Next steps: How to organize “the system” for patients and communities – within our means

By Rik Ganderton, President and CEO, RVHS

We are taking the next steps in the evolution of the health care system at Rouge Valley Health System (RVHS) and as with any change process, these first few steps will be among the hardest.

We will be analyzing what services our communities need and how best to meet those health care needs within the constraints of the global and Canadian economy and the financial environment in Ontario. I outlined this context in my blog of Nov. 23, 2012.

The changes we are considering will take analysis, careful thought, creativity, open communication, consultation and expedient action to address the burning question: How do we provide the range of services that meet the greatest needs of the communities at the highest quality and in the most fiscally responsible way within our limited resources? 

We know that highest quality care doesn't always come from hospitals offering a wide array of specialized services.  We know that it costs more to try to do this because we cannot efficiently provide services that we perform only occasionally, and worse still, we cannot deliver these services at acceptable quality levels. This has been a challenge that hospitals have faced, but rarely talked about, for decades.

We know that choosing which specialties to focus our resources on will result in better outcomes, with fewer complications and fewer return visits for our patients. We also know that everyone would much prefer to have everything available in their local hospitals. So this is the balancing act we must achieve – delivering a range of services targeted at the greatest community need at the highest quality within constrained financial resources.

This is our opportunity to focus our resources to address the greatest community needs and grow the critical mass where we choose to specialize. We have already made some of these choices in previous strategic planning exercises, such as cardiac care, high risk maternal/child and advanced paediatrics. The process we will follow will identify those things that we do only occasionally or that we do not do well and we will then have to stop doing those things. 

It's our job, as health care providers, to inform our communities that attempting to be all things to all people is not good for their health, not sustainable and not affordable. In short, we want our communities, our patients, and our team, to know that that there are hard decisions ahead.

* Analysis *
We are seeking objective, expert advice to analyze and strategize on next steps that will allow us to provide an appropriate range of services to our communities.

There are two facts that are driving the analysis:
•    The hospital projects that, during the next three years, we will need to remove an estimated $30 to $45 million from our cost structure. Of this, some $15 million relates to the 2013/14 fiscal year (Year 1).  We have already identified the majority of Year 1 savings, which will include some staff reductions which were recently announced to our employees. Our focus is now on future opportunities in 2014/15 and 2015/16 fiscal years.
•    There is acknowledgement amongst our hospital Board, medical leadership and senior management that we have untapped opportunities for greater collaboration and integration across our hospital sites as well as with our colleagues in the Central East Local Health Integration Network (CE LHIN).

The hospital is seeking expert assistance to develop a plan that will address the following questions:
1.    Which services should we expand, maintain or reduce in order to provide the appropriate quality and access to acute care hospital services that the community needs?
2.    Which site or sites should host which of the hospital’s clinical programs? What are the financial opportunities and implications, if any, that reconfiguration would offer?
3.    What is the impact on health care service access in our community (west Durham and east Toronto)?
4.    What are the financial opportunities, if any, in a reconfiguration of services (what’s offered and where)?
5.    What leadership models would best support the achievement of standardized processes, quality, effectiveness and financial performance (value for our tax dollars) and at the program and service level, including implementation of any recommended changes?
6.    What is the road map for redefining the scope and size of hospital services during the next 18 to 24 months? 

The hospital expects the plan to focus on creating a stronger organization that serves the greatest needs of the east Toronto and west Durham communities, as part of an integrated delivery system within the CE LHIN. 

Specific requirements of the study are:
•    Identification of hospital core and non-core services for each clinical program;
•    Recommendations regarding service profiles and appropriate site or sites for the hospital’s clinical and support programs that will assist the hospital in meeting its operational challenges;
•    Recommendations regarding opportunities for enhancing RVHS competitive positioning under the recent and anticipated provincial funding and service model changes;
•    Recommendations for clearly articulated identities for both hospital campuses that are compelling, respond to community needs and are consistent with directions from the Ministry of Health and Long-Term Care and the Central East LHIN;
•    Recommendations that identify partnership opportunities within the Scarborough and Durham communities and the CE LHIN; 
•    Specific plans, actions and timelines that will allow the hospital to meet its operational challenges in year two and year three.

