Executive Update. Driving Standardization to Advance Patient Care. In this issue. Feature Story. Issue 21 Fall 2015

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1 Issue 21 Fall 20 The Access to Care Executive Update is produced by CCO s ATC Business Effectiveness Team. For more information, contact us at ATC@cancercare.on.ca In this issue 1 Driving Standardization to Advance Patient Care 3 Information Transforms the Emergency Department Landscape 4 WTIS Expansion 20/: DI Efficiencies 4 ATC Surgeon Dashboard Now Available to All Surgeons Feature Story Driving Standardization to Advance Patient Care The Canadian Triage and Acuity Scale (CTAS) is the national standard used to triage patients in Ontario emergency departments (EDs). As CTAS supports triage nurses in prioritizing high acuity patients for assessment and also impacts resource allocation, funding and provincial reporting, its accurate and consistent application is critical to patient safety, performance improvement and funding equity. Both research and the 2010 Ontario Auditor General Report have shown extensive variation in the interpretation and application of these national guidelines, presenting a significant opportunity to advance patient care. Seizing this opportunity, in March 20 Deputy Minister of Health, Dr. Bob Bell announced that, on behalf of the Ministry of Health and Long-Term Care (The Ministry), Access to Care (ATC) would develop and implement an electronic CTAS (ectas) decision support solution to standardize CTAS application across the province. 6 Wait 1 Access Targets Now Available For All Surgical Specialties in the WTIS 7 Mental Health and Access Wait Times 7 Together Everyone Achieves More When It Comes to ALC 7 Fresh Faces Get all of the latest news from Access to Care at If you have examples of how your organization has effectively used ATC data to drive performance improvement, contacts us at ATC@cancercare.on.ca and have them featured here. Every journey starts with a first step; triage is a critical step in the patient journey through the emergency department, said Dr. Howard Ovens, Provincial Emergency Medicine Expert Lead. Standardizing the application of CTAS guidelines across Ontario will both improve patient safety and support more informed health system decision making. Over the past six months, ATC has engaged cross-functional hospital representatives and key health system partners to understand the current state and define a solution design with a provincial lens. Hundreds of highly engaged stakeholders have volunteered their time and expertise to ensure the solution design and implementation approach will effectively integrate with the diverse triage practices and hospital systems across Ontario.

2 Driving Standardization to Advance Patient Care SOLUTION DESIGN Based on provincial input, a single CTAS decision support system with multiple, flexible integration options will be implemented. The ectas integration options will accommodate clinical and technical variation, minimizing the impact of implementation on hospitals. Further, hospitals will be able to select the integration option best suited to their site-specific resources, readiness, clinical practices, technical systems, and preferences. Electronic Canadian Triage & Acuity Scale (ectas) System IMPLEMENTATION APPROACH The ectas implementation approach includes two key phases, each with multiple waves, to roll out the various integration options across all Pay-for-Results (P4R) hospitals. The first phase of implementation will be a small, controlled rollout to validate and enhance the solution prior to the full provincial implementation. Early adopter hospitals will work in direct consultation with ATC s technical development team to support integration activities, identify any issues, and address challenges as they arise. APPLICATION (Basic / Complex) 5-Step Triage Documentation WEB SERVICE CERTIFICATION The second phase of implementation will include all remaining P4R hospitals as well as any ER National Ambulatory Care Reporting System (NACRS) Initiative (ERNI) non-p4r hospitals wishing to participate. CTAS Decision Support (Calculator / Clinical Algorithm) Triage Data Set CTAS Validation The three ectas integration options are as follows: Application: The provincially-provisioned, web-based ectas application will support full electronic triage documentation and provide CTAS decision support. The application will be designed by the provincial Clinical Working Group to ensure an intuitive, user-friendly design that resonates with triage nurses. It will be designed to integrate effectively with paper-based processes (via print functionality) as well as with existing electronic hospital systems. The ectas initiative has been progressing at an incredible pace. Facility executives and LHIN CEOs have been formally engaged and a comprehensive implementation selection guide has been distributed to hospitals across the province. Conceptual solution design is also well underway in direct consultation with clinical experts from the ectas Clinical Working Group. In the coming months, ATC is looking forward to analyzing completed implementation selection guides and working with hospitals to identify early adopters and determine optimal site-specific technical options. Early adopter hospitals will be confirmed in December 20, followed by Phase 1 kickoff in January Web Service: The ectas web service will perform a CTAS calculation through bidirectional real-time exchange of information with a hospital s existing Emergency Department Information System (EDIS); the ectas system will receive the entered triage data from the hospital s EDIS and return a calculated score. Certification: The ectas technical specifications and test cases will be provided to a hospital in order to build the CTAS decision support algorithm directly into their EDIS. The local EDIS solution would subsequently be certified to ensure alignment to the provincial system. Ongoing provincial alignment would be monitored and maintained via timely data submissions. Issue Fall 20 2

