Background and terms of reference

Trillium Health Partners (“Trillium”, the “Hospital”, “THP”) is a large community-based academic hospital, with over 10,619 staff and 1,430 professional staff. The Hospital encompasses three main sites - Credit Valley Hospital, Mississauga Hospital, and Queensway Health Centre - offering the full range of acute care hospital services, as well as a variety of community-based and specialized programs. Currently it has 1,397 budgeted beds and 1,711,698 annual visits, making it one of the largest and busiest hospitals in Ontario located within a rapidly growing and ethnically diverse community.

Importantly Trillium Health Partners has undergone unparalleled change over the last decade. These changes include, but are not limited to:

  • The voluntary hospital merger between the Trillium Health Centre and Credit Valley (2012) with the harmonization of THP policies and committees (including the Medical Advisory Committee (MAC)), the development of common care pathways, uniform service coverage and the introduction of the Professional Staff Code of Conduct policy (2017).
  • The transition from a community hospital to a teaching hospital with the Mississauga Academy of Medicine educational program starting in 2013 and later research initiatives focusing on implementation and evaluation science at the Institute for Better Health.
  • The increasingly tertiary nature of care with several important programs.
  • The introduction of a new Health Information System: The Epic Project.
  • A 10-year strategic plan 2019-2029, and
  • External pressures such as increasing patient volumes and COVID-19; both of which have affected the Emergency Department disproportionately.

THP’s administrative and professional leadership and all its staff should be justly proud of these accomplishments.

Between December 2021 and May 2022, the Ministry of Health (the “Ministry”) received two letters from a law firm – TTL Health Law – representing an anonymous group of physicians from Trillium. The physicians made allegations of inappropriate and unprofessional behaviour by Hospital Administration and requested the Minister of Health appoint a Supervisor to investigate their allegations.

In the first letter, received on December 22, 2021, the group of anonymous “concerned physicians” indicated they were Emergency Room physicians in Mississauga and for the purposes of their complaint, the term “Hospital Administration” refers to the following individuals: the Chief of Staff, the Chief of Emergency Services, the Mississauga Site Lead for Emergency Services, and the Medical Director, Medical Affairs. They alleged that the Hospital Administration had engaged in the abuse of power, harassment, and intimidation. The second letter was received on May 27, 2022 and included an unknown number of additional physicians across six (6) departments at Trillium indicating they have “essentially identical complaints” of hospital leadership as those of the anonymous “concerned physicians” and reiterated their call for an “independent third-party investigation” of Trillium’s leadership. The focus of the second complaint letter was the hospital’s Chief of Staff.

To investigate these concerns, the Ministry appointed an Inspector, under s. 18 of the Public Hospitals Act, to Trillium to conduct a comprehensive review of the concerns shared by the “concerned physicians” about hospital physician leadership and the actions and processes followed by hospital administration (as defined in the correspondence) in respect to dealing with the professional staff of Trillium. On June 09, 2022, the Ministry informed TTL Health Law and the Board Chair of Trillium that the Ministry would be engaging a third-party – the Inspector – to conduct a review of the concerns raised by the “concerned physicians”.

Terms of reference

The terms of reference of the review are as defined below:

  1. Pursuant to section 18 of the Public Hospitals Act (PHA) and section 10 of Regulation 965 under the PHA, the inspector will review:
    1. the specific concerns shared by the “Concerned Physicians” in two letters to the Ministry dated December 22, 2021, and May 27, 2022, regarding hospital and physician leadership at Trillium Health Partners (THP).
    2. the actions and processes followed by hospital administration (as defined in the correspondence) in respect of managing the professional staff of THP.
  2. The Inspector will provide a final written report to the Minister of Health no later than October 28, 2022. The final report shall also be provided by the Ministry to Trillium Health Partners and be made public by the Minister pursuant to subsection 18(4) of the PHA. The report will set out the Inspector’s findings and include recommendations to address any issues that may have been identified in the review.
  3. Pursuant to subsection 18(3) of the PHA, the inspector shall keep confidential all information that comes to their knowledge in the course of carrying out their duties and shall not communicate any information to any other person except as required by law or except where the communication is to the Minister, or a person employed in or performing services for the Ministry.

