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  1. 1. FREQUENTLY ASKED QUESTIONS 2009-11 Multi Sectoral Service Accountability Agreement (M-SAA) As of July 10, 2008 A. TEMPLATE AGREEMENT 1. How is the 2009-11 M-SAA being developed? The template 2009-11 Multi Sectoral Service Accountability Agreement (M-SAA) is being developed through a consultative process led by the LHINs in conjunction with representatives from the Community Support Services, Mental Health and Addictions, Community Health Centres and Community Care Access Centre Sectors. The template was developed by the M- SAA Steering Committee and tabled with the sector specific groups for review and consultation. Four Sector specific Teams have been established to carry out the consultation process over the summer months. Consultation Teams will be providing suggestions to the M-SAA Steering Committee. It is the responsibility of the M-SAA Steering Committee to ensure that the structure and content of the new M-SAA template agreement is consistent with the LOCAL HEALTH SERVICES INTEGRATION ACT (LHSIA) and the MINISTRY-LHIN ACCOUNTABILITY AGREEMENTS (MLAA). The principles and values which were tabled at the first sector consultation meeting and accepted by all parties and are guiding the M-SAA and its development process are mutuality, flexibility, openness, transparency, achievability, strategic alignment, clarity of lines of communication and responsibility and recognition of the evolutionary nature of the accountability agreement. Sector Consultation Teams agree that it was imperative for the M-SAA to be: • Practical and workable for all parties • Respectful of the accountabilities, responsibilities, legal and financial obligations of both the LHIN and HSP Corporations • Clear and concise as possible • Fairly applied across the province • Built upon the existing accountability agreements/service agreements for the various health care sectors. The resulting draft template includes obligations related to planning, funding, service provision, reporting, performance management and issue resolution. The agreement will be standardized for all HSPs and HSP-specific performance standards reflective of negotiations with the LHINs will be in the appended schedules. 2. What are key differences between our current assigned agreements and the 2009/11 M- SAA? The 2009-11 template agreement is a transitional document reflecting both previous agreements as well as the LHINs’ intention over the next few years to move to the use of standardized terms and common formats in service accountability agreements (SAAs) with all health service providers. The latter will promote equitable treatment of health service providers across the 1
  2. 2. province, facilitate the administration of SAAs and ensure that the focus is on outcomes and the quality of care and treatment of individuals. The 2009-11 M-SAA template agreement sets out the roles and obligations of LHINs and HSPs in relation to planning, funding and reporting. It acknowledges and supports the role of local independent HSP boards contributing to an effective and efficient local health system. It recognizes the authority of HSP boards to govern their organizations. It continues to emphasize a collaborative, interest-based, graduated approach to issue management and performance improvement. The new agreement also consolidates the rules related to recovery of funding, including: correction of funding errors, financial penalties, integration decisions (voluntary or ordered), and for volume funded services as outlined in the schedules. 3. Why is the template agreement different from the agreements signed with the hospital sector? In the hospital sector multiyear agreements had been in place previously. There was a process of negotiation/ consultation with hospitals last year, and we are now engaged in a consultation process with the community sector. A key principle in developing the M-SAA was to use existing sector agreements as the base. See also FAQ #2 4. Will some parts of the new template agreement vary from LHIN to LHIN? The template 2009-11 M-SAA is intended for use by all 14 LHINs. Only the schedules are subject to variation based upon individual HSP service profiles, LHIN priorities and funding allocated. See also FAQ #7. 5. What are HSPs and LHINs accountable for under the new agreement? LHINs have assumed most of the Ministry’s obligations related to planning and funding of services, performance monitoring and improvement. HSPs continue to be accountable for the use of funding to provide HSP services, the achievement of performance obligations, including volumes, quality of care, and for maintaining a balanced budget in each of the two fiscal years of the agreement. 6. What is the role of the Ministry in relation to the new agreement? The M-SAA is between the HSPs and the LHINs. The Ministry is not a party to the M-SAA. 7. What parts of the new agreement are subject to negotiation? The 2009-11 M-SAA has schedules containing indicators of HSP performance related to financial health, organizational health and patient access and outcomes (including service volumes). These schedules are populated with numerical targets to be achieved in each of the two years of the agreement based on funding provided by the LHIN. The targets are negotiated between the LHIN and the HSP based on prior year results (if available), provincial policy and 2
  3. 3. obligations of the LHIN under its own accountability agreement with the Ministry. The 2009-11 M-SAA also enables LHINs to include additional HSP-specific performance obligations that would support the implementation of their local Integrated Health Service Plans. These additional requirements may vary from LHIN to LHIN and must be mutually agreed upon with each HSP. 8. What are the consequences of not meeting a performance standard under the new agreement? The M-SAA reflects three different approaches to determining an appropriate response to non- performance. While all three recognize that a response to non-performance should take into account the degree of risk posed by non-performance, they do so in three different ways. In M-SAA the parties agree to adopt and follow a proactive, collaborative and responsive approach to performance management and improvement that is based on, among other principles, a focus on relative risk of non-performance. Types of risk include risk to clients, board, staff legal etc.) Further the M-SAA fosters both relationships and flexibility at the local level to address performance issues. Province-wide prescription of process is deliberately avoided. Instead, the M-SAA identifies broad obligations, and enables a variety of actions that can be responsive to a HSP’s particular circumstances. The M-SAA focuses on achievement and performance improvement. It is not focused on identifying specific penalties for specific failures. Moreover a LHIN’s success under the Act and the MLAA will be determined, in very large part, on how well a HSP fulfils the terms of its M--SAA. Consequently a LHIN has a vested interest in working with HSPs to achieve strong performance across the system. 9. What happens if a HSP cannot meet a performance standard in year 1 but will be able to meet it in year 2 or vice-versa? See FAQ #8. The 2009-11 M-SAA requires HSP to meet negotiated performance standards at the end of each fiscal year covered by the agreement. It also contains new reporting requirements that will enable HSPs to inform the LHIN if they are forecasting a deficit or unable to meet a volume target, for example, and what mitigating strategies they are using to improve performance. 10. Will HSP’s be able to carry over funding to future fiscal years? This issue has been raised and will continue to be discussed as part of the consultation process. 3