3 Information Transforms the Emergency Department Landscape Ontario EDs are committed to enhancing the patient experience with strategies to improve wait times and access to care. The amount of time patients spend in the ED, known as Length of Stay (LOS), has been steadily decreasing over the past seven years. As of September 20, the overall provincial ED LOS decreased by % compared to the 20 baseline. This performance improvement continues with records being set month over month. The current record was set this past with 487,167 visits provincially. Provincial Performance since 20 Baseline th percentile ED Length of Stay (hours) Apr Aug Sep Oct Nov Dec Jan 09 Feb 09 Mar 09. Apr Aug Sep Oct Nov ER Length of Stay (hrs) Dec Jan Timely province-wide information gives us a clear picture of gaps or issues which enables hospitals to implement strategies and allocate the necessary resources to address them. We are now seeing the benefit of these efforts: improved access to emergency care for our patients. With continuous support from the Ministry of Health and Long- Term Care, Access to Care (ATC) at CCO has enabled the health system to evolve through information management, analytics, and public reporting. Through extensive collaboration with health system partners, ATC continues to facilitate performance improvement through the use of information provided in the Quarterly ER Local Health Integration Network (LHIN) Summary Reports, which are new reports inspired by the successful release of the Provincial Summary Report last year. In 20, ATC released LHIN-specific reports distributed to over 250 LHIN and hospital stakeholders. In an age of big data, the LHIN reports are the first in the ATC-ER series to be developed in direct collaboration with hospital and LHIN users, creating a unique report that contains only relevant, digestible information, said Jason Garay, Vice President, Analytics and Informatics, CCO Feb Mar Apr Total ER Volume (ABOVE) ER Volumes and LOS Chart highlights the trend of rising ER volumes with decreased LOS from 20 to 20 Aug Sep Oct Nov Dec Jan Feb Mar Apr Total ED Volumes (ABOVE) SAMPLE LHIN Report Information derived from key performance indicators showcases metrics from three key ED patient populations: admitted patients, non-admitted patients, and overall patients The LHIN reports are geared towards an executive audience, narrating the story of three key patient categories within the region: admitted patients, non-admitted patients, and overall patients. The report gives a voice to the patient experience throughout the health system, which is illustrated through key performance indicators. The reports also guide readers through the analytics, providing context using trends, highlights, and correlations. ATC analytics are essential for ED performance monitoring at the North East (NE) LHIN and their reports are crucial for building profiles of our P4R hospitals and consistently used for our monthly reporting, said Stephen Bellinger, Officer, Performance and Decision Support, NE LHIN. Beyond reports, the team at ATC assists by taking us beyond the numbers with their insight, experience and timely feedback to our queries. The reports offer a standardized approach for all LHINs to monitor the progress of current initiatives through its impact on ED wait times, identify top performers and local issues, and support decision making on future initiatives. A consistent view of regional performance including meaningful metrics, hospital peer groupings, and reporting aggregates is critical to effective provincial discussions and driving system improvements. Hospital staff can subscribe to receive this report via or download it from the ATC Information Site. One direct benefit of these reports is the ability for hospitals to use data to align their staffing needs with the peak hours where patient volumes are the greatest, ultimately resulting in reduced wait times. Issue Fall 20 3

