2014-17 Multi-Sector Service Accountability Agreement (M-SAA)

Presentation to the CHC and AHAC EDs/CEOs

January 2014

Agenda1. M-SAA template2. Schedules3. Community Financial Policy4. CHC Requirements5. CHC Guidelines6. Indicators7. Next Steps8. Questions and Answers9. Appendix A: Background

M-SAA Template

General Changes

• The term of the M-SAA is 2014-17.• A variety of non-material changes were made

to correct minor errors in references, use of defined terms, conformance and formatting.

• Some of the changes were made to cover all HSPs, including long-term care facilities that have M-SAAs.

1.1 Definitions Revised “Board” definition.

Recognizes that a First Nation Band Council, committee of management of a municipality is sometimes the ultimate authority, as opposed to boards of directors

“Controlling shareholder” appears in the definition for HSP’s Personnel. This is not relevant to CHCs and AHACs as we do

not have controlling shareholders.

1.1 Definitions Added “and volunteers” to definition of HSPs

Personnel, volunteers and students are under the control of the HSP, no different, from the LHIN’s perspective than any of the HSP's paid staff or other agents.

You will see volunteers added to several clauses throughout the M-SAA.

3.1 d Provision of Service• This provision prohibits the HSP to restrict

services to any one based on the geographic area in which the person resides.– This seems in conflict with Schedule A2 where

CHCs are required to define catchment areas and priority populations.

– In legislation only CCACs can restrict access as they have provincial coverage.

3.2 Subcontracting• The language was clarified to state that the

LHIN funds the HSP to provide services.– That the HSP may hire others to provide the

Services on the HSP’s behalf.– That the subcontractor must enable the HSP to

meet the M-SAA obligation.– That it does not create any kind of relationship

between LHIN and the sub-contractor.– It is important to note that this clause applies to

CHCs who may have a ‘paymaster’ agreement for flow through funds.

3.4 e-Health/Information Technology Compliance

• Changed to conform to the LHINs’ obligations under the MLPA. – LHINs are required to implement the provincial e-

Health strategies and blue prints. This obligation has been passed to HSPs.

– We argued for language that stated ‘subject to funding availability’ but did not have any success.

– NOTE: full adoption of Ontario Laboratory Information System by March 2015. All CHCs and AHACs on NOD will meet this requirement.

4.3 Appropriation

• Deleted the specific actions that a LHIN may take. – This provision reflects the Financial Administration

Act and the change was made to eliminate any implied notion that the LHIN is limited in terms of what actions it can take in the event that there is no appropriation of funds.

4.4 b Additional Funding

• LHINs had proposed to delete the 4.4b providing an opportunity for the HSPs to request additional funding.– We were successful in getting it reinstated.– No change

4.5 Conditions of Funding• 4.5. (a) (i) Removed reference to schedules

– The definition for ‘agreement’ includes ‘schedules’ so it was redundant to include it

• The LHINs tried to add a clause “not use the funding for compensation increases prohibited by Applicable Law”– Successfully argued for its deletion.– All funding must be according to applicable law

and covered under 4.5 (a) (ii) – Why signal it out.

4.6 Interest

• Change to only require funds to be put in a separate interest bearing account if HSP receives the funds prior to needing it immediately.– Small victory.

4.8 Procurement of Goods and Services

• Changes for clarity only– To clarify the obligations, Section 4.8(a) has

inserted the phrase “that are applicable to the HSP pursuant to the BPSAA.”

– The clause related to organizations over $10 M subject to the “Supply Chain Guidelines” has been deleted as this is information contained under the BPSAA.

– All organizations are required to have a procurement policy – this is no change.

6.1(c)(i) Multi-Year Planning Targets

• Clause added “in consultation with the HSP”– Requires the LHIN to consult with HSP if multi-

year planning targets are changed.

6.0 Repayment and Recovery

• We had extensive discussions re the HSPs ability to carry forward surplus with no success.

