Diagnostics & Therapeutics Laboratory Medicine

Transcription

1 South East Community Care Access Centre and Hospital Executive Forum (SECHEF) Health Care Tomorrow Hospital Services Diagnostics & Therapeutics Laboratory Medicine June 2016 *Version2-Revised June 9, 2106 Addendum-June 9 th : Please see the attached and note the following change Original Version June 2, Revised Version-June 9th Page 40 Total One Time costs, $ 1,190,200 Total Ongoing costs $500,000 Total One Time costs, $ 1,265,200 Total Ongoing costs $ 420,000

2 Table of Contents 1. Business Need Objectives / Outcome Expected Vision Understanding and Features of the Re-designed System Vision 2020 for South East LHIN Laboratory Medicine Current Model and Operating Environment Organizational Structure Staffing Salary and Supply Costs Microbiology and Histology Work Volumes Leading Practices / Benefits Current Challenges Future State Service Model Service Governance Management and Staffing Structure Organization Structure Leadership Roles / Responsibilities Regional Service Model Opportunities / Projects Stakeholder Impacts Regional Benefits of New Model Goals and Performance Measures Savings Future Frontline Staffing and Costs by Major Business Functions Transformation Costs One Time and Ongoing Costs Labour Adjustments 41 2 P a g e

3 11. Human Resource Plan HR Principles Labour Relations Overview Change Management Client and Staff Engagement Communication Learning Opportunities Ongoing Support Implementation Strategies Risk Assessment and Mitigation...47 Appendices Appendix A: Integration Estimate...49 Appendix B: Leading Practice Benefits..50 Appendix C: Proposed draft Histology changes for future consideration.52 Appendix D: Capital Costs...53 Appendix E: Courier/Transport Requirements..54 Appendix F: Metrics for Consideration 55 This document serves as a strategic business proposal as part of the Health Care Tomorrow Hospital Services project. The recommendations are directional in nature and have been scoped to provide an order-of-magnitude assessment of the opportunity for a shared service model for a Laboratory Services to be deployed regionally for the organizations in the South East LHIN. Note: All quantitative information presented is to provide reasonable order of magnitude estimates of current spend and future opportunities for savings. Canadian Institute of Health (CIHI) MIS guidelines provides some flexibility regarding accounting treatment of some expenditures which leads to some differences in how each organizations accounts for some expenditures and thus comparability issues. 3 P a g e

4 1. 0 Business Need The goal of the Laboratory Medicine working group was to explore consolidating the hospital laboratories in the South East into a Regional Laboratory with the vision of creating a patientfocused, integrated, efficient hospital laboratory service that provides evidence-based, cost effective, quality and timely laboratory testing. Laboratories in all of the hospitals in the region have worked collaboratively over the past two decades to standardize some equipment platforms, to provide continuing staff education, and to collectively meet all accreditation standards. Working together, laboratory services such as the Kingston General Hospital (KGH)/ Queen s University Laboratory Outreach Program have been established and grown to include technical and professional support in the laboratory disciplines of hematology, chemistry, microbiology and pathology. This unique Outreach program was recognized provincially as innovative in the provision of laboratory medicine and provides direct benefits to our patients, staff, and physicians across the region. In the current state, the hospital laboratories in the South East are operating separately, each with their own governance and leadership. Various test menus exist at the six operating laboratory sites for five hospital corporations 1. Core testing is done onsite for all hospital laboratories, and some hospitals in the South East refer a mix of reference level work into KGH and some hospitals also refer work to other private laboratory partners. Economic realities and evolving business practices in the Province, as actioned through funding formulas, continue to drive fiscal challenges for acute-care and specialty hospitals. Until the current year, hospitals and therefore their laboratories have had no inflationary increases over the last four years. Although there were additional funds released in fiscal 2017 by the Province, the increase received was less than one per cent for most hospitals. At the same time, wages for unionized staff and costs for supplies continue to rise. This has been the equivalent of budget reductions in the range of $ million for laboratories in the South East across all seven sites over the last five years. Faced with this reality, our laboratories have reduced their budgets by a $2.5 million through technology improvements and efficiencies to balance budgets. As discussed at the start of the Health Care Tomorrow Hospital Services project, further budget reductions by individual hospitals to meet these economic realities, without impacting services, is felt by many to be unsustainable. Our working group examined the concept of a Regional Laboratory to determine if there are opportunities to further increase efficiencies and value. Our staff and physicians are very resourceful at delivering efficient, effective, quality services, but to continue to deliver high quality services in the current environment we recognize we need to do even more collaboration, work together, innovate, and eliminate as much waste as possible. As has been described in early briefing documents provided to the boards, today, we do not 1 Hospital laboratories are sited as follows: one in Belleville serving all four QHC hospitals, in each of Perth and Smiths Falls (serving PSFDH), one site in Napanee, one site at KGH serving Hotel Dieu Hospital and Providence Care, and one site in Brockville 4 P a g e

