIONS
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 from
some 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.
27
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 consider
engaging 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.
28
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 including
the 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.
29
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 in
off-hours, despite the fact this physician is on call. According to staff in multiple interviews and focus
groups, this request is made approximately 30% of the time that this physician is on call. As a result, staff
resorts 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 hospital
policies cannot be tolerated.
30
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 through
this A/B arrangement.
In the A/B rotation, Hospitalist A would do the HOCC on-call coverage from 5pm-7am and is covered by
special funding for HOCC. S/he would then transition to Hospitalist B the next day and continue to
follow 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 responsibilities
with 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 the
expectations 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.
31
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 should
increase the degree of involvement in LHIN planning and with other potential partners in the region.
32
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 current
operation of two sites.
Figure 4: OCDM Overhead Expenditure Trends
Overhead per Direct Care Net Expense
Fiscal Year
GBGH
2010-2011
2011-2012
2012-2013
2013-2014
2014-2015
COHORT
37.1%
39.1%
36.1%
37.2%
37.3%
GBGH RELATIVE
36.1%
36.8%
36.0%
36.6%
36.6%
102.6%
106.3%
100.3%
101.6%
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.
33
Figure 5: Components of Overhead at GBGH
Fiscal Year
2010-2011
2011-2012
2012-2013
2013-2014
2014-2015
Education Per
Direct Care Net Expense
GBGH
COHORT
1.2%
0.9%
0.8%
0.8%
0.7%
0.6%
0.6%
0.6%
0.7%
0.6%
Undistributed Per
GBGH
GBGH
RELATIVE
180.0%
1.3%
144.6%
1.3%
133.5%
1.0%
106.6%
0.9%
116.5%
1.0%
COHORT
0.8%
1.0%
1.1%
1.2%
0.7%
GBGH
RELATIVE
167.9%
126.0%
84.7%
78.4%
152.3%
Administration & Support Per

GBGH
34.6%
36.9%
34.3%
35.5%
35.6%
COHORT
34.7%
35.1%
34.3%
34.6%
35.3%
GBGH
RELATIVE
99.7%
105.0%
100.2%
102.6%
100.7%
34
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.
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.
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.
35
Figure 6: Cafeteria Financial Performance

R ECOVERIES
AND E XPENSES
Recoveries
Cafeteria
Meals on Wheels
Total Recoveries
Expenses
Catering Expenses
Food Costs**
Salaries
Benefits
Depreciation Expense
Total Expenses
Surplus/(Deficit)
A CTUAL
2011/2012
A CTUAL
2012/2013
A CTUAL
2013/2014
A CTUAL
2014/2015
P RO - RATE
2015/2016
$117,455
$21,008
$138,463
$88,901
$34,529
$123,430
$62,538
$34,051
$96,589
$47,528
$33,078
$80,606
$45,615
$44,727
$90,342
$44,257
$69,232
$82,581
$23,789
$3,629
$(223,487)
$(85,024)
$53,729
$61,715
$88,544
$46,046
$5,815
$(255,849)
$(132,419)
$35,972
$48,295
$81,429
$20,769
$6,079
$(192,543)
$(95,954)
$34,427
$40,303
$69,093
$8,631
$6,195
$(158,649)
$(78,043)
$31,236
$45,171
$33,224
$8,170
$7,389
$(125,189)
$(34,847)
36
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 the
laundry services being discontinued for Waypoint.
Expenses for the same time period have also reduced. Total expenses for FY 12/13 before utility costs
were $667K and projected FY15/16 are $526K.
Figure 7: Laundry and Linen Financial Results
RECOVERIES AND EXPENSES
Recoveries
Salaries
Benefits
Supplies
Equipment Maintenance
Referred-Out Expense
Depreciation Expense
Total - Without Utilities
Utilities Allocation
Total Expenses - With Utilities
TOTAL Surplus/(Deficit)
ACTUAL
2011/2012
$4,693
$289,065
$124,902
$85,299
$8,249
$$16,045
$523,560
$177,429
$700,989
$(696,296)
ACTUAL
2012/2013
$161,204
$167,337
$80,166
$132,959
$58,072
$261,035
$19,593
$719,162
$182,752
$901,914
$(740,710)
ACTUAL
2013/2014
$6,589
$80,605
$32,832
$2,402
$(24,100)
$469,733
$3,373
$564,845
$188,234
$753,079
$(746,490)
ACTUAL
2014/2015
$1,058
$81,077
$32,949
$1,552
$$422,029
$1,253
$538,860
$193,881
$732,741
$(731,683)
PRO-RATED
2015/2016
$1,059
$86,856
$27,246
$1,569
$2,397
$407,655
$1,254
$526,977
$199,698
$726,675
$(725,616)
37
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
R ECOVERIES
AND
Recoveries
Salaries
Benefits
Supplies & Sundry
Equip't Maint
Total Expenses
Surplus/(Deficit)
E XPENSES
A CTUAL
A CTUAL
A CTUAL
P RO - RATE
2012/2013
$0
$421,256
$121,309
$16,186
$$(558,750)
$(558,750)
2013/2014
$0
$426,763
$129,632
$8,965
$100
$(565,460)
$(565,460)
2014/2015
$0
$438,665
$139,992
$13,993
$3,601
$(596,250)
$(596,250)
2015/2016
$0
$454,801
$131,273
$30,253
$$(616,327)
$(616,327)
RECOMMENDATION
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.
The hospital should target $75K to $125K.
38
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
Salaries
Benefits
Total Salaries & Benefits
Supplies
Utilities
Insurance, Fees and Service Contracts
Equipment maintenance
Total Supplies & Sundry
Depreciation - Major Equipment
Total Expense
Q UANTITY
$132,103
$45,150
$177,253
$13,749
$183,788
$7,140
$76,243
$280,920
$1,672
$459,845
RECOMMENDATIONS
Recommendation 56: GBGH should not be the landlord of the proposed health hub at the Penetang Site.
39
Materials Management
GBGH has the option to participate in HealthPRO contracts. GBGH had entered into discussions with
Orillia Solders Memorial Hospital and Muskoka Algonquin Healthcare to implement an integrated
materials management function sharing resources and expertise for strategic sourcing, completion and
sharing in Request for Proposals, and standardized policies and procedures. The integrated model has
not moved forward.
In the fall of 2015, GBGH entered into a contract with Shared Services West for Strategic Sourcing
Function. GBGH had not converted their medical/surgical and other supply contracts to HealthPro,
and as a result have not achieved purchasing savings through the HealthPRO Contracts. A contract
position was hired to start the migration of product contracts to HealthPro. There are 1113
HealthPRO contracts. In the past 18 months GBGH has migrated 217 contracts or 19.5% to
HealthPRO. Estimated annualized contract savings are $250 to $350K.
There is still a significant opportunity for savings by standardizing all products to HealthPRO. Preliminary
estimates by GBGH were savings of $5K per contract. These savings would contribute to the overall cost of
future clinical services.
RECOMMENDATIONS
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.
40
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.
41
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 additional
proposed investments or resources.
There was not an approved signing authority matrix used consistently across the organization for the
approval of expenditures and purchase requisitions. Procurement is not clear on the established signing
authority and delegation policy, and ensuring that all purchase requisitions are approved by the
appropriate 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 role
out of this policy.
Shared Services West will be using this matrix in their processes and implementing with eSign.
RECOMMENDATIONS
Recommendation 60: GBGH should develop and implement a formal Position Control Process for the replacement 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 all commitments.
42
This process needs to be inclusive of facilities, food services and housekeeping services.
The profitability of revenue-generating initiatives

Currently GBGH has rental/lease agreements with Waypoint $56,430 annually, and Hospice and
Cancer Centre, both at the Penetang site for $13,200 annually.
All three agreements are at $9 per square foot, and $2.10 per square foot for infrastructure/utility costs.
RECOMMENDATION
Recommendation 62: All rental agreements should be reviewed and compared against current market value rates to ensure
that all costs of GBGH are fully recovered.
Human Resources
GBGH requires significant leadership development, cultural transformation, and performance management
and attendance awareness attention. The current department is not meeting the needs of the organization
and appears inadequate to support the implementation of the recommendations of this report.
Recommendation 63: GBGH should explore opportunities to enhance HR functionality through partnership with another
organization in the LHIN.
43
CLINICAL SERVICES FINDINGS AND RECOMMENDATIONS

Overview of Clinical Utilization and Unit Costs by Broad Program
GBGH Program Utilization Relative to Needs
The communities served by GBGH have actual utilization rates that are comparable to other communities in
Ontario taking into account demographics and established measures of relative need including
demographics, mortality, aboriginal, rural and income.
The GBGH catchment appears neither under-serviced nor over-serviced in the Ontario context.
Figure 10: Actual and Expected Weighted Units of Service
HBAM FUNDED PROGRAMS

Acute Inpatient and Day Surgery Total Acute Weighted Cases
Emergency Room Ontario Modified Weighted Cases
Rehabilitation RPG Weighted Cases
Complex Continuing Care RUG Weighted Patient Days
ACTUAL
WEIGHTED
ACTIVITY
2013/14
5,279
1,739
194
9,625
EXPECTED
WEIGHTED
ACTIVITY
2013/14
5,273
1,727
202
9,625*
EXPECTED
WITH GROWTH
2015/16
5,623
1,791
218
10,401
*Expected Weighted Activity for Complex Continuing Care is equal to actual activity as per the MoHLTC HBAM funding methodology.
44
Actual and Expected Cost Per Weighted Unit of Activity

The Ontario Cost Distribution Methodology (OCDM), for broad hospital programs, calculates estimates of
hospital net expenses per weighted unit of activity. These estimates include all direct and indirect net
expenses after accounting for allowable revenues and recoveries that are used to offset expenditures. The
broad programs (service recipient categories) include acute & day surgery, emergency, inpatient
rehabilitation and CCC. The weighted activity is derived from hospital clinical administrative data using
standardized methodologies developed by CIHI and refined by the Ministry of Health in Ontario.
Figure 11: Actual and Expected Cost Per Weighted Unit
2012/13 Unit Costs
2013/14 Unit Costs
HBAM Funded Programs
Acute & Day Surgery

Inpatient Rehabilitation
Complex Continuing Care
Actual
CPWU
4,846
4,634
19,543
608
Expected CPWU
5,284
5,402
13,508
573
Relative CPWU
92%
86%
145%
106%
Actual
CPWU
4,779
5,105
13,796
706
Expected CPWU
Relative CPWC
5,316
5,474
12,707
582
90%
93%
109%
121%
Adjusting for the resource intensity of cases (the weights), and controlling for hospital specific factors that
influence cost (adjustment factors):
GBGH has appeared relatively efficient for Acute & newborn and Emergency department care.
GBGH has appeared relatively inefficient in inpatient rehabilitation and complex continuing care.
This analysis understates acute & day surgery cost due to the inaccurate reporting of endoscopy
expenditures in medical & surgical clinics. The basic conclusions remain.
45
GBGHs Emergency Department (ED) provides an important and needed service to residents of its
catchment area.
Communities Served and Seasonal Variation
Review of GBGH clinical administrative ED data from 2010 to 2014 indicates that:
ED visits have increased from 41.2K in 2010 to 44.3K in 2014;
The majority of patients served in 2014 (92.7%) are from GBGHs immediate catchment area,
A meaningful proportion of visits (7.3%) are from outside the immediate catchment.
The department has significant seasonal variation in demand:
July and August have a combined average 4,390 visits/month.
The remaining 10 months have an average 3,554 visits/month.
46
Figure 12: GBGH ED Visits by Patient Municipality

Fiscal Year
(3306) MIDLAND
(3307) PENETANGUISHENE
(3331) TINY
(3329) TAY
(3348) SPRINGWATER
(3334) Christian Island
(1811) TORONTO
(3301) BARRIE
(2004) GEORGIAN BAY
(3347) SEVERN
(YYYY) OOP1
(2721) MISSISSAUGA
(3317) WASAGA BEACH
All other Municipalities
Grand Total
2010
14,770
7,656
5,351
5,847
2,152
745
831
376
628
277
251
220
185
1,985
41,274
Emergency Department Visits

2011
2012
2013
16,069
15,488
15,729
8,204
7,469
7,668
6,170
6,397
6,923
6,384
6,308
6,171
2,364
2,195
2,193
831
734
712
816
827
834
441
428
442
614
633
585
330
340
305
232
274
283
248
208
205
247
241
230
2,186
2,164
2,057
45,136 43,706 44,337
2014
15,686
7,672
6,945
6,326
2,205
728
714
407
626
324
265
198
188
2,040
44,324
Emergency Department Weighted Visits

2010
2011
2012
2013
2014
588
634
628
640
649
308
319
307
323
331
205
240
252
279
280
224
241
246
247
256
87
94
85
85
91
30
32
30
30
30
29
28
30
30
26
13
16
15
16
15
25
26
26
26
28
11
14
15
13
14
10
8
10
10
10
9
8
7
8
7
7
10
8
8
7
71
77
78
75
78
1,618 1,748 1,738 1,790 1,822
Out of Province
47
Market Share for the Primary Catchment Population