• The LHINs are sympathetic as they have the same restrictions.

• It requires a regulation change.• The LHINs are pursuing this but no change at

this time.

6.3(a)(ii) Planning and Integration Activity Pre-Proposal

• Changed to enhance clarity – The LHINs require HSPs to inform them if they transfer

services from the HSP to another person or entity in the LHIN or outside.

• Includes relocation or transfer of programs from one site to another of the same HSP (The LHINs clarified that this includes if you move a program across the street!)

– According to the LHIN, it provides an opportunity to review, evaluate and provide input into the HSP's plan, rather than being limited to stopping all or part of the plan.

8.1(d) Declaration of Compliance

• Changed to once per year and revised due date.– Changed from twice a year to once per year and

revised date to factor in time for HSPs to reconcile finances and close books before submitting declaration of compliance.

– The obligation now reads “Within 90 days of the HSP’s fiscal year-end.”

– Small Victory!

8.2 (b) Cost of Review

• No change but wording to clarify• NOTE: HSPs are required to cover all costs

associated with any review if the HSP – Did not comply with a requirement– There is indication that the HSP did not fulfill its

obligations under M-SAA, Applicable Law and Applicable Policy

• Very broad interpretation!

9.2(b) Acknowledgment of Funding Support

• NEW: directive to get written permission to use LHIN or Government logo or insignia– Ontario and LHIN logos are strictly governed by

Provincial policy. – Required by Ontario’s Visual Identity Directives.

• Could be very administrative and onerous.• LHINs are developing a protocol to determine

how to implement this efficiently.

10.3(b) Governance

• Definition of “compensation award” added for clarity.– The compensation award is linked to the CEO’s

performance. – New definition: all forms of payment, benefits,

and perquisites paid or provided, directly or indirectly, to or for the benefits of a CEO who performs duties and functions that entitle him or her to be paid.

10.4(c) Funding, Services and Reporting

• Added the notion of materiality– New Clause– Requires the HSP to ensure every report is

accurate and in full compliance– Any material change will be communicated the

LHIN immediately

11 Limitation of Liability, Indemnity & Insurance

• The insurance provisions have been updated to reflect sector specific risk. – The LHINs had proposed very onerous insurance

provisions that we were able to push back on– Most CHCs and AHACs will already have Commercial

General Liability insurance coverage that is required under the M-SAA

– NEW: CHCs and AHACs are now required to have WSIA or equivalent

– Errors and Omissions reduced to $2M.

11.4 (c) Certificates of Insurance

• The HSP will ensure each of its subcontractors have appropriate insurance

• That the HSP and LHINs be named as indemnified parties

• Copies made available to LHIN upon request.

12 Termination of Agreement• 12.1 Termination by the LHIN

– No change to notice period. Remains “at least 60 days” - Tried without success to get this extended.

• 12.2 Termination by the HSP– Six months “or shorter period if agreed by the

HSP” - This is to accommodate smaller HSPs.– No success in strengthening Transition plan to

name obligations such as lease agreement, HR costs etc.

12.4(b) Consequences of Termination

• Deleted to incorporate flexibility– We tried to get this changed from “will not” to

“may” provide additional monies .– A compromise and minor victory is that the entire

clause has been deleted.– This means that it is no longer prohibited to

provide funding (as in the current M-SAA) and allows for the possibility for funding in case of a wind down of services.

14.3 Terms and Conditions on Any Consent

• “reasonably” was added– The LHINs’ state that “they are always obligated

to act reasonably and fairly in making its decisions and they do so.”

– You can smile.

14.8 No Assignment

• Clarification only – again relates to subcontractors.– “no assignment or subcontract shall relieve the

HSP from its obligations under this Agreement or impose any liability upon the LHIN to any assignee or subcontractor.”