5 have regional leadership or governance for our laboratories and while some of the laboratory sites are connected via interfaces between their Laboratory Information Services (LIS), other sites are not able to communicate electronically with their LHIN Laboratory partners. There is a network to move specimens across the region between sites, but it is not optimized and does not ensure timely delivery of samples in the way it would be needed for a more robust level of test sharing. As noted above, there has been ongoing ccollaboration between the hospital laboratories at a voluntary level that has resulted in some standardization of equipment and processes. The members of the Laboratory Medicine working group in both phase 1 and phase 2 of this Health Care Tomorrow Hospital Services project are committed to working together to optimize the delivery of laboratory care to our patients. Strong supported collaborative working relationships across the laboratories of our region will help drive higher quality, further equipment and process standardization, improve clinical consultations, and provide cost efficient service to our patients. We wish to optimize the utilization of existing resources and take advantage of any available economies of scale. We also feel it is important to do this in a manner that every hospital continues to have an ownership and real capacity to influence the development of a Regional Laboratory. Laboratory Medicine is part of the complex clinical services equation that supports patient care across the health system, it cannot be seen as a separate service, but must be seen as an integral part of the hospital services at each site. In 2010 the leadership in Laboratory Medicine in the region recommended a Regional Laboratory be created. It was rejected due to the costs of implementation of a full Laboratory Information System (LIS). Over the last 18 months, a working group of representatives from seven hospitals in the South East LHIN has revisited and further explored the opportunity that a Regional Laboratory system could bring to our patients. The group has refined the regional model and has suggested key enablers to support implementation across the sites. The entire Laboratory Medicine working group has worked hard to create this business plan supporting creation of a Regional Laboratory for consideration by the Hospital Boards in the South East LHIN. All members of the committee, with the exception of one, were able to indicate their support for the directions contained in the document at our last meeting on May 31, The one member who was unable to provide support shared their concern that there was insufficient information at this time to feel comfortable with the direction to consolidate Microbiology Services from four sites to two sites. The working group discussed the concern and reaffirmed the collective commitment to ensure the changes introduced by a Regional Laboratory would need to be tested and evaluated to ensure they were able to address the needs of each hospital site. It was noted that the appropriate laboratory staff and physicians would be engaged to help develop the detailed plans for the proposed microbiology services in the next phase of the project and if there were any quality or services issues that these would need to be addressed before implementation. The working group agreed to reconvene in July to debrief on the outcome of the June Hospital Board meetings and the LHIN s Board Meeting. 5 P a g e

6 2. 0 Objectives / Outcome Expected 2.1 Vision Regional Laboratory Medicine will be an accessible, high performing laboratory medicine program that is a valued clinical partner in the provision of high quality clinical service for patients enabled by: Strong regional accountability, leadership and governance; Laboratory Medicine will be a full partner with all the other clinical services that are offered at each clinical service delivery location; Coordinated capital investment to support further standardization of equipment and effective utilization management; High quality laboratory medicine services through continuous improvement of processes and adherence to best practice (e.g. auto-verification. This will enhance result turnaround time to help with timely clinical decision making). The extent and scope of savings that will be achieved by standardization has not been estimate or quantified in this business case but is seen by the team as being important to consider to our capacity to offset inflation and cost pressures in the upcoming budget years, if we are to sustain our quality and level of services; Utilization management of laboratory testing with a regional focus on test appropriateness and test utilization; Data management on a regional level to support decision making and system optimization; Accessible patient services- opportunities exist for implementation of technology that could allow services to be offered to patients closer to home (e.g. tele-pathology, phone consultations); Enhancement of regional medical/professional support for clinical stakeholders; Opportunity for a shared workforce to maintain competency and enhance recruitment and retention. 2.2 Understanding and Features of the Re-designed System Leadership and related governance will help drive the change in the Regional Laboratory system. Managers and staff working together with common goals that have been clearly defined within a regional context will provide direction, accountability, and a sense of purpose for the new Regional Laboratory Medicine model. Increased connectivity between laboratory sites will facilitate seamless transfer of information 6 P a g e