Review of clinical administrative data for all hospitals that served the primary catchment indicates that
GBGH market share in this growing market has been at or near 58% of visits over the past five years.
GBGH has maintained market share close to 58% or 59% of visits in this growing market.
Figure 13: ED Visit Market Share by Hospital Provider for GBGH Primary Catchment
Provider
(0726) GBGH
(0640) CGMH
(0745) OSMH
(0606) RVHC
(0931) WEST PARRY SOUND HC
(0736) SOUTHLAKE RHC
(0953) SUNNYBROOK HSC
(0968) MUSKOKA ALGONQUIN HC
(0852) ST MICHAEL'S HOSPITAL
All Other Ontario Hospitals
Grand Total
2010
ED Visit Market Share

2011 2012 2013
2014
ED Weighted Visit Market Share

2010 2011 2012 2013
2014
58.3
12.7
15.1
8.1
1.8
0.2
0.1
0.5
0.2
3.1
100.0
60.0
12.5
14.0
7.8
1.6
0.3
0.1
0.4
0.2
3.0
100.0
57.8
13.2
14.4
9.2
1.2
0.4
0.1
0.4
0.2
3.2
100.0
57.3
13.1
14.4
9.0
1.7
0.3
0.3
0.4
0.4
3.3
100.0
59.6
12.5
13.6
8.6
1.5
0.4
0.1
0.4
0.2
3.2
100.0
59.0
12.6
14.1
8.7
1.3
0.4
0.1
0.4
0.2
3.2
100.0
58.7
12.9
13.6
8.8
1.6
0.4
0.3
0.3
0.3
3.1
100.0
58.0
13.5
12.8
9.4
1.4
0.5
0.4
0.3
0.3
3.3
100.0
57.1
13.9
13.5
9.4
1.2
0.5
0.3
0.3
0.3
3.3
100.0
56.2
14.5
13.5
10.0
1.1
0.5
0.3
0.3
0.3
3.2
100.0
48
Total Cost Per Visit

GBGH total cost per ED visit has increased from $188/visit in 2010 to $233/visit in 2014, which is very
close to the average for comparably sized emergency departments in Ontario.
Figure 14: GBGH Emergency Department Cost Per Visit versus Comparably Sized Emergency Departments
Description
SAULT STE MARIE SAULT AREA
CAMBRIDGE MEMORIAL
ORILLIA SOLDIERS' MEMORIAL
ST THOMAS ELGIN GENERAL
KITCHENER ST MARY'S
OTTAWA MONTFORT
KINCARDINE SOUTH BRUCE GREY
BURLINGTON JOSEPH BRANT HOSPITAL
LINDSAY ROSS MEMORIAL
SMITHS FALLS PERTH & SMITHS FALLS
HUNTSVILLE MUSKOKA ALGONQUIN HC
ORANGEVILLE HEADWATERS HC
TIMMINS & DISTRICT GENERAL
HAWKESBURY & DISTRICT GENERAL
WOODSTOCK GENERAL HOSPITAL TRUST
NEW LISKEARD TEMISKAMING HOSPITAL
PEMBROKE REGIONAL
COLLINGWOOD GMH
COBOURG NORTHUMBERLAND HILLS
SIMCOE NORFOLK GENERAL
MIDLAND GBGH
COHORT AVERAGE
GBGH Relative to Cohort
20102011YE
63,529
52,819
53,698
38,348
47,473
45,093
48,633
46,491
43,259
49,478
46,029
35,673
41,463
35,214
30,276
22,219
31,937
31,612
31,853
27,580
41,274
41,134
100.3%
20112012YE
61,133
55,289
55,864
42,921
48,559
50,624
50,418
47,395
45,623
49,200
47,962
38,882
42,770
36,549
31,881
21,236
31,855
32,663
31,663
28,463
45,153
42,548
106.1%
ED VISITS
20122013YE
61,782
53,982
53,808
45,113
46,119
54,286
46,995
47,332
46,172
46,238
44,836
43,483
42,158
37,237
34,971
20,573
31,459
32,080
30,757
27,844
43,740
42,361
103.3%
20132014YE
54,360
54,113
52,922
46,606
46,719
54,476
42,813
46,362
45,265
44,756
43,600
40,772
41,292
38,713
36,751
19,464
34,681
31,673
31,219
27,610
44,350
41,708
106.3%
20142015YE
56,539
56,104
54,276
50,291
50,056
49,841
45,964
45,718
45,412
45,312
44,235
43,969
41,196
39,311
39,042
35,869
34,973
33,356
32,944
30,213
44,331
43,731
101.4%
20102011YE
271
245
245
230
273
384
145
255
278
133
229
230
197
187
203
109
225
219
230
203
188
224
83.9%
TOTAL COST PER VISIT

2011201220132012YE
2013YE
2014YE
303
271
244
235
234
213
255
238
215
238
240
198
273
256
285
370
382
373
147
162
170
280
272
273
258
262
278
139
149
152
313
296
300
210
193
211
193
191
199
183
145
245
240
224
226
121
125
127
233
230
258
247
238
265
236
245
230
202
224
227
177
184
206
234
229
234
75.7%
80.5%
87.9%
20142015YE
260
207
207
177
267
405
172
296
280
156
289
193
198
245
226
84
243
277
220
226
233
231
100.7%
49
General Findings for the ED

This department functions very effectively. Historically, the department has been well managed by the ED
Manager and ED Medical Chief. The Medical Chief provides effective leadership to his medical colleagues,
and regularly tracks their performance, and shares this information with them. As a result, medical quality
is appropriately tracked, and when issues arise, they are dealt with.
2014/15 ED metrics were, in general, very good.
Average time to PIA was excellent at 1.1 hours;
th
ED LOS was, on average 3.2 hours, and was 5.6 hours at the 90 percentile; and
th
ED LOS for admitted patients was, on average 13.5 hours, and 28.5 hours at the 90 percentile.
On average, 7% of patients that present to the ED are admitted. This number is remarkably low.
The ED and the hospital at large have aggressively attempted to reduce the LOS for admitted patients in the
department.
Policies and procedures have been developed to effectively deal with the number of admitted patients.
Current data from January to September 2015 indicates that these efforts have improved LOS for
admitted patients: 90th percentile ED LOS for GBGH admitted patients fell to 21.1 hours from 28.5 hours
in 2014/15.
50
Additional observations regarding the ED at GBGH include:

Triage is reported to take a very long amount of time (30 minutes).
The department is currently undergoing an extensive renovation. Flow should improve upon completion
of construction. However, the See & Treat area through which most patients flow, seems very cramped.
It is assumed that upon completion of the renovation, dedicated space for patients with mental health
issues will be improved. The current set up is less than optimal.
CDU utilization is extremely variable. It was reported that some physicians and staff do not fully
understand the purpose of this area and will use it to bed space patients in some circumstances. This
area is funded through P4R dollars.
Nursing staffing levels appear to be reasonable, however: the schedule could be flexed to reduce the
number of nurses starting shifts at 07.30 (when the department is usually quiet), and have more shifts
starting at 09.00, 10.00 or 11.00.
ED Nurses are currently required to complete Medication Reconciliation (including Best Possible
Medical History). This process can be extremely time consuming, and is not necessarily the best
utilization of an ED RN. It is also not the most cost effective method for obtaining this important
information. Previously, the department had utilized a Pharmacy Technician to complete this requirement,
and this was reported to have worked well.
It was reported that ED physicians utilization of CT scanning (both contrast and non-contrast) tends to be
high, and may need to be reviewed.
51
RECOMMENDATIONS
Recommendation 64: Consider using the management model that has worked effectively in the ED as the basis for the new
organizational model throughout GBGH.
Recommendation 65: Review CDU utilization and staffing. Develop clear criteria for admission and discharge to this area,
and monitor performance to ensure that the right types of ED patients are admitted to these 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 Medication Reconciliations 12
hours/day.
Recommendation 69: Review current state with respect to utilization of CT for diagnostic purposes.
52
Acute Inpatient Services

Communities Served
Typical of a community hospital, GBGH inpatient care is focused on the local catchment population.
Eight municipalities account for 97% of GBGH acute & newborn inpatient discharges, while
Midland, Pentenguishene, Tiny and Tay account for 88% of inpatient discharges.
Figure 15: GBGH Acute & Newborn Discharges by Municipality
Municipalities Served
(3306) MIDLAND
(3331) TINY
(3329) TAY
(3348) SPRINGWATER
(2004) GEORGIAN BAY
(3334) CHRISTIAN ISLAND 30
(3347) SEVERN
All other Communities & OOP
Grand Total
2010
41%
21%
12%
12%
8%
2%
2%
1%
4%
100%
2011
43%
17%
14%
13%
6%
2%
1%
1%
4%
100%
2012
43%
20%
13%
11%
4%
2%
1%
1%
4%
100%
2013
40%
21%
16%
12%
4%
2%
1%
1%
4%
100%
2014
38%
25%
14%
11%
5%
1%
1%
1%
3%
100%
53
Acute & Newborn Market Share

Population based funding follows the patient to hospitals that they utilize. Weighted case market share is
therefore critical to funding. The trend for GBGH is concerning as market share has been declining. The
impact of this decline is mitigated somewhat by improvements in average case mix index.
Figure 16: Market Share for Primary Catchment Population
Market Share
GBGH
CGMH
Weighted RVHS
Case Market OSMH
Share
MA-H
MA-B
Non-NSM LHIN
GBGH
CGMH
RVHS
Case Market
OSMH
Share
MA-H
MA-B
Non-NSM LHIN
Weighted Cases
Total Market
Total Cases
2010
4,334
1,451
2,112
1,763
3
17
1,757
4,167
1,215
1,769
1,494
7
20
951
11,437
9,623
2011
4,583
1,428
1,975
1,613
0
30
1,836
4,239
1,295
1,744
1,400
1
21
981
11,465
9,681
2012
4,387
1,651
2,030
1,628
9
30
1,911
3,854
1,384
1,652
1,407
7
31
1,027
11,647
9,362
2013
4,579
1,751
2,345
1,766
4
10
2,242
3,832
1,439
1,905
1,527
4
10
1,073
12,698
9,790
2014
4,456
1,662
2,556
2,174
7
29
2,028
3,623
1,522
2,066
1,613
6
15
1,079
12,912
9,924
2010
38%
13%
18%
15%
0%
0%
15%
43%
13%
18%
16%
0%
0%
10%
119%
100%
2011
40%
12%
17%
14%
0%
0%
16%
44%
13%
18%
14%
0%
0%
10%
118%
100%
2012
38%
14%
17%
14%
0%
0%
16%
41%
15%
18%
15%
0%
0%
11%
124%
100%
2013
36%
14%
18%
14%
0%
0%
18%
39%
15%
19%
16%
0%
0%
11%
130%
100%
2014
35%
13%
20%
17%
0%
0%
16%
37%
15%
21%
16%
0%
0%
11%
130%
100%
54
Inpatient Utilization and Case Mix Index

Review of clinical administrative data over the past five years (Figure 17) led to the following conclusions:
Acute & newborn discharges have declined substantially;
Weighted cases have increased slightly, owing to a higher average Case Mix Index (CMI);
CMI increased from 1.03 (76% of provincial CMI) in 2010 to 1.22 (88% of provincial CMI) in 2014;
CMI relative to the province has not increased due to changes in GBGH case mix and age profile; and
CMI has increased due to hospital specific factors that may include improved documentation and
coding, and discharges of very long length of stay outliers.
Average length of stay has increased from 5.4 days in 2010 to 6.5 days in 2014.
The key finding is that GBGH is using more beds to provide care to fewer patients.
Figure 17: GBGH Case Mix Analytics
CASE MIX INDEX ANALYTICS
Hospital Discharges
Hospital Weighted Cases
Hospital Case Mix Index
CMI Ratio - Crude Ratio to Provincial Average
CMI Ratio - Due to Case Mix & Age
CMI Ratio - Hospital Specific Practices
Average Length of Stay
Total Discharge Days
Equivalent Beds @ 95% Occupancy
FISCAL YEAR BEGINNING

2010
2011
2012
2013
2014
4,393
4,543
1.03
4,415
4,771
1.08
4,034
4,574
1.13
3,999
4,720
1.18
3,764
4,609
1.22
0.76
0.94
0.81
0.80
0.91
0.87
0.83
0.90
0.93
0.86
0.92
0.93
0.88
0.95
0.93
5.4
23,625
68.1
5.4
23,985
69.2
6.1
24,597
70.9
6.0
23,901
68.9
6.5
24,374
70.3
55
Bed utilization trends by program area in Figure 18 indicate that:

Obstetrical and neonatology discharges have fallen along with average length of stay;
Medicine discharges have fallen while average length of stay increased from 5.8 in 2010 to 7.1 in 2014;
Surgery discharges also declined with a small increase in average length of stay. The average surgery
length of stay of 6.4 days is high given the current mix of surgical cases.
Figure 18: Bed Utilization Trends
Broad GBGH Clinical Program Areas
Birthing (OB and Neonatology)
Discharges
Equivalent ALC Beds @ 95% Occupancy
Medicine
Discharges
Mental Health
Discharges
Surgery
Discharges
2010
2011
2012
2013
2014
494
2.7
3.8
0.0
483
2.6
3.7
0.0
456
2.4
3.2
0.0
404
2.3
2.7
0.0
403
2.4
2.8
0.0
3,316
5.8
55.5
11.2
3,260
6.0
56.9
13.4
2,957
6.8
57.8
15.5
2,983
6.5
56.1
15.3
2,912
7.1
59.6
14.4
185
3.4
1.8
0.5
202
2.9
1.7
0.1
179
4.6
2.4
1.1
151
4.2
1.8
0.6
87
4.5
1.1
0.6
398
6.1
7.0
0.5
470
5.2
7.0
0.8
441
6.0
7.6
1.3
461
6.3
8.4
1.8
362
6.4
6.7
1.5
56
Figure 19: Clinical Efficiency - Acute Length of Stay Analytics