Schedules2014-17

M-SAA SchedulesSchedule Title Description

A Description of Services Describes the services delivered by the HSP, client populations and geography served

B Service Plan Describes the financial and statistical status of the HSP

C Reports Identifies, describes and sets due dates for HSP reporting

D Directives, Guidelines, Policies Identifies applicable MOHLTC policies

E Performance Identifies indicators, standards and local performance requirements

F Template for Project Funding Template used for funding special projects

G Declaration of Compliance Form to be completed by the HSPs Board of Directors to declare that the HSP has complied with the terms of the Agreement

Summary of Main ChangesWhat are the key changes between current and new Schedules?

SCHEDULE DIFFERENCE COMMENTS

Schedule A • None

Schedule B • Schedule B1 - Added row 2 (HBAM) and row 3 (QBP) planning targets along with their functional centres for use by CCAC’s

Schedule C • Revised dates revised to reflect appropriate reporting period.

• Updated to reflect that Supplementary Reporting (including AAH) - Quarterly Report and Annual Reconciliation Report (ARR) will be reported through SRI

• Self Reporting Initiative (SRI) has replaced the Web Enabled Reporting System (WERS) for reporting

Summary of Main Changes (continued)What are the key changes between current and new Schedules?

SCHEDULE DIFFERENCE COMMENTS

Schedule D • Updated to reflect current directives, guidelines and policies

• Added Guideline for Community Health Service Providers Audits and Reviews, August 2012

• Added note indicating that the Community Financial policy is currently under review

• Intended to LHINs in undertaking a transparent process in identifying and responding effectively and consistently to HSPs

• Review process includes MOHLTC, LHINs and community sector representatives

Schedule E • See update from Indicators Work Group

Summary of Main Changes (continued)What are the key changes between current and new Schedules?

SCHEDULE DIFFERENCE COMMENTSSchedule F • Updated to reflect HSP “services”

rather than “deliverables”Schedule G • Added Appendix 1 - Exceptions

Schedule D• Guideline for Community Health Services

Providers Audits and Reviews August 2012 NEW

• Supply Chain Guideline – deleted– CHCs are expected to follow the Broader Public

Sector Accountability as applicable.– If under $10M, CHCs and AHACs must have

procurement policy in place as per section 4.8 of M-SAA

Schedule D:Community Financial Policy

• Work is underway to review it but it will not be completed by April 2014.

• Timing: to have input to the MOHLTC by the end of March

• Substantial rewrite in format, ordering and numbering and to incorporate changes for LTC Facilities

• Sector specific requirements are put in schedules at the end.

Schedule D: CHC Sector

• CHC Requirements 2013 (revised)• CHC Guidelines 2013 (revised)• OHRS Standards (current version)• Model of Health and Wellbeing (replaced

Model of Care)

CHC Requirements2013

CHC Requirements • 1.1 Replaced Model of Care with Model of

Health and Wellbeing• 1.3 Principles for Provision of Service

– Replaced client centered with person centered• 1.4 Priority Populations

– Added sexual identity• 1.5 CHC service model

– Added to list of program staff: dietitians, therapists including physiotherapists, rehabilitation and occupational therapists, and chiropractors among others

CHC Requirements • 2.2 Governance Responsibilities of CHC Boards

– Replaced list of responsibilities with four main roles• Represent the community• Lead the organization• Evaluate the organization• Use a sound governance structure

• 3.8 Quality Improvement Plans– Required to submit to Health Quality Ontario on an

annual basis.

CHC Requirements

• 2.4.1 Officers– States must have chair, vice, secretary and

treasurer. This is not a change.– However, only chair and treasurer are required by

the Not-for profit Act and the Corporations Act. Therefore there is an inconsistency with legislation.

– Tried to raise it but the LHINs and MOHLTC just wanted it noted for next version since they have already approved this version.

