St. Mary's General Hospital Hospital Improvement Plan. Submission date: November 11, 2011

Transcription

1 St. Mary's General Hospital Hospital Improvement Plan Submission date: November 11, 2011 Board Approval: November 4, 2011

2 Preface The Hospital Improvement Plan (HIP) was undertaken as a self correcting measure by the Board and Management of St. Mary's General Hospital in collaboration with the Waterloo Wellington LHIN, and was supported by the St. Joseph s Health System of which St. Mary s is a division. The Hospital wishes to thank the LHIN and the Ministry of Health & Long Term Care for their guidance and support. St. Mary s has engaged key internal and external stakeholders in the development of this plan. The Hospital is committed to ongoing open, transparent communication and collaboration with our staff, physicians, partners, peers, and community-at-large in implementation of this plan if it is approved by the Waterloo Wellington Local Health Integration Network. - ii -

3 TABLE OF CONTENTS Page 1. Executive Summary Benchmarking Review and Accountability Meetings HIP Planning...4 a. Principles b. Assumptions c. Financial Assumptions 4. Background and Root Causes...5 a. Current Situation b. Impending Financial Situation c. Consultative Process d. Impact on Beds e. Human Resource Impact 5. Strategic Focus and the Role of SMGH in the Integrated Health System...12 a. Cardiac b. Chest c. Surgery d. Medicine e. Long Term Care Bed Allocation f. Short-Stay Beds g. LEAN Process Improvements 6. Risk Assessment...25 a. Four Corners Risk Dashboard b. Financial Risk Assessment (Draft) 7. HIP Interventions...28 a. Health and Safety: Reduce Absenteeism, Sick and Overtime b. Revenue Generation c. Management & Non-union Restructuring d. Medical Fee Remuneration e. Clinical Efficiencies: Cardiac f. Clinical Efficiencies: Chest g. Clinical Efficiencies: Medicine h. Clinical Efficiencies: Surgery i. Clinical Efficiencies: Emergency Department j. Other Clinical Support Efficiencies k. Benchmarking Efficiencies l. Other Initiatives Considered 8. Taking Action From the Plan Looking Ahead Conclusion and Next Steps...49 Appendices iii -

4 1.0 Executive Summary St. Mary s General Hospital is a 150 bed adult acute care hospital specializing in cardiac and respiratory care. Over the past 15 years, the hospital has transformed from a general, full-service acute care hospital to a highly focused organization with a narrow scope of specialized programs and services that are highly complex, with high resource intensity. This transformation has enabled St. Mary s to become a leader in the provision of safe, quality care to thousands of patients from Waterloo Wellington, and beyond. This quality is evidenced in many ways. Two clear examples are: Full Accreditation (2011) St. Mary s General Hospital achieved full compliance with the Required Organizational Practices which are key to patient safety. Less than 20% of all Canadian Hospitals earn this award. Hospital Standardized Mortality Rates One significant measure of quality is Hospital Standardized Mortality Ratio (HSMR). This measurement is captured in hospitals Canada-wide. Rates lower than 100 suggest that care in an organization is better than the average hospital in Canada. In 2009/10, St. Mary s HSMR was 7, ranking it the 12 th best in the country. The Hospital s 2010/11 HSMR is 69, which reflects the organization s ongoing commitment to quality of care. In 1999 the Ministry of Health and Long Term Care (MOHLTC) announced a full service tertiary care cardiac program for Waterloo Region, and designated St. Mary s as the location for this program. The doors for the cardiac centre opened in 2001 and it has since become the hospital s largest and most significant program. In its brief history, the cardiac program has established itself as a provincial leader in quality, and in 2006 it scored top marks a report by the Institute for Clinical Evaluative Sciences that compared Ontario s eleven cardiac surgery centres. In 2003, provincial Health Minister Tony Clement appointed an investigator (Dennis Timbrell) to move forward the clinical realignment of programs and services between Kitchener- Waterloo s two acute care hospitals. The report, released in 2004 and endorsed by the Boards of both hospitals called for the orientation of cardiac and pulmonary services at St. Mary s and all orthopedic surgery, after hours general surgery (except cardiac), and neurology services to Grand River Hospital. The changes were implemented by the end of 2004, and St. Mary s has worked to build Centres of Excellence in its two core programs (cardiac and respiratory) since that time. In pursuit of its Centre of Excellence in respiratory, and to better serve patients in Waterloo Wellington, St. Mary s partnered with Grand River Hospital in 2008 to consolidate thoracic surgery at St. Mary s. Simultaneously, hepatobiliary surgery was consolidated at Grand River. Shortly after this the Waterloo Wellington Local Health Integration Network (WWLHIN) Board passed a motion recognizing St. Mary s as the Centre for Excellence for thoracic surgery and Grand River as the Centre for Excellence for hepatobiliary surgery. In 2009 Cancer Care Ontario designated St. Mary s as an emerging Level One thoracic surgery centre. In early 2011 St. Mary s and Grand River partnered once again to consolidate adult cystic fibrosis care at St. Mary s to help patients take advantage of the pulmonary focus at St. Mary s. St. Mary s General Hospital Hospital Improvement Plan November 2011 Page 1

5 St. Mary s continues to grow and evolve to meet the tertiary needs of patients requiring its highly specialized services. Future opportunities lie with: Repatriating Waterloo Wellington patients who receive an Implantable Cardioverter Defibrillator (ICD) implant outside of the Waterloo Wellington (WW LHIN), but access follow up care at St. Mary s; Standardizing cardiac rehab and heart failure management services throughout the WWLHIN, and; Developing a weaning unit for long term ventilated patients. St. Mary s share the WWLHIN s vision for a rational and thoughtful enhancement of services that will best meet the cardiac and pulmonary service requirements of the people in this region today, and on a continuing basis. To achieve this vision, the Hospital has developed a plan that protects and enhances its core, acute care programs and services while implementing a strong, sustainable financial state. This Hospital Improvement Plan (HIP, or the Plan) is being submitted by the St. Mary's General Hospital (SMGH, or the Hospital) to the Waterloo Wellington Local Health Integration Network (WW LHIN or the LHIN) for review and approval. This plan has been undertaken by management as directed by the Board of Directors (the Board) to restore the Hospital s financial position to a sustainable state by March 31, St. Mary s is committed to the maintenance of quality of care and the protection of the scope of our current regional services and programs, and its vision continues to focus on a cardiac and respiratory program augmented by day surgery and a more recent focus on elder care in medicine. The Hospital s ability to continue to provide these services beyond funded levels is at risk, as St. Mary s has already streamlined its scope of services to a narrow band of adult clinical priorities. The Hospital s proposed Plan finds the necessary $7 million of budget savings over the two year period ending March 31, The Hospital interventions include strategies to mitigate against the loss of beds, staff to occupancy levels, and focuses on Length of Stay (LOS) reductions so that SMGH will be well positioned for the future. While the Plan includes reductions and restructuring, these positions are not focused on a single area or a single profession. SMGH engaged front line staff, physicians, volunteers, key stakeholders, the St. Joseph s Health System, the LHIN and the MOHLTC along with other healthcare providers and subject matter experts in the development of this Plan. Early consultation with internal stakeholders (staff, physicians, volunteers) through a Bright Ideas campaign generated some budget savings improvement ideas. It also emphasized the hospital s commitment to use internal knowledge and skill to support productivity/efficiency improvements, rather than service reductions, in the journey to ongoing financial health. The hospital s use of Lean management methodologies will further support this engaged workforce on an ongoing basis. Upon successful implementation of the HIP, SMGH will be able to work with the LHIN to ensure that required programs are in place to support the LHIN s Clinical Service Plan (CSP), the Integrated Health Services Plan (IHSP) and the Annual Business Plan. The steady state will allow the Hospital to commence multiyear operating and capital plans that are built on provision St. Mary s General Hospital Hospital Improvement Plan November 2011 Page 2

6 of its clinical services priorities for the Waterloo Wellington community. As part of the clinical services suggested in the Plan, cardiac funding associated with (ICD) procedures will be repatriated back to the community. As a resource intense provider of care (SMGH specializing in the cardiothoracic care of patients in the community), a need to revisit the current funding structure or base funding has been requested. The Board supports management s belief that in order to become sustainable and have funds for innovation, SMGH must first put its financial house back in order. This means bringing increased accountability back to the front lines through benchmarking and ongoing monitoring efforts that will support forecasts to be shared with the Board and the LHIN. St. Mary s envisions that its HIP is more than a financial recovery plan it is a commitment to the community, staff, physicians, volunteers and patients that the Hospital is committed to financial stewardship and long term planning. Changes will need to occur to create a sustainable and financially stable organization that will be able to withstand funding pressures. St. Mary s is committed to continued support of the goals outlined in the Hospital Accountability Agreement such as the cardiac activity volumes, reduction in alternative level of care (ALC) volumes and reduced Emergency Department (ED) wait times. Once a stable state is reached, the Hospital will pursue continuous improvement and increased productivity through Lean efforts. In development of the HIP, hospital management was clear that no area was off limits. In engaging staff and physicians, this message was conveyed repeatedly, in an effort to have fresh eyes point to areas for potential improvement or efficiency that may have been previously overlooked. Further, St. Mary s explored both internal opportunities, as well as opportunities where support from partners and external stakeholders could be of assistance. The Hospital s commitment is to achieve our performance obligations including a balanced operating position by March 31, 2013 within our planned and approved funding allocations as defined in its Hospital Service Accountability Agreement (HSAA). It is with the support and advice of the WWLHIN that this document has been prepared. In collaboration with the LHIN the following directions were agreed to be pursued in the HIP process: Balance the operating budget while ensuring reasonable access to quality care; Eliminate reliance on our line of credit or a cash advance; Be consistent and congruent with the Integrated Health Service Plan for the LHIN; and Submit creative and innovative solutions that integrate health services and contribute to systemic solutions. The timing and condensed timeframe for development of the HIP was mitigated by creating an accountability framework that included all clinical and support departments. Quarterly accountability meetings commenced in the spring, and have allowed management at all levels to obtain and share a better knowledge base initially about the Hospital s own operations and then about peer hospitals, while seeking solutions to do more or the same volume with fewer resources. St. Mary s General Hospital Hospital Improvement Plan November 2011 Page 3

