Letterhead Template - Updated - May 2011

Central East LHIN

Governance Advisory Councils (GACs)

Expression of Interest Form

Section A: INSTRUCTIONS

This form is to be completed by individuals interested in becoming a member of a Central East LHIN Governance Advisory Council (GAC).

Three (3) GACs will be established - one for each of the Central East LHIN clusters – and each GAC will include approximately 20 people representing a cross section of Central East LHIN health service provider governors. (In the event that a health service provider does not have a board, the individual responsible for signing a Central East LHIN accountability agreement will be eligible to complete a GAC Expression of Interest Form.) At this time, we are only able to accommodate one member from an organization to sit on the GACs. An exception applies to organizations that have a LHIN-wide mandate, whereby, up to one member is permitted to participate on a GAC for each cluster.

Please review the Terms of Reference for the Governance Advisory Councils BEFORE completing this Expression of Interest Form. Applicants are also expected to review the 2010-2013 Central East LHIN Integrated Health Service Plan (IHSP) and the existing Central East LHIN Framework for Community Engagement (updates pending). Visit the Central East LHIN website to download a copy of the above mentioned documents.

Expression of Interest forms will be reviewed by a panel to identify members of the three (3) GACs. You are welcome to provide additional material to support your expression of interest such as a brief biographical sketch, resume or reference/testimonial letter. For privacy and confidentiality reasons, please submit any additional material to Jennifer Persaud at or mail to the address listed below c/o Jennifer Persaud, Governance Coordinator, Central East LHIN.

Please submit your completed Expression of Interest application to:

Attn: Jennifer Persaud

Governance Coordinator

by email

or by FAX (1-905-427-9659)

or mail to Central East LHIN, 314 Harwood Ave. South Suite 204A, Ajax, ON L1S 2J1

Section B: RESPONDENT INFORMATION

Name:

Are you currently a board member/signatory to an accountability agreement for a Central East LHIN health services organization?

Please provide the name of Organization:

Are you currently Board chair of the above-named organization?

Contact information – Mailing address:

Street:

City:

Postal Code:

Email:

Phone:

Section C: EXPERIENCE AND KNOWLEDGE

1.  Which Governance Advisory Council are you interested in joining?

2.  We are seeking Governance Advisory Council members with knowledge and experience in one or more of the three geographic clusters that make up the Central East LHIN region (please consult the 2010-2013 IHSP for cluster based maps). Please review the clusters below and answer the following questions:

Which cluster do you live in? Please indicate the applicable zones.

I live outside of the Central East LHIN region in the municipality of

Which cluster(s) does your organization serve? Select all that apply. Please indicate zones.

3.  What type of sevices does your organization provide?

4.  To aid in your application, please identify any accomplishments or leadership recognition (i.e., professional credentials, designations, publications, awards, presentations) you have received.

5.  In reviewing the Central East LHIN’s Strategic Directions for the health care system, which strategy do you have the most knowledge and/or experience? (Please check all that apply and use the space below each strategy to provide a fulsome response.)

Transformational Leadership

The LHIN Board will lead the transformation of the health care system into a culture of interdependence.

Quality and Safety

Healthcare will be person-centred in safe environments of quality care.

Service and System Integration

Create an integrated system of care that is easily accessed, sustainable and achieves good outcomes.

Fiscal Responsibility

Resource investments in the Central East LHIN will be fiscally responsible and prudent.

6.  In reviewing the Central East LHIN’s Strategic Aims contained in the 2010-2013 Integrated Health Service Plan - to reduce the impact of vascular disease and save 1,000,000 hours of time spent in emergency departments - which element of these strategies do you have the most knowledge and/or experience?

7.  Please identify one or more key success factors and associated strategies which you would recommend be implemented by all Central East LHIN HSP governors to achieve the Central East LHIN’s Strategic Directions and/or Strategic Aims? (max. 250 words)

8.  Reflecting on your work, volunteer and life experiences, please describe a challenge to creating an integrated system of care for patients and their families and the strategies you used to overcome these challenges. In your answer please consider one or more of the identified LHIN priority population (seniors, people with mental health and addictions issues, people with chronic disease and/or their caregivers, Aboriginal and Francophone). (max. 250 words)

9.  Please describe how your leadership skills, abilities and influence will be leveraged to improve integration of the patient care experience and achievement of the Central East LHIN Strategic Directions and/or Strategic Aims? (max. 250 words)

10.  How will your work, volunteer and life experiences support you in meeting the following expectation identified in the Governance Advisory Councils’ Terms of Reference? Please be specific in the sectors and communities/populations with which you have had experience.

“Governance Advisory Councils will, through a process of discussion of common issues of governance and accountability, identify opportunities for integration, provide advice to the LHIN as well as to the HSP Boards on matters related to the enhancement of system integration.” (Terms of Reference Governance Advisory Councils). (max. 250 words)

Please provide any additional comments or information to support your application.

Please check off the items if YES is the answer to the following questions:

Governance Advisory Councils

APPROVED MEETING SCHEDULE 2011/12

All meetings for each geographic GAC will be scheduled to start at 6:00 pm.

Information requested in this form will be used ONLY by the LHIN and the review panel to evaluate suitability of all potential candidates for appointment to the three (3) Governance Advisory Councils, and will not be disclosed without the consent of applicant. Additional disclosures of personal information may be separately requested in order to evaluate your suitability as a candidate as well as to verify the accuracy of the information you have provided and for no other purposes. Any questions about the collection, use of disclosure of personal information requested on this application should be directed to Jennifer Persaud, Governance Coordinator, at or 1-866-804-5446 ext 229.

Declaration: By signature I am declaring that the information in this form and in my resume/biographical sketch or other supplemental information submitted is true.

Signature: ______Date: ______

(if submitting electronically, please include electronic signature)

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