CHC Guidelines2014-17

CHC Guidelines• References to CHC Model of Care changes to

Model of Health and Wellbeing.• Several non-material changes to clarify • 2.5 List of some of the Acts relevant to CHCs

were added.– Excellent Care for All Act added

• 3.2 Information Management section was updated

CHC Guidelines• 6.0 Capital

– Totally rewritten; much briefer– Directs CHCs to MOHLTC for current documents

• 7.1 Provincial Salary Structure– References 2013 Interprofessional Primary Care

Compensation Structure that replaced 2009 Hay.– References to Broader Public Sector

Accountability Act (2010) and the provision that executives can not get increases until provincial deficit is eliminated.

CHC Guidelines

• Appendix 2: References that the CHC Results Based Logic Model is under review– It is being refreshed to align with the Model of

Health and Wellbeing– Will be presented to the February CHC & AHAC ED

Network meeting.

Indicators 2014-17

Indicator Work Group Focus & Approach

• Review current indicators and develop recommendations to

reduce the number of indicators

• Develop recommendations regarding the definition and

target setting approach for the administrative indicator

calculation

• Align existing indicators with pan-LHIN imperatives

Core (All Sectors)Performance Indicators

Balanced budget - Fund type 2Proportion of budget spent on administrationVariance forecast to actual expensesPercentage total marginService activity by functional centreVariance of forecasted to actual units of serviceNumber of individuals servedPercentage of Alternative Level of Care (ALC) days

Core (All Sectors)Explanatory Indicators

Cost per individual serviced by program/service/functional centre

Cost per unit of service by functional centreClient experience (New Category)

Details: – Indicators Work Group identified need to enhance

linkage with quality and patient experience for all sectors

CHC Performance Indicators Cervical cancer screening Colorectal Screening rate Inter-professional diabetes care rate Influenza vaccination rate Breast cancer screening rate Periodic health exam Vacancy Rate (for NPs and Physicians) Access to primary care clinical service (New)

RETIRED• Individuals served by functional centre (Retired)

Details: Already a Core indicator

CHC Explanatory Indicators: Related to Primary Care Access : Select three

Clinical support staff per primary care provider (New) Cultural interpretation (New) Exam rooms per primary care provider (New) New grads/new staff (New) Number of new patients (New) Non-Primary Care activities (New) Number of registered clients (New) Specialized care (New) Supervision of students (New) Third next available appointment (New) Non-insured clients (New) Emergency visits best managed elsewhere (New) Client satisfaction – Access (New) Vacancy

CHC Explanatory Indicators (continued)

RETIRED:

–Repeat unscheduled emergency visits within 30 days for mental health conditions

–Repeat unscheduled emergency visits within 30 days for substance abuse conditions

–Data a challenge as cell size too small

CHC Developmental Indicator

CHC clients hospitalized for Ambulatory Care sensitive conditions

Technical Specifications

• See Tech Specs for detailed specifications of all indicators

• Special in-depth section on explanatory indicators for access to primary care

Questions?

Comments?

More Work Required….M-SAA Advisory Committee1.Community Financial Policy2.Guidelines for Community HSP Audits and Reviews3.Visual Identity Guidelines4.Cash Management Directive: interest requirementsIndicator Working Group1.Admin indicator

Appendix A

Background

What is an M-SAA?Core lever for HSP accountability and performance management

• A tool to bring all the various contractual agreements between community HSPs and the LHINs into one document

• Required under LHSIA and Ministry-LHIN Performance Agreement (MLPA)

• A vehicle to delineate accountabilities and performance expectations

• A mechanism to clarify that the HSP will be responsible for performance as well as planning and integration towards the development of a health system

Pan-LHIN Development, Local ExecutionDeveloping provincial templates for local execution

• Consistent template agreement for all community sector HSPs developed through comprehensive consultation with HSP associations and member representatives (membership listed in Appendix 1)

• Schedules for each sub-sector (CCAC, CHC, MH&A and CSS) developed through consultation with sub-sectors

• Individual LHINs negotiate performance indicator targets with each HSP in alignment with pan-LHIN guidelines

2014-17 M-SAA ApproachLHIN Negotiating Team, Mandate and Processes

• In May 2013, Louise Paquette (CEO, NE LHIN) was confirmed as Chair of the M-SAA Advisory Committee and Scott McLeod (CEO, CW LHIN) was confirmed as Vice-Chair.