Length of Stay Analytics
Hospital Discharges
Hospital Discharge Days
Hospital Average LOS
LOS Ratio - Crude Ratio
LOS Ratio - Case Mix & Age
LOS Ratio - Hospital Specific Factors
2010
4,393
23,625
5.38
0.89
1.11
0.80
Fiscal Year Beginning

2011
2012
4,415
4,034
23,985
24,597
5.43
6.10
0.92
1.09
0.84
1.04
1.09
0.96
2013
3,999
23,901
5.98
2014
3,764
24,374
6.48
1.03
1.13
0.91
1.12
1.14
0.98
In 2010:
GBGH length of stay was 89% of the provincial average LOS despite having an expected LOS 11%
higher than the average, controlling for case mix and age.
GBGH would have been considered one of the more clinically efficient hospitals in Ontario with a
LOS of only 80% of the expected GBGH LOS (20% below expected) controlling for case mix and age.
In 2014,
GBGH LOS is only 2% below the provincial experience controlling for case mix and age.
GBGH is a typical community hospital with some opportunities for improvement in clinical utilization.
57
General Findings 2 North

2 North is a 27 bed unit with 4 overflowbeds (which are usually full) and is comprised of: 3 obstetrical
beds, LDR; Medical beds; and Surgical beds for adults and children; and beds that are used for postoperative recovery of some day surgical cases. Staffing is extremely difficult in this area given the diverse
clinical needs of patients admitted.
Quality of care is affected by a number of issues on this unit.
Occupancy rates varied from 82% to 109% in 2014/15.
Nurses are required to provide care to patients with multiple varying clinical concerns, and may not
possess the expertise to do so.
Hospitalists provide medical support for medical patients and will frequently be on the unit as late as
midnight writing orders and admitting patients. This places considerable stress on the system: nurse
staffing levels are at their lowest during these hours; there is no support from ward clerks; Pharmacy is
closed; and there is minimal service available in the Laboratory and Diagnostic Imaging Departments.
In the focus groups front line staff shared numerous examples of:
Unacceptable behaviours that were not effectively addressed and concerns regarding the consistent
quality of nursing care and increasing numbers of medication errors;
Periods of insufficient staffing when obstetrical patients are admitted to the unit;
Perceived pressure to admit patients from ED; and
Ineffective use of nursing resources including the need to porter patients and the recent decision to
assign commode cleaning to nursing staff.
The current Manager is concerned about the status of this unit and recognizes that staff morale is very low.
58
RECOMMENDATIONS
Recommendation 70: Explore the opportunity to establish a 4 bed higher acuity room to accommodate those patients that
require a higher level of monitoring/oversight.
Recommendation 71: Provide additional support to Managers of Clinical Services to deal with aberrant behaviours, 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 74: Establish guidelines for hospitalist practices ensure rounding is done earlier in the day.
Recommendation 75: GBGH should develop a utilization management program to identify opportunities to improve clinical
utilization of hospital resources. The Joint Medical/Management Committee should oversee the work.
59
General Findings 2 East

2 East is 36-bed medical unit. Occupancy varied from 90% to 99% in 2014/15. There are a higher number
of ALC patients on this unit. One patient has been on the unit for more than 400 days.
Staff reported that family physicians who admit patients to this unit tend to be reluctant to discharge their
patients in a timely fashion.
Evenings are extremely busy in this area given admissions from the ED and a high number of physicians
writing orders late in the day.
Staff is involved in the Health Links program focused on high users (CHF/COPD) and meet with
Chigamik once a month to review progress in this area.
Utilization could be improved with:
A more rigorous approach to the Home First initiative;
Increased utilization of low occupancy convalescent care beds available at Georgian Manor;
More effective engagement of the CCAC Case Manager in this unit; and
Enhancement of Discharge Bullet rounds by including physicians in this patient review process.
60
RECOMMENDATIONS
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 hospitalists and family
physicians in these rounds.
Recommendation 78: Enhance partnership with CCAC personnel and engage them more effectively in discharge planning.
Recommendation 79: Consistently adhere to Expected Date of Discharge (EDD) Guidelines.
Recommendation 80: Explore the possibility of providing a Discharge Clinic for discharged medical patients run by the
hospitalists out of Ambulatory Care.
61
General Findings ICU

Currently the ICU is a 6 bed Level 3 Intensive Care Unit.
Patients are admitted and cared for by the Internist on call, and on occasion, a surgeon. Admission criteria
were last updated in January 2011. It is reported that admissions are determined by the internist on call, and
are not guided by specific criteria.
There are 2 additional beds in the ICU that can be used if required.
Occupancy varied from 78% to 96% in 2014/15.
The acuity of the patients is variable. It was reported by GBGH staff and physicians that:
Patients are frequently admitted for monitoring purposes due to concerns on the part of the physician
that higher level monitoring is not available on the medical inpatient units.
Palliative patients are frequently admitted.
The need for a Level 3 ICU is questionable.
Physician coverage on off-hours was identified as a significant issue by nursing staff. One physician will
direct nurses on occasion to not call him when he is the designated internist on call. Nurses report that
this occurs about 30% of the time that this individual is on call.
62
RECOMMENDATIONS
Recommendation 81: Document response times and incidents in which physicians on call direct staff to not call them.
This information should be shared with the Chief of Staff, and immediate action should be taken to ensure
that the on-call physician is actually on-call.
Recommendation 82: Partner with RVHC to ensure that higher acuity patients are transferred in a timely manner 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 partner more effectively with
RVHCs critical care program to improve the quality of care.
Operate these beds with 3 RNs on all shifts.
This will result in a reduction of 2.1 FTEs annually.
Recommendation 85: Enhance admission, transfer and discharge criteria, and implement the revised criteria consistently.
63
General Findings OR/PACU

The OR/PACU currently operates from Monday-Friday 07.30-15.00 hours. However, in reality, it
frequently runs cases after the scheduled hours of operations. GBGH currently operates 2 rooms with 25
scheduled blocks monthly. The total annual budget for the OR/PACU is $1.33M. The OR benefits from a
particularly dedicated Charge Nurse who diligently manages her resources with little technological support.
Services provided by the surgical team are listed below:
General Surgical cases (3 General Surgeons with 9 blocks of time/month)
Dental Procedures (2 blocks/month)
Pregnancy Terminations (1 block/month)
Opthalmology (4 blocks/month)
Gynecology (6 blocks/month)
Orthopedics (2 visiting orthopaedic surgeons with 2 blocks/month)
ENT (1 visiting otolaryngologist with 1 block/month)
Nurses provide support in the OR, PACU and conduct Preoperative clinics 2 days/week. They also are on
call for emergency procedures, including emergency endoscopies.
Surgical cases are both inpatient and ambulatory, and some paediatric procedures are done in the OR
(50% dental, some appendectomies and myringotomies).
Caesarian sections are done on as necessary basis, as well as emergency surgical procedures.
It is reported that many after-hours cases are not in fact emergency cases, and could be delayed until the
next operating day. There are a high number of call backs and add on cases. In 2014/15, there were a
total of 129 call-backs. The total costs associated with call-backs and overtime was $103,330 in 2014/15.
There are frequent room closures. In 2014/15, excluding a 7-day planned Christmas closure, the OR was
closed with no rooms open for 25 days. One room was closed for 20 days in the year.
It is also reported that surgeons blocks are not always fully booked.
64
Rehabilitation and Complex Continuing Care

Cost Per Weighted Unit of Volume
It has already been noted that cost per weighted unit of volume has been higher than expected for both slow
stream rehabilitation (CCC) and inpatient rehabilitation.
2012/13 Unit Costs
2013/14 Unit Costs
HBAM Funded Programs
Inpatient Rehabilitation
Complex Continuing Care
Actual
CPWU
19,543
608
Expected CPWU
13,508
573
Relative CPWU
145%
106%
Actual
CPWU
13,796
706
Expected CPWU
12,707
582
Relative CPWC
109%
121%
Per Diem Costs

GBGH Rehabilitation and CCC program per diem costs were compared to similarly sized programs in
Ontario.
Inpatient rehabilitation has a lower per diem ($518/day) than similarly sized rehabilitation programs
which have an average per diem of $685; and
CCC has a much higher per diem ($764/day) than similarly sized CCC programs which have an average
per diem of $583.
These programs are co-located on 1 North with 15 rehabilitation beds and 21 CCC beds, of which 3 are used
for palliative care. There have been historical issues with cost allocation between these services.
65
Figure 20: Rehabilitation Cost Per Day for GBGH and Similarly Sized Rehabilitation Programs
Description
CHATHAM-KENT HEALTH ALLIANCE
BELLEVILLE QUINTE HEALTH CARE
BRANTFORD BRANT COMMUNITY
SARNIA BLUEWATER HEALTH
NORTH BAY REGIONAL HEALTH CENTRE
PEMBROKE REGIONAL
BURLINGTON JOSEPH BRANT HOSPITAL
OTTAWA MONTFORT
RICHMOND HILL YORK CENTRAL
TORONTO HUMBER RIVER REGIONAL
CAMBRIDGE MEMORIAL
TORONTO EAST GENERAL
OWEN SOUND GREY BRUCE
STRATFORD GENERAL
CORNWALL COMMUNITY
WINDSOR REGIONAL
BARRIE ROYAL VICTORIA REG HC
MIDLAND GEORGIAN BAY GEN HOSPITAL
COHORT AVERAGE
GBGH RELATIVE TO COHORT
20102011YE
7,597
6,051
8,416
5,156
7,344
7,233
5,600
7,331
6,169
6,443
5,287
2,614
4,623
4,728
4,747
3,734
2,562
3,160
17,933
5,255
2,863
4648
5675
82%
REHABILITATION PATIENT DAYS

2011201220132012YE
2013YE
2014YE
9,589
10,320
10,453
6,421
6,382
8,245
8,402
8,321
9,186
5,672
8,946
8,976
8,596
7,300
8,229
9,917
9,811
8,699
6,921
7,934
7,269
5,866
8,334
7,879
7,447
7,289
7,355
3,737
4,948
5,208
5,684
7,114
6,239
6,167
6,319
5,200
5,574
5,216
4,511
4,744
5,067
4,544
4,585
4,602
4,561
4,424
4,948
4,748
4,686
5,009
3,657
3,552
3,595
2,808
3,450
3,766
3,143
3,381
3,499
18,413
18,841
11,670
9,906
6,489
3,798
2,678
2,701
2,466
5316
5398
5306
6280
6637
6448
85%
81%
82%
20142015YE
9,336
9,229
8,931
8,875
8,186
7,683
7,457
7,390
7,227
6,710
6,460
6,272
5,643
4,951
4,608
4,470
3,829
3,385
3,319
3,227
2,793
2,716
2,464
5147
5877
88%
20102011YE
529
605
564
599
693
788
694
636
629
440
430
1,062
503
797
665
608
861
434
616
619
449
747
575
130%
TOTAL PER DIEM

2011201220132012YE
2013YE
2014YE
605
626
645
603
670
660
602
560
536
678
554
581
649
698
658
654
758
716
661
651
711
746
595
681
637
680
698
777
694
581
608
631
453
500
552
395
367
387
794
782
674
515
460
556
839
754
700
702
712
688
627
617
631
431
794
728
406
657
496
650
599
734
727
755
834
443
447
949
678
682
504
583
636
658
116%
107%
77%
20142015YE
697
710
610
592
649
786
715
583
760
618
499
561
412
710
550
806
725
711
741
699
1,048
821
746
518
685
76%
66
Figure 21: CCC Cost Per Day

CCC PATIENT DAYS
Description
20112012YE
20122013YE
20132014YE
20142015YE
20102011YE
20112012YE
20122013YE
20132014YE
20142015YE
12,760
12,707
12,859
13,130
14,484
479
450
481
488
434
BROCKVILLE GENERAL
13,730
14,137
13,771
14,074
14,104
491
502
541
630
619
BRAMPTON WILLIAM OSLER
23,445
25,061
19,596
14,483
12,919
505
493
475
488
603
NEWMARKET SOUTHLAKE REGIONAL
11,798
11,953
11,871
11,922
11,931
472
583
623
588
577
8,698
9,326
10,517
10,490
11,667
449
500
497
495
487
PETERBOROUGH REGIONAL HEALTH CENTRE
9,748
10,092
10,191
11,267
10,791
692
642
601
541
513
13,920
29,131
23,993
13,535
10,766
426
515
511
584
550
CHATHAM-KENT HEALTH ALLIANCE
22,175
19,477
17,817
15,230
10,218
451
510
562
624
716
11,204
13,007
13,285
9,213
9,887
551
550
477
578
534
11,624
12,457
13,862
11,413
8,440
537
567
548
660
663
BELLEVILLE QUINTE HEALTH CARE
12,326
13,777
13,118
8,420
7,229
608
564
624
656
631
ORANGEVILLE HEADWATERS HC
7,208
7,297
7,956
7,057
7,134
594
599
588
662
565
8,746
8,718
8,772
8,940
6,980
721
711
552
629
647
PEMBROKE REGIONAL
6,650
6,620
6,929
6,936
6,586
575
457
358
360
380
HAWKESBURY & DISTRICT GENERAL
6,109
5,723
5,669
6,215
6,230
643
656
611
631
653
HUNTSVILLE MUSKOKA ALGONQUIN HC
7,793
8,192
8,569
7,260
6,226
646
594
648
677
605
STRATFORD GENERAL
6,937
7,054
6,775
6,890
4,870
593
602
652
639
730
MIDLAND GEORGIAN BAY GEN HOSPITAL
12,724
11,326
11,165
11,014
8,165
448
531
538
617
764
COHORT AVERAGE
11,463
12,631
12,091
10,381
9,439
555
559
550
584
583
111%
90%
92%
106%
87%
81%
95%
98%
106%
131%
GBGH RELATIVE TO COHORT
20102011YE
TOTAL PER DIEM
67
Rehabilitation Case Mix, Clinical Utilization and Outcomes