7 2.0 Benchmarking Review and Accountability Meetings Engage & Monitor Programs As part of the budget process, SMGH reviewed two groups of hospitals using the HIT tool community cardiac centres and teaching cardiac centres. Other comparatives were obtained from the work of two external consultants performed in 2007, 2010 and again in Finance and Decision Support staff met the hospital managers group (operational groups of about 25 managers) to share the benchmarking tools available and how the HIT tool works. On a program by program basis Finance and Decision Support then met with the Vice President (VP) and managers of each area of the hospital to discuss benchmarking results and next steps. It is the intent of management to hold accountability meetings for all programs and services on a quarterly basis. These meetings will be held with the medical and administrative directors and cover the financial and activity results for the quarter, review the targets and savings from the benchmarking exercise and be instrumental in providing feedback on HIP implementation results and forecasting information for year end. The results of these meetings will be summarized and shared with the Board and the LHIN. 3.0 HIP Planning With the support of the Board the following principles and assumptions formed the Hospital s decision making framework for the development of the HIP: A) PRINCIPLES The HIP will: Be our journey document that will chart the course to a stable and sustainable state; Realign accountability structures and bridge quality and cost under the value proposition; Be a living document that will span the 2 year commitment and then go beyond the 2 years by creating an accountability structure that will support continuous improvement using Lean methodologies to ensure sustainability We will do this by: Maintaining levels of service to the community; Establishing new models of care that offer efficiency and same or greater level of support to patients, staff and physicians; Maintaining direct provider roles as a priority; Collaborating with community partners in establishing new models of care (Grand River Hospital (GRH), Community Care Access Center (CCAC), family health teams etc.); Ensuring core clinical programs cardiac, chest, medicine and surgery remain as priorities; with a plan for sustainable growth to meet community needs; Collaborating with physicians as key stakeholders in clinical service changes to models of care, and Ensuring leadership has the attributes and skills to move SMGH forward. St. Mary s General Hospital Hospital Improvement Plan November 2011 Page 4

8 B) ASSUMPTIONS In executing the HIP, St. Mary s will: Maintain quality and safety; Continue to use performance targets as drivers; Maintain program capacity for our clinical service priorities, even though fewer beds may be staffed; Community based resources including long term care capacity and Home First philosophy will be emphasized, addressing the ALC issues; Mitigate job losses with attrition; Use top quartile indicators to identify performance targets; Honour and follow the applicable language and processes in our collective agreements; Use the most economical staff patterns and practice standards; Use the risk based decision tool to ensure quality decision making using a broad based risk approach as described in the Risk Assessment section; and Implement initiatives by March 31, 2013 C) FINANCIAL ASSUMPTIONS The savings identified in the proposed recovery plan reflect a 100% implementation success; Any slippages will be recovered using a new cost reduction program; No major external events (beyond managements control) occur (pandemic, disaster etc.); Further restructuring analysis will continue over the recovery period and beyond; Where possible acceleration of the savings will be achieved; and The plan will be done in conjunction with the WWLHIN acute service plan 4.0 Background and Root Causes To create a plan for corrective action, St. Mary s thoroughly reviewed its past events and current state. This review enabled a better understanding of how the organization ended up in its current position. In 1999 St. Mary s was designated as the host hospital for Waterloo Region s tertiary cardiac centre. The first cardiac catheterization (cath) lab was opened in 2001 with the second lab opening in In July of 2003 St. Mary s began offering angioplasty and cardiac surgery. Demand for these advanced services quickly grew (see below) and by 2005 the 6-bed recovery unit that serviced the post-procedural needs of cath patients was no longer sufficient. A request to expand the recovery unit was submitted to the MOHLTC but was unsuccessful. To cope with this increasing demand St. Mary s opened a second recovery unit in a different part of the hospital, requiring a costly duplication of staff in the two recovery areas. This is neither the best model for patient care, nor the most efficient use of resources however, it was necessary in order to maintain access to care for patients locally. St. Mary s General Hospital Hospital Improvement Plan November 2011 Page 5

9 Activity 2003/ / /06 11/12 Projection (Based on Apr- Aug/11) Cardiac Cath Angioplasty Cardiac Surgery This rapid growth also lead to increasing demand for cardiac rehabilitation services, a three month post-procedural program that helps patients with lifestyle modification including smoking cessation, diet and stress counseling and exercise. Initially set up to meet the needs of the cardiac surgery patients, the base funding was set at 250 patients. As the cardiac surgery volumes grew, no additional funding was provided for cardiac rehab. St. Mary s chose to use its own funds to make this valuable service available to all patients recovering from open heart surgery as well as to a limited number of post-angioplasty patients. In 2006, the Institute for Clinical Evaluative Sciences (ICES) published their Report on Coronary Artery Bypass Surgery in Ontario. This report examined outcomes from all eleven cardiac surgery centres in the province including Toronto General Hospital, London Health Sciences Centre and the Ottawa Heart Institute. A total of eight indicators were reported, and St. Mary s topped all centres in five of them including the lowest in-hospital mortality rate and the highest percentage of high-risk patients. While this independent review spoke to the excellent quality of care being provided at St. Mary s, it also highlighted that the patients being cared for in Waterloo Wellington are among the sickest in the province, requiring intensive resources. In alignment with its vision to become a full-service cardiac centre, in 2007, St. Mary s invested $2 million in own funds to build a hybrid operating room in preparation for a full arrhythmia service (ICD implants, Electrophysiology Studies and Ablations) and to prepare for combined cardiac surgery/angioplasty cases. In support of its mandate as the Centre of Excellence for cardiac care, St. Mary s has continued to grow and develop an innovative cardiac centre. In 2008, through a partnership with Research In Motion and Waterloo Region EMS, St. Mary s began to use Blackberrys to receive ECG s (electrocardiogram) from paramedics in the field - facilitating a rapid access protocol for suspected heart attack patients. The result of this protocol was faster diagnosis, faster care and more lives saved. This model has improved access to Gold Standard care for heart attack patients in Waterloo Region, and has since been replicated across the province, and Canada. In 2010, using Lean improvement methodologies, the cardiac team further improved upon its rapid-access protocol. The team discarded the BlackBerry and instead trained over 150 paramedics to diagnose heart attack ECG rhythms themselves. This has led to even faster diagnosis and expansion of the service to be available 24/7, providing even better access to care. However, expanded access to this program (24/7 coverage) required St. Mary s to invest its own funds to ensure that three dedicated beds are available for emergent patients at all times. In addition to providing better care for patients, this approach eases the burden in Emergency St. Mary s General Hospital Hospital Improvement Plan November 2011 Page 6

10 Departments elsewhere in the WWLHIN by allowing paramedics to by-pass other ED s and come directly to St. Mary s Regional Cardiac Centre. The centre continues to grow and evolve to meet the tertiary cardiac needs of patients living in the WWLHIN. Future opportunities lie with repatriating ICD patients who receive their follow up care at St. Mary s but their implant outside the LHIN, with standardizing cardiac rehab services closer to home throughout the LHIN, and with improved community based heart-failure management, one of the most frequent causes of readmission to hospital in Ontario. Other underlying causes of the Hospital s current financial problem are now well understood by management and the Board, and have been addressed at the hospital level. The Hospital was previously considered to be efficient and have excellent cost per weighted case results. Three years have lapsed since the Hospital last undertook an extensive benchmarking review, and in that time it has lost ground to peer hospitals. In addition, St. Mary s had been balancing its bottom line using one time and deferred revenues. The focus of governance and management had been on the statement of operations and the operating margin; it is now to have a combined approach on many indicators and on the balance sheet in addition to the operating margin (see draft financial indicators in the Financial Assessment section). Management and the Board promote a wholesome review of actions using a risk based framework addressing areas beyond those financial and operating including: Organizational health; Quality care/patient, safety/service provision/community support; and Employee health and safety. The Board and management are cognizant of the Hospital s HSAA performance obligations and remain confident that this plan supports St. Mary s ability to achieve such obligations. The financial issues reflected in the balance sheet are a result of the capital project overrun, depletion of reserves to cover increasing costs such as increasing emergency acuity and bed pressures, and increasing cardiac services demand. This is compounded by the Hospital being a small large community hospital specializing in a resource intense narrow band of service provision that do not allow for financial flexibility. St. Mary s has an acute interest in improving its long term financial wellbeing which is a requirement to sustain acute care services and growth of its regional programs. A) Current Situation In February of 2011, management approached the WWLHIN with concerns about the sustainability of hospital operations, particularly in 2011/12. Significant deferred revenues had been taken into income in the previous years, resulting in small surpluses which may have masked the impending problem to some degree. Management was able to balance the year with a small surplus of $24K at the HSAA margin and -$162K at the bottom line (after building amortization). Following this initial discussion, Hospital management and Senior Management from the LHIN began a series of meetings to better understand the options that could be undertaken to improve St. Mary s financial health. St. Mary s General Hospital Hospital Improvement Plan November 2011 Page 7

11 At the end of Q , the current ratio was 0.4 (or 0.3 after correcting for paymaster funds). The organization s net assets have grown from -$2.6M to -$4.2M as a result of continued decline of the balance sheet and deficit operations. The year-to-date results at the end of Q1 are a favourable variance of $28K on a deficit budget of $1.7M. The forecasted deficit is $5.2M. Actions have commenced in some areas to improve the outcomes as evidenced by the positive variances in the months of July and August. Management is committed to implementing initiatives and mitigating future losses, and efforts are being made to reduce the forecasted deficit for to less than $3.2M. At the end of Q1 ( ) performance volumes for service suggest that St. Mary s will meet its annual obligations and targets. Management continues to work on initiatives to earn Emergency Department Pay for Results funding, budgeted at 50% of the potentially funded amount for At the end of Q1, results have not supported taking revenue into income. July and August results note improved performance, and the Hospital s management is optimistic about achieving the three corridors and earning this performance revenue. A request for a cash advance on operating funds was submitted on September 6, The prepayment of these funds will allow the hospital to continue to pay vendors on approved terms and continue to make payroll. Management has secured bridge financing through the St. Joseph s Health System. It is the intention of management to draw down on this cash advance vehicle each year over a three to five year period commencing in Capital equipment is being purchased on a contingency basis for 2011/12, solely dependent upon Foundation funds (see Figure 4 for the role of capital spending in the working capital deficit recovery plan). An evergreen program will be set up for beds and a full capital plan for equipment and building maintenance is required for sustainability. Unfortunately, cash constraints of have prohibited such planning and implementation. B) Impending Financial Situation Over the past three years, the hospital balanced operations using one time revenues and reserves. The Board and management want a sustainable solution that restores the financial health of the hospital while recognizing the other areas that drive Hospital business, such as quality patient care, safety for patients and staff, and satisfied staff, physicians and volunteers. St. Mary s also recognizes that it is challenged by issues faced by all health service providers in the years to come, as the demand on health care increases as funding becomes less available. A systemic change is required to support Ontario s public health system as it stands. To do this the changes must include other service providers, patients, the community, the LHIN and more broadly the entire Province. Hence, St. Mary s approach has been to look first within its own walls to find efficiencies, as well as right fit of service provision. Secondly, it has looked externally to other service providers in an effort to explore new opportunities for models of care that better enhance the patient experience, while bringing greater value to each dollar spent. These system ideas are still percolating at the Board and management levels and will continue to be developed as the hospital proceeds with its improvement plan, and likely beyond March 13, St. Mary s General Hospital Hospital Improvement Plan November 2011 Page 8

