CEO blog: Decision-making at Holland Bloorview (part one of a two-part series)

A graphic showing some of the factors that go into decision-making: research, design, style, and inspiration.

As the 2018-year comes to a close, I’m planning a two-part year-end set of posts to the blog (do you see how I am cleverly distracting you from the fact I didn’t post in November?).

This first one will focus on decision-making at Holland Bloorview especially regarding budgeting (it is, after all, that time of year). The second one will focus on some myths and truths about Holland Bloorview (spoiler alert: there will be numbers!).  And to start off the New Year in January, I will focus on a subject particularly near and dear to my heart, the wellness of our team. Stay tuned.

All three of these of these posts are likely to be of greatest interest to our Holland Bloorview team and in the spirit of transparency – more information is always better than less – and I’m eager for your comments and questions!

As promised, this post will focus on decision-making at Holland Bloorview especially, but not only, regarding budgeting. This is what I sometimes hear:

“It’s impossible to understand how decisions get made in this place!”

This post is an attempt to help to clear some of that up.

There are other ways to better understand decision-making: ask your manager if there’s something happening on your team or in your department that you want to know more about; check out HBConnect (the Holland Bloorview intranet) where information on major initiatives can be found (e.g. Meditech EXPANSE, our health care information system); come to a CEO Coffee Chat and ask me directly!

But here are a few FAQs to help make it (hopefully) clearer:


How are money decisions made?

By now all departments will have completed their financial optimization and budget process and submitted the results to the Finance Department. Our Chief Financial Officer has brought preliminary numbers to the Senior Management Team to show us that all departments have met their savings targets (thank you – we know it wasn’t easy!).

[Why savings? Because the increases in funding we have gotten each year in the past few years while terrific, don’t keep up with inflation (the amount our costs go up). Stay with me!]

These departmental budgets also include new operating budget “asks.” Later, capital (e.g. equipment) requests will be brought to the Senior Management Team. Where operating and capital need exceed our funding (always), Senior Management Team is responsible for prioritizing.

This priority setting gets reflected in the annual Operating Plan, which is prepared to demonstrate alignment with our No Boundaries strategy. In other words, our activities in the coming year are shown organized around how they will advance the impact areas of our strategic plan: Personalize Pathways, Discover for Action, Connect the System (as well as our four enablers).

The Operating Plan pulls together financial requirements with priorities. In other words, are there things we want to stop doing, consolidate, start doing, or do differently? For example last year, a key priority was to develop a plan to transition medically complex and younger clients from specialist acute care (primarily SickKids) to Holland Bloorview for rehabilitation. This change (and the funding required to make it happen which we ultimately received from the Toronto Central Local Health Integration Network (LHIN)) had been developed by our Rehabilitation and Complex Continuing Care team with support of lots of other resources across the hospital before it made its way into the Programs and Services priorities and finally into the Operating Plan.

The Operating Plan is reviewed by the Quality Committee of the Board of Trustees  – to ensure focus on services, programs, safety and quality – and the Business and Audit Committee of the Board of Trustees – to ensure that it demonstrates financial responsibility and adherence to our Hospital Services Accountability Agreement (HSAA), which is our contract with the government for our funding. Then the whole thing goes to the full Board of Trustees

Aren’t you glad you asked?


What about equipment and IT?

Similar process for capital requests but Information Systems/Information Technology (IS/IT) equipment is reviewed by the Digital Health Strategy and IS Committee. This committee has been newly constituted this year and includes physician and health discipline representation as well as two family leaders.

The Senior Management Team also decides on equipment needs in line with the No Boundaries strategy and quality and safety (as well as lifecycle of current equipment). For example, last year some big approvals were for capital required for Meditech EXPANSE and new X-Ray equipment to replace an aging existing machine.


Where does the Foundation come in?

Great question! Much of what we do as the bread and butter of Holland Bloorview couldn’t happen without the generous support of our donors. Roughly $9M annually of donor dollars are spent on equipment (e.g. new inpatient sleeper beds – finally!), programs (e.g. therapeutic recreation, therapeutic clowns, parent education), the family support fund, and research (e.g. the new research MRI which will come to Holland Bloorview next year as part of the Bloorview Research Institute Growth Strategy) and innovation (e.g. No Boundaries Fund projects such as KneuroKnits anxiety reduction through knitting for kids with ASD). In addition there are generous endowments (donor funds which are invested to create an income stream), which fund particular research areas (e.g. named chairs/positions supported by targeted funding like the Holland Family Chair held by Dr. Nick Reed, the Bloorview Children’s Hospital Chair held by Dr. Melanie Penner, and the Chang Family Chair held by Dr. Tom Chau).