Four rehabilitation groups (stroke, fracture of lower extremity, other disabilities, and amputation of lower
extremity) account for 81% of all inpatient rehabilitation admissions with stroke accounting for 1/3rd of all
admissions.
Figure 22: GBGH Inpatient Case Mix
GBGH REHABILITATION GROUPS 2014/15
11 - Stroke
54
22 - Fracture of Lower Extremity
33
31 - Other Disabilities
22
18 - Amputation, Lower Extremity
19
25 - Cardiac
14 - Neurological
28 - Maj Mult Trauma, Oth Mult Trauma & Maj Mult Frac
24 - Other Orthopedic
23 - Replacement of Lower Extremity
16 - Non-Traumatic Spinal Cord Injury
15 - Traumatic Spinal Cord Injury
26 - Pulmonary
Grand Total
CLIENT COUNT
158
68
Review of clinical administrative data for GBGH inpatient rehabilitation led to the following findings:
Average LOS is has ranged from 26 days to 34.1 days over the past four years.
Total and active rehab LOS are close indicating that there is minimal waiting for discharge.
LOS efficiency (change in total function score/day) is low.
There is a general increasing trend in RPG-weighted case mix
Increased complexity on admission and
Decreasing total function score on discharge, with
A net increase in total function score change from 18.7 in 2011 to 22.2 in 2014
Increase in average total function score.
Figure 23: Rehabilitation Utilization, LOS Efficiency and Case Mix Trends
2011
2012
2013
2014
Case Mix Clients (COUNT)

Clients with a Complete Discharge FIM Instrument Assessment (COUNT)
Case Mix, Length of Stay (COUNT)
167
167
4373
165
165
5681
179
177
5423
158
158
4677
LOS (AVG)
LOS Efficiency (AVG)
Active Rehab LOS (AVG)
Active Rehab LOS Efficiency (AVG)
26
0.88
25.8
0.88
34.1
0.84
33.3
0.85
30.1
1.05
29.4
1.06
29.3
0.92
28.5
0.93
90.7
109.5
18.7
85.1
105.6
20.6
83
106.3
23.3
82.3
104.5
22.2
0.93
155
1.18
194
1.09
194
1.21
191
Discharge Fiscal Year
Total Function Score at Admission (AVG) - AD

Total Function Score at Discharge (AVG) - AD
Total Function Score Change (AVG) - AD
Cost Weight - Current Methodology (AVG)
Weighted Cases - Current Methodology (COUNT)
69
In comparison to peer hospitals, GBGH has room for improvement.

GBGH stroke patients in the least function level have an average LOS that is 52% higher than peers;
GBGH stroke patients in the mid functioning level have an average LOS that is 75% higher than peers.
With respect to improvement in functional scores at discharge, GBGH does slightly better than peer
hospitals. The data suggests that GBGH provides an effective rehabilitation service over an inordinately
long length of time. This helps to explain why cost per weighted unit is high, while cost per day is low.
Figure 24: Rehabilitation LOS Efficiency
2014-2015 GBGH
V OLUMES
A VERAGE T OTAL
F UNCTION S CORE AT
D ISCHARGE
M EDIAN T OTAL
F UNCTION S CORE
C HANGE ( DISCHARGE
MINUS ADMISSION )
Function
Level
Rehab
Patient
Group
(RPG)
GBGH
Count
GBGH
Peers
Diff
(days)
Diff
(%)
GBGH
Peers
Diff
(score)
Diff
(%)
GBGH
Peers
Diff
(score)
Diff
(%)
GBGH
Peers
Diff
(score)
Diff
(%)
least
1100
41.3
43.3
2.0
4.6
0.61
1.23
-0.62
-50.4
86.8
84.9
1.9
2.2
27.5
38
-10.5
-27.6
1110
12
54.4
35.7
18.7
52.4
0.52
1.06
-0.54
-50.9
87.5
78.8
8.7
11
27
30
-3
-10
1120
15
32.1
23.3
8.8
37.8
1.12
1.46
-0.34
-23.2
109.7
98.6
11.1
11.2
36
28
28.6
1130
25
21.8
3.2
14.7
1.56
1.27
0.29
22.8
123
105.2
17.8
16.9
39
22
17
77.3
1140
23
12.7
10.3
81.1
0.78
1.76
-0.98
-55.7
108
111.5
-3.5
-3.1
18
19
-1
-5.3
1150
19
24.2
13.8
10.4
75.4
0.92
1.5
-0.58
-38.7
115.1
110.5
4.6
4.16
22
17.5
4.5
25.7
1160
STROKE
mid
most
A VERAGE LOS ( DAYS )
A VERAGE LOS
E FFICIENCY
(T OTAL F UNCTION
S CORE CHANGE / DAY )
8.1
0.85
118.1
70
Complex Continuing Care Referral Sources

The vast majority (980 of 1111) complex continuing care patients were referred from acute care services in
the region.
Figure 25: GBGH Referral Sources for Complex Continuing Care
Referral Source
INPATIENT ACUTE CARE SERVICE
HOME CARE SERVICE
INPATIENT REHABILITATION SERVICE (GENERAL)
NOT APPLICABLE
INPATIENT CONTINUING CARE SERVICE
RESIDENTIAL CARE SERVICE (BOARD AND CARE)
INPATIENT REHABILITATION SERVICE (SPECIALIZED)
OTHER/UNCLASSIFIED SERVICE
INPATIENT PSYCHIATRY SERVICE
RESIDENTIAL CARE SERVICE (24-HOUR NURSING CARE)
Grand Total
Discharges
980
43
31
26
16
7
3
2
2
1
1111
Average
LOS
49.6
50.0
87.1
35.3
43.7
29.1
98.3
5.5
31.5
13.0
50.1
71
CCC Average Case Mix Index

The average Case Mix Index for GBGH is lower than the Ontario average in each of the past five years. In
Ontario, hospitals have experienced an increase in CMI year over year while GBGH is variable without an
upward trend.
Figure 26: GBGH Assessed CCC CMI versus Ontario Average
Fiscal Year
GBGH
Assessed CMI
Ontario
Assessed CMI
2010-2011
2011-2012
2012-2013
2013-2014
2014-2015
0.83
0.86
0.86
0.87
0.85
0.97
0.98
0.99
1.00
1.02
72
CCC Quality and Safety Indicators

Of some concern is the GBGH performance with respect to safety indicators. In particular,
th
The rate of falls is consistently above the 90 percentile in Ontario;

th
The rate of worsened stage 2 to 4 pressure ulcers is consistently above or near the 90 percentile.
GBGH performs well with respect to dealing with depression and the use of physical restraints.
Figure 27: CCC Quality Indicators
interRAI Quality Indicators
Safety
Taken antipsychotics without a diagnosis of psychosis
Has fallen
Worsened stage 2 to 4 pressure ulcer
Quality of life
Worsened mood symptoms of depression
Daily physical restraints
Has pain
Worsened pain
Ontario Complex Continuing Care, 2014-2015
GBGH
10th
percentile
Median
facilityadjusted
rate
90th
percentile
20142015
Q1
20142015
Q2
20142015
Q3
58
64
63
9.1
1.6
0.5
29.7
6.9
2.7
54.4
17.5
8.8
6.2
27.5
9.8
5.5
24.1
5.9
5.5
25.2
6.5
63
64
65
61
4.8
0.0
2.5
3.0
17.6
5.9
23.2
11.1
33.3
23.6
49.8
23.9
9
3.7
34.6
23.5
6.2
3.5
41.3
15.6
6.6
0
44.1
13.8
Overall
adjusted
rate
Number
of
facilities
32.0
9.6
2.8
20.3
7.8
19.2
12.3
73
General Findings -1 North

1 North is comprised of 15 Rehab beds, 18 CCC (Slow Stream Rehab) and 3 Palliative beds. Physician
coverage is provided Monday Friday, 07.00 23.00hrs. I North also has a dedicated Nurse Practitioner.
On call coverage is provided by the 3rd GP on call. Staffing has been revised over the past few months since
the move from the Penetanguishene site.
In addition to nurses and PSWs, Rehabilitation beds are supported by:
1 FT Physiotherapist and 1 FT Physiotherapist Assistant;
1 FT Occupational Therapist and1 Speech Language Pathologist who provides 15 hours of
service/week, as well as covering the entire hospital;
2 Social Workers who provide service 4 days/week. One of those SWs also covers the rest of the
hospital; and
1 FT Recreational Therapist.
In addition to nurses and PSWs, the CCC beds are supported by:
0.2 FTE Occupational Therapist;
07 FTE Physiotherapist; and
1 FT Physiotherapist Assistant.
A nurse completes MDS and FIM Assessments. An audit conducted by the consultants, revealed that
assessments are frequently completed two to three weeks after the patient has been on 1 North.
Assessments are not available in the patients medical records, so there is limited access to the
information collected. Plans of care are not focused early enough, and contribute to longer LOS.
Patients may not be discharged if ambulatory physiotherapy or SLP services are required. These patients
will go home on weekend passes, and are not discharged in a timely fashion. This results in delays in
getting patients who truly require active rehab into the 1 North beds.
The quality of palliative care is of some concern. The physical facility is not conducive to supporting a
good death, and staff may not possess the clinical expertise to mange these complex cases.
74
RECOMMENDATIONS:
Recommendation 86: Add 1 full shift of physiotherapy coverage on weekends
Focused and effective rehabilitation services should be provided 7 days per week. By maintaining
rehabilitation on weekends, it is expected that the service will be able to decrease LOS to more reasonable
levels.
Recommendation 87: Initiate assessments immediately upon admission to the unit
The assessments should be completed by the multidisciplinary team and serve as the basis of care planning
and goal setting. This will facilitate a decreased LOS.
Recommendation 88: Eliminate the practice of providing ambulatory rehabilitation on an inpatient basis with weekend
passes
The goal is to decrease LOS and increase access to this service. If LOS cannot be reduced and volumes
increased within 1 year, then GBGH should close beds in this area.
Recommendation 89: Conduct a review of clinical information practices and develop a new model that integrates the use of
assessments into care planning and delivery
75
Ambulatory Care
Day Surgery and Endoscopy Trends in Market Demand
GBGH catchment day surgery and endoscopy volumes have declined in each of the past four years.
The decline has been experienced, to varying extents, for all communities served;
The largest decline, experienced in 2014 was for residents of Penetanguishene and is due to the
repatriation of ECT to Waypoint.
Figure 28: GBGH Day Surgery & Endoscopy Catchment Population
MUNICIPALITY
(3306) MIDLAND
(3331) TINY
(3329) TAY
(3348) SPRINGWATER
(3317) WASAGA BEACH
ALL OTHER MUNICIPALITIES
Grand Total
2010
1430
1642
675
603
254
248
514
5366
2011
1580
1575
810
637
253
212
571
5638
2012
1539
1528
776
641
194
216
553
5447
2013
1427
1359
813
642
189
197
438
5065
2014
1373
865
731
560
177
176
415
4297
76
GBGH day surgery cases are predominantly in one of four major ambulatory clusters:
Digestive system procedures account for more than half of GBGH day surgery cases and have remained at
or above 2500 cases over the past five years;
Eye procedures were the second most common procedure in 2014, though service volumes have
fluctuated from a low of 589 in 2014 to a high of 831 in 2012;
Mental Health procedures fell to near zero volumes in 2014 from more than 1,000 cases three years ago
due to the Waypoint repatriation of ECT services provided to residents of the catchment and, in particular
the residents of Penetanguishene; and
Urological and Gyneacological procedures, the majority of which are cystoscopy.
Figure 29: GBGH Day Surgery & Endoscopy Volumes by Major Ambulatory Cluster
MAJOR AMBULATORY CLUSTER
BLOOD AND LYMPHATIC SYSTEM
DIGESTIVE SYSTEM
EAR NOSE MOUTH AND THROAT
EYE
HEPATOBILIARY SYSTEM AND PANCREAS
KIDNEY GENITOURINARY TRACT MALE & FEMALE REPRODUCTIVE SYSTEM
MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE
NERVOUS SYSTEM
RESPIRATORY SYSTEM
SKIN SUBCUTANEOUS TISSUE AND BREAST
EXAMINATION AND OTHER HEALTH FACTORS
MENTAL D&D
UNGROUPABLE
Grand Total
2010
2551
185
800
119
508
114
16
1
14
70
988
5366
2011
2
2917
178
705
112
498
77
24
2012
9
2744
150
831
120
436
100
22
2013
2
2490
151
702
116
476
147
27
24
59
1042
20
79
936
5638
5447
24
67
862
1
5065
2014
2
2569
170
589
89
470
118
19
1
20
65
184
1
4297
77
GBGH has provided a small volume of pediatric day surgery. In 2014 there were only 121 pediatric surgical
procedures:
More than half of these cases (63) in 2014 were for dental procedures;
18 cases were tonsillectomy/adenoidectomy;
13 cases were myringotomy; and
21 cases were procedures with fewer than four pediatric cases in 2014.
Figure 30: GBGH Pediatric Day Surgical Case Volumes in Fiscal 2014
CACS
C101
C105
C109
C251
C253
C256
C257
C259
C260
C282
C353
C469
C470
E755
C999
DESCRIPTION
Tonsillectomy/Adenoidectomy
Myringotomy with Tubes
Dental/Periodontal Intervention
Inspection Digestive Tract
Hernia Repair, Open Approach
Other Major Digestive System Intervention
Other Minor Digestive System Intervention
Biopsy Lower Digestive System
Biopsy Esophagus, Stomach
Cholecystectomy
Abdomen & Trunk Skin Intervention
Other Minor Female Reproductive Intervention
Termination of Pregnancy
Intervention Not Carried Out
Intervention Not Generally Ambulatory
Total
2014 GBGH CASES