12 The cost structure at St. Mary s is flawed and must be changed to provide a stable and sustainable operating surplus and sufficient funds to allow: Elimination of the working fund deficit; Retirement of long term debt; Enhancement and sustainability of core services; Management of inflation, while balancing not just for 2013 but future years; For proper planning and purchase of capital equipment and the development of safety nets for emergencies; Flexibility in piloting new innovative partnerships, models of care and introducing technology to enhance service provision; and For the introduction of new innovation technology that supports best clinical practice Resolution of the Hospital s financial issues requires immediate attention. The working fund deficit will continue to deteriorate if St. Mary s improvement plan initiatives are not implemented. The current plan has the working capital return to a surplus position in 2020 (figure 4). The preliminary analysis at the time of SMGH board approval in August 2011 resulted in the operating funds in a balance position before restructuring costs in 2012/13. This and the surplus in of $1.4 million will almost cover the anticipated costs of restructuring. By the end of 2014/15, the aforementioned costs plus the capital costs will be covered and the ongoing investment in opportunities and savings is covered throughout the remaining years ending 2020/21. The costs on implementing the HIP include: Estimated restructuring costs of $3,090,311 (one-time); Estimated capital costs of: $1,000,000 (one-time); and Estimated investment in opportunity costs of: $520,000 (one-time) and $180,000 ongoing. These are necessary investments to allow the hospital to save millions in future years. The opportunity investments include investments in staff resources, technology, infrastructure and Lean tools, resources and education to guide our quality improvements. As part St. Mary s internal review, there has been a focus on the entire organization from quality of clinical care to operations and governance accountability. Management has thoroughly assessed areas of concern that can be strengthened and has addressed these areas through a risk based methodology using the indicators suggested in the Guidelines for Hospital Audits and Reviews, document. Management and the Board will continue to monitor all areas of focus as it moves forward with implementation of the HIP. As St. Mary s developed its proposed Plan, the broader scope of risk was not ignored. Preliminary risk analyses were performed with focus on safety and quality. The preservation of these measures will be monitored with specific outcome measures to assess any impacts whether positive or negative. St. Mary s General Hospital Hospital Improvement Plan November 2011 Page 9

13 C) Consultative Process St. Mary s worked to directly consult key stakeholders in the development of its plan. It began this process first by engaging staff and physicians in consideration of efficiency opportunities both through a Bright Ideas campaign and quarterly accountability meetings. The Bright Ideas campaign provided staff, physicians and volunteers with direct access to the President, and asked for any and all suggestions that would improve St. Mary s financial health and organizational well-being, or would contribute to an improved experience for patients and families. More than 100 submissions were received during this campaign. The hospital s quarterly accountability meetings are supported by a newly merged decision support and finance team, which will also be utilized support and co-ordinate the implementation of the HIP project charters. This approach will allow for consistency in the implementation process and reporting thereon for each budget balancing initiative. This team further dovetails with the Benchmarking and Accountability meetings and ensure that budgeted savings are captured and that financial and service activities are monitored throughout the transformation. Direct consultation with key stakeholders has also included ongoing dialogue with the following organizations: WWLHIN MOHLTC Cardiac Care Network of Ontario London Health Sciences Grand River Hospital Guelph General Hospital Cambridge Memorial Hospital St. Joseph s Health System St. Joseph s Health Centre Guelph Halton Healthcare Waterloo Wellington Community Care Access Centre (WW CCAC) Other CCACs and other LHINs In addition to this direct consultation, St. Mary s has conducted broadly focused engagement activities with an objective to: Provide accurate information and detail regarding the three core components of its plan; Allow for questions and input from both internal and external stakeholders; Create a common understanding of the hospital s fiscal challenges and the driving factors behind the challenges; Create an understanding and awareness of the impact of the proposed changes on access to high quality, compassionate care; St. Mary s General Hospital Hospital Improvement Plan November 2011 Page 10

14 Foster support and participation of all members of the organization in implementing the plan once approved, and; Allow a mechanism for audiences to ask questions, voice concerns, provide feedback and/or offer suggestions for improvement. Broad-spectrum engagement conducted: AUDIENCE FORMAT # OF PEOPLE DATE President s Message re: decline in efficiency and undertaking benchmarking to address deficit ( , print) May, 15, 2011 Hospital Staff, Physicians & Volunteers Staff (Fiscal) Advisory Committee Medical Advisory Committee Board of Trustees SMGH Foundation Community at Large Launch of Bright Ideas Campaign internal request for suggestions for improvement Town Hall Meetings re: projected deficit and steps to develop a plan President s Message summarizing town hall contents and discussion ( and print) Town Hall Meetings re: projected deficit and steps/action to date President s Message summarizing content of town hall meetings Town Hall Presentation of key changes with time for Q&A. Presented surgical plan to GRH/SMGH Joint O.R. Committee Personal meetings with surgeons re: impact on scheduling Presentation of key components of the plan (Benchmarking, Management & Clinical) with time for Q&A and input on communication to general staff Presentation of key components of plan, availability for Q&A targeted 100+ suggestions received July 22, 2011 August 4, 2011 (x2 sessions) September 28, 2011 (x2 sessions) 500+ November 1 and 3, x daily 12 November 2nd 15 November 4, November 1, November 1, 2011 Presentation of key components of plan, overview of communication plan, Q&A 22 October 26, 2011 Overview of plan, supporting documentation, key 25+ November 1 and messages and Q&A ongoing Targeted media distribution November 1 and Kitchener Post Circ. 60,000 ongoing Waterloo Region Record (+online) CTV Southwestern Ontario Circ. 223, News (Rogers Media) (print + online) Annual Community Update 85+ November 2, 2011 Website 75+ hits November 1 and ongoing Tweeted to followers November 1, 2011 ReTweets St. Mary s General Hospital Hospital Improvement Plan November 2011 Page 11

15 General feedback from the community at large has been supportive of the proposed plan, which speaks to the reputation for excellence St. Mary s has in Waterloo Region. Many people have contacted the organization to offer their support and encouragement as we move forward with making difficult decisions. Others have remarked that they have confidence St. Mary s will be able to implement the plan effectively and regain ground as a leader in efficiency. An editorial in the Kitchener Post summarizes another common theme that: hospital executives should be applauded for providing the public with clear details about how they plan to turn things around. (Kitchener Post, Op/Ed, November 3, 2011) Feedback from engagement with staff and physicians is summarized in the initiative-specific sections. D) Impact on Beds The closure of 10 medical beds most recently occupied by alternative level of care (ALC) is planned. This is based on the assumption that St. Mary s will continue to have access to community programs and services to support a transition plan from the acute hospital back to the community. There are plans to transition the Hospital s surgical inpatient unit to a short stay model that maintains commitment to volumes and allows weekend bed closures. E) Human Resource Impact The most valued resource to a quality organization is its people. St. Mary s has been blessed with exceptional staff, physicians and volunteers throughout its 85+ year history. The Hospital is committed to treating its staff with dignity and respect as it works to implement the proposed improvement plan. Through years of trust, St. Mary s has developed excellent working relationships with its unions, and it has committed to these unions that vacancies for reassignment and deployment will be used wherever possible. Offers of voluntary exit and early retirement will be offered. To avoid eliminating positions, St. Mary s is looking where possible at reductions in scheduled hours and attrition. 5.0 Strategic Focus and the Role of SMGH in the Integrated Health System In 2010, the Hospital commissioned Agnew Peckham Healthcare Planning Consultants to prepare a Master Program. This results of this work reflect St. Mary s commitment to partnership and integration at clinical and operational levels locally and regionally. Further, the development of this Program involved community stakeholder engagement (Appendix B). The strategic focus of St. Mary s clinical activities is documented in this master program and relevant aspects have been extracted and updated for the purposes of the HIP with consultants permission. Master Program Overview Major clinical programs include the regional cardiac centre, thoracic surgery and respirology, day surgery, emergency, and medicine with a focus on elder care. The Hospital s services within Kitchener-Waterloo have continued to be refined and realigned between St. Mary s and Grand River Hospital (GRH). SMGH s plan reflects its commitment to partnership and integration at clinical and operational levels, both locally and regionally. As a member of the St. Joseph s St. Mary s General Hospital Hospital Improvement Plan November 2011 Page 12

16 Health System, SMGH is enriched by its affiliation with the Father Sean O Sullivan Research Centre and by the opportunity to share resources, such as ethics professional consultation, spiritual care services, and collaborative capital purchasing across the system. The regional cardiac centre works collaboratively with the cardiac program at London Health Sciences Centre (LHSC) and has partnered with the LHSC electrophysiology group to develop a Southwest Ontario arrhythmia program proposal. There is a similar partnership with LHSC for specialty ophthalmologic care provided locally. Therapeutic and support services integration/regionalization initiatives underway or under evaluation include supply chain management, pharmacy and information technology. Integration and Alignment: Service Delivery Model Alignment with the LHIN Continuum of Care SMGH is committed to working collaboratively with health care provider partners and other stakeholders. Hospital services are clearly aligned with those of Grand River Hospital and coordinated with Waterloo Wellington LHIN hospitals and community providers. For example, a partnership was developed with two family health teams and the University of Waterloo Health Centre to share qualified respiratory educators to set standards, screen for those at risk and teach patients in the primary care setting. SMGH currently has similar partnerships with Langs, Kitchener Downtown & Woolwich Community Health Centres and Forest Heights Long Term Care Home. SMGH is the paymaster and strategic support for the WWLHIN Nurse Led Outreach Team. This group of nurses has accountability for the metrics of reducing ED transfers and or admissions from long term care homes when care can be safely provided in that environment. This team works closely with the SMGH geriatric team to ensure strategic and operational alignment. The Ontario Telemedicine Network is used to link respirologists at SMGH with patients at Louise Marshall Hospital in Mount Forest. Through this venue, respirologists provide consults for the patient and family. A cardiac surgery clinic is provided in Owen Sound once per month to see cardiac surgery patients before and after surgery. A treat and transfer myocardial infarct (MI) protocol has been developed with regional referring acute care hospitals whereby appropriate cardiac patients are treated with intravenous thrombolytics and immediately transferred to a cardiac bed at SMGH for further assessment and follow up. As SMGH plans for the future needs of its community, several expanded role services have been included in the master program for site and facility planning purposes. These service expansions include: Arrhythmia services, including ICD implants as an extension of the existing regional cardiac centre; Surgical capacity for two options: a potential regional ophthalmology service, or continuation of the existing, more local, service role; and Local vascular surgery services to support the cardiac program which would be implemented in partnership with the regional centre at Guelph General Hospital. St. Mary s General Hospital Hospital Improvement Plan November 2011 Page 13

17 While SMGH believes these services are appropriate to its role and capacities, inclusion in the master program for facility planning purposes in no way signifies SMGH s intention to implement them without the support of partner providers and the LHIN. Process Re-engineering Initiatives to achieve Efficiency Targets The following process changes are incorporated in the master program: Cardiac catheterization and PCI patients now admitted to the cardiology inpatient unit will be cared for within a designated bed area adjacent to cardiac catheterization, when expanded capacity is available. This approach will streamline the care path, potentially reducing length of stay Service Integration, Consolidation and Collaboration SMGH has a track record of service integration, consolidation and collaboration, locally with Grand River Hospital and regionally in its participation and support for service regionalization initiatives. Locally, the distribution of clinical programs and services by hospital continues to be refined to ensure clinical cohesion and responsiveness, operational effectiveness and efficient resource management. A common medical staff and shared Chief of Staff position in partnership with Grand River Hospital also support service integration and collaboration. Alignment with LHIN Planning and MOHLTC Priorities LHIN Alignment SMGH has consulted with LHIN representatives in the master program development and will continue to develop innovative and collaborative initiatives toward the achievement of LHIN priorities as identified in the Integrated Health Service Plan (IHSP) Working Together for a Healthier Future. Highlighted in the bullets below are examples of initiatives identified in the clinical planning component of the master program process and for which enabling space is included in SMGH s master program. As SMGH has no direct role in mental health services and stroke care, initiatives are not identified for these priority areas. Improving emergency department access: o Relocate scheduled care to the ambulatory care area o Continue development of geriatric services, including the nurse led long term care (LTC) outreach service Improving Access to Primary Care: o Increase the supply of physicians through the Medical Education Centre Improving Chronic Disease Prevention and Management o Ensure a process for comprehensive patient/family assessment, education and coordination services for chronic obstructive pulmonary disease (COPD) and asthma management. Transition planning at discharge will be enhanced to minimize readmissions o As part of the proposed arrhythmia program, develop a vascular health education program which will be integrated with cardiac rehabilitation. St. Mary s General Hospital Hospital Improvement Plan November 2011 Page 14