* Process *
It is the hospital’s expectation that the process used to meet these requirements will be:
•    Built on our existing Strategic Plan;
•    Evidence-based from known and valid sources;
•    Dynamic, engaging and paint a vision that is compelling for all participants;
•    Inclusive, transparent and engage the community in west Durham and east Toronto, our staff, physicians and volunteers.

Our analysis and planning make only a few assumptions, among them that community level birthing and pediatric services as well as emergency services will be maintained at each of our hospital campuses in Ajax and in east Toronto.
We are expecting to have a preliminary report in April and will be sharing this with our communities and partners at that time.

. . . 

As always your thoughts, questions and comments are welcome in this series of blogs discussing how we can provide the best care to patients within available resources.
Please either post your comments to this blog, or email us at communityrelations@rougevalley.ca. 

Why big changes are needed in our health care “system”

By Rik Ganderton, President and CEO, RVHS 

This blog may be considered controversial by some and beyond the purview of a hospital CEO. I am writing it because, as a leader in the system I need to communicate the valid need for change and what is driving that. The need has been there for years. The difference now is the globally-precipitated financial crisis. I am not taking political sides, but am saying the system needs to change.

It has been widely reported in the media that the province has a $14 billion annual operating deficit and accumulated debt of $237 billion. The accumulated debt represents approximately $17,770 for every man, woman and child in Ontario. The province’s annual revenues were $106 billion in 2010/11. (This is all the money the province collects from taxation and user fees, which are the government’s only source of income). So the accumulated debt is 2.25 times the province’s annual revenue.

While there are diverse, if not diametric opinions, on the reason for the deficit and the debt, there is considerable consensus that a major causal factor is the global financial crisis of 2008 and the subsequent anemic economic growth globally. By March 31, 2018, the projected date by which the province has publically said it will balance the annual books, the accumulated debt is expected to be some $275 billion. The Wall Street rating agencies have been to town and have said that if Ontario wants to retain its credit rating it has to get its fiscal house in order. This mandate will apply to any future government, regardless of political stripe.

One of the ways the province is balancing the annual books is by reducing the rate at which health care expenditures are growing. The government is trying to cap that rate to 2.5 per cent a year. That’s no small order. In the last 10 years, health care spending increases amounted to more than six and a half per cent a year.

Currently the province spends $47 billion per year or 42 per cent of its annual revenue on healthcare (hospitals, doctors, homecare, long-term care, community care and drugs). So there really is no need to change very much in the health care system as long as we keep spending more, right?

In my opinion – wrong!

Hidden in the numbers are three important facts that have profound implications for how health care is delivered.

1.     The population of the province will grow by a little more than one per cent a year over the next few years. Every one of these additional people will be entitled to health care.

2.     We are all aging and the impact of this, on health care demand, will result in yet another increase of a little more than one per cent.

3.     We have to deal with inflation factors, such as increasing costs of supplies, drugs and salaries of unionized and non-unionized employees, and billing rates of doctors.

In real terms that 2.5 per cent will be eaten up by growth in demand through aging and population increases. That means every nickel for increased salaries or supply and drug costs, not offset by improved efficiency, will result in real service reductions unless we quickly restructure how we deliver services.

From a hospital perspective the impact is likely to be greater. In Ontario’s Action Plan for Health Care, the government has also said that it intends to shift certain procedures and care from hospitals to community based care – increasing investment and shifting resources to the community by four per cent a year. Since hospitals are the largest component of health care expenditures it is pretty clear that they will be one of the main places from which to take those health care tax dollars. (Physician services are likely to be the other one). This may not necessarily be a bad thing; hospitals are often not the most cost efficient delivery model for many services.

In my opinion there is very little financial wiggle room left to avoid the necessary and needed restructuring of the health care system.

The suits from Wall Street are watching and the debt rating is crucial. If the province’s debt rating decreases, then the province’s cost of borrowing increases. The government’s ability to fund health care is diminished even more by every dollar spent on interest payments. Any future government will have the same problem.