  4. 4. B. PROCESS 11. What roles do LHIN and HSP boards play in the negotiations or the execution of the M-SAA? HSP are accountable to the LHIN for living up to the conditions and obligations of the M-SAA. HSP boards should have mechanisms in place that gives them information on the status of negotiations and to ensure they are briefed on the results, including how their management team intends to meet the agreed upon obligations. HSP boards will also want to be briefed on the consequences of non-compliance, as well as internal systems and processes in place for monitoring and managing ongoing performance. HSP boards that do not already have one in place should consider entering into performance agreements with their CEOs/EDs that are tied to the fulfillment of the HSP’s obligations under the M-SAA. HSP boards must sign the M-SAA and the HSP board holds the legal corporate accountability for its execution. LHIN Boards are ultimately responsible for ensuring that health service providers live up to the conditions and obligations in each Service Accountability Agreement (SAA), as well as being accountable to the Ministry for local health system performance under the MLAA. Participation of LHIN board members in other facets of the negotiation process will vary at the discretion of the individual LHINs. Your LHIN will provide you with information on the process to be followed. 12. Is there an appeal process if a HSP feels that it was not treated fairly during the negotiations? The composition of M-SAA negotiation teams will vary from LHIN to LHIN as will the manner in which each LHIN approaches the negotiations. Every effort will be made to ensure that discussions are undertaken in a climate of trust, mutual respect and open communication. Questions or concerns related to the process or outcomes of individual HSP negotiations may be directed to the operational lead for negotiations in your LHIN, typically the Senior Director Performance Contracting & Allocations. If concerns remain, the matter may be brought to the attention of the LHIN CEO. Please contact your LHIN for more details on the negotiation process to be undertaken 13. What benchmarks are LHINs using to measure the success of the upcoming M-SAA negotiations? The first benchmark is that all M-SAAs are signed on or before March 31, 2009. The second benchmark is the successful achievement of HSP and LHIN obligations under the agreement. Some LHINs have explicitly identified additional success factors such as maintaining positive working relationships, communicating regularly with HSPs, and understanding the impact of system pressures on HSP sustainability and ongoing HSP performance 4
  5. 5. 14. How will the lessons learned during the HSP sector consultations be identified and shared with the field? At the conclusion of the consultation sessions and in conjunction with the Sector Specific Consultation Teams, the M-SAA Steering Committee will be preparing a document highlighting lessons learned from the development of the 2009-11 template agreement and negotiation of the schedules. More information will be available in upcoming issues of the M-SAA Update newsletter 15. When and how can this agreement be altered in the future? The M-SAA is a two year agreement covering the fiscal period 2009-2011. The M-SAA Steering Committee in conjunction with the Sector Specific Consultation Teams will meet again in 12 – 18 months post April 2008 to review the M-SAA template and implementation process in light of HSP experiences, Ministry policy and LHIN plans. The review will examine what is working and what needs to be changed in preparation for the development of the next template agreement. 16. What will be expected of HSPs when LHINs begin consultation on service accountability agreements with other sectors? As LHINs begin consultation on the service accountability agreements with Community Health Centres, Community Mental Health and Addictions Agencies and Community Service Agencies in 2008/09 and LTC in 2009/10, the obligations for community engagement and the identification of integration opportunities will reach across sectors. All HSPs, will be expected to assist the LHIN achieve effective planning across the LHIN. 17. Why does the M-SAA include insurance and indemnity provisions? The M-SAA includes insurance and indemnity provisions for the same reason that a HSP’s agreements with its service providers include insurance and indemnity provisions. These provisions are risk management tools that are used to ensure that a larger share of the risk inherent in a contract, is appropriately allocated to the party best able to control that risk. Reduced to its most basic elements, the LHIN – HSP relationship is one of funder and provider. The transfer of funding is a low-risk activity. The provision of health care services to third parties is a complex, high risk, activity requiring a high level of expertise at all service delivery levels. As the delivery of services is under the control of the HSP, it is appropriate that the HSP bear the risk inherent in the provision of the services. In the present instance the OHA and the LHIN have confirmed that the provision of the indemnity to the LHIN will not result in increased insurance costs for the HSP. It may also be useful to note that service agreements between the Ministry and HSPs, have included both insurance and indemnity provisions for many years. 5
  6. 6. 18. What are the timelines for completion of the M-SAA? The LHINs will be completing M-SAAs with approximately 1500 HSPs during the 08/09 fiscal year for implementation April 1, 2009. The timelines have been established to allow sufficient time for the LHINs and the HSPs to provide input and complete the HSP and supporting Community Annual Plan Submission (CAPs) in a timely manner. June – August Sector Team Consultation with input back to Steering Committee by August 31 2008 June – August Schedules and Guidelines Working Group completes its tasks September Steering Committee considers suggestions from the Consultation Teams and Schedules and Guidelines Working Group Mid September Community Annual Plan Submission Plan Guidelines out to the field Education sessions for HSPs will be led by LHINs End of September Feedback to the Sector Teams End of September to mid – November LHIN Boards Approval of M-SAA Template End of October Completed CAPs forms due to LHINS End of November Template and Schedules sent out to LHINS to begin the individual negotiation process on the schedules December - March LHINs finalize SAAs with service providers 6