18 o Build on and apply the findings from the WWLHIN pilot program to improve Congestive Heart Failure outcomes to manage complex patients requiring integrated care who live distant from SMGH. Decreasing Alternate Level of Care (ALC) Days o Implement ventilator weaning service for long term ventilated patients o Continue development of geriatric services, including the nurse led LTC outreach service, to support more patients in community settings Improving patient safety and enhancing quality of care as per the SMGH Quality Improvement Plan HIP Initiatives Key to the Success of Our Vision and Provision of Services There are three initiatives that have been included in the HIP initiatives that require the ongoing support of the LHIN. They are detailed below: Cath Lab Consolidation The Regional Cardiac Program was approved by the Ministry of Health and Long Term Care (MOHLTC) in February 1999 and as part of our Master Plan approval in December The expansion of the Catheterization recovery area fits with the goals of St. Mary s to continue to serve patients in a timely manner. In February 2001, St. Mary s was pleased to open the first component of its Regional Cardiac Program, the Cardiac Catheterization Suite. The recovery area in the suite has 6 stretcher bays to accommodate original projected target volumes of 1606 catheterizations by 2003/04. Volumes have since increased to greater than 3390 in 2010/11. The Hospital needs to expand its current cath recovery area from six to 12 stretcher bays to care for patients in an appropriate and safe environment. Currently patients are recovering in a split fashion using both the current cath suite and in an inpatient floor. This project will allow for the consolidation of two existing recovery areas, resulting in a more efficient and a superior model of care which reduces annual operating costs. The capital costs are estimated to be $1 million. Previous requests were made in 2004 and A further request has been made to the LHIN and the MOHLTC and a comprehensive cardiac pressures letter has been sent by the Hospital, endorsed by the LHIN and sent on to the MOHLTC which outlines priority programs area for consideration. This letter addresses the recovery room consolidation, ICD monitoring implants, as well as other unfunded activities St. Mary s performs to serve patients of the Waterloo Wellington, as well as beyond in its entire cardiac catchment region. ICD Implants Each year approximately 135 patients from the Waterloo Wellington LHIN (WWLHIN) travel to London, Hamilton or Toronto for an Implantable Cardioverter Defibrillator (ICD). The ongoing monitoring of these patients is carried out at St. Mary s General Hospital (SMGH) in Kitchener. Currently more than 400 ICD patients are monitored at St. Mary s. St. Mary s General Hospital Hospital Improvement Plan November 2011 Page 15

19 St. Mary s proposes that the implanting of these ICDs and the associated funding be repatriated to the WWLHIN so that both the implant and the ongoing monitoring are carried out locally. This will: Improve access to care; Improve the continuum of care; Improve the overall quality of care; Provide care closer to home; and Respect the allocation of tax payer dollars by having funding follow the patient. Currently, funding for ICDs ($32,500/implant) is awarded to the implanting centre. Approximately two-thirds of this funding is to cover the device and implantation costs while the rest covers the ongoing monitoring. At present no funding comes to St. Mary s even though the ongoing monitoring takes place locally. The battery in an ICD lasts approximately five to seven years, at which point the ICD needs to be replaced and the funding is refreshed. St. Mary s proposal requests that the existing funds that follow Waterloo Wellington patients to implanting centres outside the community be repatriated back to WWLHIN to ensure patients continue to have access to care in their own community. A request for funding to continue to monitor these patients close to home has been made on prior occasions, and a further request for approval and funding to commence implanting ICDs for WWLHIN patients as soon as possible has also been made. No additional capital dollars are required but the operating funds for these implants will need to be repatriated along with the patients. These service changes are consistent with the vision of St. Mary s to be a full service Cardiac Centre as have been part of the Hospital s master and functional planning. High Resource/Intensity Weights Most hospitals have a variety of services of differing levels of resource intensity. This allows the Hospital some flexibility in the use the Hospital s global funds as the funding for less intense services can compensate for the additional resources required for those with greater intensity. St. Mary s programs are all resource intense. HBAM (funding model) should address this on a go forward basis but to date its use will be to award incremental funding. We are reviewing funding methodologies, and wish to engage the Ministry to see if we can participate in a pilot study around a policy based approach to patient based global funding for our organization and for the LHIN. As the chart below demonstrates our already high weighted cases continue to grow. In addition to the intensity of the services the Hospital delivers, the region experiences great growth beyond the Provincial average. The hospital received $442,200 as the hospital growth allocation in 2011/12. The growth funding for the region addresses some but not all of the needs of a resource intense service provider. St. Mary s General Hospital Hospital Improvement Plan November 2011 Page 16

20 Figure 1 RIW Trend Inpatient Weighted Cases - OCDM 13,200 13,000 12,800 12,600 12,400 12,200 12,000 11,800 11, / / / / /2011 Weighted Cases 12,523 12,151 12,257 12,517 13,051 Strategic Clinical Programs Goals and Initiatives All clinical areas work in a collaborative and integrative manner and some of these areas are showcased within the program descriptions that follow. SMGH has a focused approach to service delivery in key areas. Each program strives, and is accountable for, excellence in patient outcomes and growth in a meaningful way in this community. Often this growth is the provision of services within the LHIN where the local expertise is available and a partnership with an academic centre supports the service (ophthalmology, cardiac). Partnerships are a core part of the success of the clinical programs at SMGH and key partners are the WWCCAC, Grand River Hospital and local Family Health Teams. SMGH has invested in Nurse Practitioners (NP) to support the strategic programs at SMGH understanding the additional value that this level of practitioner brings in care and treatment, expanding the caseload for the physicians and often providing the liaison to the patient post discharge. A) Cardiac SMGH is a leading provider of advanced cardiac diagnostic and interventional services for the Waterloo-Wellington and surrounding areas. Our catchment area stretches traditional geographic and dividing areas so that we are able to provide access to quality standards of cardiac care. St. Mary s has a highly respected, expert medical team and excellent facilities. These, combined with our values of compassion and respect, make it possible to provide quality care and continue to achieve world class clinical outcomes. St. Mary s General Hospital Hospital Improvement Plan November 2011 Page 17

21 Cardiac Services Include: Cardiovascular Surgery 24/7 Cardiovascular Intensive Care Unit (CVICU) Inpatient Cardiovascular Surgery ward Inpatient Cardiology Coronary Care Unit (CCU) Cardiology ward, including step-down beds Diagnostic Catheterization Angioplasty (including Pharmaco-Invasive and STEMI protocol service 24/7) Heart Function Clinic Pacemaker and Arrhythmia Clinic Cardiac Rehabilitation Non-Invasive Cardiodiagnostic Services (including: Transesophageal ECHO, Stress ECHO, Cardiac Nuclear Imaging, ECG, Holter, Loop Recorders) Regional Cardiac Centre Milestones 1999 Regional Cardiac Care Centre approved by MOHLTC 2000 Pacemaker Clinic opened 2001 Low risk, diagnostic, cardiac catheterizations initiated 2001 Cardiac Rehab Program launched 2002 Heart Function Clinic opened 2003 Tinzeparin Clinic to bridge anticoagulation pre op or post op 2003 Interventional Cardiology offered Cardiovascular Surgery offered 2006 STEMI protocol initiated during business hours using Blackberry technology/partnership with Waterloo Region Emergency Medical System (EMS) 2009 Arrhythmia Partnership with London initiated 2009 Pharmaco Invasive Program initiated 24/ STEMI protocol expanded and offered 24/ STEMI protocol expanded to include Waterloo EMS transfers direct from the field and bypass the emergency department, 24/ STEMI protocol expanded to include Wellington EMS transfers direct from the field and bypass the emergency department, 24/7 St. Mary s General Hospital Hospital Improvement Plan November 2011 Page 18

22 Figure 2- Regional Cardiac Centre Volumes Activity Year 1 Initial volumes of Year 1 11/12 Funded volumes 11/12 Projection (Based on Apr- Aug/11) Variance Cardiac Cath 01/ (34) Angioplasty 1 03/ Cardiac Surgery 03/ (30) Pacemaker implants 2 00/ Pacemaker Clinic 3 Visits Started in 1990 s N/A 3530 N/A Cardiac Rehab 01/ Clinic 4 Heart Function Clinic 5,6 02/ N/A 1438 N/A 1. 25% of angioplasty cases are funded by the MOHLTC for Drug Eluting Stent (DES) implants. In Ontario, the average percentage of angioplasty cases receiving a DES is greater than 45%. Approximately 36% of St. Mary s angioplasty patients receive a DES 2. ICD insertions from the Waterloo Wellington area are approximately 135 patients per year. These patients travel to London, Hamilton or Toronto for insertion and then return. 3. This includes all pacemaker activity. Note: ICD pre-insertion assessment and follow-up care is provided at St. Mary s at the rate of 400 patients monitored per year and 892 clinic visits per year 4. Cardiac Rehabilitation is a standard of care post cardiac surgery and post angioplasty. St. Mary s program was started as part of a pilot and funded for 250 cases. Added to base funding at 400 patients in 2005/06 with no change since despite significant growth in cardiac surgery and angioplasty. This number refers to new patient intake. 5. Heart Function Clinic provides aggressive management for advanced heart failure. It facilitates patient self-management and admission avoidance in the management of this chronic disease. There is a direct relationship between patients that are seen in the Heart Function Clinic and those that are assessed for and go on to require ICD patients in 2009 were followed for combined heart failure and ICD care. 7. In 2006 St. Mary s first initiated a STEMI (ST-segment Elevated Myocardial Infarction) program to provide emergency angioplasty service to the region initially during regular working hours and in 2010, the program was expanded to 24 hrs/day, 7 days/wk. The program requires dedicated beds (1 CCU and 2 ward beds), supplies and staff, the cost of which has been absorbed by St. Mary s. Annual costs since expanding to 24/7 total $500,000/yr. Future Growth Plans ICD proposal submitted to WWLHIN in August 2011 (repatriation to serve our community) Cardiothoracic regional centre as per the letter to the LHIN (Feb 23, 2007) from Dr. Leclerc recommending a combination of vascular and cardiovascular surgeries, we continue to promote a partnership with Guelph General Hospital to support a combined partnership model Heart Failure Care: St. Mary s General Hospital Hospital Improvement Plan November 2011 Page 19