Furthermore, there is ample evidence demonstrating that the current health care system is not really a system. (Ask most patients trying to navigate through it!) It is inefficient, quality is not consistently high, access is confused with geographic proximity and a high quality patient experience is often lacking.

In my view there is currently enough funding in the health care system (with the proposed 2.5 per cent annual budget growth) to meet patient need during the provincial budget balancing cycle. However, the status quo is not an option if we are to achieve this. We have to fundamentally change the delivery model and create a real “system” not a bunch of fragmented silos. 

Here are a few examples of such fundamental changes needed:

• We need to eliminate the fragmented governance and create real integrated delivery organizations that are accountable for quality, access and cost across the continuum of care - this means reducing the number and levels of governance/boards;
• Good quality is more important than proximity to mediocre or poor quality service that is available just around the corner – we must consolidate services to drive quality and cost effectiveness;
• We have too many physical hospitals (particularly in the GTA) – many are aging and are too expensive to maintain – we need to merge and rationalize our physical plant so that we can deliver more and better care more efficiently. (We can pay for much of the upgrades and new facilities from the savings gained by eliminating old plants.)
• We need to understand and accept the research evidence that shows that aggregating services increases quality and efficiency – this means physicians and other clinicians with specialized expertise need to move and work together in hospitals which will focus on services and patients they are trained to serve;
• Hospitals cannot be all things to all people - many procedures can be done outside a hospital more cheaply, safely and with better quality outcomes;
• We have to deliver care using best practices – Medicine is more science than art these days and using best practices and measuring compliance by all care providers is critical.

In the coming electoral campaigns we will hear much in the way of promises from every political party. The provincial financial numbers paint a serious picture, irrespective of which political party occupies Queen’s Park!

There is a danger that we will tax our way out of this need to change. Raising taxes to provide more health care funding would be wrong as we would be wasting more money on an inefficient system and delaying the inevitable – fundamental change that is required.

Health care has to change. The way we are presently organized is a barrier to delivering better quality and better value for our limited tax dollars. We need the political will from every party to support change that is necessary and inevitable. Moreover, we need our citizens, and voters, to fully understand the problem, to contribute to the debate on solutions, and to accept and support the solutions required to create a sustainable health care system.

…

This blog is part of a series we’ve been talking about this year on transforming health care. We will have more to come. In future blogs I will talk about some of the alternatives for the needed restructuring.

I welcome your views on this topic. What options seem realistic to you, or what would you propose?

* Post a comment or email communityrelations@rougevalley.ca.

Good quality costs less

By RVHS President and CEO Rik Ganderton 
Presented at RVHS 2012 Annual General Meeting of Members, June 26, 2012

It’s my pleasure to provide my report on the successes of our team in the last year and to describe how we are preparing to meet the future challenges.
One of our favorite themes, as you know, is: Good quality costs less.
At its simplest, it means getting it right the first time. When we get it right the first time your parent, your daughter, son, or friend, doesn't have to stay in hospital for extra days as the result of an infection acquired in the hospital, or doesn't need to be readmitted because of a complication stemming from our care.
Our community will be pleased to know that our focus on infection rates remains strong. One of the simplest and most effective prevention measures for staff, patients and visitors is hand washing. Our hand hygiene compliance rates were at 80 per cent in 2010-2011, and have improved to over 89 per cent compliance in the last fiscal year. We can improve on that, but 89 per cent is a good start. And I thank our staff, doctors and volunteers for that. As patients and visitors you can help by ensuring you wash your hands entering and leaving the hospital and going in an out of your loved ones room.

Less waiting - but more improvement needed

We have continued to focus on emergency department (ED) wait times at both hospital campuses because our patients are waiting longer than they should. Our patient volumes have increased significantly, with 117,000 emergency patient visits last year across both campuses. The amount of time a patient waits in emergency to be admitted to a bed has decreased from 78.8 hours in 2010-11 to 72.8 hours in 2011-12 at RVAP. This is in part reflective of needing more acute care beds to support this campus but also needing to improve our internal processes significantly. By focusing our efforts more on patient flow, from emergency department to a medical bed, we have already seen things improve to less than 40 hours in the three months to June 30, 2012. This is a great improvement, but still more work to do!
The time a patient at Rouge Valley Centenary waits in emergency to be admitted to a bed was 50.4 in 2010-11 which was reduced to 43.1  hours in the fiscal year ended on March 31, 2012. In the last three months, we have reduced that wait to less than 33 hours. Again good improvement but more work to do. Our objective is simple—to have no admitted patients waiting in the ED!
We’ve had many important developments since last year’s AGM that will help us get things right for patients today and in the future.