• The mandate and scope of authority of the negotiating team was established through dialogue with the LHIN CEOs and was confirmed in July as follows:

• Working with LHIN Legal Services, identify opportunities to revise language that either requires updating or would benefit from greater clarity

• Working with community sector representatives, invite and review sector feedback

• Finalize a 3-year M-SAA by the end of 2013 to enable local execution by March 31, 2014.

• Each and every suggestion submitted by the Sector and MOHLTC was reviewed by LHIN Legal and revisions were incorporated where appropriate. Ongoing updates were provided to the LHIN CEOs and specific issues were brought forward to the CEOs for input and resolution.

M-SAA Development PrinciplesEnabling close ongoing collaboration with the Community Sector

• The M-SAA Advisory Committee is co-chaired by Louise Paquette and Scott McLeod and brings together senior executives from M-SAA sector associations, community HSPs and the LHINs to provide a central forum for enabling dialogue on provincial M-SAA issues

• The Committee is guided by the following principles:

• The process is undertaken with a spirit of trust and collaboration among the province’s community HSPs, sector associations and the LHINs.

• The M-SAA will align with provincial health system priorities and be consistent with MOHLTC policy, legislation and regulations.

• The M-SAA will strive to streamline processes, minimize administrative burden and provide clarity for HSPs where possible.

M-SAA StructureComprehensive Consultation through Multiple Tables

M-SAA INDICATOR SUPPORT: HEALTH SYSTEM INDICATOR INITIATIVE

M-SAA LEGAL COUNSEL SUPPORT: LHIN LEGAL SERVICES BRANCH

M-SAA SECRETARIAT SUPPORT: LHIN COLLABORATIVE

LOCAL M-SAA IMPLEMENTATION: LHIN M-SAA LEADS

LHIN/Sector ResponsibilitiesAdvisory Committee and Work Group Mandates

M-SAA Advisory Committee•Established to provide advice to the LHIN CEOs and support for the completion of the 2014-17 M-SAA template agreement and schedules in alignment with provincial strategic directions.

M-SAA Indicators Work Group•Established to support the M-SAA Advisory Committee. Based on direction from the LHIN CEOs, the Work Group is responsible for producing a series of documents and recommendations including a list of recommended M-SAA indicators, technical specifications, target setting guidelines and education materials.

M-SAA Planning & Schedules Work Group•Established to support the M-SAA Advisory Committee. Based on direction from the LHIN CEOs, the Work Group is responsible for producing a series of documents and tools including M-SAA Schedules, CAPS forms and planning submission guide and educational documents.

LHIN/HSP Accountability RelationshipHow do the various CAPS/M-SAA components fit together?

Community Accountability

Planning Submission(CAPS)

Multi-sector Service Accountability

Agreement(M-SAA)

Quarterly Reports

[Ontario Healthcare Report Standards (MIS)]

RemediationNegotiation,

Implementation of Consequences

Planning Commitment Measurement Adjustment

Negotiations/Consultations Negotiations

• The Community Accountability Planning Submission (CAPS) is a three-year planning document that facilitates the negotiation of the M-SAAs between the LHIN and each HSP.

• In the absence of definitive funding targets, CAPS will be based on a planning assumption of 0% base adjustment. CAPS should be prepared to maintain service levels within the 0% planning assumption

• The M-SAA Schedules will be refreshed in the Fall of each year of the agreement to confirm the current year’s planning assumption and to update the agreement’s performance and explanatory indicators

• The provincial due date for the submission of a Board approved CAPS was November 15, 2013.

2014/17 CAPS ApproachWhat is a CAPS and how is it used?