23 o Community Transition Advanced Practice Nurse for high risk discharges to avoid readmission o Expansion and formal linkages to community practitioners ( family physicians, retirement homes, long term care homes to share expert knowledge) Evolve Regional leadership for best practices in cardiac care. Examples of initiatives to date: o Consultation and support to implement best practices for cardiac rehabilitation centre, Cambridge (2010) o Consultation and support to ensure best practice for cardiac rehabilitation program, Hanover (2011) o Partnership with GRH cardiology support and consultation regarding cardiology imaging quality and standards (2011) SMGH serves the needs of Waterloo Wellington patients with cardiovascular disease. As described earlier, some of these essential services are unfunded. The sum of these costs is approximately $2 million per year. The recovery plan assumes a one-time cardiac pressure of $2 million with an increase for ICD monitoring and an additional increase of $500,000 for ongoing cardiac pressures. Figure 3 below illustrates some of the unfunded services provided by SMGH over the past 6 years and the projection for the current year. A separate funding request for cardiac pressures has been sent to the LHIN and the MOHLTC. It is important to note that should this funding not be secured, St. Mary s will be required to make additional difficult decisions about its ongoing ability to provide these valuable services close-to-home for the residents of Waterloo Wellington. Figure 3 - Unfunded Costs Impacting the Cardiac Program at SMGH St. Mary s General Hospital Hospital Improvement Plan November 2011 Page 20

24 05/06 06/07 07/08 08/09 09/10 10/11 Proforma 11/12 Total Funded Funding Volume Rate Shortfall (if applicable) DES* Angioplasty Cases 1,108 1, ,063 1,078 7,083 Drug Eluting Stent Cases ,738 $ 2,338 Drug Eluting Cases above funded levels of 25 % to meet best practice $ 2,338 $ 2,316,374 multiple (greater than 1 per case) DES used as we use more than 1 DES per angioplasty $ 1,250 $ 579,000 STEMI 24-7 ongoing standby costs of running a 24-7STEMI program $ 200,000 $ 285,000 $ 365,000 $ 400,000 $ 450,000 $ 500,000 $ 2,200,000 ICDs** New ICDs implanted outside of WWLHIN and monitored at SMGH $ 10,500 $ 5,019,000 Cardiac Rehab Cardiac Rehab Patients above funded level of 400 patients ,324 $ 1,000 $ 2,324,000 Funding Shortfall $ 1,203,910 $ 1,688,879 $ 1,236,500 $ 1,683,570 $ 2,138,606 $ 2,149,561 $ 2,337,349 $ 12,438,374 prior year actual shortfall $ 2,149,561 current year projected shortfall $ 2,337,349 assumption of base funding increase in the Hospital Improvement Plan $ 2,000,000 accumulated shortfall $ 12,438,374 Notes: * FROM PAPER ON CARDIAC FUNDING 2005/06 In 2003/04 the ministry approved recurring one time funding to support new drug eluting stent technology. Currently hospitals receive a funding adjustment to support the use of this technology for a predetermined volume of PCI procedures annually. In 2003/04 this funding supported 22% of all PCI volumes initially approved. Note that the blip in reduced use of DES was an industry practice where for approximately a year, DES fell out of clinical practice until results supported its use. ** ICDs were initially funded at $22,000 per case and covered the cost of the device. In 1999, the JPPC reviewed the funding rate for ICDs and recommended a revised rate that incorporated direct patient care, device and follow-up costs. In 2000/01, the ministry adopted a revised funding rate of $32,500 for incremental ICD volumes. Hospitals that have been awarded base volumes prior to the funding increase only receive the new rate on incremental volumes. The difference being the cost of monitoring ($32,500-22,000). B) Chest This program of excellence in respiratory medicine and thoracic surgery was started in 2003 with a dedicated inpatient unit and co-location of respiratory patients, recognizing the benefits such a model would have for these patients by providing continuous care. Working with Grand River Hospital, thoracic surgery was consolidated at SMGH in 2008 to meet Cancer Care Ontario guidelines for thoracic surgery and ensure a sustainable quality program for this community. A strong relationship exists with the Grand River Regional Cancer Center in the diagnosis assessment center for thoracic surgery. Cancer Care Ontario (CCO) recognized the innovative model of care provided at SMGH (Nurse Practitioner) with an award of excellence. Growth is planned to this thoracic program to ensure compliance with the volumes set out by CCO for thoracic surgery and address the needs of this community. SMGH established an airway clinic in 2003 with the goal of decreased Emergency readmissions for asthma. The clinic quickly demonstrated success in this area and has grown in partnership with GlaxoSmithKline and their PRIISME program, which allows SMGH to provide education, patient assessment and teaching in the family practice offices, community health team or in the community setting. St. Mary s General Hospital Hospital Improvement Plan November 2011 Page 21

25 The respiratory outpatient reactivation program has been incorporated into the Cardiac Rehab program recognizing the overlapping and common elements of chronic disease management. Recently SMGH worked with GRH to transfer the outpatient adult cystic fibrosis clinic to SMGH to provide a comprehensive program (align inpatient and outpatient services) for these patients in one location. An additional goal for this program is to work with the LHIN to create a new model of care for long term ventilation adults and minimize the long ALC hospital stays for these complex patients. A proposal has been developed and awaits funding from the Critical Care Secretariat. SMGH has recently received (Sept 2011) pilot funding under the LHIN ALC strategy to implement this program in a limited fashion. Further chest program goals currently pending available funding are the creation of a hospital based sleep lab and introduction of the endoscopic ultrasound. Currently requires patients to travel to Hamilton for this diagnostic assessment. C) Surgery The provincial restructuring plans put in place in 2004 between SMGH and GRH determined and defined the surgical sub specialties and a focus on adult day surgery for St. Mary s. Appropriately 80% of all surgery at SMGH is done as day surgery with extended hours to support any ongoing monitoring required. SMGH does have a small surgical inpatient unit for the remaining surgical cases. Ophthalmology This is a program of focus at SMGH and beyond cataracts, the Hospital provides retinal surgery and ocular plastic surgery. The Hospital s accompanying outpatient clinic provides treatment for the associated medical ophthalmology conditions such as macular degeneration and diabetic retinopathy. St. Mary s also has a partnership with London Health Sciences in which an ophthalmologist comes to SMGH bi-monthly to provide local specialty care. This clinic is limited in growth as SMGH has funded this on a revenue basis from diagnostic exams. SMGH submitted a proposal to the WWLHIN in 2008 to establish a Centre of Excellence for Ophthalmology and to consolidate LHIN-wide services at St. Mary s. Urology SMGH has a focus on urology surgery and as such, provides cystoscopy in an outpatient setting. D) Medicine The medical program focuses on excellence in senior or elder friendly care. Waterloo Region geriatricians were invited to host their office in the hospital recognizing their value in the care of the aging population and the requirement to support the practice of the geriatric Nurse Practitioners (NP) who require access to physician consultation. The geriatric NP supports outpatient visits and has developed a strong relationship with CCAC. Together they case manage multiple community clients to avoid ED visits, admissions or readmissions. The three geriatricians and the NP provide outpatient clinic services that support the WWLHIN. St. Mary s General Hospital Hospital Improvement Plan November 2011 Page 22

26 Recently in partnership with CCAC, SMGH refreshed its Home First program. This refresh was modeled after the very successful program at Halton Healthcare in an effort to replicate the success seen in that organization in reducing the number of patients awaiting long term care in the hospital. The refreshed philosophy supports research that the hospital is not the optimal environment for elderly patients. Every effort is made to discharge patients home. Preliminary data demonstrates an effective new model of senior care emerging. The Home First philosophy and implementation is very dependent upon community resources and primarily CCAC in resourcing the wait at home program. Emergency Department (ED) SMGH has a busy ED that has more than 45,000 visits per year. SMGH introduced Nurse Practitioners into this department in 2002 and as funding allows has continued to grow these practitioner hours to support timely, quality ED care in the non-urgent cases. A recent initiative has placed the NP geriatrics in the ED for two days per week, seeing the complex frail elderly and working with community partners to avoid admissions. This may involve a home visit or dedicated case management by this NP with an occupational therapist (OT) as care is transitioned back to CCAC or primary care. This initiative is reliant upon timely CCAC supports and collaboration and engagement with family practitioners. This same NP in partnership with the geriatricians and the retirement homes (initially Luther Village) are providing on site assessments in a new model with the goal of early assessment and intervention in the community. Endoscopy SMGH has a large endoscopy program which provides bronchoscopy for the respiratory and thoracic program, offers preventative screening with the Nurse Endoscopist program (supported by CCO) and diagnostic and emergent endoscopy by the gastroenterologists. Endoscopy is primarily an outpatient program but supports the inpatient or Emergency Department needs as required. St. Mary s is a willing partner within the Waterloo Wellington healthcare system and will embrace an opportunity to work with the community including the CCAC to support best placement of patients for appropriate care. Opportunities to work with the CCAC to improve ALC statistics, to minimize repeat ED visits and improve transitions to the community at discharge, are in the initial implementation or planning stages. The Hospital is also exploring the purchase of such services with an accountability agreement with the provider. E) Long Term Care Bed Allocation Management at the Hospital would like to further investigate and potentially host a web site for ALC bed allocation based on a model in the Central LHIN. The information would be collated from all the hospitals and a daily risk based methodology would be enacted to place ALC patients into long term care beds. This would require the collaboration of all WWLHIN hospitals. It would allow the LHIN, CCAC and all hospitals to see and respond to the ALC pressures in the system. St. Mary s General Hospital Hospital Improvement Plan November 2011 Page 23

27 F) Short-Stay Beds/Transition Beds SMGH is interested in pursuing funded opportunities to host a short-stay unit (express beds) at the Hospital to manage the flow of patients from the Emergency Department. This would mitigate the Hospital s risks with planned bed closures while ensuring the flow of admitted inpatients from the ED. It would also assist with the best practice infection prevention and control standards as early access to isolation beds is a barrier to current bed allocation strategies. G) Lean Process Improvements All programs and services have developed unit specific goals that are aligned with St. Mary s vision and strategic directions/goals. As of the end of June, every area has reviewed their unit specific goals/targets and relevant metrics daily to determine where there are opportunities for improvement. Staff members are invited to post new ideas for improvement each day. As of the end of September 893 improvements have been implemented across the hospital (since January, 2011). Approximately 20% of these improvements involve some financial savings. A few examples of improvements that have provided savings are described below. Reduction in wasted supplies for isolation patients The inpatient units and the Emergency department reviewed the process for supplying patient rooms/stretcher bays with supplies for isolation patients, with a goal to reduce waste when the isolation patient is discharged. The Chest Unit has been able to reduce the number of supplies wasted on this floor by 95%. Improving the utilization of outpatient diagnostic services The Nuclear Medicine and Diagnostic Imaging departments identified that several slots per day were not being used. After further exploration they learned that many patients were not showing up for scheduled appointments. The staff implemented strategies to improve utilization and have reduced unused slots to below 2%. In addition to being better for patients this has generated additional revenue from OHIP amounting to close to $100,000/year. Reduction of wasted supplies in the Cardiac Catheterization Suites The Cardiac Catheterization Suites monitored the wasted supplies for their procedures daily. The team estimated that they were wasting approximately $12,000 per year in supplies due to a technique being used. The team changed their practice and thus far, estimates that they will save approximately $8,000 per year in supplies. Changes in type of IV bag used for cardiac procedures The Cardiac OR team changed the type of IV bag/solution being used for specific types of procedures and estimate this will save $3,000 per year. There have also been numerous improvements implemented across the organization that relate to quality/safety, patient and family centered care, and people. St. Mary s General Hospital Hospital Improvement Plan November 2011 Page 24