18
13
63
3
2
3
1
4
1
1
1
1
2
4
1
121
78
Day Surgery & Endoscopy Market Share

For the primary GBGH catchment and excluding mental health procedures (ECT),
GBGH market share for day surgery declined 2.5% from 34.3% of cases in 2010 to 31.7% in 2014;
RVH, the second largest provider experienced a small decline in market share to 22.4%; and
OSMH, CGMH and hospitals outside the NSM LHIN each experienced an increase in market share of 1%
or more.
Figure 31: GBGH Market Share Trend for Day Surgery & Endoscopy (Excluding Mental Health)
PROVIDER
CASES
2010
2011
2012
MARKET SHARE
2013
2010
2011
2012
2013
2014
GBGH
4,141
4,373
4,255
3,962
3,877
34.3
35.1
34.1
33.4
31.7
RVHC
2,817
3,020
2,889
2,504
2,736
23.3
24.3
23.2
21.1
22.4
OSMH
1,902
1,890
1,931
1,994
2,050
15.7
15.2
15.5
16.8
16.8
CGMH
1,127
1,144
1,187
1,213
1,251
9.3
9.2
9.5
10.2
10.2
0.1
WCMH
MAHC
2014
77
52
47
46
62
0.6
0.4
0.4
0.4
0.5
Non-NSM
2,016
1,966
2,158
2,149
2,250
16.7
15.8
17.3
18.1
18.4
Grand Total
12,080
12,445
12,467
11,868
12,233
100
100
100
100
100
79
Clinical Support Services

Clinical Laboratories General Findings
GBGH offers laboratory services (chemistry, hematology, Blood Bank) 24/7. The department also provides
phlebotomy services as well as ECGs and non stress tests. RVHC provides medical leadership, as well as
support in areas such as microbiology.
The Laboratory has been under a great deal of scrutiny lately given the decision of the hospital to cease
providing outpatient ambulatory laboratory services. This accounted for approximately 50% of its
volumes but not total workload. This decision was implemented on September 8th, 2015.
Target savings associated with this initiative have been quoted as ranging from $1.3M to $700K. The
consultants were unable to obtain a clear business plan for this decision. They were provided with a
number of potential schedules, email messages and high-level financial analyses. A Briefing Note dated
May 15, 2015 was also provided. The Note focused on number of samples, and not the true impact of
workload. Fixed non-service recipient laboratory workload will remain largely unchanged even with the
reduction in samples collected. Staff is still required to do calibrations, QC and other activities that will
not be impacted by the outpatient closure.
Morale among the front line staff is understandably low, as they feel they have been misled by the
hospital. They were informed of the decision, however, it was pitched as leading to a reduction in part
time hours. This is in fact true, and no immediate job losses were incurred as a result of the decision.
However, the new schedule results in a reduction of 10,400 hours/year that equates to 5.4 FTEs. All of
the part time staff have seen their hours reduced significantly, and it is having a profound impact on the
money that they take home on a bi-weekly basis. Many are looking for other work, and will likely leave
GBGH. It is also assumed that there will be a large number of grievances submitted as a result. GBGH
should explore opportunities to provide part time Laboratory staff with as many hours as possible.
80
RECOMMENDATIONS
Recommendation 90: Adjust the Clinical Laboratory target savings estimate to $300,000 this fiscal year, and $600,000
annually on a go forward basis.
These savings include annual costs of $200,000 for contracted out work associated with the outpatient
laboratory.
81
Diagnostic Imaging
Diagnostic Imaging Services are provided on a 24/7 basis at GBGH. Modalities provided include general
radiography, ultrasound, CT (contract and non-contrast), and bone densitometry.
The department is staffed with 13 Radiology Technologists (of which 4 are CT technologists), 3 Allied
Health Assistants, and 3 full time Ultrasound Technologists.
With the exception of the Ultrasound Technologists and 1 Technologist who is a dedicated CT
Technologist and supports the PACS 3 days/week, all the staff are part time.
The biggest issue this department faces is the high number of call-backs on weekday off hours, weekends
and holidays. The Manager estimates that call backs will account for almost $60,000 in costs this year.
The primary reason for the high number of call-backs is the high number of CTs ordered by ED
physicians.
The issue was raised with the Emergency Physician Chief who agreed that there might be opportunities
to improve CT utilization.
According to DI staff, a protocol for CT utilization was developed, but is not followed. When ED
physicians are aware that a CT Technologist is in house, the number of CT requisitions tends to
increase.
The other complicating factor is that only 4 Technologists can provide contrast. Therefore, when contrast
is required, if the Technologist that is on duty is unable to provide this service, someone else is called in.
Staff does not feel they have a positive collaborative relationship with key departments such as ED.
Morale in the department is very low. They do not feel supported by their Manager, and are resentful of
the fact that a union member does the schedule. There are a number of outstanding grievances with
respect to scheduling, seniority and work environment in this department.
82
RECOMMENDATIONS
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; Ordering Physician; 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 increase the numbers of
full time staff.
Recommendation 95: Establish a DI/ED Council to meet on a quarterly basis to discuss issues affecting service in each
department. This council should include representation from Georgian Bay Radiology.
83
Pharmacy
The Pharmacy operates from 06.30 18.00 hours on weekdays, and 06.30 14.30 hours on weekends. It is
staffed with a Pharmacy Manager, 4 Pharmacists and 8/9 Pharmacy Technicians (approximately 6.5 FTEs).
The department implemented a new distribution system - an automated oral solid packager in January
2015. By all accounts this has not gone well. The Manager identified a number of concerns about the
new processes, and felt that the solution was additional staff. Pharmacy staff in the focus group expressed
frustration as well, and is concerned about the new system. They feel as if their suggestions are falling
on deaf ears.
The incidence of medication errors is increasing. However there is little follow-up.
There is role confusion between the Pharmacists and Pharm Techs.
The Manager provided the consultant with a list of significant challenges and concerns confronting the
department, but was unable to identify potential solutions.
RECOMMENDATION
Recommendation 96: Conduct a focused review of Pharmacy operations by an experienced Pharmacy Leader.
84
CLINICAL SERVICES SUSTAINABILITY AND THE ROLE OF GBGH IN THE LHIN

Context
One of the principle objectives of the review was to:
Assess GBGHs current and future clinical service profile and service sustainability; and
Make recommendations that apply to GBGH as a singular organization and to the wider local health
system of which it is a part.
There are three clinical services that require focused attention and immediate action.
Acute Mental Health;
Obstetrics and Neonatology; and
Surgical Services.
The following recommendations related to these programs are not made to achieve a fiscal imperative.
Rather, they are all strictly based on the objective of providing high quality care in the most appropriate
setting. The goal is to enhance quality, sustainability, and access to the best care for the communities served
by GBGH.
85
Mental Health
The need to expedite the transfer of acute care beds from Waypoint to GBGH is widely recognized.
However, the proposed transfer of financial resources from Waypoint to RVH and GBGH was based on
using the Health Restructuring Implementation Team (HRIT) methodology with:
Waypoints Ontario Cost Distribution Methodology (OCDM) rate and patient days for 2010/11 for its
acute mental health unit were calculated, forming the basis for the proportional re-allocation of funding
for the 31 beds.
An assumption was made that incremental variable overhead operating costs would be offset by increased
non-MOHLTC revenue.
Opportunities will be pursued between GBGH and Waypoint to address Day Hospital requirements in a
collaborative manner.
The proposed funding reallocation
Excludes start-up expenses, as well as room/unit capital set-up requirements.
Excludes stipend and sessional fees.
The funding envelope for the transfer of beds to GBGH will be adjusted annually by Waypoints annual
MOHLTC funding adjustment rate.
86
Figure 32: NSM Funding Transfer Agreement Parameters for Acute Mental Health
Funding Data
Waypoint
Funding Agreement Current State

2010/11 OCDM rate
2010/11 patient days
2010/11 funds available for reallocation
plus 1.2% (Waypoint budget adjustment for 2011/12)
2011/12 funds available for reallocation
2011/12 cost per bed
Proposed Future State
2011/12 cost per bed
Other Adjustments
Total Re-allocation
31 beds
$533.29
8,717
$4,648,688.93
$55,784.27
$4,704,473.20
$151,757.20
Royal Victoria
Hospital
Georgian Bay
General
Hospital
25 beds
$446.75
8,878
11
151,757.20
$1,669,329.20
20
151,757.20
74,958.47
$3,110,102.47
The proposed funding of $3.1 million will not support a high quality acute mental health service at GBGH
since, unlike RVH,
GBGH does not have an acute mental health program to build on the beds are not incremental, and so
the costs are not marginal;
GBGH does not have ambulatory mental health that will augment the services provided on an acute
inpatient basis
There is no question that there is a need for these beds, and that the service would be more accessible and
appropriately sited at GBGH.
87
By contrast, a funding target is proposed as follows:

20 beds operating at 95% occupancy at OSMHs 2014/15 full per diem cost ($749) for acute mental
health ($5.193 million in acute inpatient costs);
An investment in ambulatory mental health based on OSMHs ambulatory care percentage of acute
expenditures for mental health (15%). Applied to GBGHs 20 beds, this would amount to $0.766 million
for ambulatory mental health; and
Target funding is therefore, approximately $6 million, and almost twice the amount in the current funding
transfer agreement.
RECOMMENDATIONS
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 mental health 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 for acute mental
health and $0.766 million for ambulatory care.
88
Obstetrics and Neonatology

GBGHs birthing program:
Has experienced declining volumes and market share as local patients have increasingly selected other
providers in the LHIN;
Does not have the critical mass required to support the effective and safe provision of service;
Has frequently experienced shortages of obstetricians, anaesthetists and nurses which has necessitated
closing the program for periods of time;
Has consistently had poor outcomes on established measures of appropriateness and risk;
Does not have sufficient volume to support an economically viable cadre of 3-5 obstetricians; and
Has a limited market of gynecological inpatient and day surgical procedures.
At the time of report submission, the program was at risk due to the impending retirement of the lone GBGH
obstetrician.
89
Birthing Program Market Share

The Birthing Program includes Obstetrics and Neonatology. For GBGH, the catchment volumes are
relatively flat, though GBGHs market share trend is troubling:
Over the past five year the hospital has saw market share decline from less than one-third to less than one
quarter of obstetrics and neonatology case volumes.
Figure 33: Birthing Volume and Market Share for GBGH Primary Catchment Area
Obstetric and Neonatology Cases
Provider
2010
2011
2012
2013
Birthing Program Market Share