The details of the review (goals, process, scope, and deliverables) were finalized in August 2022.

Inspector conflict of interest and biography

Inspector conflict of interest statement: Dr Jeffrey Turnbull

While I have met several professional staff and leaders at THP in the past, I have no conflict of interest in my role as Inspector. Of note while a senior medical leader at Health Quality of Ontario, I engaged 2 medical leaders as Regional Quality Leads who are now at THP.

Inspector biography

Dr Jeffrey Turnbull, MD, FRCPC, was appointed as Inspector on July 12, 2022.

In addition to a Bachelor of Science (University of Toronto) and a master’s degree in education (University of Western Ontario), Dr. Turnbull received his Doctorate in Medicine at Queen's University and later achieved specialty certification in Internal Medicine through the Royal College of Physicians and Surgeons of Canada in 1982.

Dr. Turnbull has been the Vice Dean of Medical Education at the University of Ottawa (1996-2001), the President of the Medical Council of Canada (1998- 2001), the President of the College of Physicians and Surgeons of Ontario (2006-2007) and the President of the Canadian Medical Association (2010-2011).

Dr. Turnbull was the Department Chair of Medicine from (2001-2008), the Chief of Staff at The Ottawa Hospital (2008-2017), and Chief, Clinical Quality for Health Quality Ontario (2014-2017), where he also held the position of Health Equity Clinical Lead. He also served as Senior Medical Officer for Correction Services Canada (2011-2014).

He remains committed as a medical educator with special interests in “Poverty and Health Equity” and associated health policy.

Dr. Turnbull has pursued an interest in poverty and its effect on health nationally and internationally. He is one of the founders and was the Medical Director of Ottawa Inner City Health for those experiencing homelessness which works to improve the health of people who are chronically homeless.  He is the recipient of several national and international grants and awards, including the Order of Canada, the Order of Ontario, the Queen Elizabeth II Diamond Jubilee Medal and two Honorary Degrees of Law from Carleton University and The University of Western Ontario.

Allegations as outlined in TTL Health Law letters

The allegations made by the “concerned physicians” in their letters of December 22, 2021, and May 27, 2022, are summarized below.

Alleged abuse of administrative power

The “concerned physicians” allege that “the Hospital is abusing its administrative power, obstructing the course of justice, violating the common law and, as a public body empowered by Government legislation, it is breaching the principles of fundamental justice which are protected under section 7 of the Charter of Rights and Freedoms”. The letter also states that there are “several instances wherein Hospital Administration has obstructed the course of justice by interfering with, what is supposed to be, neutral, unbiased and transparent investigations within the hospital”.

They report that this has led to a toxic culture rooted in harassment, intimidation, and threats of loss of privileges by targeting physicians who question hospital administration’s decision-making.

Alleged Interference with Statutory Process and/or Procedural Fairness

The “concerned physicians” report that the Chief of Staff interferes with procedural rights to fairness prescribed in the Public Hospitals Act thereby undermining the delivery and quality of patient care. They report that the Chief of Staff will often inform a physician that they must attend a meeting, or they cannot return to work, physicians are provided no notice or agenda for said meeting, and they are informed that they cannot bring legal counsel to a meeting, or the legal counsel present may not speak.

They accuse the Chief of Staff of abusing his power by:

  • Circumventing procedural fairness prescribed in the Public Hospitals Act and undermining the delivery and quality of patient care.
  • Illegally suspending physicians by circumventing the statutory process and interfering with the course of justice.
  • Interfering with a physician’s rights to procedural fairness by preventing counsel from speaking at meetings.
  • Altering or misrepresenting minutes of meetings.
  • Refusing or obstructing physicians from taking medical leaves of absence.
  • Manipulating hospital bylaws to circumvent fair process (e.g., Chief of Staff is not limited to 2 consecutive 5-year terms).
  • Lack of neutral unbiased transparent investigations, for instance the Coke review.
  • Refusing transparency regarding the management of financial resources.

