2014-17 Multi-Sector Service
Accountability Agreement (M-SAA)
An Overview
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
2
Pan-LHIN Development, Local Execution
Developing provincial templates for local execution
• Consistent template agreement for all community sector HSPs developed
through comprehensive consultation with HSP associations and member
representatives.
•
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 panLHIN guidelines
3
M-SAA Structure
Comprehensive Consultation through Multiple Tables
M-SAA Advisory Committee
(see slide 7 for membership)
M-SAA Indicators
Work Group
(see Appendix 1 for membership)
M-SAA Planning & Schedules
Work Group
(see Appendix 1 for membership)
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
4
LHIN/HSP Accountability Relationship
How do the various CAPS/M-SAA components fit together?
Community
Accountability
Planning Submission
(CAPS)
Planning

Multi-sector Service
Accountability
Agreement
(M-SAA)
Commitment
Negotiations/Consultations

Quarterly Reports
[Ontario Healthcare
Report Standards (MIS)]
Measurement

Remediation
Negotiation,
Implementation of
Consequences
Adjustment
Negotiations
5
LHIN/Sector Responsibilities
What 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.
6
Process for Finalizing New M-SAA
At 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.

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.
7
Summary of Main Changes
What are the key changes between current and new M-SAA?
REFERENCE
DIFFERENCE
REASON FOR CHANGE
General Update
A variety of changes were made to correct
minor errors in references, use of defined
terms, conformance and formatting.

Revised “Board” definition.
To correct inadvertent errors and typographical errors.
1.1 Definitions

Added “controlling shareholder”
definition.

Added “and volunteers” to
definition of “HSP’s Personnel.”

Some long-term care homes have M-SAAs. The changes recognize that committees
of management and boards of management are sometimes the ultimate authority,
as opposed to boards of directors, for some long-term care homes.

“Controlling shareholder” appears in the definition for HSP’s Personnel. A definition
was provided for “controlling shareholders” in order to be clear on who is captured.
It is only relevant to HSPs that have controlling shareholders.