2014
2010
2011
2012
2013
2014
Discharges
GBGH
NSM LHIN Hospitals
Hospitals Outside LHIN
483
1098
36
477
1114
21
441
1145
40
396
1137
26
393
1237
44
30%
68%
2%
30%
69%
1%
27%
70%
2%
25%
73%
2%
23%
74%
3%
Weighted Cases
GBGH
NSM LHIN Hospitals
Hospitals Outside LHIN
179
576
14
175
562
8
165
633
17
142
572
11
148
624
16
23%
75%
2%
24%
75%
1%
20%
78%
2%
20%
79%
2%
19%
79%
2%
1,617
1,612
1,626
1,559
1,674
100%
100%
100%
100%
100%
768
746
815
725
788
100%
100%
100%
100%
100%
Total Discharges
Total Weighted Cases
90
Even when excluding secondary and tertiary cases and focusing on low-risk primary obstetrical and
neonate care, market share has fallen from 34% in 2010 to 30% in 2014.
Figure 34: Discharge Market Share for Obstetric and Neonatology
Level of Care and Provider
Neonatology
Obstetrics
2010
2011
2012
2013
2014
2010
2011
2012
2013
2014
Primary Discharges
GBGH
NSM LHIN Hospitals
CGM
RVHC
OSMH
Other Ontario Hospital
696
29%
68%
16%
27%
25%
2%
678
31%
68%
17%
28%
22%
1%
651
27%
70%
16%
27%
26%
3%
625
26%
72%
16%
28%
27%
2%
699
24%
74%
18%
29%
26%
3%
444
34%
63%
16%
23%
23%
3%
428
34%
65%
18%
25%
21%
2%
437
34%
65%
18%
20%
26%
2%
431
32%
66%
19%
23%
24%
2%
425
30%
68%
21%
23%
24%
2%
Secondary Discharges
GBGH
NSM LHIN Hospitals
CGM
RVHC
OSMH
66
24%
76%
3%
26%
47%
0%
73
18%
81%
5%
27%
47%
1%
84
21%
76%
5%
23%
49%
2%
83
17%
83%
13%
25%
45%
0%
82
16%
82%
9%
26%
48%
2%
378
29%
69%
14%
29%
26%
2%
389
29%
70%
13%
30%
28%
1%
379
22%
75%
11%
33%
31%
3%
372
21%
78%
12%
28%
37%
2%
426
20%
77%
13%
32%
32%
3%
Tertiary Discharges
GBGH
NSM LHIN Hospitals
29
10%
90%
0%
40
0%
100%
0%
65
11%
89%
0%
46
7%
93%
0%
39
5%
95%
0%
4
25%
75%
0%
4
0%
100%
0%
10
50%
40%
10%
2
50%
50%
0%
3
0%
100%
0%
91
Related to the viability of the obstetrical practice at GBGH is consideration of the surgical gynecology
volumes related to the GBGH catchment. Day surgery and inpatient cases are declining for GBGHs
catchment population, as has GBGHs share of this declining market.
Figure 35: Gynaecology Day Surgery Market Share
PROVIDER
GBGH
RVHC
OSMH
CGMH
MAHC
Non-NSM
Total
2010
178
116
111
43
2
67
517
DAY SURGERY CASES

2011
2012
2013
158
156
138
107
111
110
84
85
106
58
51
51
0
0
1
56
68
63
463
471
469
2014
138
109
100
65
5
59
476
2010
34%
22%
21%
8%
0%
13%
100
MARKET SHARE
2011
2012
2013
34%
33%
29%
23%
24%
23%
18%
18%
23%
13%
11%
11%
0%
0%
0%
12%
14%
13%
100
100
100
2014
29%
23%
21%
14%
1%
12%
100
2010
24%
8%
29%
27%
0%
12%
100%
MARKET SHARE
2011
2012
2013
32%
22%
24%
11%
9%
8%
27%
28%
35%
26%
33%
23%
0%
0%
0%
5%
8%
10%
100%
100%
100%
2014
18%
6%
35%
33%
1%
7%
100%
Figure 36: Gynaecology Inpatient Surgery Market Share

PROVIDER
GBGH
CGM
RVHC
OSMH
MAHC
Non-NSM
Grand Total
2010
50
16
60
56
24
206
INPATIENT CASES
2011
2012
2013
63
43
39
21
17
14
52
53
58
51
64
38
9
15
16
196
192
165
2014
30
10
59
56
1
12
168
92
Birthing Program Appropriateness and Effectiveness

The Canadian Institute of Health Information (CIHI) reports the rates of Low-Risk Caesarian Sections as a
measure of Appropriateness and Effectiveness. The most recent data suggests that GBGH low-risk
Ceasarian Section rates (22.8%) have been higher than the comparable rates for:
The Other medium community hospitals 15.2%;
The NSM LHIN 15.1%;
Ontario 14.8%; and
Canada 13.9%.
Birthing Program Risk
Confidential and proprietary data regarding the number of sentinel events resulting in claims per 100
deliveries at GBGH was shared with the consultants and the Operational Review Steering Committee. This
data indicates that:
GBGH has had a claim rate 6.25 times the rate of all hospitals over the past five years, and
GBGH had a rate that was 22 times higher in 2014.
93
Birthing Program Reliability

Obstetrical Service closures amounted to 325 hours in 2014:
112 hours were due to a lack of nursing availability
204 hours due to a lack of medical availability.
Delivering mothers are redirected to OSMH or CGMH during these periods. The closures of obstetrics have
ranged from 156 hours per year to 679 hours per year over the past 5 years.
Birthing Program Reputation

The market share trends noted previously are understood in terms of the current reputation of the program.
During the consultation, the following perspectives were shared with the consultants:
My midwife told me to deliver in Collingwood.
OSMH is too interventional and
GBGH is very old school;
I have two daughters and I would not let them deliver here; and
We come a long way only to find out that the program is closed and we have to go to OSMH anyway".
94
Summary of Key Findings for the Obstetrics and Neonatology Program at GBGH
Significant reputation issues;
Quality and Risk Issues;
Physician support has been inadequate;
GBGH birthing (obstetrics and neonatology) volumes and surgical gynaecology volumes have been
declining on a case and weighted case basis;
Increasingly, the catchment population has been choosing to receive their maternity care and
gynecological surgical care at other LHIN hospitals including CGMH, RVH and OSMH;
GBGH market share has declined across all levels of care dispelling any suggestion that the trend in
market share has anything to do with patient needs for higher levels of care;
The market is not growing in size;
Repatriation of all activity would still have trouble supporting 3-5 obstetricians for 24/7 call;
The average obstetrician in Ontario handles approximately 220 births per year; and
The surgical gynaecology market is not as large as many stakeholders believe.
RECOMMENDATIONS
Recommendation 100: Close the obstetrical program and pursue a partnership with OSMH for all obstetrical, gynecological
and pediatric care.
Reduce staffing by 1 RN 24/7 (4.2 FTEs) on 2 North concomitant with program closure;
Reassign remaining 1 RN 24/7 (4.2 FTEs) to 2 North; and
Reduce 2 North nursing FTEs by an additional 2 in 2017/18.
Note that the initial reduction in staff is 50% of the current budget allocation for obstetrics.
95
Surgical Services
The following summarizes some of the key findings from the review of GBGHs surgical program.
Frequent room closures due to a lack of cases being booked and/or the availability of surgery/anaesthesia;
OR blocks that are available and staffed are not fully utilized;
Lack of rigour with respect to OR start times and other OR metrics;
There are a high number of expensive overtime premium after-hour cases that are not emergent;
Procedures such as cataracts and pregnancy terminations currently performed in the OR would be better
provided in a less acute ambulatory care setting;
Overtime costs are high despite the high number of unused blocks; and
With the proposed closure of obstetrics, there is no longer a need for caesarian section coverage.
RECOMMENDATIONS
Recommendation 101: Reconfigure the OR schedule to operate 3 days/week with 13 blocks per month.
This model will not affect the 3 General Surgeons or the visiting orthopaedic surgeons and otolaryngologist.
Their blocks will remain the same.
Recommendation 102: Reallocate ophthalmology procedures to a designated space in Ambulatory Care (consistent with
best practice), and recover patients in the same area.
To support these transfers, 1 FTE RN should be reassigned from the OR to Ambulatory Care.
96
With the decision to close Obstetrics and Gynecology, there will be no requirement for elective OR time or
emergent OR time for Caesarian sections; there will be opportunities to reduce scheduled blocks as well as
call back.
Recommendation 105: GBGH should develop clear criteria to guide the decision to conduct surgical procedures after regular
hours. These criteria should be applied consistently in all situations in which a request is made to conduct a case after hours
and is a joint administrative and medical decision.
The majority of emergent cases should be transferred to OSMH or RVHC.
Given the low volume of paediatric surgery there is inadequate critical mass to support offering this
service.
OSMH offers first-rate paediatric care and is 40 minutes away.
97
The Role of GBGH in the LHIN

GBGH has an important role to play in the provision of care to the residents of Midland, Penetanguishene,
Christian Island and the Townships of Tay and Tiny.
Specifically:
Emergency Department GBGH should remain the primary provider of high quality and timely
emergency 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-organ
failure 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 economically provided by itinerant surgeons.
Complex Continuing Care and Rehabilitation GBGH should provide clinically efficient and effective
rehabilitation 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 appropriate
GBGH based ambulatory mental health care services. The model should share medical staff and
program management.
98
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.
Figure 37: GBGH Inpatient Bed Projections
BEDS
Medical & Surgical
Obstetrics
ICU
CCC
Rehab
Mental Health
Total Beds
2015/16
60
3
6
21
15
0
105
2016/17
60
0
4
21
15
0
100
2017/18
2018/19
55
0
4
21
15
0
95
2019/20
55
0
4
21
15
0
95
55
0
4
21
15
20
115
99
FINANCIAL IMPACT OF RECOMMENDATIONS

Summary of Recommended Savings and Reinvestments
The recovery plan recognizes one-time and ongoing savings, increases in revenues and recoveries, and onetime and ongoing reinvestments:
$395K in one time reinvestments and $230K in ongoing reinvestments that are thought to be critical to
GBGHs ability to implement the recovery plan;
$1.5 million in one-time LHIN funding to be received in fiscal 2015/16;
$5.2 million reduction in net expenses by 2018/19; and
$6 million for 20 mental health beds with ambulatory mental health supports are added to GBGH in 2019.
Figure 38: Cumulative Impact of Recommendations
IMPACT OF RECOMMENDATIONS
Ongoing Savings
Ongoing Reinvestments
Ongoing Recoveries Increase
New Program Funding
New Program Expenses
One Time Revenue Increase
One Time Investment
Total Revenue & Recoveries Increase
Total Expense Decrease
Total
2015/16
$550,000
$$$$$1,500,000
$395,000
$1,500,000
$155,000
$1,655,000
2016/17
$2,170,333
$280,000
$100,000
$$$29,333
$0
$129,333
$1,890,333
$2,019,667
2017/18
$4,858,025
$230,000
$100,000
$$$0
$0
$100,000
$4,628,025
$4,728,025
2018/19
$5,108,025
$230,000
$100,000
$$$0
$0
$100,000
$4,878,025
$4,978,025
2019/20
$5,108,025
$230,000
$100,000
$6,000,000
$6,000,000
$$$6,100,000
-$1,121,975
$4,978,025
100
Clinical and Clinical Support Services Initiatives

For clinical and clinical support services:
Total savings targets are $3.5 million to be achieved by 2017/18.
Total revenues for mental health and ambulatory care are targeted at $6 million in 2019.
Figure 39: Financial Summary of Clinical and Support Services Initiatives
INITIATIVE
(CUMULATIVE SAVINGS)
SAVINGS INITIATIVES
ICU Closure of two beds
2 North Staffing Adjustments
2 North Staffing Efficiencies (2.0 FTE)
Medical Bed Utilization Improvement
Reduction of Evening Supervisor
OR Efficiencies/Redesign
Outsourcing of Laboratory Services
TOTAL CLINICAL AND CLINICAL SUPPORT SAVING INITIATIVES
REVENUE INITIATIVES
20 Mental Health Beds & Ambulatory Care
TOTAL CLINICAL AND CLINICAL SUPPORT REVENUE INITIATIVES
TOTAL CLINICAL AND CLINICAL SUPPORT INITIATIVES
ESTIMATED ANNUAL SAVINGS/REVENUE AND INVESTMENTS

2015/16
$300,000
$300,000
$0
$300,000
2016/17
2017/18
2018/19
2019/20
$186,438
$373,896
$223,725
$448,675
$220,000
$1,200,000
$146,625
$700,000
$600,000
$3,539,025
$223,725
$448,675
$220,000
$1,200,000
$146,625
$700,000
$600,000
$3,539,025
$223,725
$448,675
$220,000
$1,200,000
$146,625
$700,000
$600,000
$3,539,025
$0
$3,539,025
$6,000,000
$6,000,000
$9,539,025
$400,000
$600,000
$1,560,333
$0
$1,560,333
$0
$3,539,025
101
Corporate Services
For corporate services:
Total savings targets are $1.6 million to be achieved in 2018/19.
Ongoing increases in recoveries of $100K are targeted for 2016/17.
Figure 40: Financial Summary of Administrative & Support Services Initiatives
INITIATIVE
SAVINGS INITIATIVES
Closure of Cafeteria
Closure of Penetang Site
Health Pro Savings
Food Services
TOTAL CORPORATE SERVICES SAVINGS INITIATIVES
REVENUE INITIATIVES:
Increased Revenue for Security Services
TOTAL CORPORATE SERVICES REVENUE INITIATIVES
TOTAL CORPORATE SERVICES INITIATIVES

2015/16
2016/17
2015/16
2018/19
2019/20
$90,000
$250,000
$500,000
$20,000
$610,000
$90,000
$459,000
$750,000
$20,000
$1,319,000
$90,000
$459,000
$1,000,000
$20,000
$1,569,000
$90,000
$459,000
$1,000,000
$20,000
$1,569,000
$0
$250,000
$100,000
$100,000
$710,000
$100,000
$100,000
$1,419,000
$100,000
$100,000
$1,669,000
$100,000
$100,000
$1,669,000
$250,000
102
ONGOING AND ONE-TIME INVESTMENTS

The recommendations include:
One-time investments of $395K for 2015/16;
Ongoing investments of $230K by 2018/19; and
Ongoing investment of $6 million in acute and ambulatory mental health.
Figure 41: ONGOING AND ONE-TIME INVESTENTS
INITIATIVE
ON-GOING INVESTMENTS:
Additional Physiotherapy support weekends 1 North
Enhance Leadership and Medical Remuneration Model
Staff Engagement Survey Instrument
20 Mental Health Beds
TOTAL ON-GOING INVESTMENTS
ONE -TIME INVESTMENTS
Budget and Reporting Software
Management Education/Training
Explore Partnerships with RVH/CCAC
Pharmacy Review
Review of CCC & Rehab Clinical Data Capture and Utilization
TOTAL ONE TIME INVESTMENTS
TOTAL INVESTEMENTS