New medical beds

This spring we opened 10 new short-stay medical beds here at Rouge Valley Ajax and Pickering. Those beds help patients get the attention they need in the right place at the right time, rather than being kept in the emergency department. By reducing the time admitted patients spend in the ED it frees up staff and physician time as well as space meaning patients are seen by a doctor more quickly. We call it patient flow. If it’s your mother, father or family member waiting to see a doctor in the emergency department, you just might call it better care.
The 10 additional beds were approved by the Central East Local Health Integration Network (CE LHIN), and the Ministry of Health and Long-Term Care. We thank them for their continued support of this hospital in meeting growing community needs.
Another of our recent success stories had its one-year anniversary in January. The transitional restorative care program (TRCP) at Rouge Valley Ajax and Pickering is a great example of how the health care system needs to change to improve care and to make the system sustainable.

Collaborative care

Supported again by the CE LHIN, the TRCP, as we call it, is a fine example of collaborative care in action for patients. Collaborative care makes the best use of staff skills and training – better for patients and more engaging for our team members at the same time. The TRCP is configured as a collaborative team of nurses, physicians, personal support workers, physiotherapists, recreational therapists, social workers, and caseworkers from the Central East Community Care Access Centre. That pooling of expertise is all there for patients in one place. This teamwork centres on providing restorative care for frail and elderly patients, enabling them gain strength to return home to their normal lives. The TRCP results in about four patients a week returning to their homes sooner than they would have, and in much better physical shape.

Regional cardiac care

In June 2011, we significantly enhanced the regional cardiac care program, by adding coordinated cardiovascular rehabilitation services in Durham.
We thank the CE LHIN and our partners at Durham Emergency Medical Services and Lakeridge Health for making this program even better. Lakeridge, Rouge Valley and The Scarborough Hospital work together to deliver this regional cardiovascular rehabilitation and secondary prevention program. It provides services to an additional 680 patients a year, to a total of 1,980 residents.
The whole concept of a regional program is another example of how the provincial health care system is changing to better deliver specialized services. The centralised organization of expertise and resources means improved quality care for patients, while maximizing the use of limited tax dollars through avoided duplication.It also improves quality through having a critical mass of highly trained experts working learning and treating patients together in a single location.
For people such as Gary McCormack, of Bowmanville, having that regional expertise available was a lifesaver. Gary had three heart attacks enroute with emergency medical services from Lakeridge Health in Oshawa. He was then taken straight into our catheterization lab at Rouge Valley Centenary. There, he received the timely, highly-specialized care he needed from a cardiologist and staff. That was about two and a half years ago. Thanks to our fast-track cardiac program, called Code STEMI, Gary was well enough to come to the hospital and celebrate the one-year anniversary of Code STEMI at the start of the last fiscal year in April 2011.
The work of our team continues to be recognized externally as well. Just this month, Accreditation Canada recognized a partnership between Durham Mental Health Services and Rouge Valley as a leading practice for providing crisis service outside of the hospital. The services provided in this partnership result in patients receiving the crisis mental health care they need without having to come into the busy emergency department. This is better for mental health patients, who receive the care they need sooner, and better for the hospital’s patient flow. My thanks to all members of our mental health team, as led by acute care services vice-president Cheryl Williams, and our community partner, Durham Mental Health Services.