Volunteers and students are under the control of the HSP, no differently as regards
the LHIN, than any of the HSP's paid staff or other agents.
This provision clarifies that the HSP may hire others to provide the Services on the HSP’s
behalf and states the terms on which they can do so.
3.2 Subcontracting
Changed to enhance clarity.
3.4 eHealth/Information
Technology
Compliance
4.3 Appropriation
Changed to conform to the LHINs’
obligations under the MLPA.
LHSIA requires that LHINs provide their funding to HSPs in accordance with the LHIN’s
accountability agreement with the Ministry (i.e. the MLPA). These changes are therefore
required to conform to the LHINs’ obligations under the MLPA.
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.
8
Summary of Main Changes Continued
What are the key changes between current and new M-SAA?
REFERENCE
DIFFERENCE
REASON FOR CHANGE
4.6 Interest
Adjusted language to incorporate flexibility.
This section has been revised to incorporate flexibility into this requirement.
4.8 Procurement of
Goods and Services
Changed to enhance clarity.
The M-SAA requires HSPs to abide by all Applicable Law and Applicable Policy. To
clarify the obligations, Section 4.8(a) has been revised to by inserting the phrase “that
are applicable to the HSP pursuant to the BPSAA.”
6.1(c)(D) Multi-Year
Planning Targets
6.3(a)(ii) Planning and
Integration Activity
Pre-Proposal
Changed to reflect that LHINs typically
consult with an HSP on changes multi-year
planning targets.
Changed to enhance clarity such that the
obligation captures the notion of physical
change.
Changes to multi-year planning targets should be addressed at the local LHIN level.
HSPs should discuss this issue with their local LHIN and ask for the appropriate
assumptions for planning purposes.
The LHINs are responsible for possible impacts to the health system of service
changes and need to be made aware of changes to service delivery for health system
planning purposes. In addition, this provision gives the LHIN the 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 frequency 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.”
9.2(b)
Acknowledgment of
Funding Support
Added to conform to Ontario’s Visual Identity
Directives.
Ontario and LHIN logos are strictly governed by Provincial policy. The provision in the
M-SAA reflects what is required by Ontario’s Visual Identity Directives.
9
Summary of Main Changes Continued
What are the key changes between current and new M-SAA?
REFERENCE
DIFFERENCE
REASON FOR CHANGE
10.3(b) Governance
Definition of “compensation award” added for clarity.
The wording of the provision states that the compensation award is linked to
the CEO’s performance and a definition has been added in this regard.
10.4(c) Funding,
Services and
Reporting
11 Limitation of
Liability, Indemnity &
Insurance
12.2(a) Termination
by the HSP
Revised to reflect materiality.
Language has been added to incorporate notion of materiality.
The insurance provisions have been significantly
amended with input from the sector.
The insurance provisions have been updated to reflect sector specific risk.
Revised to reflect circumstances where an HSP may
require the ability to exit the Agreement on short
notice.
Deleted to incorporate flexibility
Section 12.2(a) has been revised by inserting "(or such shorter period as may
be agreed by the HSP and the LHIN)".
Adjusted language to reflect reasonableness.
The LHINs’ are always obligated to act reasonably and fairly in making its
decisions and they do so.
Added language to enhance clarity
This section now states “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.”
12.4(b)
Consequences of
Termination
14.3 Terms and
Conditions on Any
Consent
14.8 No Assignment
Section 12.4(b) has been deleted to incorporate flexibility into process.
10
Performance Indicators
Health System Indicators Initiative (HSII)
•
In April 2010, the LHIN-led HSII was established to create a coordinated, system-based
approach to indicator identification, development, maintenance and reporting.
•
Central to the mandate of HSII is the close collaboration with provincial and national
partners in order to leverage their organizational expertise related to indicator
development, benchmarking, data extraction, and analysis.
•
The revised mandate introduced in September 2013 provides a greater focus on
alignment to system priorities, advancing system performance improvement through the
SAAs and other mechanisms, and enabling monitoring and reporting.
•
The M-SAA Indicators Work Group is accountable to the M-SAA Advisory Committee
through the HSII Executive Group, comprised of 3 LHIN Senior Directors.
11
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.
12
Performance Indicators
Why 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.
13
Performance Indicators Continued
How 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
14
Performance Management
How 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.
15
2014-17 M-SAA Indicators
16
Core (All Sectors)
Performance Indicators
•
•
•
•
•
•
•
•
Balanced budget - Fund type 2
Proportion of budget spent on administration
Variance forecast to actual expenses
Percentage total margin
Service activity by functional centre
Variance of forecasted to actual units of service
Number of individuals served
Percentage of Alternative Level of Care (ALC) days (transitioned
from sector specific to core)
LHIN Collaborative
17
Core (All Sectors)
Explanatory Indicators
•
•
•
Cost per individual serviced by program/service/functional centre
Cost per unit of service by functional centre
Client experience (New Category)
Details:
– Moved from being only an explanatory indicator for North
West LHIN to a provincial core indicator.
LHIN Collaborative
18
Community Care Access Centres
Performance Indicators
•
•
•
Access: Wait time 1. From Hospital Discharge to Service Initiation
(Hospital Clients)
Access: 90th Wait time 2. 90th percentile Wait time from Community
Setting to Community Home Care Services
Percentage people registered with Health Care Connect who are
referred (Retired)
Details:
– Reporting obligations are already in place with the Ministry
LHIN Collaborative
19
Community Care Access Centres
Explanatory Indicators
•
•
•
•
•
Access: Wait time 1. From hospital discharge to service initiation
(hospital clients) by population groups (short stay, short stay rehab,
long-stay complex)
Access: Wait time 2. 90th percentile wait time from Community
setting to community home care services by population groups
(short stay acute, short stay rehab, long-stay complex)
Average monthly cost per episode (adult short stay, adult long-stay
complex, end of life, children medically fragile)
Clients with MAPLe scores high and very high living in the
community supported by CCAC Clients placed in LTCH with (New
Category)
MAPLe scores high and very high as a proportion of total clients
placed (New Category)
LHIN Collaborative
20
Community Care Access Centres
New Category Explanatory Indicators
•
•
Clients with MAPLe scores high and very high living in the
community supported by CCAC
Clients placed in LTCH with MAPLe scores high and very high as a
proportion of total clients placed
Details:
– Moved from CCAC performance indicator category
– Indicators fit this category and provide valuable information
about how the system is functioning and the opportunities for
change
– Indicators are not a good measure for performance as targets
are set locally by each LHIN
LHIN Collaborative
21
Community Care Access Centres
Developmental Indicators
•
•
•
Percentage of clients with a new or existing pressure ulcer that
failed to improve (Retired)
Medication safety (Retired)
Percentage of home care clients who say they have fallen in the last
90 days (Retired)
Details
– Indicators retired as developmental
– Indicators were not identified by HQO as on the Common
Quality Agenda
LHIN Collaborative
22
Community Support Services
Explanatory Indicator
• Number of persons waiting for service (by functional centre)
LHIN Collaborative
23
Community Support Services
Developmental Indicators
•
•
•
Average number of days waited for first service (by functional
centre) (New Category)
Details:
– Moved from CSS Explanatory indicator category as the data
is not yet available
– Move to explanatory in years 2 or 3
Repeat unscheduled emergency visits within 30 days for mental
health conditions (Retired)
Repeat unscheduled emergency visits within 30 days for substance
abuse conditions (Retired)
Details:
– Indicators are difficult to measure as cannot follow clients
between the hospital and the community
LHIN Collaborative
24
Community Health Centres
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)
Individuals served by functional centre (Retired)
Details:
– Already a Core indicator
LHIN Collaborative
25
Community Health Centres
Explanatory Indicators
•
•
•
•
•
•
•
•
Emergency visits best managed elsewhere (New)
Client satisfaction – Access (New)
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)
LHIN Collaborative
26
Community Health Centres
Explanatory Indicators Cont’d
•
•
•
•
•
•
•
Number of registered clients (New)
Specialized care (New)
Supervision of students (New)
Third next available appointment (New)
Non-insured clients (New)
Repeat unscheduled emergency visits within 30 days for mental
health conditions (Retired)
Repeat unscheduled emergency visits within 30 days for substance
abuse conditions (Retired)
LHIN Collaborative
27
Community Health Centres
Developmental Indicator
•
CHC clients hospitalized for Ambulatory Care sensitive conditions
LHIN Collaborative
28
Community Mental Health & Addiction
Explanatory Indicators
• Number of days waited from referral/application to initial
assessment complete
• Average number of days waited from initial assessment complete to
service initiation
• Repeat unscheduled emergency visits within 30 days for mental
health conditions (New Category)
• Repeat unscheduled emergency visits within 30 days for
substance abuse conditions (New Category)
Details: Moved to Explanatory indicator
LHIN Collaborative
29
Community Mental Health & Addiction
Developmental Indicator
•
OCAN/GAIN Indicator
LHIN Collaborative
30
North West LHIN Specific – Local
Indicators/Obligations
31
North West LHIN Specific Local Indicators