Alleged Threats

The “concerned physicians” report that the Hospital Administration abuses its power by targeting physicians who question its decision-making in the form of threatening privileges. They believe that it is the threat of privileges that allows the Hospital to circumvent the legal process under the Public Hospitals Act.

They accuse the Hospital Administration of:

  • Threatening physicians with a suspension or revocation of privileges.
  • Threats of reporting physicians to the College of Physicians and Surgeons of Ontario.
  • Publicly shaming physicians.

Alleged Consequences

The physicians report that the alleged abuses by the Hospital Administration has resulted in the following:

  • Physicians are prevented from advocating for improvements in the delivery of quality patient care for fear of retribution, thereby endangering the public.
  • Financial resources for the management of the health care system are diverted for hospital legal fees.
  • An exodus of experienced and talented physicians, across departments, from the hospital (nearly all physicians from an entire department left the hospital and many current physicians have less than 5 years of clinical experience).
  • Physicians taking medical leaves of absence because of bullying, intimidation, and harassment while others were said to have been refused or prevented from taking medical leaves of absence thereby endangering the public.
  • Chilling effect on debate and collaboration within the hospital, which would reasonably appear to be crucial to delivering quality patient care.

Alleged Conflict of Interest

In their first letter to the Ministry, the “concerned physicians” request that the current Secretary of the Cabinet, and immediate past President and CEO of THP, be recused from any subsequent investigation of their allegations on the basis that she is reasonably in a conflict of interest that could bring the administration of justice into disrepute.

The other reasons given for this request include:

  • The Secretary of the Cabinet can arguably not be neutral in an investigation into the management and administration of the Hospital as the alleged abuses of power at the hands of Hospital Administration occurred during the time when she was the President and CEO of the Hospital.
  • The spouse of the past President and CEO of the hospital runs a medical supply company, Mohawk Medbuy, that supplies the Hospital, and this raises a reasonable apprehension of bias and conflict.
  • The Chief of Staff of the Hospital is on the board of Mohawk Medbuy.

Response by THP leadership to TTL Health Law letters

The Board Chair, CEO and medical leadership have reaffirmed their support for and full confidence in the physician leadership identified in the TTL Health Law letters and specifically the Chief of Staff. Many responded that “change was necessary” and that the allegations made were factually incorrect. All felt that THP had undergone significant cultural and organizational change and that while difficult, these changes were considered necessary to ensure a respectful workplace and the consistent availability and competency of professional staff.

The Professional Code of Conduct and Professional Staff Bylaws were considered by leadership to be of a high standard and were implemented fairly with compassion and understanding and without intimidation nor harassment. They felt that there was no attempt to suppress dissent and often professional staff were encouraged to respectfully raise concerns. New efforts had been initiated to support and enhance communication with the professional staff and to engage the Professional Staff Association (PSA). THP leadership also referenced efforts to enhance leadership and physician wellness.

It was also felt by leadership that THP had a very thorough process to prevent any real or perceived conflict of interest such as those alleged above.

In keeping with the THP Whistleblower Policy, THP General Counsel was engaged to review the concerns raised in the 2 letters described. After a review of THP Bylaws, Policies and Procedures, as well as the Public Hospitals Act and other relevant legislation, the concerns were not felt to be substantiated.

All THP leadership have expressed their disagreement with the way in which these concerns have been brought forward.

Process of the review

I conducted wide-ranging interviews with all concerned parties as summarized below:

  • Interviews with “concerned physicians” through TTL Health Law and others represented by legal counsel (19)
  • Interviews with THP Respondents namely the Chief of Staff, Chief and Medical Director, Emergency and Urgent Care, Former Emergency Department Division Head and Service Medical Director, Mississauga Health/Queensway Health Centre Sites, Medical Director, Medical Affairs (4)
  • Interview with THP Board Chair (1)
  • Interviews with THP administrative leadership including the President and CEO, the Executive Vice President, Quality, Risk, Practice and Performance and Chief Nursing Executive, Senior Vice President, Patient Care Services, Program Director, Emergency Department and Urgent Care Centre, Director, Professional Practice, Senior Vice President, Quality and Patient Experience, Practice and Medical Affairs, Director, Medical Affairs and Education (8)
  • Interviews with THP Medical Leaders (Chiefs) (10) and Emergency Department (ED) site leads (2)
  • Interviews with past and present Professional Staff Association executives (8)
  • Interview with THP General Counsel and review of THP Chief Compliance Officer’s January 2022 report following THP’s “Whistleblower” approach (1).
  • Other interviews with Physicians spontaneously coming forward (25) *