28 6.0 Risk Assessment The success of the HIP is its implementation through feasibility and risk mitigation. The Board, management, staff and physicians have been engaged in the journey that the hospital must embark upon to return to financial health. Risk has been assessed for each initiative in Appendix A and risk mitigation strategies have been included in the following section for each initiative. Risk is greater when the efforts and outcomes change or challenge the status quo. Many items have been shaded grey in the Appendix as these interventions require support and collaboration outside the hospital itself. For each initiative, St. Mary s utilized a risk framework that guided the team through the following questions: Can we do this? Should we do this from a strategic and mission perspective? Should we do this from a best for patient care perspective? Does this initiative cause harm? Are services best placed at St. Mary s or elsewhere? Is this feasible and will it help sustain our financial health? The initiatives were also given the four corners test, where each of the four quadrants of risk identified in the Guidelines for Hospital Audits and Reviews are considered to ensure that the risk tolerance in each quadrant was sufficient to allow delivery on the savings that would benefit the financial quadrant. The following figure outlines that the risk assessment for Organizational Health, Quality of Care/Patient Safety/Service Provision/Community Support, and Employee Health and Safety is quantified as low, while the Financial/Operational Health risk is ranked as high. A) Four Corners Risk Dashboard The financial risk assessment is included here and will become part of the quarterly reporting that will be shared with management, the Board and the LHIN on a regular basis. St. Mary s General Hospital Hospital Improvement Plan November 2011 Page 25

29 DRAFT SKELTON - Dashboard/Action Plan (as referenced to the Guidelines for Audits and Reviews of Hospitals (June 2011) 1. Organizational Health Sentinel signals that help assess hospital board and leadership is functioning within commonly accepted best practices. Overall Risk Assessment: low X 2. Quality of Care/Patient Safety/Service Provision/Community Support Sentinel signals that help assess how well a hospital is performing in areas related to quality of care, patient safety, etc. Overall Risk Assessment: low X 4. Employee Health and Safety Sentinel signals that show how well the hospital is performing in areas related to employee satisfaction, safety, health, and performance. Overall Risk Assessment: low X 3. Financial/Operational Health Sentinel signals that show how well the hospital is performing in commonly accepted financial elements. Overall Risk Assessment: high X St. Mary s General Hospital Hospital Improvement Plan November 2011 Page 26

30 B) Financial Risk Assessment St. Mary s General Hospital Hospital Improvement Plan November 2011 Page 27

31 7.0 HIP Interventions (see Appendix A for Risk Assessments) financial sustainability initiatives # initiatives $ annualized 2011/ /13 future years and on estimated restructuring costs FTE reductions Health and Safety OT and sick accountability & additional work on the 1 absenteeism 350, ,000 - Revenue Generation 2 ABANDONED Plasma Screens in waiting rooms 5,000-5,000-4 ABANDONED Increase Ultra Sound revenues 95,000 41,250 53,750-6 OHIP reject process improvement 25,000-25,000-7 confirmed one time revenues (at risk for future years) 300, , confirmed increase in base funding - growth 422, , increase to parking - already in preliminary budget 10 increase revenue from out patient DI 140,000 70,000 70,000 - Approve ICD monitoring and implants at SMGH by 11 repatriating patients and their funding from other non-local centres 1,250,000-1,250, patient preferred accommodation 200, , , Explore the impact of the high Resource Intensity Weights of St. Mary s patients and programs on our base funding. Initiative Management and Non-Union restructuring nonunion realignment of management, administration and non-union 1,395, ,750 1,046,250-1,305, Medical Fee Remuneration 20 medical fee remuneration review 600, ,000 - Clinical Efficiencies and special initiatives a. Clinical Efficiencies: Cardiac 21 Continue to pursue the capital funding to amalgamate cath lab recovery with the post-angioplasty care area - $1M requested from MOH in 2004 and , , , ,000 5 b. Clinical Efficiencies: Chest 25, 27 change in coverage (hours) 62,000 31,000 31,000 - c. Clinical Efficiencies: Medicine staged closure of medical beds that have been occupied by 22, ALC patients and renewal of Home First Strategy and 22A, 29 weekend closure of surgical beds with surgical scheduling changes 1,433,333-1,075, ,333 1,014, ambulatory clinic reallignment with community 140,000 35, , , , 26 change in coverage (FTEs and hours) 199,000 81, ,000-38, further skill mix changes - still to be explored d. Clinical Efficiencies: Surgery 29 see medicine - combined 30 reduction of perfusion team - completed already in preliminary budget 31 skill mix change in OR 45,000-45,000 - e. Clinical Efficiencies: Emergency Department 32 further clinical efficiencies in ER and related clinical areas 200, ,000 f. Other Clinical Support Efficiencies 33 ABANDONED centralized patient registration and bookings 200, , ,000 4 Benchmarking Efficiencies , 41benchmarking non direct patient care 540, , , conservable bed days approx 20 and the LOS goal 750, , , , ,851,799 1,329,200 5,911,500 1,611,099 3,090, A B C 7,240,700 8,851,799 A+B total savings: A+B+C St. Mary s General Hospital Hospital Improvement Plan November 2011 Page 28

32 Using the recently released documents Guidelines for Hospital Audits and Reviews, St. Mary s has listed and assessed each of the initiatives in its proposed HIP. Please see Appendix A for the spreadsheet that will be used for ongoing monitoring of our progress. A quarterly report similar to that shared with the Board and LHIN from the August 18, 2011 meeting will include updates to all initiatives in a format combining the assessments below and the format in the Appendix. HOSPITAL IMPROVEMENT PLAN INITIATIVES An initial list of 41 HIP interventions was shared with the LHIN in earlier discussions. For ease in tracking these initiatives we have maintained a numbering system. Some initiatives have now been grouped for reporting purposes. Management will utilize project charters for each of the initiatives and will monitor and track these respectively. The grouping will continue for ongoing external and Board reporting. Please note that the absence of sequential numbering of initiatives is deliberate for internal and LHIN tracking as the initiatives have been grouped and refined during the construction of the HIP. A) HEALTH AND SAFETY 1. Goal: Reduction in overtime and sick time corporately and in specific pockets Target: To be better than the 25%ile on the HIT tool for overtime and sick time $350,000 in 2012/13. This initiative includes modified work and return to work program review with an emphasis in certain programs and services where prior good results have slipped in the past 2 years. Target Timeline: 2011/ /13: $350,000 Risk: This goal could be achieved but may adversely impact staff morale. Risk Mitigation: Several staff suggested this type of initiative in the Hospital s Bright Ideas Campaign. Management will continue to update and engage staff in pursuit of this goal. To support safe, effective and sustainable gains, the Hospital has reintroduced an attendance management system and will continue to ask the staff for feedback about this program. Quarterly accountability meetings will create a vehicle to assess the pulse of the organization. Management will continue to review and monitor staff absenteeism along with quality indicators for patient needs and health and safety indicators for staff. Investment required: estimate of $100,000 in year one and $30,000 ongoing resource Status: Planning phase X Underway Complete St. Mary s General Hospital Hospital Improvement Plan November 2011 Page 29

33 B) REVENUE GENERATION 2. This initiative has been abandoned. 3. Goal: Plasma screens in waiting rooms generation of revenue through advertising fees and education of patients on services available in community Target: $5,000 per year Target Timeline: 2011/ /13: $5,000 Risk: none Risk Mitigation: none required Investment required: none Status: Planning phase X Underway Complete 4. This initiative has been abandoned. 5. Goal: Increase ultrasound revenues and other outpatient revenue opportunities Target: $95,000 Target Timeline: 2011/ /13: $95,000 Risk: small risk as opportunities from open blocks have been identified Risk Mitigation: not applicable Investment required: none Status: Planning phase X Underway Complete 6. Goal: Improvement to OHIP revenue collection/ reduction to reject levels Target: $25,000 Target Timeline: 2011/ /13: $25,000 Risk: small risk as opportunities for improvement have been identified. St. Mary s General Hospital Hospital Improvement Plan November 2011 Page 30

34 Risk Mitigation: overall revenue increases will compensate for unexpected savings Investment required: $20,000 ongoing Status: Planning phase X Underway Complete 7. Goal: Increase to one-time revenues A budget increase of $300,000 has been achieved as the WWLHIN has confirmed some of the one time revenues that had not been communicated at the time of budget preparation. The associated expenses were and remain included in the preliminary and current budget. Additional one time revenues have yet to be confirmed and management has communicated their omission from the budget. The Hospital will continue to optimize and increase one time revenue opportunities. Target: $300,000 + Target Timeline: 2011/ /13: $300,000 Risk: One time nature of funding leads the organization to remain at risk for securing such funds to support budgeted expenses. Risk Mitigation: The Hospital will build surpluses in the future to allow for proactive management of service provision and programs with one time revenues while remaining in a balanced or surplus position. Investment required: none Status: Planning phase Underway X Complete 8. Goal: Increase to base funding Base increase and growth funding was confirmed by the WWLHIN in August. These funds have been reflected in the current budget. Target: Amounts confirmed beyond that budgeted are $422,200 (growth funding). Target Timeline: 2011/ /13: $422,000 Risk: None, confirmed by funding letter August Risk Mitigation: not applicable Investment required: none Status: Planning phase Underway Complete X St. Mary s General Hospital Hospital Improvement Plan November 2011 Page 31

35 9. Goal: Increase to parking to match peer hospital rates Target: $108,000 already reflected in preliminary budget, hence not double counted Risk: none Risk Mitigation: not applicable Investment required: none Status: Planning phase Underway Complete X 10. Goal: Increase in revenue from outpatient Diagnostic Imaging Target: $140,000 Target Timeline: 2011/ /13: $140,000 Risk: Small risk as opportunities from open blocks have been identified Risk Mitigation: Not applicable Investment required: $10,000 ongoing Status: Planning phase X Underway Complete 11. Goal: Approval for implants for ICDs and funding to be directed to St. Mary s MOHLTC/LHIN approval for current and ongoing monitoring to enhance the cardiac services performed as provisions offered as the Regional Cardiac Centre. Currently St. Mary s performs post-implant monitoring that it does not receive funding for. Implant centres in London, Hamilton and Toronto currently receive this funding although they do not perform the post-implant monitoring. As St. Mary s monitors such patients and has the capacity and clinical expertise to perform the implants, approval to perform these implants and repatriate patients to WWLHIN is requested. Such repatriation would serve the community and St. Mary s well with the dollars following the patient. Target: $1.25 million + Target Timeline: 2011/ /13: $1,250,000 Risk: Delay in receipt of approval and transfer of patients and services. SMGH will not be able to sustain follow up local services for this patient group without sufficient funding. St. Mary s General Hospital Hospital Improvement Plan November 2011 Page 32