Cost per Unit (All Sectors)
Number of CCPD Clients (CCAC only)
Number of Hip and Knee Clients (CCAC only)
Admission/Readmission Rates for Active CCAC Clients to Hospital Rate per 100 (CCAC only)
CCAC Waitlist (CCAC only)
32
Home First Philosophy requirement

To contribute to an improved health system, the HSP will align their
strategic and operating activities with, and proactively adopt the
North West LHIN’s “Home First” philosophy. As requested by the
North West LHIN, the HSP will collaborate with stakeholders with
planning, implementation and reporting related to adoption of the
Home First philosophy.
33
Diversity Planning requirement

The HSP will implement their LHIN approved cross-cultural
competency plan. In cases where the plan has not been endorsed
by the LHIN, the HSP will work with the LHIN to amend the plan as
necessary. The HSP will report back on progress made on
implementation as requested by the LHIN.
34
Behavioural Supports Ontario (BSO) Action Plan
requirement

The Health Service Provider will work with the North West LHIN and
partners to:
• Implement the Behavioural Supports Ontario Action Plan and
participate in quality improvement training related to the
Behavioural Support Ontario Strategy;
• Integrate care for the target population through the creation of
common care pathways and commit to training of front-line staff
as it relates to this strategy.
35
Emergency Preparedness Plans requirement