2015/16
2016/17
2017/18
2018/19
2015/16
$40,000
$140,000
$100,000
$40,000
$140,000
$50,000
$40,000
$140,000
$50,000
$0
$280,000
$230,000
$230,000
$40,000
$140,000
$50,000
$6,000,000
$6,230,000
$70,000
$200,000
$50,000
$50,000
$25,000
$395,000
$395,000
$0
$280,000
$0
$230,000
$0
$230,000
$0
$6,230,000
103
Other Revenue and Recoveries

Other revenues and recoveries include:
One time LHIN funding to be received in 2015/16; and
Additional rent of $29K in 2016/17.
Figure 42: Other Revenues and Recoveries
INITIATIVE(CUMULATIVE SAVINGS)

2015/16
One Time Revenue Adjustment

LHIN One Time Funding(additional revenue)
Penetang Rent Increase
Total One-Time Revenue Adjustment
2016/17
2017/18
2018/19
2019/20
$29,333
$29,333
$0
$0
$0
$1,500,000
$1,500,000
104
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 by 2017/18.
Inflationary pressures will require GBGH to implement further improvements or receive additional base
funding 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-time
revenues. It is assumed that any proceeds from the sale of the building will be used to reduce hospital
debt.
Figure 43: Projected Financial Performance
PROJECTED FINANCIAL PERFORMANCE
Total Revenue
Total Expenses
Amortization
Surplus/Deficit
2014/15
2015/16
2016/17
2017/18
2018/19
$56,726,909 $56,705,957 $55,346,187 $55,316,854 $55,316,854
$56,950,688 $57,096,780 $56,595,558 $55,077,523 $56,017,265
($223,779)
($390,823) ($1,249,370)
$239,331
($700,411)
($1,045,538)
($943,996)
($943,996)
($943,996)
($943,996)
($1,269,317) ($1,334,819) ($2,193,366)
($704,665) ($1,644,407)
2019/20
$61,316,854
$63,231,460
($1,914,606)
($943,996)
($2,858,602)
($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 lags
behind performance by two years.
105
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
Appendix 2. Board Leadership is responsible for monitoring performance with respect to the successful
implementations of the recommendations of this report.
106
APPENDIX 1 INTERVIEWS AND FOCUS GROUPS

INTERVIEWS AND OPEN DISCUSSIONS
BOARD
INTERVIEWS
B. Scott,
N. Foot,
J. Lees,
S. Lankshear,
R. Befort,
SPECIAL MEETING OF THE GBGH
BOARD
Chair Board Quality & Safety Committee

Board Member & Past Chair
Chair Audit & Finance Committee
Vice Chair Board of Directors
Chair Board of Directors
Discuss the scope, objectives and context for the operational review.
ADMINISTRATION
INTERVIEWS
K. McGrath,
J. Kurvink,
L. Canadic,
J. McLaughlin,
B. Whittaker,
President & CEO

VP Corporate Services & CFO
VP Patient Services & CNE
Director Communications & Health Information
Director, Human Resources & Support Services
107
ADMINISTRATION, FINANCE AND CORPORATE SERVICES

INTERVIEWS
J. McCutcheon,
B. Durrwachter,
C. Brake,
D. Payne,
B. Dorion-Duquette,
C. Ayres,
D. Charbonneau,
O. Harries,
Andree Gagnon,
David Gravelle,
FOCUS GROUPS
WITH FRONT LINE STAFF
Director, Finance
Manager I.S.
Manager Food Services/Housekeeping
Manager Facilities & Operations
Manager Health Records/Privacy
Manager Supply Chain
Decision Support Analyst
Transformation Leader
Human Resources Analyst (staffing/scheduling)
Physician Recruitment Officer
22 front line corporate staff members
3 front line clerical staff
3 Executive Assistants
108
CLINICAL SERVICES
INTERVIEWS
Nancy Bradley,
Sheree Noon,
Dawn Major,
Sue Salway,
Theresa Hartley,
Leigh Pallister,
April Hawke,
Cindy Hawkins,
Jacquie Belcourt,
Judy Eakley,
Mary Falls,
Lisa Ladouceur,
Kerry Zimmer,
Karla Trewin,
Mr. Philip Debruyne,
Director, Rehabilitation, Geriatric Services & Quality Management

Director, Acute Care Services
Manager, Quality, Utilization & Risk
Manager, 1 North
Interim Manager, ICU, ED & Respiratory Therapy
Manager, Perioperative Services, MDRD, Ambulatory Care & OTN
Manager, 2 North & Float Pool
Manager, 2 East, Infection Control & Supervisors
Manager, Pharmacy
Manager, DI & Laboratory (interim)
Interim Laboratory Lead
Outpatient Nurse Practitioner
Clinical Educator
Nurse Educator
Past GBGH patient
109
CLINICAL SERVICES FOCUS GROUPS
FOCUS GROUPS WITH

FRONT LINE STAFF
8 clinical front line staff from the ICU & ED

6 clinical front line staff from the OR/PARR
6 clinical front line staff from 2 East (Medicine)
3 clinical front line staff from 2 North (Medicine/Surgery/Obstetrics/Paediatrics/PARR)
10 clinical front line staff from 1 North (Rehabilitation/CCC/Palliative Care)
11 front line Allied Health staff
8 front line DI staff
5 front line Laboratory staff
2 front line Ambulatory Care staff
110
PHYSICIANS
INTERVIEWS
Dr. J. Dolezel,
Dr. I. Wagg,
Dr. P. OHalloran,
Dr. J. Golisky,
Dr. E. Sacks,
Dr. M. Veall,
Dr. P. McGuire,
Dr. A. Mathai,
Dr. D. Bayfield,
Dr. R. Thomas,
Dr. V. Ralhan,
Dr. J. Nadarajah,
Dr. M. McNamara,
SPECIAL MEETING
OPEN DISCUSSION
Chief of Internal Medicine

Chief of Anaesthesia
Chief of Obstetrics
Chief of General/Family Medicine
Chief of Surgery
Chief of Staff
President Medical Staff Association
Chief of CCC, Rehabilitation & Palliative Care
Chief of Emergency Medicine
Chief of Hospitalists
ED Physician and Past VP, Medical Staff Association
GBGH Internist and Hospitalist
ED Physician and former Chief of Staff
Special Meeting of the MAC to discuss scope, objectives and context for the operational review.
Open discussion with approximately 15 GBGH front line physicians.
111
EXTERNAL STAKEHOLDERS
Carol Lambie,
Dr. J. Karagianis,
Janice Skot,
Ben Petersen,
Nancy Savage,
Pat Campbell,
Dr. Ardash Tailor,
Kathy Wolfer,
C. Minielly, PHN,
David Jeffrey,
Barry Monoghan,
Gerry Marshall,
Gord McKay,
Bill Johnston,
Marni Van Kessel,
Scott Warnock,
George Cornell,
Guy Chartrand,
OPEN DISCUSSIONS
President & CEO, Waypoint

Psychiatrist in Chief, Waypoint
President & CEO, Royal Victoria Hospital
VP, Corporate Services & CFO, Royal Victoria Hospital
Executive VP, Patient & Family Experience, RVH
President & CEO, Orillia Soldiers Memorial Hospital
LHIN Lead, Critical Care
Director, Client Services, NSM CCAC
Communicable Disease Program Liaison
Executive Director, Chigamik CHC
Interim CEO, North Simcoe Muskoka CCAC
Mayor, Town of Penetanguishene
Mayor, Town of Midland
Superintendent, Central North Corrections Centre
Regional Director NSM ORN & RKCP SM
Mayor, Tay Township
Mayor, Tiny Township
President & CEO, CGMH
GBGH Advisory Membership Group and GBGH Community Health Care Partners
112
THE NORTH SIMCOE MUSKOKA LHIN

Jill Tettman,
CEO
Neil Walker
COO
Dr. Rebecca Van Iersel
Physician Lead
Ligaya Byrch
Sr Manager Planning, Integration, Evaluation & Community Engagement
Jeff Kwan
Director, Financial Health and Accountability
113
APPENDIX 2 IMPLEMENTATION RESPONSIBILITY AND TIMELINES

RECOMMENDATION
RESPONSIBILITY
START
DATE
END
DATE
Recommendation 1: GBGH should immediately reinvigorate the Code of

Conduct.
Board Chair, CEO, CoS
Immediate
April 2016
Recommendation 2: All GBGH physicians should be required to sign the Code of

Conduct as part of annual credentialing.
Immediate
Annually
Recommendation 3: GBGH should consistently apply the expectations of the

Code of Conduct to all staff and physicians.
Immediate
Ongoing
Recommendation 4: GBGH should include staff satisfaction metrics into regular

Balanced Scorecard reporting.
Director, Human Resources
Immediate
December
2016
Recommendation 5: All GBGH position descriptions should include expectations

with respect to employee and physician roles to contribute to a positive work
environment.
Director, Human Resources, CoS
January
2016
December
2016
Immediate
April 2016
Recommendation 6: GBGH should establish a broad based Advisory Committee CEO

to oversee the promotion of a positive work environment. This Committee should
be accountable to the Board Quality & Safety Committee.
114
RECOMMENDATION
RESPONSIBILITY
START
DATE
END
DATE
Recommendation 7: Appropriate whistle blower protection policies should be

developed and implemented within 6 months.
Director, Human Resources
January
2016
June 2016
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.
CEO
April 2016
September
2016
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.
Board Chair, CEO
September
2016
December
2016
Recommendation 10: A consistent approach for reporting to the Board on tactics

identified in the strategic plan should be developed and implemented.
CEO, CFO & CNE
March 2016 September

2016
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.
Board Chair, Board Vice Chair
March 2016 June 2016
Recommendation 12: The Board should consider engaging a Coach to provide

mentorship and support through the implementation of the recommendations in
this report.
Board Chair & Vice Chair
Immediate
December
2016
115
RECOMMENDATION
RESPONSIBILITY
START
DATE
END
DATE
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.
Board Chair
September
2016
January
2017
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.
Board Chair
Immediate
January
2016
Recommendation 15: Critical incidents leading to death or harm need to be

reported to the Board and Quality & Safety Committee in a timely fashion.
CEO
Immediate
Ongoing
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.
Chair, Board Quality & Safety Committee,

Vice President, Patient Services
March 2016 June2016
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.
Board Chair
September
2016
January
2017
Recommendation 18: Develop a Board education plan that includes a Board

education session related to quality at the majority of Board meetings.
Board Chair & Vice President, Patient

Services
January
2016
March 2016
116
RECOMMENDATION
RESPONSIBILITY
START
DATE
END
DATE
Recommendation 19: The Board should include a patient story at each meeting
of the Quality & Safety Committee.
Completed
Completed
Completed
Recommendation 20: Create a joint medical/management committee focused on CEO & CoS
quality and safety as the operational counterpart to the Board Quality & Safety
Committee.
June 2016
September
2016
Recommendation 21: The Board should revise and strengthen the terms of
reference for the MAC to ensure the appropriate focus on medical quality and
credentialing issues.
Board Chair, CoS
Immediate
March 2016
Recommendation 22: The Board should direct GBGH staff to move towards a
revenue-based approach to budgeting.
Chair, Board Audit & Finance Committee,

CFO
Immediate
January
2018
Recommendation 23: The Board should only accept and/or approve proposals
when there is a credible financial plan showing sources of necessary funds.

CFO
Immediate
Ongoing
Recommendation 24: The Board should also develop a policy requiring that
proposals will only be considered when a robust sustainability plan is included.

CFO
Immediate
Ongoing
Recommendation 25: The Board should increase the amount of time it dedicates
to relationship building.
Board Chair
Immediate
Ongoing
117
RECOMMENDATION
RESPONSIBILITY
START
DATE
END
DATE
Recommendation 26: The Board should regularly consider Collaboration and

Partnership as a potential tactic to achieve strategic directions.
Board Chair, CEO
Immediate
Ongoing
Recommendation 27: Terms of Reference for The GBGH Community Health Care
Partners Forum should be developed.
CEO & Vice President, Patient Services
Immediate
April 2016
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.
CEO
April 2016
April 2017
CEO
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.
April 2016
April 2017
CEO
April 2016
June 2016
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.
118
RECOMMENDATION
RESPONSIBILITY
START
DATE
END
DATE
Recommendation 31: Key corporate departments such as Finance, Decision

Support and Human Resources should play a supporting role to all clinical and
clinical support departments and programs.
CEO, CFO & Vice President, Patient

Services
April 2016
June 2016
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.
CEO & CoS
April 2016
September
2016
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.

Services
April 2016
April 2017
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.
CEO
April 2016
Ongoing
Recommendation 35: GBGH leadership should develop further skill and

competency in financial management.