36 Risk Mitigation: St. Mary s is working with the Cardiac Care Network (CCN) to review implant designations and is dialoguing with the WWLHIN and MOHLTC to create appropriate service delivery in the region. Risk of this initiative is in timing (of approval). Investment required: none Feedback from Stakeholder Engagement on this Initiative: The development and implementation of an ICD program has been a vision for the staff and physicians at St. Mary s for years. Having access to care close to home for cardiac surgery, catheterization, angioplasty and pacemakers has greatly enhanced the quality of life for patients in Waterloo Wellington and our clinical team is looking forward to providing the same benefits to those who need an ICD. They strongly support the inclusion of this proposal as part of the Hospital Improvement Plan. Status: Planning phase X Underway Complete N.B. Tied to cardiac letter written November Goal: Increase in preferred accommodation revenues Target: $200,000 Target Timeline: 2011/ /13: $100, /14 and beyond: $100,000 Risk: Infection control issues prevent use of private rooms Risk Mitigation: Raising existing rates to be in line with other organizations will accommodate approximately $100,000. Investment required: none Status: Planning phase X Underway Complete 13. Goal: Exploration of HBAM and other funding models St. Mary s will explore HBAM vs. other funding models on the services it offers which are Resource Intense and are not offset by lower intensity activities. Management has communicated the need to examine hospital funding and believes that a LHIN wide review of the patients in the LHIN would foster better funding. Target: no financial impact has been reflected in the HIP Risk: none St. Mary s General Hospital Hospital Improvement Plan November 2011 Page 33

37 Risk Mitigation: not applicable Investment required: $20,000 ongoing Status: Planning phase X Underway Complete C) MANAGEMENT AND NON-UNION RESTRUCTURING Goal: Consolidation of management in many areas. Anticipate $1 million of these savings will be in management/administration. Target: $1,395,000 Target Timeline: 2011/ /13: $1,395,000 Risk: Staff reaction to the restructuring could lead to exit of talent, loss of engagement in critical initiatives for success (such as Lean, Benchmarking). Further pressures due to increasing demands such as FIPPA will compound workload. Spans of control may become too great. Risk Mitigation: Ongoing communication about progress with the HIP, quality indicators, successes and achievements will be important, as will ongoing monitoring of staff morale and performance. With already large spans of control ( direct reports in some patient care areas) this change needs to be monitored via performance appraisals, sick time and turnover. St. Mary s we will support this change through education and quarterly meetings where structural issues will be reviewed. Investment required: $105,000 onetime costs, and $1,305,000 onetime restructuring costs Status: Planning phase X Underway Complete D) MEDICAL FEE REMUNERATION 20. Goal: Reduction of medical staff remuneration Target: $600,000 Target Timeline: 2011/ /13: $600,000 Risk: Loss of physician support St. Mary s General Hospital Hospital Improvement Plan November 2011 Page 34

38 Risk Mitigation: Ongoing communication and dialogue will be critical. Physician engagement will be required to ensure that this is successful. Investment required: none Status: Planning phase X Underway Complete E) CLINICAL EFFICIENCIES: CARDIAC 21. Goal: Consolidation of post-operative care areas for cath lab and angioplasty Target: $500,000 Target Timeline: 2011/ /13: $250, /14 and beyond: $250,000 Risk: Capital investment ($1 million) is required and proposals have been submitted to the Capital branch and WWLHIN for this consolidation in 2004 and The project approvals, tendering etc. will force a delay in consolidation of activities and realization of savings. The operational savings will be delayed until approval and funding is obtained and construction is completed. Risk Mitigation: If capital can not be secured from the capital branch as a separate effort then the shared costs associated with the capital project could be utilized for this effort. Management has submitted a request to the capital branch for the cost sharing associated with unforeseen asbestos abatement for approximately $1 million. Investment required: $1 million in capital and one time operating costs of approximately $100,000. Restructuring costs of $250,000 will occur in future years post construction. Status: Planning phase X Underway Complete N.B. Tied to cardiac letter written November 2011 F) CLINICAL EFFICIENCIES: CHEST 25, 27. Goal: Change in staffing to align with other similar clinical areas (hours) Target: $62,000 Target Timeline: 2011/ /13: $62,000 St. Mary s General Hospital Hospital Improvement Plan November 2011 Page 35

39 Risk: Based on other SMGH similar clinical units, there is no clinical risk to align staffing models. There is the ability to reduce the scheduled hours without layoffs and ensure quality of patient care. Risk Mitigation: not applicable Investment required: none Status: Planning phase Underway Complete X G) CLINICAL EFFICIENCIES: MEDICINE 22, 29. Goal: Reduce 10 medical beds (in a phased approach related to reduction in ALC long term care (LTC) patients). Target: $1,433,333 * this total encompasses #22 & #29 In 2010/11 approximately 25 of St. Mary s 150 beds were occupied by ALC patients. On August 1 st, the Hospital introduced a refreshed approach to Home First in with WW CCAC, and have since seen an average of 13 ALC patients occupying its beds. The Hospital therefore proposes the closure of 10 beds no longer needed by ALC patients. The Hospital is suggesting a phased approach to these closures, commencing in with five beds in May of 2012, followed by an additional five beds in October of This will allow the Hospital to gain more experience with the Home First philosophy, while also allowing it to meet its collective agreements. Home First aligns easily with the SMGH focus on elder friendly care and recognition of the risk inherent in the hospital environment for seniors. It is recognized that there needs to be careful monitoring but this early success provides confidence that this goal is achievable. Target Timeline: 2011/ /13: $1,075, /13 and beyond: $358,333 Risk: Approximately $300,000 is covered with Pay for Results funding, should this one time source of funding decrease we are at risk and will require additional savings. If hospital acquired infections, admissions or acute lengths of stay increase we may see increased wait times in the ED. Bed closures are contingent on the continuing support of Home First program by WW CCAC Risk Mitigation: SMGH is basing the success of this strategy of ALC bed closures on our learning from the Halton Mississauga LHIN who have seen a significant reduction in ALC by partnering with CCAC and adopting Home First. SMGH management staff and management have visited Halton Healthcare to understand their processes and have implemented these same protocols at SMGH. St. Mary s General Hospital Hospital Improvement Plan November 2011 Page 36

40 SMGH has several initiatives that it is undertaking to ensure and support timely ED access and flow of additional patients. Protecting ED wait times is the rationale for a phased approach to these bed closures so that monitoring of impact both internally and externally can inform our actions and progression to the next phase. SMGH remains committed to the appropriate utilization of the ED resources, a decrease length of stay in the ED and supporting the reduction in the use of non urgent ED resources. Examples of ongoing ED wait time initiatives are as follows: Deployment of an ED flow co-ordinator will ensure the optimal and timely utilization of available beds. There has been a focus on the Emergency Department process and flow starting with the ED Performance Improvement Project (PIP) funded in this LHIN in This has continued on and been renewed using the LEAN lens to exam performance metrics on a daily basis with clarity of targets. Using the pay for results funding, SMGH has moved our Nurse Practitioner (NP) Geriatrics to the ED to support rapid assessment and treatment plans for these frail and often vulnerable elderly patients - with the goal of reducing time in the ED, facilitating earlier access to specialists and admission avoidance. This NP works in concert with the GEM nurses and leverages their work. This NP is partnered with an Occupational Therapist (OT) who, with the NP geriatrics, is also available to do home visits in the community post discharge or case management by phone as care is transitioned back to the family physician, CCAC or other community supports. Early feedback is encouraging based on admission avoidance, direct involvement and participation & transition to relevant family physicians, early comprehensive care plan and communication with family members. This same NP and OT will work with a geriatrician in a new model of providing assessments to frail seniors in retirement homes on a monthly basis. Frail seniors will be selected by recent ED visits, as a follow up to a SMGH ED visit or those seen to be failing by the retirement home staff or family members. This is a proactive strategy for early assessment and intervention and the opportunity to link patients with CCAC as necessary, their family physician and SMGH geriatric clinic to provide support as required. There are many patients who make frequent visits to the ED and many of these patients commonly frequent both SMGH and GRH for non urgent care needs that may not be strictly medical. A subset of these frequent ED visitors also use ambulance services as their primary mode of transportation to the ED. SMGH is finalizing an initiative that the ED team of practitioners takes a more active role in case review and meets with community practitioners, including family physicians as applicable to review the frequency of ED visits and work to develop a treatment or case management strategy that avoids the ED. Transition planning at discharge to avoid readmissions is another focus as the readmissions come via the ED. There is much evidence to support that NPs are well St. Mary s General Hospital Hospital Improvement Plan November 2011 Page 37

41 positioned for this role as follow up visits with family practitioners are often not within a two week window. CCAC is often involved with these patients, however the scope of practice and knowledge of the hospital stay allows the St. Mary s NP to enhance this transition to the community as well as respond to queries that CCAC providers may not be able to answer (medication reactions, new symptoms or changes). Currently SMGH has freed up dedicated time for the NP respirology to support case management for this group of patients and there are plans to provided dedicated time to support the cardiology patients and specifically the heart function patients. WWLHIN Community Provider Support: CCAC has worked with the hospitals to implement a refreshed approach to Home First in This philosophy is not unique to acute care but is also applicable to post acute discharge destinations or programs such as rehabilitation, functional enhancement unit, and geriatric assessment units. Over the next year it is anticipated that improved flow through in these programs will also support a decreased ALC length of stay at SMGH. Other LHIN Initiatives such as the rehabilitation services review, complex care review all promise some system efficiencies in meeting the needs of the patients in their care trajectory and will support this initiative. There will be an ongoing evaluation of current metrics (patient volumes, ALC days and ALC volumes, applications for LTC in the hospital, etc.) and this will continue post-bed closures to monitor any impact of bed closures. Summary of Impact: Area Service levels Human Resources Other providers HSAA performance indicators Anticipated Impact Plan to maintain current will monitor ONA, CAW, non union GRH & CCAC - monitor any impact None Summary of Stakeholder Feedback for this Initiative: Both staff and physicians expressed concern about the hospital s ability to successfully close all ten medical beds, without seeing negative repercussions in other areas of the hospital specifically, with potential backlog in the emergency department. It was noted by these groups that external factors beyond the hospital s control (such as potential outbreaks during influenza season) might drive volume and activity, and that the loss of these ten beds would limit the hospital s ability to successfully manage patient flow during this type of influx. In addition to outlining the risk mitigation strategies above to these stakeholders, hospital management stressed that the phased approach to this initiative (five beds by May 2012, remaining five beds by October 2012) would allow for ongoing monitoring and assessment of this strategy to ensure that access to, and quality of care are not compromised. St. Mary s General Hospital Hospital Improvement Plan November 2011 Page 38