I reviewed the following documents:

  • All relevant Bylaws, Policies, and Procedures
  • Reports pertaining to the Emergency Department (Coke/Internal Practice Review, 2020)
  • Emails spontaneously submitted (2) **
  • Submissions by Medical Affairs
  • Submissions by CEO regarding the Conflict-of-Interest process
  • Submissions of support by Board and Medical Leadership

* After notification of all staff by the THP CEO and then the President of the PSA, of the naming and then visit of the Inspector, individual professional staff without prompting/invitation asked if they could also provide information which may be of benefit to the investigation. To the extent that this fell within the mandate of the review this request was granted.

** Similarly, 2 individuals submitted emails outlining concerns.

Limitations of the review

Although I met with and interviewed 19 physicians represented by TTL Health Law and 25 others who spontaneously came forward, almost all would only agree to speak to me on condition that I would maintain their anonymity throughout the investigation and would not reveal to anyone in the administration anything that would identify them including any specific events that would potentially identify the source of my information. In keeping with this condition, the “concerned physicians” would not agree to allow me access to individual files pertaining to any of the allegations of “illegal suspension” or “refusing or obstructing leaves” or indeed any of the other allegations of abuse of power by the Chief of Staff.

As a result, I was not given sufficient information to properly investigate many of these allegations or to provide the Chief of Staff with an opportunity to know and respond to these allegations, to interview other relevant persons or to come to a fair and evidence-based conclusion on the strength or weakness of the allegations. This fundamental limitation on my work was made clear to the “concerned physicians” and is reflected in the limited nature of my findings set out below.

Fear of retaliation and in some cases prior nondisclosure agreements were cited as the principal reasons given for this requirement for confidentiality.

The scope of this review did not permit meeting individually with all members of the involved departments as requested and I was only able to meet a segment of the “concerned physicians” who were willing to bring their concerns forward.

In addition, even though in the second letter from TTL Health law there was reference made to similar concerns from six of nine programs within the Hospital, I was unable to systematically sample the general physician morale and happiness with medical leadership. Those who came forward independently were also a subset of the general physician population who may not have represented all professional staff.

Approach to Conflict-of-Interest Concerns raised by TTL Health Law

To avoid any influence or bias in the report that may arise because the past President and CEO of THP is now the Secretary of Cabinet for the Provincial Government of Ontario, the Ministry procured an external advisor to act as a Substitute Decision Maker to assess the issue and provide impartial advice to the Minister of Health.  The Substitute Decision Maker received this report. This process has ensured that my work has met the objective of being fully Independent.

The letters from TTL Health Law also refer to a conflict of interest between the past CEO and Mohawk Medbuy, a company led by her husband. While this was not the focus of my review, I did have the opportunity to review all processes related to this potential conflict of interest.

General findings

During my interviews I did not principally focus on the issues that were raised such as on call coverage, access to resources, specific policies and procedures, and the introduction of the Health Information System. While these issues were inherently controversial, this is to be expected. Rather, the focus of the report was on whether these were introduced in a collaborative, respectful fashion.

Due to the limitations resulting from the confidentiality requirements placed upon this review, I was not able to substantiate or refute many of the allegations raised. Nevertheless, some of the findings and recommendations that follow are informed by the commonality of complaints and number of complainants arising from different departments.