7 for patient care and leadership and governance is a required foundation to support the formation of a Regional Laboratory. The ideal infrastructure for the laboratories is a single Hospital Information System (HIS) for all South East LHIN sites and a single Laboratory Information System (LIS) linked or impeded into the HIS. However, this does not currently exist and even if approved in the future, would take several years to implement. Fortunately, a solution has developed over the last few years for Laboratory to Laboratory connectivity and this approach will support the regional laboratory in the short term. This approach is now being utilized by Providence Care and LACGH for movement of laboratory information between their sites and KGH. At a minimum this level of integration solution must be in place to support a Regional Laboratory. For example, any consolidation of Microbiology services is dependent on this connectivity. Information from the testing lab will flow into the LIS at the sending lab and patient testing information will be available through the sending site HIS. This design is similar to approaches used by other regional laboratories in the province. Some of the features of the Regional Laboratory Medicine model we would aspire to create can be described as follows, it will: Utilize improved data management to inform system changes (e.g. data mining using currently available tools propagated on a regional level, use data to inform performance metrics and priority of process improvement initiatives and subsequent decisions); Leverage unused capacity and improve access to laboratory medicine services; Drive appropriate test utilization to provide downstream value within the patient care continuum (e.g. support to clinical programs for QBP performance, P4R performance); o Examples of utilization initiatives include unusual test order gating, approaching tests like a drug formulary (need approval to add tests), order set management and elimination of daily testing. Improve collaboration with laboratory professionals and stakeholders to design and define lab orders, test utilization and appropriate tests for referral; Through continuous process improvement, provide cost efficient and cost effective laboratory medicine services thereby improving the quality of services to partner hospitals; Where appropriate, reduce any duplication of laboratory medicine services; Where clinically relevant, improve test turnaround times which will contribute to improved patient experience and outcomes (e.g. use point-of-care testing (POCT) if clinically relevant and cost effective, ER departments will continue to ask for this technology in their clinical area); 7 P a g e

8 Maximize utilization of the existing technology; Adopt new technologies that are available and are based on best practice and business case justification; Open new opportunities and new roles to staff members as we implement new technology and approaches to laboratory utilization; Work with staff to get them to work to full scope of practice; Repatriate reference testing to region where this is efficient and effective insource reference lab tests; Investigate a common reference laboratory to leverage any potential economies of scale for better cost and service options; and Provide a foundation to support future regional clinical collaboration to ensure laboratory medicine services are available across the South East in a consistent and complete service. Quick wins*: Process analysis and improvement will commence immediately and will have benefits but full realization will take several years. Send lymphoma cases to KGH site Start repatriation of easy to do reference testing Initiate region wide capital plan to ensure equipment and contract standardization Launch request for proposal (RFP) for regional document system Increase professional collaboration between microbiology testing sites Automated tracking system for Histology at QHC (capital already approved) and Brockville if capital is approved *implementation plans for quick wins will be checked and tested to ensure we maintain high quality standards, maintain turnaround times and can provide cost savings 8 P a g e

9 2.3 Vision 2020 for South East LHIN Laboratory Medicine (more specifically) The geographic size and service design of our region requires that Regional Laboratory Medicine be distributed across our South East LHIN. There are opportunities to consolidate some laboratory medicine services to optimize services and cost, but most importantly to meet our purpose and goals we need to be located where we are needed to support optimal patient care. Therefore Core Laboratories (chemistry, hematology, transfusion services) will remain at all six sites where they are present today test menus will be optimized at each site and will be designed to support the clinical program services on that site (e.g. need test menu to support ER departments). Some additional details of that we envision for the Regional Laboratory design are as follows: The KGH laboratory site further established as reference Laboratory for reference testing, reference/core service microbiology and reference/core histology; Two Microbiology laboratory sites at KGH site and at QHC Belleville (Selected 2 reference and core testing) 3 ; Microbiology work currently done at Brockville to be sent to KGH site, and some specific tests added to the Brockville site core laboratory; Microbiology work currently done at Smiths Falls to be sent to KGH site, and Smiths Falls will have some specific tests added to core laboratory; Further consultation with clinical microbiology will help develop a standardized protocol for handling of C. difficile testing, blood culture and body fluid testing; Limited Histology changes Histology testing to remain at current sites in KGH, Belleville and Brockville where they are currently processed. The working group has identified an opportunity to consolidate testing for lymphoma cases from Belleville and Brockville to KGH site. If this is successful further opportunities for histology sites to collaborate will be explored in the future. For example we have discussed future histology service models such as Pathology grossing and slide interpretation/consultation done on one site with histology specimen processing work done at another. We will also explore further consolidation of special stains/immunohistochemistry at KGH site for the other two sites; Standardization of equipment, technical support, and new technology is expected to enable quality patient care closer to home; Maximize use and capacity of existing technology - we have equipment today that is 2 Carefully and deliberately selected as most appropriate site for that time, recognizing that these site locations could change in the future 3 Process for planning will bring together experts in impacted areas to ensure that high quality standards are maintained 9 P a g e

10 underutilized and by extending some hours of operation we could reduce overtime on some of the capital investments required. Each opportunity will be subjected to business case analysis; Appropriate investment will occur to optimize the system and improve quality and efficiency e.g. specimen transport system will be improved given the opportunity we see in developing a region wide service with scale to attract a professional provider of the service; Development of a single reference lab provider for South East LHIN esoteric/specialty level testing will be evaluated to determine if it provides cost savings by utilize existing capacity and will retain resources within the LHIN; Repatriate appropriate testing to KGH reference site if sufficient volume, if is cost effective and improves test turnaround time for regional labs. We see several tests that will be brought back into the region as result of this opportunity and again some cost savings will result. 10 P a g e