42 Further, while staff acknowledged the need to move forward with a plan that will ensure a strong, sustainable future for St. Mary s, they are understandably concerned about the job losses required as a result of the proposed plan. Investment required: none, restructuring costs of $1,014,081 and $50,000 ongoing investment for the surgical scheduling Status: Planning phase X Underway Complete 23. Goal: Transfer of ambulatory clinic activity to the community Target: $140,000 Target Timeline: 2011/ /13: $140,000 Risk: physician relationship may be compromised. Risk Mitigation: A component of the rheumatology clinic providing infusion treatments for one physician was transferred to a community setting under the leadership of this same rheumatologist in June These drugs are not OHIP funded but through private insurance or other venues so there is no financial impact to patients. There is a coordinator associated with these community infusion centers that assisted these patients transfer to a community infusion center often closer to their home (e.g. Mount Forest).These patients (thirty six) remain linked to the same physician. The transfer of these patients allowed a different model of staffing for the weekly clinic and remaining patients. The diabetes clinic is a physician led weekly clinic following 360 reoccurring patients who are seen at intervals determined by the endocrinologist (e.g. six months or annually). The plan for this clinic is to work with the physicians to transfer this activity back to their offices and simultaneously work to create an individual plan of care for each patient to ensure any other diabetes management needs are met. This may mean a referral to the Diabetes Intake Coordinator (central intake) for services. Discussions have occurred with the Regional Coordinator for Diabetes to ensure system capacity. Investment required: none, restructuring costs of $114,000 Status: Planning phase X Underway Complete X (two areas) 24, 26. Goal: Change in staffing models to align similar clinical unit coverage (FTEs and hours) and review and modify clinical areas of coverage and respond to benchmarking from peer hospitals. Focus resources on inpatient acute activity. St. Mary s General Hospital Hospital Improvement Plan November 2011 Page 39

43 Target: $199,000 Target Timeline: 2011/ /13: $199,000 Risk: This staffing model is in alignment with other similar clinical units and or aligns with peer benchmarking findings. Risk Mitigation: Monitor impact of the changes in the staffing and scheduling on hospital operations, such as effective discharge planning, hospital acquired infections, access to care. Investment required: restructuring costs of $38,000 Status: Planning phase X Underway Complete 28. Goal: Skill mix changes in professional staff Target: under review Risk: relationships with unions, inability to recruit for new model Risk Mitigation: monitor quality and expenses, advance discussion and professional staffing plans approved after review at professional advisory committees. Look to Professional Associations for any professional designation staffing guidelines. Investment required: $10,000 ongoing Status: Planning phase X Underway Complete H) CLINICAL EFFICIENCIES: SURGERY 29. Goal: Close the inpatient surgical unit on weekends by aligning the booking with expected length of stay. Target: now combined with initiative 22 SMGH has a focus on day surgery (~ 80 %) excluding cardiac and thoracic surgeries. This focus on day surgery and transfer of inpatient surgical beds between SMGH and GRH was directed by the Investigator Report (Timbrell) and implemented in SMGH retained a small inpatient surgical unit for primarily elective surgery cases. The surgical length of stay is short and the longest length of stay is five days. In order to maintain St. Mary s commitment to the community, volumes outlined in its HSAA and CCO agreements, the Hospital plans to book surgical patients according to their predicted length of stay. Thus surgical procedures that require a five day length of stay will be booked on a Monday to support a Friday discharge. As the majority of surgery cases have at least a stay of one to three days, this is possible. Having most St. Mary s General Hospital Hospital Improvement Plan November 2011 Page 40

44 surgical patients discharged by Friday will allow for the closure of some of inpatient surgical beds over the weekend. Surgeons in Waterloo Region have joint privileges at both St. Mary s and Grand River, and most have operating room (OR) time at both organizations to support their practice. Surgical OR time is allocated by blocks to the surgical sub specialties (such as general surgery, urology, ENT, etc). Surgeons also have access to other resources at both organizations which may include minor outpatient procedures, cystoscopy (only at SMGH) or dedicated clinics (fracture/hand clinic for orthopaedics or plastics at GRH) as well as endoscopy at both organizations. In order to make any necessary changes to other clinical commitments including physician offices, it is necessary to provide the time to make these adjustments and three to six months will be provided to achieve any concurrent scheduling changes. GRH has been apprised of this strategy and will be involved in facilitating this change, as will the Chief of Surgery, Chief of Anesthesia, Medical Lead Surgery and VP Medical at SMGH. Initial meetings with the stakeholders suggest, while requiring significant changes in physician office schedules and at GRH, the strategy is feasible. In order to assist with these changes it is identified that the surgeon s offices and the SMGH OR booking office will require support and there is a temporary part time position pending to facilitate this change. Risk: need to confirm stakeholder engagement and testing of the new model of utilization of existing operating room blocks to ensure the throughput and efficiencies. Community response and media coverage is a concern. These surgical beds are often used to support overcapacity and ensure the ED flow through. This staff is unionized with the majority of the impact residing with the RN staff. see initiative #22 Summary of Impact: Area Service levels Human Resources Other providers HSAA performance indicators Anticipated Impact None ONA Surgeons GRH None Risk Mitigation: St. Mary s will work with physicians as well as other partners including Grand River Hospital and the WW CCAC. To mitigate risk, a dedicated OR flow coordinator position will be required to transition to this new model. Additional surgical instrumentation will be required to support this change in booking. Metrics such as case volume and case type will be monitored via the GRH and SMGH Joint OR Committee to ensure that there is no unanticipated financial impact to GRH. SMGH will also continue to monitor all the volume metrics related to our contractual obligations (CCO, WTIS) etc. Impacts will be monitored via the SMGH perioperative committee and SMGH surgical program. St. Mary s General Hospital Hospital Improvement Plan November 2011 Page 41

45 Summary of Stakeholder Feedback for this Initiative: During consultation, surgeons expressed that they were pleased that St. Mary s is proposing an innovative solution to reduce costs in the surgical program that will not impact patients, or access to care. However, they acknowledged that moving forward with the rescheduling initiative will be a significant upheaval in their practices, as they rework their schedules to achieve the goal. They recognized that the six-month lead-time identified to implement the strategy will be crucial in creating a successful framework. Investment required: now combined with initiative 22 Status: Planning phase X Underway Complete 30. Goal: Reduce hours of perfusion to align with cardiac case volumes Target: $90,000 already reflected in starting budget Risk: none Risk Mitigation: not applicable Investment required: none Status: Planning phase Underway Complete X 31. Goal: change skill mix in the operating room Target: $45,000 Target Timeline: 2011/ /13: $45,000 Risk: Dependent on the appropriate cases types to continue to be provided at St. Mary s. This may restrict the Hospital s ability to recruit the level of practitioner desired in new model. Risk Mitigation: Not applicable. Advocate for new roles and funding opportunities for RNSFAs. May need to train existing staff if unable to recruit. Investment required: none Status: Planning phase Underway X Complete St. Mary s General Hospital Hospital Improvement Plan November 2011 Page 42

46 I) CLINICAL EFFICIENCIES: EMERGENCY DEPARTMENT & RELATED CLINICAL AREAS 32. Goal: Review processes and associated staffing models in the emergency department to meet the peak periods Target: $200,000 Target Timeline: 2011/ /13: None 2013/14 and beyond: $200,000 Risk: Any change in model of care takes time, support and needs to be tested. Risk Mitigation: Ongoing planning and monitoring of ED wait times. Review all roles, job responsibilities and accountabilities with patterns of patient flow and existing schedules. Investment required: $20,000 ongoing Status: Planning phase Underway X Complete J) OTHER CLINICAL SUPPORT EFFICIENCIES 33. This initiative has been abandoned. 34. Goal: Centralize registration to improve the accuracy of patient registration data and improve the patient experience by introducing self electronic registration kiosks. Target: $200,000 Target Timeline: 2011/ /13: $200,000 Risk: This initiative requires capital and resource to implement. Risk Mitigation: This is in the pilot stage and will require further research, task force meetings have commenced and an investment from IT and ongoing support will be required. Investment required: $100,000 restructuring costs and an investment of $100,000 one time and $20,000 ongoing Status: Planning phase X Underway Complete St. Mary s General Hospital Hospital Improvement Plan November 2011 Page 43

47 K) BENCHMARKING EFFICIENCIES 35-39, 41. Goal: Reduce costs through benchmarking at 25%ile- non-direct patient care Target: $540,266 Target Timeline: 2011/ /13: $400, /14 and beyond: $140,266 Risk: none Risk Mitigation: not applicable Investment required: $20,000 ongoing, $50,000 onetime Status: Planning phase X Underway Complete Peer Hospitals used for benchmarking corporate indicators were those community hospitals with cardiac care such as: William Osler, Trillium Health Centre, Southlake Regional Health Centre, Peterborough Regional Health Centre, Sault Area Hospital, Toronto East General Hospital, Rouge Valley Health System and Windsor Regional Hospital. Teaching hospitals were also used for comparisons on specific programs. The following cardiac care teaching hospitals were used as peers for benchmarking programs: Hamilton Health Sciences, Kingston General Hospital, London Health Sciences, Ottawa Heart Institute, Sudbury Regional Hospital, Thunder Bay Regional Health Sciences, St. Michael s Hospital, Sunnybrook Health Science Centre and University Health Network. 40. Goal: Improve conservable bed days by approximately 20 and reduce the length of stay to best quartile where possible. Home First approach to discharge planning commences in the Emergency department, working in collaboration with community partners and coordinated by CCAC discharge planners and GEM nurses. Pursuit of inpatient discharges by 1100 hrs. Review of existing and development of care maps based on best practices and guidelines for top case mix groups (CMGs). Target: $750,000 Target Timeline: 2011/ /13: $187, /14 and beyond: $562,500 Risk: Bed closures need to be aligned with efficient and effective staffing models. Difficult to achieve if not a significant opportunity in a cluster of case mix groups as it requires additional changes in clinical unit configuration and staff educational costs. St. Mary s General Hospital Hospital Improvement Plan November 2011 Page 44

48 Risk Mitigation: Monitoring opportunities. Investment required: none, restructuring costs of $269,231 Status: Planning phase X Underway Complete L) OTHER INITIATIVES CONSIDERED Management looked at a number of additional alternative solutions and for various reasons passed on them. These included: Merging administration and/or outsourcing areas Reducing student training commitments Abandoning case costing project Consolidation or reduction of specific services Management chose to hold and revisit initiatives as they did not meet tests of risk or meet the principles used for the HIP. 8.0 Taking Action from the Plan The figure below (Figure 4, Recovery Plan) illustrates the current and proposed budgets for 2011/12 and the proforma operating statements up to and ending The savings from all initiatives and the investment in opportunities have been included. The assumptions follow the cash adjusted or non-cash items. After listing the revenue and expense assumptions, the cash and working fund position changes are demonstrated, with the cash outflows for capital and inflows from potential sources beyond regular operations and donations from the Foundation. Hospital operations before one-time restructuring costs balance by the end of Working capital is balanced during 2021 or earlier using potential safety nets. The recovery plan is based on implementation of the HIP initiatives at specific points in time. Delays in implementation will result in prolonged deficits and may result in the Hospital failing to meet the plan. The Hospital will endeavor to mitigate any time and savings lost due to delays that within management s control. Should initiatives with savings of great magnitudes be delayed the recovery plan may need to be recast. Management has not recast the forecast. The support of pressure funding for cardiac services would compensate for the delay in implementation of initiatives which required stakeholder engagement. St. Mary s General Hospital Hospital Improvement Plan November 2011 Page 45

49 Figure 4: Recovery Plan St. Mary s General Hospital Hospital Improvement Plan November 2011 Page 46