  1. All individuals (complainants, respondents, administration, and other professional staff interviewed) were deeply committed to THP and its historical and future service to its community.
  2. While concerns were raised about the potential for quality care to be disrupted, overall, it was felt that the care provided by THP was excellent. Many of those raising concerns and respondents highlighted that changes as outlined earlier in this report had been needed to ensure good patient care.
  3. THP has an appropriate governance structure with up-to-date and best practice policies and procedures in keeping with the Public Hospitals Act.
  4. Important administrative and planned professional leadership changes (as outlined in the requirements of the 2014 Medical Staff Bylaws) have and will take place, which guided by a new strategic plan and leadership development will be an important step toward resolving concerns and building for the future. Efforts are underway to strengthen the input of the PSA and to enhance communication and engagement between Administration and Physician staff.
  5. While there are numerous routes to raise legitimate concerns within the structures of THP which include, medical leadership, the PSA, and the Whistleblower Policy, the “concerned physicians” felt “compelled” to engage external legal counsel. All parties felt that this is not the most appropriate or usual way to have concerns regarding leadership addressed however, I believe that the “concerned physicians” have done this in good faith. The complainants felt that when their concerns had been raised, their concerns had been disregarded and they had been targeted and punished for speaking up. The very fact that all “concerned physicians” and almost all of those who came forward independently insisted on confidentiality for fear of retribution suggests, real or perceived, this problem exists for some and may be more widespread.
  6. Management strategies over the last decade were consistently referred to as “top-down” or “autocratic” with little or no opportunity for dialogue. Those physicians interviewed spoke of an adversarial approach, and distrust and disrespect of physician staff who were to be “managed”. It was alleged that the Code of Conduct policy and the Professional Staff Bylaws were used as a tool to implement and enforce change. This was felt to disempower medical leaders. The professional staff that were interviewed reported that they had become disengaged especially when individuals are encouraged to leave if they do not agree. While these concerns are disputed by THP and even if not borne out in individual cases, it is now a widespread perception by those physician complainants interviewed.
  7. Reportedly, there were few opportunities for the physicians’ voices in advocating for quality medical care and workplace health through medical leadership to the Board and to senior administration.

    There are opportunities at multiple levels where issues can be brought forward at THP. When they did speak up, some physicians felt that their concerns were often discouraged and discounted. I was unable to support or refute this concern.

  8. There were many reports of declining Professional staff morale and engagement. The earlier Pulse Survey results (response rate of 31.3%) did not detect this. However, while average physician staff engagement was 64.8% of those responding in 2019 in Mental Health and the Emergency Department, this had dropped to 54% and 54.5% respectively. A full Pulse survey is planned for this year.

    Of note, a PSA survey of 2021 (response rate of 15.2% of all members and 30% of active members) showed that 60% of professional staff responded neutrally or negatively to whether they felt valued at THP, 70% felt neutral or unsupported when experiencing challenges in their workplace and 49% responded neutrally or negatively on whether they would recommend THP to others. Importantly, 79.3% of respondents expressed concerns of burnout.

    The “Coke Report”/ Internal Practice Review of 2020 of the Emergency Department also suggested there was poor morale amongst the ED professional staff.

Findings relevant to the specific concerns raised by the “Concerned Physicians”

Alleged abuse of administrative power

A respectful workplace and the definitions of disrespect and harassment are defined in the Respectful Workplace Policy of Trillium Health Partners - Policies and Procedures. I have no doubt that subjectively, the complainants felt that there was a culture of harassment and intimidation. Fear of administrative action against them and those other physicians who voluntarily came forward led to the insistence on confidentiality for fear of reprisal (even though THP has a No Reprisals principle). I accept that they felt that that the Professional Code of Conduct Policy was used as a tool to enforce compliance and to suppress dissent.

Conversely, medical leadership felt that in enforcing the Professional Code of Conduct Policy and Professional Staff Bylaws (which were supported by almost all), that it was only appropriate to inform individuals of the consequences of further actions and this was not intended as a threat.

Due to the limitations of this review arising from concerns of confidentiality and prior non disclosure agreements, I was not able to determine if the actions outlined in the Professional Staff Code of Conduct Policy, were used coercively or were preferentially applied to people who spoke out in questioning the actions of THP administration as alleged, even though others outside of the “concerned physicians” have also raised this as a common concern.