4 WTIS Expansion 20/: DI Efficiencies Access to Care (ATC) is collaborating with facilities provincially on the Wait Time Information System (WTIS) Expansion 20/: Diagnostic Imaging (DI) Efficiencies project. The main scope of this project is to incorporate efficiency data for both MRI and CT scans into the WTIS and to change from a retrospective to a prospective, or near real time, data submission process. Having access to near real time data enables the province to be nimble, quick and proactive rather than reactive in our approach to diagnostic imaging access issues, said Dr. ian Dorbronowski, DI Provincial Clinical Champion, ATC. Near real time data also allows for us to monitor and examine the effects of future wait time initiatives as they are happening. First and foremost, ATC would like to acknowledge and thank the 16 Beta facilities that successfully went live with the expansion project early this summer. This group of facilities helped to shape the deployment for the rest of the province by contributing meaningful feedback which resulted in process enhancements, material improvements and important lessons learned. For the rest of the province, many facilities have completed all activities to meet their go-live dates of October 19, November 2 and November 16. ATC continues to work with facilities who face significant challenges to meet our project milestone dates, especially where impacted by their third party vendors. At the present moment, ATC has developed an Alternate Data Submission Process (ADSP) to ensure that facilities who are unable to meet the project Go-Live dates will still be able to meet the WTIS data submission requirements. In addition to the DI Efficiencies component of the project, all surgery reporting facilities have also updated the data set submitted for surgery wait times. With the introduction of Patient Type and Wait 1 Priority fields, hospitals, LHINs and the ministry will have a more comprehensive view of surgical waits. ATC remains committed to supporting facilities and their specific requirements to ensure a successful project implementation. We look forward to receiving the new data that will be gathered to inform future wait time and efficiency initiatives and predictive analysis and to better support resource allocation across the province with the ultimate aim to improve access and efficiencies in to Surgery and DI services. We thank all facilities for their diligence and commitment to affecting change to patient care in the province. ATC Surgeon Dashboard Now Available to All Surgeons On y 20, 20, Access to Care (ATC) rolled out the ATC Surgeon Wait Time Dashboard to over 3,200 surgeons in Ontario. Each quarter, every surgeon in Ontario who enters data into the Wait Time Information System (WTIS) will now receive an automated, personalized report showing how many patients are waiting for surgery (Wait 2), how long patients waited for a surgical consult (Wait 1), and how many surgeries they have completed in that quarter. The sheer scale of this provider-level wait time reporting initiative is a first for Ontario. The dashboard provides surgeons with a quick and easy way to review their own individual wait time data on a quarterly basis, said Dr. Jonathan Irish, Provincial Head, Surgical Oncology Program, Princess Margaret Hospital. It allows surgeons to compare their practice to their peers and consider processes to improve access. I have used it in my own practice to improve access to care for my patients. The data enables surgeons to develop a better understanding of their wait times and see opportunities to improve patients access to surgical procedures. At the practice level, this may mean reviewing their priority assignment practices or referring some patients to other surgeons with shorter wait lists. At some hospitals, surgeons share their results and meet to collectively strategize ways to reduce wait times and improve access to care. The power of data to improve performance is evident in the results of initial program pilots (phase 1 and 2) which preceded the full provincial launch. In August 20, the team rolled out the dashboard to more than 200 surgeon volunteers across Ontario, including prostate, lung and colorectal surgical oncologists, hip and knee surgeons, corneal transplant and cataract surgeons. The results were dramatic! Depending on the service area, between 72% and 81% of surgeons reduced their patients wait times, and showed a combined overall waitlist reduction of more than 1,000 patients. Surgeons commented that the dashboard is, easy to access, manageable and user-friendly, very helpful to see how you are doing in relation to peers and, validates what is working well and highlights what might need to be looked into. By reviewing the dashboard, surgeons can earn Continuing Professional Development credits Issue Fall 20 4

5 ATC Surgeon Wait Times Dashboard Now Available to All Surgeons General 1 General 2 General 3 General 4 (ABOVE) ATC Surgeon Wait Time Dashboard - SAMPLE An interactive, physician-level reporting tool which is distributed to 3,200 surgeons and allows benchmarking wait time performance against peers, LHINs and the province. with the Royal College of Physicians and Surgeons of Canada. The estimated time commitment for a surgeon to review each quarterly dashboard is minutes plus any additional time a surgeon may choose to invest in feedback activities. Ongoing information sessions are being offered by ATC throughout the fall to further support surgeons in their interpretation of the report s metrics. of the report. Once completed, this new format would address another important phase of our performance improvement model: knowledge transfer. ATC will continually monitor and evaluate results of this initiative through surgeon feedback and WTIS data to further enhance the dashboard and determine how it can better aid wait time improvements. The next distribution of the dashboard is set for January The success of the program is generating new interest from the Ministry and LHINs in the development of a regional version Issue Fall 20 5