LHIN/Sector ResponsibilitiesWhat are the responsibilities of the LHINs and the HSPs?

LHINs are responsible for:

•Training and supporting HSPs through the CAPS and M-SAA processes

•Negotiating performance targets within the context of a provincial framework

•Monitoring the achievement of specific performance goals under the M-SAA and ongoing performance management

HSPs are responsible for:

•Ensuring governance and operations that support high quality care

•Promoting leading performance improvement approaches

•Providing access to high quality health services and coordinated health care in an effective and efficient manner

•Identifying integration opportunities and engaging the public and stakeholders in any planned service changes.

Process for Finalizing New M-SAAAt a high level, how was the M-SAA developed and finalized?

• LHINs revised language in the 2011-14 M-SAA that required updating or would benefit from greater clarity as a draft 2014-17 M-SAA for sector feedback.

• Three 3-hour M-SAA Advisory Committee meetings to review and discuss comments and suggestions on draft 2014-17 M-SAA.

• 175 sector comments received and individually addressed.

• Committee endorsed 2014-17 M-SAA and Schedules on December 17, 2013.

• Pan-LHIN commitment to reduce, align and enhance consistency of local indicators.

• Committee will continued to meet throughout the life of the agreement to advance M-SAA related priority issues.

Performance Indicators (Schedule E)Pan-LHIN Performance Indicators and LHIN-Specific Obligations

The Performance Schedule (Schedule E) contains the following two indicator sections:

1. Pan-LHIN Indicators are developed through the M-SAA Indicators Work Group through HSII (core indicators are relevant to all LHINs and all community sector HSPs; sector-specific indicators are only relevant to a specified sector).

• Performance Indicators are measures of HSP performance for which a Performance Target is set; Technical specifications of specific Performance Indicators can be found in the “M-SAA 2014-17 Indicator Technical Specifications” document.

• Explanatory Indicators are measures of HSP performance for which no Performance Target is set. Technical specifications of specific Explanatory Indicators can be found in the “M-SAA 2014-17 Indicator Technical Specifications” document.

2. LHIN-Specific Performance Obligations: A section where each LHIN adds specific performance objectives and obligations for their HSPs is included. LHINs are committed to minimizing any undue burden placed on providers with respect to performance management by focusing on a limited number of outcome indicators aligned with local priorities.

Performance IndicatorsWhy Performance Standards?

• All performance indicators have an associated target and standard of performance. Variance outside of the standard triggers the performance management processes in Article 7 of the M-SAA.

• The LHIN or the HSP can identify a Performance Factor that “…could or will significantly affect a party’s ability to fulfill its obligations under the Agreement.”

• The identification of a Performance Factor is made formally, in writing, to the other party and will include a description of the Factor’s actual or anticipated impact and a description of any action the party is undertaking, or plans to undertake, to remedy or mitigate the Performance Factor.

Performance Indicators ContinuedHow are Indicator Targets and Corridors Determined?

• Following the submission of the CAPS, LHINs and HSPs discuss indicator targets that are appropriate to each organization and its local circumstances. Targets are expected to reflect performance and drive continuous improvement.

• To complete the targets and corridors for the performance indicators, the following principles will be employed:

• Where provincial targets and corridors exist, the LHINs and HSPs will take these into consideration

• Where appropriate, use past experience from M-SAA and MLPA indicators

• Incorporate analyses of historical variation to inform corridor recommendations

• Use % range for financial and volume indicators

Performance ManagementHow are Performance Factors Addressed?

• How a LHIN chooses to deal with an indicator outside the corridor depends on a number of factors, including:

– What is the realized and/or potential impact on the clients served?

– Is this the first blip on an otherwise clean performance record?– Is this a unique event and unlikely to recur?– Are other areas of the organization or other HSPs affected?– What is the LHINs confidence in the HSPs ability to manage

performance going ahead?

• Depending on the above, the LHIN could choose to start with a less formal tact. The formal process is always available...and can be triggered at any point.