Great fundraising and community support

In addition to our staff and physician efforts, I’m proud to acknowledge and thank the Rouge Valley Health System Foundation for its support and partnership to ensure the hospital has the best, and most essential, medical equipment for the community. A few weeks ago the community, staff and doctors came out in droves to push old medical beds on a stretch of pavement at the Scarborough Town Centre. They raised $50,000, or 10 medical beds, for the Foundation’s Buy-A-Bed Campaign. Not only that, the entire event, televised live on CTV, connected us further with our communities. We had members of the Toronto Police, the fire department and businesses, such as Best Buy, participating in the event. During the last fiscal year, the Foundation also completed its fantastically successful Image Is Everything Campaign for a new MRI at the Rouge Valley Ajax and Pickering hospital campus. The $5 million MRI came across the 401 for delivery last September. It was community engagement and fundraising at its best.
The reason we were able to install the new, state of the art MRI, relates to another hard won achievement by our Board, our management team, our physicians and our staff. And that is the consistent generation of annual surpluses. For the last five years, Rouge Valley has broken with its past of running deficits, and instead has become more efficient allowing us to reinvest in our facilities. Our surpluses are used to maintain our aging facilities and to buy essential medical equipment, such as the MRI. We were able to purchase the MRI in advance of the completion of fundraising campaign thanks to the efficiency of our team. That meant our community was able to benefit from this MRI scanner years sooner.
As we look ahead to the next three years and more, we know there are many challenges coming. It’s my pleasure to report that Rouge Valley Health System is well positioned to meet these challenges head on for our patients and our communities.

* Read the hospital's 2012 Annual Report.

What Ontario’s action plan means for patients and the system

By Rik Ganderton, President and CEO, RVHS

In this blog I will talk about the Ontario Government’s Action Plan for Health Care and why it (or something similar) is needed to ensure that we and our children will have a sustainable, quality health care system in the future.

The time for action is past due really. It’s a thorny, difficult issue that has been around for at least two decades and it’s one that few have been keen, or able, to tackle head on, although many have tried unsuccessfully. I think the difference this time is that there is a comprehensive plan with real incentives and disincentives to drive the change.

Health Minister Deb Matthews puts it this way. “We can’t keep spending our health dollars the way we used to. If we don’t change, we simply won’t be able to guarantee sustainable universal public health care for ourselves, our children and our grandchildren.”

I have to agree.

-Starting the conversation-

That’s why we are talking about Ontario’s Action Plan for Health Care. The transformation required and set out in the government’s plan is the most significant change in health care since the introduction of Medicare in the 1960s. In my view, it’s long overdue.

Rouge Valley Health System has been discussing this internally and externally with our local political leaders in recent weeks. (Our April 27, 2012 presentation to them is available to the public.)

Now it’s time we talk about the changes needed and what they might mean to our organization, our patients and to our communities. One June 7, I spoke to municipal councillors on Durham Region’s Health and Social Services Committee about Ontario’s Action Plan for Health Care and what it could mean. (Here is a link to that presentation.)

-The right path-

We believe the province’s action plan is the right path to pursue and we want you, our community, to be aware and as involved as you choose to be in the discussion that is beginning. The plan is based on the principle that good quality costs less. I’m convinced that this is true: it has been our experience at Rouge Valley Health System (RVHS) in the last five years.

Please read the Ontario Action Plan for Health Care for your own education as it will have real impact on our health care system. Here’s what it could mean to you and your health care system.

·      For decades the bricks and mortar of the hospital have been the centre of the health system and many services have grown around and with the hospital. This is a costly and ineffective way of organizing care as its focus is on acute intervention, rather than managing wellness, health, personal responsibility and management of disease at home with community support.

·      In the future, patients will be at the centre of the system. To drive change in the system, the way it is funded will change from global budgets, inflated by some amount on an annual basis, to patient-based funding.  That will create incentives for all providers to deliver more high quality, cost effective care in the right setting.

·      We will see much greater involvement of primary care (your family doctor, community agencies and clinics) in the system, coupled with greater access and greater accountability of that sector for managing care – particularly of those with chronic diseases such as cancer, diabetes and cardiac issues. This expansion of primary care’s role will be supported with greater funding, shifted primarily from hospital and physician payment components of the funding pot. We’re already hearing some of that debate in the media.

·      From a hospital perspective our role will change. We will become a part of the system focused on the patient, as opposed to being the focal point of the system. We will focus on those complex cases, the difficult surgeries, the most critically ill but treatable patients. We will no longer be the provider of all things to all people.