To minimize risks to the North West health system, the HSP review
and update its emergency preparedness plan annually and include
in the plan the process for communication with the North West LHIN
in the event of a emergency situation.
36
e-Health requirement

The HSP will participate in the development and implementation of
a harmonized North West LHIN eHealth Strategic Plan and
subsequent iterations of that plan
37
Information Technology requirement

The HSP will ensure that any Information Technology/Information
System implementations material to provincial (eHealth Ontario) and
local (North West LHIN) eHealth Strategic and Tactical Plans will be
aligned with and contribute to the advancement of these Plans
38
Health Services Blueprint requirement
The North West LHIN is implementing the North West LHIN Health Services Blueprint (the
Blueprint), a ten-year plan to reshape the health care system in the North West LHIN. The
provincial Health Link initiative is aligned to this local plan and is being implemented in
conjunction with the Blueprint at the Integrated District Network level. More details about the
Blueprint and Health Links in the North West LHIN are available at
http://www.northwestlhin.on.ca/.
To advance the implementation of the Blueprint, the HSP will:

Align their strategic and operating activities with the Blueprint and Health Link objectives
and local priorities;

Continue to collaborate with stakeholders with planning, implementation and reporting
related to the implementation of the Blueprint and Health Links, and formalize this
commitment to collaboration through a Collaboration Agreement (e.g. providing human
resource expertise, information, data and analysis to the North West LHIN, Health Link
Steering Committees or Working Groups, or Local, District and Regional Planning Tables
as necessary to inform and support planning and implementation activities);
39
Health Services Blueprint requirement (con’t)

Play an active role in the implementation of the Blueprint and Health Links through:
• Actively leading and championing Blueprint and Health Links implementation;
• Formalizing planning tables at the Local Health Hub and Integrated District Network levels;
• Initiating partnerships across both LHIN-funded and non LHIN-funded providers;
• Initiate planning and implementation activities with a focus on system level improvement
across the continuum of care;
• Identifying and promoting innovative approaches to integrated health care delivery with a
focus on improving the client experience through improved transitions in care across the
continuum, improving access to care, and improving value for health care dollars;
• Providing ongoing education to staff, partner and public stakeholders
• Participation in knowledge exchange forums, channels and value stream mapping
sessions;
• Realignment of services and related delivery as necessary;
• Coordination of implementation activity, including stakeholder analysis, communications
and change initiatives; and
• Implementation of standardized, quality based care pathways, processes and associated
standardized costing.
40
Expansion of CCACs Role in Placement Activities
with CSS Programs requirement (CCAC and CSS)

As provided in Regulation 251/09 (554/09), and when instructed by
the North West LHIN, the HSP will actively collaborate with
stakeholders in the planning and implementation of the North West
CCACs enhanced role, related to managing placement activities for
community programs. Placement activities may include
assessment, eligibility determination, waitlist management and/or
placement.
41
2014-17 M-SAA Schedules
42
Summary of Main Changes
What are the key changes between current and new Schedules?
SCHEDULE
DIFFERENCE
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
• 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
Schedule C
COMMENTS
• Self Reporting Initiative (SRI) has
replaced the Web Enabled Reporting
System (WERS) for reporting
43
Summary of Main Changes (continued)
What are the key changes between current and new Schedules?
SCHEDULE
DIFFERENCE
Schedule D
• Updated to reflect current directives, guidelines
and policies
Schedule E
COMMENTS
• Added Guideline for Community Health Service
Providers Audits and Reviews, August 2012
• Intended to LHINs in undertaking a
transparent process in identifying and
responding effectively and consistently
to HSPs
• Added note indicating that the Community
Financial policy is currently under review
• Review process includes MOHLTC,
LHINS and community sector
representatives
• See update from Indicators Work Group
44
Summary of Main Changes (continued)
What are the key changes between current and new Schedules?
SCHEDULE
DIFFERENCE
Schedule F
• Updated to reflect HSP “services” rather than
“deliverables”
• Added Appendix 1 - Exceptions
Schedule G
COMMENTS
• Will be done once a year with a due
date of June 30
45
Questions?
46