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.)