11 3.0 Current Model and Operating Environment Today we have six hospital based laboratories in our South East LHIN region helping meet the needs of our patients and health care staff. To keep up with increasing demand on Laboratory Medicine, we also find ourselves in the position of referring laboratory work outside the region or to private organizations. We are now exploring what a Regional Laboratory Medicine model would look like, and how to approach executing on the proposed model, and what timeframes and investments would be necessary. As noted above, there is strong collaboration between our hospital laboratories already, but the working group is looking at ways of increasing connectivity, standardization, process improvement, and operating structures to further improve services for patients and clients across the region. Based on our review of models that exist and our own past experience we are proposing that a Regional Laboratory for the South East is the best solution to meet our needs. 3.1 Organizational Structure 11 P a g e

12 Current Test Volumes by Site Site QHC Napanee (LACGH) PSFDH KGH Brockville (BGH) Test Volumes (for all tests performed in house) 684, , , million 379,000 (Data from LHIN document phase 1 HCT fiscal 2014) Tests done on site. * Core Laboratory Services include Chemistry, Hematology, Transfusion Services (services available 24/7 all sites). Some microbiology specimens/tests such as blood cultures, gram stains and fluids are also performed in core laboratories after regular hours of operation. 12 P a g e

13 Service level Services with Hours of Operation KGH HDH BGH LACGH Prov. Care PSFDH QC Tertiary care academic teaching Laboratory Limited POCT, GI Lab Service agreement with KGH Core lab with: -Micro - Histology Core Lab Blood cultures on site Histopathology and microbiology referred Limited POCT on site Service agreement with KGH 2 sites -Perth -Smiths Falls main site with Micro Histo pathology to KGH, Microbiology at SF 4 sites -Bellevillecentral lab with Micro and Histology -Bancroft- POCT -Picton- POCT -Trenton- POCT Ref lab HICL other KGH GD KGH KGH KGH GD Lab hours 24/7 24/7 24/7 24/7 24/7 (Perth oncall) Micro. 7 days 7 days BC only 5-6 days 7 days Histopathology 5 days 5 days 5 days Cyto 5 days Refer to Gamma Refer to KGH Note: KGH: Specialty testing includes-cytogenetics, Molecular Genetics, Immunology 13 P a g e

14 3.2 Staffing (Current state (March 2015), does not include Pathologist MD/Clinical Lab PhD positions) 4 4 Staffing in the above table is reflective of phase 1 data gathering for fiscal Staffing numbers fluctuate over time. Please consider this table for comparative purposes only. Future detailed planning will use GL financial data to ensure site accuracy around staffing complement. 14 P a g e

15 3.3 Salary and Supply Costs to All Sites to The table below outlines all the total costs for the laboratories in the region. Individual hospital data is available. The table is provided to share scale and scope of the laboratory services in the region, and a brief explanation can be found below the table. FY 2011/12 FY 2012/13 FY 2013/14 FY 2014/15 Gross Expenses $42,587,724 $46,767,255 $46,954,857 $45,766, LAB Administration $1,353,346 $1,062,342 $563,800 $474, LAB Pre/Post Analysis $302,898 $768,834 $1,149,074 $1,414, LAB Clinical Chemistry $6,410,761 $6,430,416 $7,318,516 $7,373, LAB Clinical Hematology $2,843,222 $3,049,035 $3,423,722 $3,261, LAB Transfusion Medicine $1,679,209 $1,606,228 $1,740,898 $1,862, LAB Anatomical Pathology $8,253,306 $10,685,047 $9,529,615 $8,851, LAB Cytopathology $506,759 $574,401 $556,138 $584, LAB Clinical Microbiology $3,407,936 $3,548,373 $3,506,646 $3,273, LAB Immunology $1,005,672 $1,140,674 $1,362,569 $1,286, LAB Cytogenetics $773,716 $762,785 $837,060 $880, LAB Molecular Genetics $906,664 $1,120,553 $1,151,903 $1,368, LAB Combined/Muli Functions (Core Lab) $15,144,235 $16,018,567 $15,814,916 $15,135,725 Income -$7,428,526 -$10,214,458 -$10,285,434 -$9,531, LAB Administration -$8,775 -$21,823 -$20,066 -$14, LAB Pre/Post Analysis -$294,016 -$402,526 -$498,631 -$548, LAB Clinical Chemistry -$1,431,515 -$1,688,751 -$2,488,741 -$2,273, LAB Clinical Hematology -$320,380 -$350,511 -$576,989 -$555, LAB Transfusion Medicine -$137,665 -$113,119 -$120,150 -$114, P a g e