Alleged interference with Statutory Process and/or Procedural Fairness

Regarding the allegations of circumventing of procedural fairness prescribed in the Public Hospitals Act, illegally suspending of physicians, and interfering with physicians’ rights to procedural fairness, the complainants specifically alleged the following:

  • In the Professional Staff Code of Conduct Policy pertaining to escalated complaints of level two and three, that this was an unfair process. Individuals reported that they were notified to attend a meeting pertaining to a complaint with short notice, little opportunity to have legal support/input, no agenda, and no understanding of who would be in attendance. Legal or PSA support were not permitted to speak, and the process was to be entirely confidential.
  • At times these meetings would lead to agreed-upon settlements again with a nondisclosure clause. Those physicians involved felt that this was a very isolating and intimidating process and that they were obliged to cooperate for fear of further action through the MAC, the Board and possibly the College of Physicians and Surgeons of Ontario.

I agree with medical leadership that this was a clearly outlined process in line with the Public Hospitals Act. However, having complaints against you is always uncomfortable and the process followed seemed to be overly formal and legal, lacking empathy and opportunity for discussion and de-escalation. I should point out however, that I have only been informed of a subset of those individuals leading to level 2/3 concerns and that most concerns are dealt with by the program chief more informally.

While escalated concerns were dealt with by Medical Affairs and often the Chief of Staff, the Credentials Committee of the MAC whose mandate it is to “ensure compliance with the Professional Staff Credentialing Policy and Professional Staff Credentialing Procedure” and to report to the MAC, was not engaged beforehand but after when decisions had been made.

Altering or misrepresenting minutes of meetings: To the allegation of altering and misrepresenting minutes put forward by the physicians, given the limitations on my review this allegation was unsubstantiated.

Illegal Suspension of Physicians: I saw no evidence that individuals were illegally suspended in accordance with the Public Hospitals Act. If individuals were intimidated into agreeing to an outcome (as some allege) without proper preparation, information, and legal support, this would call into question procedural fairness. The Hospital Professional Staff Bylaws outline the process for revocation and temporary suspension of privileges, all medical staff should be aware of this.

Refusing requests of Medical Leaves of Absence: When individuals request a Medical Leave of Absence, Medical Affairs uses a standard process for medical leaves of absence for physicians that is aligned to such requests from staff.  This includes an assessment from a clinician with their assessment of what the professional staff member can and cannot do against the context of their role and responsibilities in their program. This may have been interpreted as obstructing physicians from taking medical leaves as alleged. The Hospital reports that there has not been an increase in requested leaves.

Manipulation of Hospital Bylaws: Contrary to allegations made, the Professional Staff Bylaws were adjusted in 2014 to limit the Chief of Staff position to two consecutive five years terms.

Lack of neutral unbiased transparent investigations: The ‘Coke’ review was in response to several critical incidents pertaining to adverse paediatric outcomes in the Emergency Department. Its mandate was not to address specific grievances by Emergency Room physicians. This confusion pertaining to mandate and the confidential and internal nature of the report further worsened suspicions.

The THP review of the two letters from TTL Health Law outlining physician concerns followed the Whistleblower policy of THP and this review was conducted by THP General Counsel. It was not considered to be independent and focused principally on existing policies and procedures.

Refusing Transparency regarding the management of financial resources: The TTL Health Law letter also refers to the use of funds by the Head of the Emergency Department. This fund now has physician staff oversight.

Alleged threats

As mentioned above, the physicians alleged that they were threatened with suspension/revocation of privileges as well as “weaponization” of the College of Surgeons and Physicians of Ontario. It should be noted that the simple notification of the requirements as laid out in the Public Hospitals Act and Medical Staff Bylaws when dealing with a Code of Conduct issue does not constitute a threat. When used arbitrarily or coercively, this could lead to a culture of fear of further action. I was not able to determine that notification of these requirements was used to intimidate and suppress debate however, I do appreciate that this may have been how it was perceived. There were frequent references made by complainants to “just accept decisions or leave”. If true, (I was made aware of one correspondence from THP leadership where this was implied) this would not enhance a respectful workplace.