·      All current hospital services won’t stay in hospitals. Surgical centres, private clinics and other community-based providers will perform services that people are accustomed to receiving in a hospital.

·      Higher performing hospitals, with lower costs per patient and higher quality outcomes, will be assigned more patient volumes for complex treatments and procedures they are doing best.

·      As a result, hospitals will have to be more competitive on quality care for patients and cost.  This is an example of good quality costing less.

·      During the next three years, funding of hospitals will shift from global budgets to a variable patient-based budget with incentives for quality and efficiency. By 2015, 70 per cent of hospital funding will be variable based on performance, compared to the three per cent currently in place. John Aldis, our RVHS vice-president, corporate and post acute services, and chief financial officer, puts it this way: “This is a very dramatic change over a short period of time and has the potential to be disruptive as hospitals adjust their plans in response to funding shifts.  Some hospitals will get more money, while many will get a funding cut.  There will be significant pressure to integrate services within and among hospitals to deliver higher quality care more cost effectively.” (Read his March 15, 2012 blog on this.) Worldwide research shows that consolidation of service improves quality and efficiency, particularly for low volume complex procedures. This will clearly impact where patients get their service, and where physicians and staff work.

·      Funding reform will be a huge improvement over the current funding model because it is patient based, takes into account the complexity of patients’ conditions, provides incentives to hospitals for their efficiency and will include incentives for providing better quality outcomes for patients.

·      The implications of Ontario’s Action Plan for Health Care are that quality of care will be improved in the province and costs will be lowered as services migrate to the best performers in the most appropriate care setting. It’s the migration, or transfer of services, from one hospital to another, or from a hospital to a community-based provider, that will test public anxieties and political fortitude to forge ahead.

·      Services, staff, doctors and volunteers will move based on where it is best for patients to receive various health care services. Integrations of programs among hospitals, or with community providers will become the norm.

·      Mergers of hospitals will clearly be on the table to create critical mass and improve quality while driving down cost inefficiency. That will generate some talk!!

Our experience in implementing transformational change at Rouge Valley will be invaluable as we start on this journey. In recent years, our team of RVHS Board of Directors, doctors and staff have succeeded at:

·      Eliminating our deficit;

·      Generating surpluses needed for reinvestment in our facilities and medical equipment;

·      Constant improvement through the Lean philosophy.

-Collaborative Care-

Our latest focus has been on making the best use of our team’s skills for our patients through collaborative care. In short, collaborative care respects the full skill set of every staff member and makes their jobs more focused on the very things they trained for, and entered health care for, in the first place.

In a collaborative care setting: nurses do more patient care and fewer other duties; allied health staff concentrate on the roles they are trained for in diagnostic imaging and other areas; and personal support workers focus on their duties for patients. Each person’s job is designed to serve patients to the best of their abilities, rather than being diluted with less-relevant tasks. Plus, it makes coming to work more much meaningful and enjoyable for everyone – and that’s a benefit to patients as well. In essence it’s the right provider, doing the right job at the right time in the right place in the right way!

The next few years will be filled with (hopefully) intelligent debate and (hopefully) less rhetoric as anxieties flare over what the changes could mean in the location of services and who performs them.

The bottom line is that the system has to change. The changes stemming from the action plan will be centred on improving quality care for patients and sustaining our essential health care system. We wholeheartedly support this.

Stay tuned!

Rouge Valley better than average and working hard to continue improving for patients

By Rik Ganderton, President and CEO, RVHS 

The details are out on the Canadian Institute for Health Information’s (CIHI) Canadian Hospital Reporting Project – and our hospital has above average results overall.

We also have several areas that require more focus and actions to improve for patients. We view the CIHI report as an opportunity to examine our services and improve.

Data from the report showed the performances of more than 600 acute care hospitals from all provinces and territories in the country covering the fiscal years from 2007–08 to 2010–11 in 21 clinical indicators and nine financial indicators.

When looking at the four fiscal years covered in the report, our hospital fares well compared to the national and provincial averages for the 21 clinical indicators. We’re better than average on 14 of them.

Better than average

There are many examples of better than average results in the report for Rouge Valley.