16 LAB Anatomical Pathology -$3,793,627 -$5,985,833 -$4,962,219 -$4,083, LAB Cytopathology -$80,574 -$102,458 -$119,274 -$122, LAB Clinical Microbiology -$321,394 -$396,589 -$426,025 -$385, LAB Immunology -$195,770 -$228,732 -$332,596 -$314, LAB Cytogenetics -$14,980 -$14,431 -$2,634 -$2, LAB Molecular Genetics -$17,373 -$23,065 -$21,798 -$70, LAB Combined/Multi Functions (Core Lab) -$812,457 -$886,620 -$716,311 -$1,046,520 Net Expenses $35,159,198 $36,552,797 $36,669,423 $36,235,565 (Data source LHIN data repository) Expenses at all sites have remained stable across four years to The combined rate of inflation over the four years is 8.41 per cent. Wage increases and vendor supply increases have been substantial over the period and have kept pace with inflation. Funding to hospitals has not seen any inflationary increases in this same period. The laboratories have absorbed approximately $1.5 2 million in inflationary pressure over this period. In addition, in 14-15, and budgeted 16-17, QHC and KGH have realized savings of over $2 million through changes that drive efficiency and system optimization. The smaller hospital laboratories budgets have remained stable but have also absorbed inflationary increases. The 2009 Health Tech report predicted that without major changes, the lab budgets of the South East LHIN hospitals would grow to $51 million by Due to careful management, improvements in efficiencies and strong continued efforts to balance budgets this has not yet occurred. 3.4 Microbiology and Histology Work Volumes Two of the areas often explored when regional laboratories are created or services have been consolidated are Microbiology and Histology. Our region similarly has seen consolidation of these services and previous reports done on Regional Laboratory services for our region have identified these areas as well. Moving forward, the working group is committed to evaluating our future impact on the system to ensure that changes occurring from consolidation maintain or exceed our high quality standards and turnaround times. The distribution of the tests helped us develop our model and look at ways to accommodate each site via the two Microbiology Labs plus expanded Core testing. We also settled on retaining 16 P a g e

17 the Histology at three sites in favour of developing a model that will ensure we create a service that will support the evolving clinical system that is yet to be developed. In the mean time we can build further cooperation and collaboration among our sites. Note: This is SPECIMENS performed in house. Data gathered during phase 2 from site managers. SE LHIN Microbiology specimen volumes KGH* QHC PSFDH BGH LACGH** Total Blood cultures Urine cultures MRSA screen VRE/ESBL Fluid culture (inc CSF) Throat culture Wounds superficial culture Sputum culture (inc Bronch) C difficile Vaginal exam/culture Anaerobic culture Stool culture Group B Strep culture Misc cultures Totals % of Total P a g e

18 Notes: * There is additional work done at KGH that is not reflected in these totals (mycology, molecular, virology) ** LACGH positive blood cultures are sent to KGH Volumes reflected by specimen volumes do not reflect complexity and related workload SE LHIN Histology volumes KGH QHC PSFDH BGH LACGH Total Surgical Cases XX* 7148 XX* Specimens Cytology (regional volume) XX* XX* XX* XX* # Blocks IHC tests XX* Special stains Frozen sections intraoperative Autopsies Consults % of Total by Cases Notes: XX* specimens sent to KGH, volumes included in KGH volumes KGH already set up as reference lab for PSFDH and LACGH 18 P a g e

19 3.5 Leading Practices / Benefits The following is a list of leading practices that have been or are being implemented in the sites across the South East LHIN. Appendix A provides a full description of each of these initiatives. We have already established some consolidation of select laboratory services in the south east, including: QHC Lab Consolidation has created a sub -region within our South East LHIN; Lennox and Addington Hospital sends microbiology and histo-pathology work to KGH; Perth &Smiths Falls District Hospital sends histo-pathology to KGH; Hotel Dieu Hospital and Providence Care send their laboratory work to KGH. Other best practice adopted or developed at some of the regional hospitals in the region includes: Standardization of coagulation instrumentation and related processes and standards of practice (SOP) development (e.g. across all sites); POCT Technology implementation (e.g. QHC); Decision support tools (e.g. data mining capabilities at QHC); Microbiology MALDI_TOF technology (e.g. KGH and QHC); Microbiology equipment standardization (e.g. QHC, KGH, PSFH, Brockville); Specimen tracking for histo-pathology (e.g. KGH); Reduction of specimen collection errors (e.g. KGH); Chemistry automation (e.g. KGH large track system); Transfusion Safety Officer (e.g. KGH); Consolidated immunohistochemistry testing (e.g. KGH); Molecular testing to support infectious disease service and infection control (e.g. QHC and KGH); Auto-verification tools (e.g. KGH and QHC). Each of these best practices offer opportunities to further leverage and bring benefit to the region. 19 P a g e