Services
April 2016
April 2017
Recommendation 36: GBGH should continue to incorporate annual

benchmarking as part of the financial management process.
CFO
Immediate
April 2016
119
RECOMMENDATION
RESPONSIBILITY
START
DATE
END
DATE
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.
Director, Finance & CFO
January
2016
April 2016
CoS
January
2016
April 2016
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.
CoS
January
2016
April 2016
Recommendation 40: Increase the stipend paid to Chiefs and define the time to
be dedicated to this role (.5 days/week).
CoS & CFO
April 2016
Ongoing
Recommendation 41: Revise and strengthen the role of the Chief of Staff to
increase his/her role to oversee the quality of medical care.
Board Chair
Immediate
Ongoing
Recommendation 42: Consider the possibility of providing the Chief of Staff with
a mentor/coach for a 6-month period.
Board Chair & CoS
Immediate
December
2016
120
RECOMMENDATION
RESPONSIBILITY
START
DATE
END
DATE
Recommendation 43: Invigorate the MAC with the goal of increasing focus on
quality and accountability for all medical staff at GBGH.
Board Chair & CoS
Immediate
April 2016
Recommendation 44: The Board Chair or Vice Chair should attend MAC meetings
on a regular basis.
Board Chair & Vice Chair
April 2016
Ongoing
Recommendation 45: Consider developing an in house medical leader boot

camp program to become a regular item on the MAC agenda.
CoS
September
2016
Ongoing
Recommendation 46: Integrate selected medical leadership development

sessions with Administrative Leadership to facilitate team development.
CoS & CEO
September
2016
Ongoing
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.
Board Chair, CEO & CoS
Immediate
Ongoing
Recommendation 48: GBGH should develop written contractual agreements with

the hospitalists that outline the expectations and roles and responsibilities for
both parties.
CoS, CEO & CFO
April 2016
June 2016
121
RECOMMENDATION
RESPONSIBILITY
START
DATE
END
DATE
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.
CoS & CFO
April 2016
June 2016
January
2017
Ongoing
CoS
Recommendation 50: GBGH should make efforts to enhance communication
with local primary care physicians, and should increase the degree of involvement
in LHIN planning and with other potential partners in the region.
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.
CFO & Manager, Food Services
January
2016
Ongoing
January
2016
Ongoing
April 2016
Ongoing
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.
CFO & Vice President, Patient Services
January
2016
June 2016
Board
Immediate
September
2016
122
RECOMMENDATION
RESPONSIBILITY
START
DATE
END
DATE
Recommendation 56: GBGH should not be the landlord of the proposed health
hub at the Penetang Site.
Board
Immediate
June 2016
Board
Immediate
January
2017
CFO
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.
Immediate
June 2016
Recommendation 59: Current budget tool (BUDMAN) should be upgraded to the CFO
most recent version and the Executive Support Manager (ESM) tool be purchased
and implemented.
January
2016
January
2017
Recommendation 60: GBGH should develop and implement a formal Position

Control Process for the replacement 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.
CFO & Director, Human Resources
January
2016
January
2017
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 all commitments.
CFO
January
2016
April 2016
123
RECOMMENDATION
RESPONSIBILITY
START
DATE
END
DATE
Recommendation 62: All rental agreements should be reviewed and compared

against current market value rates to ensure that all costs of GBGH are fully
recovered.
CFO
January
2016
April 2016
Recommendation 63: GBGH should explore opportunities to enhance HR

functionality through partnership with another organization in the LHIN.
CEO
Immediate
September
2016
Recommendation 64: Consider using the management model that has worked
effectively in the ED as the basis for the new organizational model throughout
GBGH.
CEO
April 2016
April 2017
Recommendation 65: Review CDU utilization and staffing. Develop clear criteria
for admission and discharge to this area, and monitor performance to ensure that
the right types of ED patients are admitted to these beds.
Director, Acute Care Services & Chief of ED Immediate
April 2016
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.
Director, Acute Care Services, Manager ED Immediate

& Chief of ED
April 2016
Recommendation 67: Review triage process with the goal of reducing triage time Director, Acute Care Services, Manager ED Immediate
& Chief of ED
by 50%.
June 2016
124
RECOMMENDATION
RESPONSIBILITY
Recommendation 68: Within the current ED budget, add in a Pharmacy

Technician to conduct Medication Reconciliations 12 hours/day.
Director, Acute Care Services, Manager ED Immediate

& Chief of ED
April 2016
Recommendation 69: Review current state with respect to utilization of CT for

diagnostic purposes.
Director, Acute Care Services, ED a& DI

Managers & Chief of ED
April 2016
September
2016
Recommendation 70: Explore the opportunity to establish a 4 bed higher acuity

room to accommodate those patients that require a higher level of
monitoring/oversight.
Vice President, Patient Services &

Director, Acute Care Services
April 2017
January
2017
Recommendation 71: Provide additional support to Managers of Clinical Services Clinical Directors & Director, Human
Resources
to deal with aberrant behaviours, and adhere to the collective agreement re:
disciplinary actions that may be required.
April 2016
January
2017
Recommendation 72: Review educational needs of nurses on all nursing units,

and develop a structured program to enhance their level of competency.
Clinical Managers & Nurse Educators
Immediate
April 2016
Director, Acute Care Services &

Perioperative Services & 2 North
Managers
January
2016
June2016
START
DATE
END
DATE
125
RECOMMENDATION
RESPONSIBILITY
START
DATE
END
DATE
Recommendation 74: Establish guidelines for hospitalist practices ensure

rounding is done earlier in the day.
CoS & Chief of Medicine
June 2016
September
2016
Recommendation 75: GBGH should develop a utilization management program

to identify opportunities to improve clinical utilization of hospital resources. The
Joint Medical/Management Committee should oversee the work.
Vice President, Patient Services & CoS
June 2016
March 2017
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.
Vice President, Patient Services, Director,

Acute Care Services & respective Medical
Chiefs
June 2016
March 2017
Recommendation 77: Improve efficacy of daily discharge rounds by support the

engagement of hospitalists and family physicians in these rounds.
Chief of Medicine & Director, Acute Care

Services
June 2016
September
2016
Recommendation 78: Enhance partnership with CCAC personnel and engage

them more effectively in discharge planning.
Director, Rehabilitation & Geriatric

Services & Manager I North & 2 East
April 2016
September
2016
Recommendation 79: Consistently adhere to Expected Date of Discharge (EDD)

Guidelines.
Chief of Medicine & Manager, 2 East
Immediate
June 2016
Recommendation 80: Explore the possibility of providing a Discharge Clinic for

discharged medical patients run by the hospitalists out of Ambulatory Care.
Chief of Medicine & Manager, 2 East
March 2017 December

2017
126
RECOMMENDATION
RESPONSIBILITY
START
DATE
END
DATE
Recommendation 81: Document response times and incidents in which

physicians on call direct staff to not call them.
Manager ICU, Director, Acute Care

Services
Immediate
Ongoing
Immediate
April 2016
Recommendation 82: Partner with RVHC to ensure that higher acuity patients are CEO, CoS & Chief of Medicine
transferred in a timely manner 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 partner more effectively with RVHCs critical care program to
improve the quality of care.
CEO & CoS
April 2016
September
2016

Acute Care Services, Manager, ICU &
Chief of Medicine
Immediate
October
2016
Recommendation 85: Enhance admission, transfer and discharge criteria, and

implement the revised criteria consistently.
Manager, ICU & Chief of Medicine
Immediate
April 2016
Recommendation 86: Add 1 full shift of physiotherapy coverage on weekends

Services
Immediate
April 2016
Recommendation 87: Initiate assessments immediately upon admission to the

unit

Services & 1 North Manager
Immediate
Ongoing
127
RECOMMENDATION
RESPONSIBILITY
START
DATE
END
DATE
Recommendation 88: Eliminate the practice of providing ambulatory

rehabilitation on an inpatient basis with weekend passes

Immediate
April 2016
Recommendation 89: Conduct a review of clinical information practices and

develop a new model that integrates the use of assessments into care planning
and delivery

Immediate
June 2016
Recommendation 90: Adjust the target savings estimate to $300,000 this fiscal
year, and $600,000 annually on a go forward basis.
CFO, Director, Rehabilitation & Geriatric

Services & Laboratory Manager
Immediate
Ongoing
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; Ordering Physician; reason for request;
etc.
Director, Acute Care Services, DI Manager, February

Chief of Radiology & ED
2016
April 2016
Recommendation 92: Encourage and support staff to become certified in CT

testing.
Manager DI
Immediate
January
2017
Immediate
Ongoing
Recommendation 93:Require that Technologists being hired into the department Manager, DI & Director, Human
Resources
are CT certified.
128
RECOMMENDATION
RESPONSIBILITY
START
DATE
END
DATE
Recommendation 94: Review current complement of full time and part time
staff, and set a goal to increase the numbers of full time staff.
Director, Acute Care Services & DI

Manager
Immediate
January
2017
Recommendation 95: Establish a DI/ED Council to meet on a quarterly basis to

discuss issues affecting service in each department. This council should include
representation from Georgian Bay Radiology.
Director, Acute Care Services, Chief of ED

& DI /ED Managers
April 2016
Ongoing
Recommendation 96: Conduct a focused review of Pharmacy operations by an

experienced Pharmacy Leader.
Vice President, Patient Care Services
January
2016
April 2016
Recommendation 97: GBGH should aggressively pursue adding 20 acute mental

health beds to the complement of beds.

Services
Immediate
2020
Recommendation 98: GBGH should explore opportunities to partner with OSMH

in the provision of mental health services with a shared medical staff and senior
leadership for the program.
CEO
Immediate
2020
Recommendation 99: GBGH should target and seek to negotiate a total

operating budget of $5.2 million for acute mental health and $0.766 million for
ambulatory care.

Services
Immediate
2020
129
RECOMMENDATION
RESPONSIBILITY
START
DATE
END
DATE
Recommendation 100: Close the obstetrical program and pursue a partnership

with OSMH for all obstetrical, gynecological and pediatric care.
Board, CEO, CoS, CFO & Vice President,

Patient Services
Immediate
September
2016
Recommendation 101: Reconfigure the OR schedule to operate 3 days/week with Vice President, Patient Services, Director,
Rehabilitation & Geriatric Services,
13 blocks per month.
April 2016
March 2017
Recommendation 102: Reallocate ophthalmology procedures to a designated

space in Ambulatory Care (consistent with best practice), and recover patients in
the same area.

Manager, Perioperative Services & Chief
of Surgery
April 2016
September
2016

of Surgery
April 2016
September
2016
CoS & Vice President, Patient Services
Immediate
Ongoing
Recommendation 105: GBGH should develop clear criteria to guide the decision
to conduct surgical procedures after regular hours. These criteria should be
applied consistently in all situations in which a request is made to conduct a case
after hours and is a joint administrative and medical decision.
CoS, Vice President, Patient Services,,

Services, and Chief of Surgery
April 2016
June 2016

of Surgery
130
RECOMMENDATION
RESPONSIBILITY
START
DATE
END
DATE
Board
January
2016
March 2016
Board
January
2016
March 2016

Services, and Chief of Surgery
January
2016
April 2016
131

Report From GBGH Operational Review

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GEYER & ASSOCIATES INC.

Georgian Bay General Hospital

Geyer & Associates Inc.

PROCESS AND TIMELINES FOR THE REVIEW

Extensive review of documentation provided by the hospital;

Geyer & Associates Inc.

Geyer & Associates Inc.

RECOMMENDATIONS TO IMPROVE GBGH CULTURE

Geyer & Associates Inc.

RECOMMENDATIONS TO IMPROVE GBGH GOVERNANCE

Geyer & Associates Inc.

Geyer & Associates Inc.

RECOMMENDATIONS TO IMPROVE MANAGEMENT EFFECTIVENESS

RECOMMENDATIONS TO IMPROVE MEDICAL LEADERSHIP AND QUALITY OF CARE

Geyer & Associates Inc.

RECOMMENDATIONS TO IMPROVE CORPORATE PERFORMANCE AND INCREASE THE SHARE OF GBGH

RECOMMENDATIONS RELATED TO CLINICAL OPERATIONS

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ACUTE INPATIENT UNITS

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REHABILIATION AND COMPLEX CONTINUING CARE

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THE ROLE OF GBGH IN THE LHIN

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RECOMMENDATIONS REGARDING GBGHS APPROPRIATE FUTURE ROLE IN THE LHIN

PROJECTED GBGH BEDS

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SUMMARY OF THE RECOMMENDED SAVINGS AND REINVESTMENTS

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IMPACT OF RECOMMENDATIONS ON KEY MEASURES OF FINANCIAL PERFORMANCE

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:

REQUIREMENTS FOR SUCCESS

Geyer & Associates Inc.

INTRODUCTION AND CONTEXT

ORGANIZATIONAL FINDINGS & RECOMMENDATIONS

CORPORATE SERVICES FINDINGS AND RECOMMENDATIONS

CLINICAL SERVICES FINDINGS AND RECOMMENDATIONS

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CLINICAL SERVICES SUSTAINABILITY AND THE ROLE OF GBGH IN THE LHIN

FINANCIAL IMPACT OF RECOMMENDATIONS

APPENDIX 1 INTERVIEWS AND FOCUS GROUPS

APPENDIX 2 IMPLEMENTATION RESPONSIBILITY AND TIMELINES

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INTRODUCTION AND CONTEXT

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Review Methodology and Timelines

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Assessment of the Draft Hospital Improvement Plan

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Figure 1: Conservative Inflation Assumptions

Figure 2: Estimated Impact of Inflation for GBGH

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Current Financial Condition

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ORGANIZATIONAL FINDINGS & RECOMMENDATIONS

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