6 Wait 1 Access Targets Now Available For All Surgical Specialties in the WTIS The Wait 1 access targets for non-oncology surgical areas provide benchmarks to: allow for the measure and comparison of appropriateness of wait times for surgical consultation assist surgeons in standardizing patient prioritization between referral and consult guide analysis and identification of Wait 1 access issues for non-oncology surgical patients provide a more comprehensive understanding of the full continuum of care support the Ministry and LHINs in optimizing distribution of resources across the province to enhance access to care Wait 1 access targets information and education sessions for facility end users, LHIN performance leads and surgeons have already commenced and will continue into On March 29, 2016, enhancements to the WTIS will go live, giving surgeons the ability to enter a Wait 1 priority level separate and distinct from Wait 2 (currently, assigned Wait 2 priority level is used as a proxy for Wait 1 in a wait list entry). Following the successful launch of Wait 1 access targets for surgical oncology, ATC announced Wait 1 access targets for all WTIS non-oncology surgical service areas across the province in September 20. The positive surgical oncology pilot results supported the expanded development and implementation of Wait 1 access targets to the other surgical specialties captured in the WTIS, said Claudia Zanchetta, Clinical Manager, Surgery and Diagnostic Imaging Wait Time and Efficiency Programs, ATC. The targets will increase transparency in the system and accountability through benchmarking, and ultimately enhance performance management to provide better access for patients waiting for surgical consults. ATC worked closely with the ministry and provincial clinical experts to review the current trends and patterns in care through extensive outreach with stakeholders, jurisdictional review and extensive data analysis. This led to the development of Wait 1 access targets that provide clinically meaningful context to the Wait 1 data for all procedures. As a result of this work, the Access Target Working Group and Surgery and Diagnostic Imaging (SDI) Advisory Council recommended, one set of access targets for all the non-oncology surgical specialties based on three guiding principles: clinical credibility, realistic and simplicity of implementation. The initial surgical oncology service area was chosen for the pilot as clinical evidence existed to support targets and clinical pathways and possessed existing organizational clinical expert framework to support implementation. The pilot provided insight into current Wait 1 performance and the impact of Wait 1 access targets on the entire surgical oncology patient journey, directly leading to this latest expansion to all other surgical areas. (ABOVE) Quick Reference Cards (QRCs) QRCs are pocket-sized reference tools provided to surgeons which contain access targets and consult patient descriptions Issue Fall 20 6

7 Mental Health and Access Wait Times Fresh Faces ATC is pleased to announce a new wait times initiative on behalf of the Centre for Addiction and Mental Health, Ontario Shores Centre for Mental Health Sciences, Royal Ottawa Mental Health Centre, and Waypoint Centre for Mental Health Care. The opportunity we have here at ATC to set a foundation for the collection of data around mental health in our province is exciting new territory, said Cathy Cattaruzza, Director, ATC. Working with these renowned facilities will help our province understand challenges facing this population and ultimately implement strategies to improve their access to and quality of care. The current scope of work includes standardizing and reporting mental health and access wait times measurements and carrying out a technical feasibility assessment to support the near-real time collection and reporting of information associated with mental health patients. This work will be undertaken for the remainder of and Together Everyone Achieves More When it Comes to ALC Working with the Ontario Association of Community Care Access Centres (OCCAC), ATC has begun work to link Alternate Level of Care (ALC) information from the WTIS to CCAC information to further understand ALC patients and their journey through our healthcare system. The patient population designated as requiring an alternate level of care is complex as many require access to a number of specialized needs at varied care settings, said Amanda Westwood-Smith, Group Manager, Alternate Level of Care at ATC. As we continue working to improve how we share the information we have about these patients, it will help us improve the care they receive and the time in which they are able to access it. Earlier this year, ATC ramped up engagement of CCAC and LHIN partners, to look beyond hospital walls to provide a more robust understanding of a patient s entire journey when requiring an alternate level of care. By bringing both hospital and community data sets together, a more holistic view of the entire patient journey, related to ALC wait times, can potentially differentiate and identify process versus system ALC issues. Through continual engagement and partnership with stakeholders, the ALC patient journey work is one example of the ability to leverage ALC information to support better access to care. ATC would like to welcome the following new members: Joining the SDI Advisory Committee Fredrika Scarth Director, Health Quality Liaison and Program Development Branch, Advisory Council Member Joining the SETP Advisory Committee Dr. Wael Hanna Physician Leader, Thoracic surgeon in Hamilton Niagara Haldimand Brant LHIN, Assistant Professor at McMaster University Dr. Carol-Anne Moulton Physician Leader, General surgeon and Medical Director, Operating Room, General Surgery Intensive Care at Toronto General Hospital, Associate Professor at the University of Toronto and scientist at the Wilson Centre Patty Welychka Clinical Perioperative Leader, RN, Executive Lead and CNO, Director Perioperative Program at Niagara Health Systems Kalen Paulson Advisor, Health System Transformation at Hamilton Niagara Haldimand Brant LHIN Joining the ALC Advisory Committee Cheryl Cullimore Advisor, Access to Care Hamilton Niagara Haldimand Brant LHIN Shehnaz Fakim Senior Consultant, Health System Integration, Design and Development, Toronto Central LHIN Elan Graves Senior Accountability Specialist, Champlain LHIN Laurie Zimmer Health System Manager, ED/ALC, Critical Care, Sub-Acute Programing, Transplant, Erie St. Clair LHIN Joining the ER Advisory Committee: Stefanie Hopkins ERNI Coordinator, Brockville General Hospital Jill Schitka Program Director, Grand River Hospital Kiki Ferrari Executive Director, William Osler Health Centre Issue Fall 20 7