Public shaming of physicians: The goal of any interim action must be to ensure patient safety and then to minimize the impact on the physician involved. While individuals may have felt publicly shamed because of agreed upon settlements, these should be set out with compassion and empathy for the individual assuming that the decision was fair, transparent, and always protecting the interests of patients.

Alleged consequences

As stated above, the “concerned physicians” report that the alleged abuses by the hospital administration have led to serious consequences including preventing physicians from advocating for improvements in the delivery of quality patient care, diversion of financial resources for legal fees, an exodus of physicians from the hospital, and a consequent chilling effect on debate and collaboration within the hospital. To these allegations, I will note the following:

  • A consistent theme that was raised by the “concerned physicians” and those who independently voiced concerns was that they would no longer advocate for quality patient care, and they had become disengaged from the affairs of the Hospital. The Public Hospitals Act and Excellent Care for All Act support the important role of medical staff and medical leadership in bringing safety and quality concerns through the MAC and Chief of Staff directly and independently to the Board. If the medical staff and leadership are disengaged as alleged and they feel that they can not speak out in a fair and collegial fashion, this will not serve the patients of THP.
  • It is common practice that legal fees arising from the credentialing process are covered by the Hospital and are a legitimate public expense. Good stewardship suggests that these should be prudently used and accounted for.
  • There has been significant physician staff and leadership turnover in several key areas (overall staff resignation/ retirement was 6-7.9% per year between 2017-2021 approximately 2-3 times that of a comparator hospital). In Mental Health and the Emergency Department, this was annually, approximately 15% and 10% respectively at its peak. The number of staff who have reduced their FTE (Full Time Equivalent) clinical load or the impact of a relatively large number of courtesy staff is not included.
  • I have been reassured by THP administration that a whole Medical Department has not left THP. There have been concerted efforts to recruit newer medical graduates to THP, however losing staff many of whom are mid-career or senior staff with expertise and experience and who act as leaders and mentors is concerning.
  • I have been reassured by the Senior Vice President Quality and Patient Experience, Practice and Medical Affairs that there have been no adverse impacts on the quality of patient care because of these changes. Given the limitations of my review, I was unable to substantiate claims relating to medical leaves of absence.

Alleged conflict of interest

I have had the opportunity to review how the Hospital has isolated decisions regarding the purchasing of medical supplies from the past President and CEO. While I have no expertise in this area, the processes in place to guard against inappropriate influence seem to be thoughtful, robust, and transparent.

Mention was made of the Chief of Staff sitting on the Board of Mohawk Medbuy. He no longer has this responsibility and was never in a position to influence purchasing at THP.

Recommendations: A way forward

THP has successfully undergone remarkable change and has navigated the challenges of increased service requirements, budgetary limitations, and COVID-19. This has required strong leadership. It is now time for THP to further promote its leadership and governance strategies in keeping with its 2019-2029 strategic plan.

  1. Recruitment of new Physician Leaders: Specifically, in accordance with the 2014 Bylaws, and without attributing responsibility or blame, searches should proceed for the Chiefs of the Emergency Program and Mental Health Program and then for the Chief of Staff position. These individuals should be thanked for their very significant contributions in bringing THP to where it is today.
  2. Continued support for Medical Leadership: There are over 100 Site and Program Medical Leaders at THP. There is a very strong leadership development program that needs continued support for program specific leadership. This is a challenging role as these individuals must be held accountable for ensuring the highest quality of medical care for their patients and at the same time, “creating a healthy work environment that enables teamwork and collaboration while also promoting staff and professional staff satisfaction” (THP Program Chief Accountability). Medical leaders must also respect their role in bringing quality of care concerns, as envisioned in the Public Hospitals Act, up through the Medical Advisory Committee to the Board, collaboratively, constructively but independently of the hospital administration. They must be free to do this without fear of retaliation.
  3. Devolution of decision making and accountability: There should be a devolution of decision making and accountability to program leadership. There should be greater input from medical staff within the program in the process of leader appointment, annual performance review, and reappointment for a second term. Recommendations to the Board pertaining to appointment and reappointment should be based on external program reviews where appropriate and 360 leadership assessments that include meaningful input from physician membership. These appointments are the exclusive responsibility of the Board and must be based on what is best overall for patient care. Equally, the Chief of Staff appointment, annual performance reviews and reappointment at the level of the Board should include input from the general medical staff, possibly through the Professional Staff Association. The independent voice of the Professional Staff Association should be strengthened, and its input encouraged at all levels of the organization. While it must advocate for the well-being of physicians, it must always do this in the context of what is best for patients and indirectly THP.
  4. Independent 3rd Party Review of culture and physician staff engagement: Efforts to support physician staff through engaging the Professional Staff Association and through the newly appointed position for Physician Wellness are well received.