Decisions on how the annual donor support is spent are made by the Senior Management Team (SMT) through the annual grants process. Grant fund requests are made on a template, VPs review all the grants coming through their areas to make sure they represent the most important priorities, the whole bundle gets reviewed by me, and then the full “ask” comes to SMT. Once we have decided which among the grant requests the hospital will ask be funded, I sign off on the package and it goes to the Board of Directors of the Foundation for approval. The Foundation will only fund something that has been identified by the hospital as a priority.

The Foundation President and CEO also looks at the Senior Management Team approved equipment needs and will fundraise for a significant proportion so we can purchase more through donor support then our capital budget each year would make possible (thank you donors!).

More questions on donor funding, how you can help generate more of it, or anything else about community support? Stop Sandra Hawken our terrific Foundation President and CEO in the halls, chat with any of her great team or join the staff philanthropy champions group.


I have a great new idea, how do I get it funded?

If it is something that will help to personalize pathways, give us an edge in discovering for action or connecting the system and you can do it for less than $5000 it is perfect for the No Boundaries Fund. This is a fund that members of the Holland Bloorview team can apply to. Check out HBConnect (Holland Bloorview’s intranet) for more information.

Not every new idea requires new money. Doing things differently to make our organization better and to enhance the care and services we provide is always top of the agenda. But it isn’t always clear where to go with those ideas. If your idea doesn’t fit the No Boundaries Fund requirements talk to the relevant manager or if you aren’t sure talk to a VP or come chat with me and I’ll help to steer you in the right direction.


Okay, those are decisions about money, but what about other decisions? How do they get made?

The answer is … it depends. Lots of decisions are made locally. Of course clinical care decisions are made by physicians, nurses and clinicians as part of their everyday responsibilities. Managers and Directors make decisions for their areas and the VPs make decisions in the portfolios for which they are responsible (most often in consultation with colleagues across the hospital). “Final” decision-making typically (but not always) resides with the Senior Management Team, and ultimately, on matters of governance, with our Board of Trustees.

There are committees such as the Medical Advisory Committee that have a number of sub-committees that ensure safety and quality. These committees for example review incidents and determine whether and how they could be prevented and take steps to do so working with practice councils and our Quality, Safety and Performance team. Policies regarding care, quality and safety are approved through this mechanism. The Medical Advisory Committee reports into the Quality Committee of the Board of Trustees every month.

The Family Advisory Committee sets goals every year and then works with Programs and Services leadership to coordinate how to achieve them. For example last year one of the Family Advisory Committee goals promoted by our Chief Nurse Executive was the creation of Family Communication Whiteboards for inpatients.

The Digital Health Strategy and Information Systems Committee make recommendations to the Senior Management Team on how to enhance the use of technology at Holland Bloorview.

Academic and research priorities are set by the Teaching and Learning Institute and the Bloorview Research Institute in annual plans and budgets that go to the Research, Teaching and Learning Committee of the Board of Trustees.

Sometimes important and strategically aligned (i.e. supporting No Boundaries) ideas come directly to me. For example this year we launched Canada’s first Autism ECHO, a very important initiative to build healthcare provider capacity where there is huge client need across the province. This was “pitched” to me, we decided as a Senior Management Team that it was a very important, impactful and strategically aligned idea and put our support behind the team creating a proposal that was ultimately funded by the Government.


Is that it?

No! There are lots of committees and groups that promote change and new actions at Holland Bloorview. There’s the Equity, Diversity and Inclusion Committee, the Social Committee, the Evidence to Care Committee and the Human Resources Council, to name just a few. There is BRITE (the Bloorview Research Institute Trainee Executive) and an emerging council looking at integrating learning opportunities across the hospital building on work in the Teaching and Learning Institute, strength-based nursing and Organizational Development and Learning. There is a brand new (and our first!) affinity group that is a grass-roots initiative of staff interested in LGBTQI2S issues.

Have ideas about this (or anything else?) then come to one of my quarterly CEO Coffee Chats to share your thoughts!



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