Managing risk: One hospital’s experience

It’s been almost two months since we opened the new Oakville Trafalgar Memorial Hospital (OTMH), one of several new health care facilities completed in 2015 and certainly the largest capital project in Oakville’s history. While the opening came together in an intense 12 hours on a rainy winter day on December 13th (when we moved more than 270 patients and simultaneously closed the legacy hospital and opened the new one), the work actually began much earlier with a decade of planning, four years of construction and many months of operational readiness and facility activation work.

The new OTMH is intended to serve the community for more than half a century, growing alongside it. Its design and construction deliberately integrated new technologies while providing opportunity to incorporate future innovation. Standing eight stories tall and measuring 1.6 million square feet, the new hospital is indeed monumental, dominating the skyline.

From the very beginning it has been an ambitious and complex project and, as with all such large scale projects, carried significant risk. Failure, whether clinical, financial, or reputational, looked stark: cost overruns, deficiencies that impaired the effective use of the hospital and physicians and staff ill-equipped to function in their new work space. In their thought-provoking discussion of major infrastructure projects, “Megaprojects and Risk: An Anatomy of Ambition,” authors Flyvbjerg, Bruzelius and Rothengatter identify several key factors that can make potential risks a reality and propose solutions. Our approach mirrors many of these proposals.

Flyvbjerg and company suggest a new approach to decision-making and shared accountability from the very beginning of a project; we shared many of their ideas. While certainly we worked closely with the Ministry of Health and Long-Term Care as well as Infrastructure Ontario, we also took steps to partner with the consortium (Healthcare Infrastructure Partners) that designed and built the hospital. This resulted in a very interactive relationship that enabled us to reflect patient care needs more fully in the finished facility as well as institute appropriate risk-sharing among all parties.


We also engaged very closely with a wide spectrum of stakeholders by striking a Capital Planning Advisory Committee of the Board and drafting a Capital Projects Governance Charter. This enabled a shared understanding of risk (thus avoiding the potential pitfall of underestimation of risk and provided a forum for seeking communications advice from experts and partners including municipal government. The charter also empowered appropriate board oversight over the executive team and stipulated reasonable constraints on the office of the CEO. I am pleased to note that these particular initiatives were commended by the Ontario Hospital Association’s Governance Centre of Excellence for their innovation.

It’s been said that life is not lived by intentions but through action. Similarly, a capital project of the magnitude such as ours must at some point devolve from planning to action… to real-world use. This entails a different strain of risk but one that can be managed all the same. This is where the operational readiness work paid off.

In essence, Halton Healthcare became an ‘operational readiness organization.’ This demanded the creation of an operational readiness and transition planning framework as well as seven tactical elements. Both aspects of the strategy worked to generate not only a disciplined way of working but also a culture of operational readiness. This was particularly vital as there were significant changes not only to the physical space (three times the size of the legacy hospital, almost 150 more beds and 80 per cent single patient rooms) but also to work processes (decentralized food, nursing and registration services and at the same time a single point of service for ambulatory procedures, for example).

We knew that we wanted a ‘smart’ hospital but that human beings, many with clinical (not information technology) expertise, would need to work with the new technologies we planned to deploy. So we piloted systems such as the Emergency Department Information System (EDIS) at all three of our hospitals to provide staff and physicians with opportunity to gain familiarity with them. And we went beyond piloting, in fact front-end loading the installation of the IT systems we knew we’d need. Of the 89 IT projects needed at the new hospital, 90 per cent had been installed, tested and put into daily use at our legacy hospital well before our move. These included EDIS and systems such as  patient flow, operating room tracking solutions and telemetry.


We also knew that, with the new hospital much larger than the one it replaced, staff would need to become familiar with their new environment. This prompted an intensive series of orientations that included not just presentation of key information but opportunities to walk through all areas of the new hospital to get an on-the-ground understanding of the space. Once again, we took a front-end load approach and implemented the changes we anticipated at the new hospital in our existing hospital, for example, introducing decentralized nursing pods in our inpatient units at the legacy hospital. We also took steps to mitigate operational risk by introducing a new role – the contract manager, who has responsibility for identifying, managing and rectifying new facility issues in concert with our Design Build Finance and Maintain (DBFM) partners. This helps ensure that, from a patient perspective, facility issues have little or no impact on clinical operations.

The result of such preparation work was a state of readiness that saw us not only able to safely move all of our inpatients but also receive our first emergency department visit and deliver our first baby the very day we opened the new OTMH.

This is the very tangible side of risk management – ensuring the organization can deliver on its mandate and purpose. When coupled with an on-time and on-budget delivery of a very large and complex DBFM project, I believe it shows the value of a considered, careful and inclusive approach to risk management.