·      5-Day In-Hospital Mortality Following Major Surgery – Above average. In fact, we ranked fifth of 19 Greater Toronto Area hospitals in the category, as reported by The Toronto Star.

·      28-Day Readmission After Acute Myocardial Infarction (AMI or heart attack) – As the regionally designated centre in cardiac care, we are proud of this result.

·      Use of Coronary Angiography Following Acute Myocardial Infarction (AMI) – RVHS is better than the national and provincial averages for all four years.  

·      90-Day Readmission After Hip Replacement – RVHS was worse than the national and provincial averages in 2007-08 and 2008-09, but has improved to better than the average for the last two fiscal years in this category.

·      30-Day Readmission Rate (Obstetric, Paediatric, Adult Surgical, Adult Medical and Overall) – Data for these indicators are only reported for 2009-10, in which RVHS was better than the national and provincial averages. 

·      Obstetrical Trauma for Vaginal Delivery With Instrument and in Obstetrical Trauma for Vaginal Delivery Without Instrument – RVHS is better than the national and provincial averages for all four years for both indicators.

Worse than average

There are a handful of areas listed in the report which we are reviewing and working to improve on for patients and our communities.

·      C-section Rate (Excluding Pre-Term and Multiple Gestations) and Vaginal Birth After C-Section (VBAC) Rate – RVHS is higher than the national and provincial average for all years reported for both indicators.

·      30-Day In-Hospital Mortality following Acute Myocardial Infarction (AMI) – RVHS was better than the national and provincial average in the first two years, but has become higher in the final two years reported on. We are examining the factors that contributed to this result. As the regional centre for cardiac care, we see a variety of heart attack patients in dire need of our expertise. We will take the report’s findings as a further motivation to examine how we can improve our highly specialized services for patients. Our readmission rate after AMI, for example, is better than the average in the report, so we know there are daily success stories in our cardiac program. This downturn may be tied to introducing the Code STEMI Program in February 2009, serving Scarborough; and in February 2010, fully expanded to Durham. Measures that have been implemented to improve care of AMI patients include:

-       Increased focus on clinical guidelines and order sets, medication reconciliation practices, patient and family education programs, coordination with pre- and post-hospital providers, cardiac support programs;

-       Quality improvement committees, participation in quality collaboratives; holding staff accountable for quality;

-       Communication and coordination among providers;

-       Problem solving and continuous learning;

-       Development of a cardiology focus unit with enhanced staff presence and expertise in AMI care; sustained cardiologist physician champions, empowered nurses, involved pharmacists.

·       Administrative Service as a Percent of Total Expenses – RVHS is worse than the national and provincial averages for all three years reported.

·      Cost per Weighted Case – RVHS is higher than the provincial average for all three years reported, reflecting that it is more expensive to deliver care at RVHS than the average hospital. 

As I said we’re working on all of these. I should elaborate also on the administrative service cost percentage, in which we are listed as being the worst in the province. 

In 2009/10, the most recent year for which data is available, the provincial average for administrative expense was 5.92 per cent. RVHS’ was at 8.79 per cent. There are a few reasons for this including:

·      Severance costs and early retirement incentives as part of our necessary and very well publicized Deficit Elimination Plan for 2008-2011; and

·      Insurance premium increases stemming from a fraud discovered in 2007 and an old class action lawsuit dating back to the late 1990s. These are included as administrative costs in the CIHI report, and if reduced to normalized amounts, then RVHS’ administrative costs would be in line with the Ontario provincial average.

The hospital has been steadily improving its quality of patient care and improved overall safety — which will gradually push down our insurance premiums over time.

As part of our strategic plan, improving the patient experience is our number one priority and daily mission. As our staff and physician team knows very well, we have been applying a Lean philosophy of constant improvement for patients since 2008. That is having a positive impact on patient readmission rates, wait times and quality of care in general. All of this will have a favourable impact on our insurance premiums, which are included in the percentage of administrative overhead listed in the CIHI report.

It’s important to note that our admin costs continue to drop in 2010/11 and in 2011/12, but are still high because of insurance and ongoing severance costs incurred through ongoing restructuring.