20 3.6 Current Challenges Service Delivery challenges (order is not reflective of importance): Fiscal challenges are ongoing and it appears funding shortfalls will occur in both the near and distant future; The limited transportation system across the region has not been optimized for a timely or efficient Regional Laboratory system; There is limited IT connectivity between sites with limited existing interfaces between the numerous LIS systems in use within the region this limits data management between sites and can cause transcription errors if information must be entered manually into the system; There is no specimen tracking technology across most sites in the region. This is especially important for histology and has become an expected best practice for all laboratory services. This will be a priority for the working group to resolve; There is no common document management system that can be used across the region this is essential for a Regional Laboratory program or any other regional service; There is no capital planning on a regional level. Funding streams are varied by corporation (hospital vs foundation) with limited available funds. This further restricts equipment standardization and realizing possible financial savings from bulk purchase(equipment standardization was successful in the mid-2000 s timeframe but has not been followed until recently for hematology when standardization was followed for coagulation instrumentation); SOP standardization has not been done due to limited equipment standardization and limited incentive; Need stronger regionally shared Clinical / Medical advisory leads to support standardization, quality improvement, and best practices; There is no standard approach for Medical /technical consultation at each site. This is a big issue to help maintain quality. OTN could be explored to facilitate this need; Funding streams differ between organizations; Clinical services offered differ between organizations; There is no common data management system; There is no common reference laboratory; Need to maximize use of POCT technology where cost effective and clinically required; 20 P a g e

21 There is no regional level of HR planning for recruitment, retention, and staff sharing; There are multiple collective agreements across the region, with varying compensation clauses for things like call back. These could be standardized in the region; As clinical services expand there is little flexibility in the system to absorb any additional work. Many of the above challenges would need to be addressed by the new leadership and governance and the lack thereof has been a major hurdle to moving forward with any of the solutions to these problems. 21 P a g e

22 4.0 Proposed Future State 4.1 Service Model Core Laboratory services (chemistry, hematology, blood transfusion services) will remain at QHC Belleville, KGH site, Perth and Smiths Falls hospitals (PSFDH), Lennox and Addington hospital (LACGH) and Brockville hospital (BGH). Microbiology services will be consolidated and specimens will move from Brockville and Perth and Smiths Falls hospitals to KGH site. Some microbiology tests that are performed 24/7 will be maintained in the core laboratory sites at PSFDH and BGH. Histology services will continue to be provided in Kingston, Belleville and Brockville. The Histology team will look at quick win projects including sending lymphoma cases to KGH from BGH and QHC. An extensive engagement will also take place with medical and technical staff to determine the possibility of areas that could be consolidated in the future. We will pilot any proposed changes at a single site to ensure they will not negatively impact patient care or the availability of laboratory professionals to provide support to the clinical services. Reference laboratory services to be consolidated and tests repatriated as appropriate. Some tests that are currently sent to private laboratories could be done on an extended test menu at the KGH site. This would improve turnaround time and save money. Where private laboratories provide a better, more cost effective solution a coordinated regional wide agreement would be negotiated to improve services for all sites. 22 P a g e

23 The test model below demonstrates that there is a hierarchy of options to be considered by the Regional Laboratory as it looks at solutions to optimizing services, and central to that equation is that the patient needs are met. 23 P a g e

24 Benefits: Ensures patients are well served by doing tests they need locally and in a timely manner; Provides cost savings through consolidation of low volume high cost at referral site; Keeps funding allocated for laboratory services within the South East LHIN; Improves efficiencies through removal of unnecessary cost and duplicate testing infrastructure. 4.2 Service Governance Service governance for the Shared Service Organization is being developed by another working group. It is our understanding that ultimately the Laboratory management team will report to a Vice President within the Shared Service Organization. The SSO will report to a SSO Board which will have accountability to the Hospital Boards. We also understand there will be a Clinical Counsel within the SSO that will support the SSO Governance and Leadership, including providing hospital representation to interact and guide Laboratory Medicine and other SSO services. We also envision having a Laboratory Advisory Council that will provide more direct advice regarding issues related to laboratory best practices, service performance etc., which will be populated by hospital and expert members. Further information on service governance will be provided as it is finalized and approved. 24 P a g e

25 5.0 Management and Staffing Structure 5.1 Organization Structure The structure we envision for the Regional Laboratory is similar to other Regional Laboratory structures and also meets the legislated requirements. We have added in a Regional Quality / Utilization & Safety Coordinator and a Business Development & LIS Coordinator, both of these roles are part of other leadership roles today but are acknowledged by all of us to be underdeveloped as a result. Dedicating positions and time to these areas is seen as one of the major benefits a Regional Laboratory can bring to the region. We have not quantified the benefits these roles will bring to the region, nor the risk reduction they will contribute to, but feel strongly that they must be part of the new design. It should also be noted that the Medical Director, while accountable to the Vice President, will also have responsibilities to support and work with academic and clinical leadership (e.g. Chief of Staff). 25 P a g e