    Nevertheless, concerns have been raised that there are more widespread issues pertaining to low morale and disengagement of physician staff as noted above. It is recommended that a formal process to assess culture, morale, trust, safety, and engagement be undertaken immediately for all THP professional staff. THP should engage a 3rd party independent review and this more formal targeted review could complement the full Pulse Survey proposed for this year.

  5. Review of Professional Staff Code of Conduct, Policies, and Procedures: While THP policies and procedures are of high quality, it is time to re-evaluate how these and specifically the Professional Staff Code of Conduct Policy are applied without altering the high standard established. When dealing with issues of capacity, competence, and behaviours:
    • Deal with these principally at the program level and focus on de-escalation.
    • Adopt a Just Culture approach which recognizes that quality concerns arise from both individuals and specific circumstances.
    • For those rare circumstances that are escalated to level two or three, minimize the formality, caution individuals about talking to complainants or pleading their case but drop the confidentiality/nondisclosure clause.
    • Address concerns as soon as possible (especially if they pertain to patient safety) but make individuals fully aware of the agenda, those attending and their right to representation.
    • At any time during the meeting the individual should feel free to engage their personal/legal support and they should not feel coercion but should have a clear idea of the path going forward and the strategies to remediate the problem with the goal being to return the physician to active high-quality care. Consider allowing 1-2 days before finalizing agreements.
    • Issues identified in the past that are not related to a current complaint should not be brought forward and an individual should be able to see their complete dossier.
    • The guiding principles underlying the use of the Professional Staff Code of Conduct Policy must always respect the highest standard of quality care and reflect the values of the organization such as compassion, respect, and transparency. Negotiated settlements must firstly protect quality care but after that must be minimally intrusive to the physician involved.
    • Recognizing the challenge of a negotiated settlement, the Credentials Committee should be more engaged beforehand in the Code of Conduct process, thereby broadening the decision-making process from just the Director of Medical Affairs and the Chief of Staff. Issues should be brought forward to the Medical Advisory Committee through the Credentials Committee for debate.
  6. Engagement of a 3rd Party Arbitrator to oversee Individual Complaints: If after reviewing the general recommendations more is still required to address the individual complaints of the “concerned physicians”, moving forward will require the Hospital and the individuals involved to drop all confidentiality requirements where the specifics of each case can be reviewed and contrasted against best practices. To reduce the fear of retaliation, a 3rd party arbitrator should be engaged to hear concerns and adjudicate decisions relating to the Professional Staff Code of Conduct.
  7. Sustainability - Engagement of an Independent Facilitator to assist in the implementation of the recommendations: An independent facilitator should be engaged by THP to work with the Board, CEO and Professional Staff, to assist in the implementation of the recommendations and to advise the Ministry, through periodic updates, on progress with implementation of these recommendations.

It is hoped that the recommendations as outlined, will provide a way forward for all that is acceptable.

Conclusion

There have been many important changes at THP. There is now an opportunity for THP and its Board to reflect upon its successes over the last decade and to position itself for the future.

Providing the highest quality of care through investing in staff is the 4th pillar of the Institute for HealthCare Improvement and will position THP for success when faced with the inevitable challenges of the future. The degree to which the Board and its administrative and professional leadership accept this challenge will determine its success going forward.

If the Board, with new administrative and medical leadership, continue to focus on assessing, and investing in strategies to improve the workplace, I am confident that they have the capability to continue the success of THP. I would like to thank those who have given freely of their time to make this review possible, and the excellent support received.

Respectfully submitted
Jeffrey Turnbull