Given the new funding formulas being introduced this year, the continuous pressure to reduce costs will escalate and will continue for several years. Based on these changes I foresee that severance costs will continue as we constantly restructure to meet these challenges. By its very nature insurance will continue to be high for another several years even without any major claims as we continue to pay off the old claims.

There is so much we can learn from in the CIHI report, as in other substantive reports done on hospitals. We will focus on improving our patient care in all areas, including those in which we are worse than average and those many areas in which we are better than average.

Our goal has been, and remains, to be the best at what we do for our patients. 

(Read the entire CIHI report on its website.)

 

Annual publishing of "the Sunshine List" - 2011

Rouge Valley Health System note

The Ontario government has moved up its annual posting of government employees who have earned $100,000 or more in the last year. That provincial list is being released on Friday, March 23, 2012, a week earlier than in previous years.

In alignment with the provincial posting, Rouge Valley Health System has published its list.

For more information on the annual salary disclosure, please read last year's blog by Rik Ganderton, RVHS president and CEO.

The 2011 list has grown as more union and management employees cross the $100,000 threshold set back in 1996. Please note that non-union staff salaries have been frozen for two years, with the exception of some graduated step increases in pay.

Our new list is published on our public website, via this link on our financial page. 

Quality based funding begins for hospitals

Good concept – now the hard part – doing it right

By John Aldis, vice-president, corporate and post acute services, chief financial officer, RVHS

As part of the Minister of Health’s Action Plan for Healthcare, the Ontario government is introducing health system funding reform. The new funding approach, which will be phased in starting in fiscal 2012/13, is a paradigm shift in how the government will fund and hold hospitals accountable for the services they deliver.  

Health Minister Deb Matthews recently summarized it this way: “We have to shift spending to where we get the highest value. Our funding models need to be updated, to accelerate the transition from a provider-centred funding model towards a patient-centred funding model, where funding is based on the services provided.” 

This funding reform is the most significant change in the way Ontario hospitals are funded in over 25 years.  The changes will present challenges and opportunities for hospitals which are used to a mostly fixed funding stream, with annual increases to partially offset inflation.  Over the next three years, 70 per cent of hospital funding will be variable, compared to three per cent currently, and change from year to year based on a hospital’s volume of services, level of cost efficiency, and quality of care.   This is a very dramatic change over a short period of time and has the potential to be disruptive as hospitals adjust their plans in response to funding shifts.  Some hospitals will get more money, while some may even get a funding cut.  There will be significant pressure to integrate services within and among hospitals which will impact patients, physicians and staff.  

Since details of the formula have not yet been released, the impact on individual hospitals is not yet known.  What we do know is that starting in fiscal 2012/13, 46 per cent of hospital funding will be variable, increasing to 70 per cent within three years.  Part of the variable funding will be based on the volume of key services and associated costs.  Hospitals with the capacity to provide more services, to better match demand for those services in their communities, will attract funding.  And hospitals that deliver these services most cost-effectively will also benefit under this funding method.  The rest of the variable funding will be for specific services which the Ministry will target for quality improvement and cost rationalization.  Funding for these, so called “Clinical Quality Groupings” will be provided at a set price, for a specified volume of procedures.  Hospitals that can deliver these services with high quality outcomes, at low cost, will have the opportunity to attract more revenue.  The first three Clinical Quality Groupings to be funded this way are cataracts, joints, and chronic kidney disease.

So what does this mean for RVHS?  We need to build on the good work we have begun over the last few years to enhance the quality of care, become more productive, and drive down the cost to deliver our services.  It means we have the opportunity to be rewarded financially for being a high quality, low cost provider and to grow services which our community needs.  We must redouble our efforts to deliver the highest quality care using evidence based order sets and care pathways, better understand and manage our costs, and apply our Lean approach to continually eliminate waste and become more productive.  In other words, we need to be "the best at what we do."  And in areas that we cannot, we must be prepared to divest and do so responsibly, being respectful and minimizing the impact to our patients, staff, and physicians.

RVHS has embarked on a journey of continuous, positive change over the last few years.  We have embraced change and we have outperformed.  Funding reform will challenge us all to do even better.

(For more information on quality based funding, please read the Ministry of Health and Long-Term Care’s presentation.)