26 5.2 Leadership Roles / Responsibilities As is the current laboratory approach in the region, the Leadership structure will continue to be closely aligned to the laboratory medical leads. The structure will support the regional shared services laboratory model. Some of the attributes we are committed to designing into the service are the following: All sites will have supervisory support and a local leadership presence in hospital; Roles will be standardized across all sites with clear role descriptions and related duties/accountabilities; Span of control and geographical limitations will be taken into consideration; There will be initial investment in staffing with flexibility to change and optimize the model as the shared services model continues to mature; Success of implementation of the regional lab is dependent on knowledgeable and highly skilled leaders in each laboratory discipline; Each hospital laboratory will have one senior or charge technologist on site who will be supported by their respective Site Manager; Site Managers, Regional Managers and Coordinators will report to the Regional Operational Director; Regional Operational Director works closely with the Regional Medical Director who jointly report to the Vice President who works within the structure of the shared service organization. Regional leadership model proposed includes: Regional Operational Director; Regional Medical Director; Hospital based Chiefs of Laboratory Medicine and Specialty Heads; 5 Regional Managers (Discipline Specific) and 3 Site Managers; 2 Regional Coordinators; Represents transition needs, would likely change over time. 26 P a g e

27 Proposed Leadership Model Leadership position Current budgeted FTE Future FTE Beyond 2020 Director 1.7 (4 people) 1 (several directors are responsible for areas other than lab) Regional Discipline Managers/site managers 7 8 May adjust the # manager positions once Regional Laboratory matures Coordinators As above Total 8 11 TBD Change +3 The increase in leadership is required in order to deal with the change management workload and to help drive system changes through leadership. The managers will have a regional level of responsibility and will be expected to travel to all sites to ensure knowledge and understanding of issues, to ensure a high level of visibility and to ensure engagement with staff and other stakeholders. We anticipate a review of the structure will be ongoing, but expect it will undergo a full review in 2020, and if the transition is complete the roles should be reviewed again. Proposed Staff Changes Staff level positions May reduce the # senior/charge positions once Regional Laboratory matures Change P a g e

28 Costing for Proposed Leadership Model Position Current state Vision 2020 Reduction Addition Cost savings or additions Directors 1.7 FTE 4 People $80,000 Managers (note use existing people, positions are upgraded) $100,000 Coordinators $170,000 Staff positions $504,000 Savings -$314,000 As Regional Laboratory matures, leadership structure will be further streamlined; Charge tech, senior tech positions are not required for areas where work is consolidated, e.g. microbiology; Staff positions are streamlined with technology and workflow efficiencies. Proposed Leadership model provides the following benefits: Managers (non-union) have several staff reporting to them; Coordinators (non-union) have minimal staff reporting to them; Both roles have regional level responsibility; Quality and Utilization Coordinator- provide leadership and direction for quality management activities, help drive standardization with corresponding quality and efficiency, and help coordinate utilization initiatives; Helps smaller sites with technical and medical expertise (e.g. service chief for hematology helped coordinate and provided advice to coagulation standardization to meet laboratory accreditation requirements); Helps drive best practice across all South East LHIN sites; 28 P a g e

29 Dedicated manager for clinical lab areas, with regional level responsibilities who work closely with laboratory medical leads. 29 P a g e

30 6.0 Regional Service Model 6.1 Opportunities / Projects Project Comments Implement leadership and governance structure and clinical council structure to support integration of regional clinical laboratory Develop plan for either single or multiple employer model Specimen transport/courier system developed and implemented Includes specimen tracking so specimen is instrument ready Must meet current requirements for specimen transport including biosafety, specimen integrity, timeliness of transportation, etc Each hospital area that currently has a regional network (e.g. QHC) may not be impacted if scope of new courier routes does not include this current network. Must ensure specimen transport meets current standards for transporting biologically fragile samples within current turnaround times to ensure specimen integrity and safety and quality for required patient care needs. Includes pathology tracking capabilities from sending site, to testing site back to reporting site IT connectivity to support communication of work moved between sites will be developed and implemented. Consolidation of microbiology services 1. Send microbiology samples from Brockville to be processed at KGH site 2. Send microbiology samples from PSFDH to be processed at KGH site A HIS that includes a LIS is preferred, or a single LIS would be next on the list. Preferred for the future and part of IT Working Group looking at HIS offered for the future Microbiology samples will continue to be collected and transported to QHC microbiology laboratory. Reference level testing will be referred to KGH site and or QHC site or Public Health Laboratories as best meets the need of patients served and laboratory capacity to provide the service. 3. Microbiology critical work to be done on site at BGH and PSFDH. (e.g. blood cultures, body fluids, gram stains) Pilot Histology changes in practice Set up an engagement with medical and technical staff to further explore possible opportunities for Histology consolidation. Send Lymphoma cases to KGH as quick win. Any test sharing for Histology services deferred until further medical and technical staff engagement has occurred. Will require participation and support of clinicians using the services as well as MAC of the respective hospitals Consolidation of Reference Laboratory testing out to external vender across all South East LHIN Labs This will require a future RFI and RFP. 30 P a g e

31 Equipment standardization/regional level capital planning and related technology updating (and corresponding funding plan for capital purchases and related foundation stakeholder involvement) In some cases equipment may not be standardized if volume does not justify larger equipment but test must be done on site. Contract management and standardization Auto-verification development The focus here is on high volume chemistry and hematology testing, not lower volume and text based testing such as in microbiology Document control and SOP standardization Develop POCT strategic plan for South East LHIN laboratories. (consolidation/ connectivity and technology development) HR labour relations planning Communications (ongoing) Data management tools to support decision making on a regional level Quality management development Clinical/Medical level support Quality metrics and development (an initial draft has been created with future lab advisory council to advise on this) Lab costing model* (this is in development) Laboratory Costing Model The pricing of laboratory tests and services for the Regional Laboratory is being built to deliver on our desire to provide an efficient, effective, and quality service that is focused on the needs of our patients and their care teams. As we developed the approach the following principles helped guide our work. It must be: transparent and understandable; easy to implement and maintain; approach is consistently applied; reflect the true cost of the services (full cost); costs are fairly distributed to hospitals. 31 P a g e

32 It is important that the pricing and the resulting information provided to hospitals and the laboratory supports a sustainable model that we can continue to improve and adapt, it must provide an accurate and true reflection of costs so hospitals and laboratory can make informed decisions. The model will capture the laboratory costs at each laboratory location (the six sites 5 ) in cost centres representing the laboratory services on site, and we will have at least one corporate cost centre for region. At each of the six sites we will each capture the direct costs required to operate the site: labour, supply costs, utilities, etc. in its cost centres. The corporate cost centre will contain all costs that are shared and support the Regional Laboratory s six sites, for example, the cost of the Administrative Director (shared leadership); consider these shared overhead costs that support all locations. These overhead costs will be allocated to the laboratory location cost centres on an ability to bear (e.g. relative size (total direct costs) of each laboratory). It is from these laboratory site cost centres that the seven hospitals have cost shares / prices will be determined. We have reviewed approaches used by other regional laboratories to allocate their costs to hospitals. All the models we saw are variations based on measures of consumption; tests ordered and services used. The most cost effective and efficient approach is to use weighted laboratory test volumes to distribute the cost. In the past our region has often used LMS pricing, or a derivative thereof, to charge for services rendered. The LMS prices are out of date and in many cases significantly exceed cost. The utilization of weighted test volumes and actual costs is simple and efficient for dealing with pricing of individual tests, and without time consuming costly / pricing studies, there are limited other options. We tested a model utilizing a bottom up pricing of actual tests, and found it time consuming and costly to complete. It requires significant manpower and must be updated on a regular basis as practices change; very detailed. Given we are looking at allocating the full cost of a laboratory site in our regional model we do not need individual test costs, but can utilize total cost, which we have. We do need a weighting for this model. The utilization of LMS weighted test volumes, applied consistently across the region, becomes a viable option. Even given the fact our Ministry of Health and Long Term Care is less than timely on updating the LMS weights for individual test, the consistent application of LMS weights across our hospitals makes the approach a fair and viable method for weighting our test volumes provided by each laboratory. With this model we will be able to distribute costs consumed by each cost centre to the benefiting hospitals that received the services. We are comfortable that the LMS weights provide an accurate distribution of cost and have tested this fact between two sites with F2015/16 data. As noted above, we will accumulate costs of producing tests at each cost centre location, including the share of overhead costs. We will have total LMS weighted test volume by each location, by requesting hospital, and therefore will allocate the costs of a laboratory site to the benefiting hospitals. All the hospitals in the region will be treated the same using the same 5 The current hospital laboratories are Belleville (QHC site), Kingston (KGH site), Brockville (BGH), Napanee (LACGH), Perth, and Smiths Falls (PSFDH). All these sites are retained as Operating Laboratories in the Regional Laboratory. 32 P a g e

33 pricing methodology. Also to be taken into consideration will be the overhead costs of the shared services organization and its administrative functions and costs that would attribute to laboratory medicine. Transportation costs are a reality of laboratory services where some tests must be moved from hospital to the laboratory site that will process the work. These costs will be captured and charged to the requesting hospital as is the case today for referred out work. These costs are of course part of the overall service equation and are considered as the regional laboratory works to optimize services across the region to ensure timely and efficient delivery of services to the patients and clinicians. Transportation s impact on cost of service and timing of services would be considered before any test location decisions are made. In Phase 3 of HCT our plan is to build and test this methodology to be able to provide hospital specific pro-forma financial statements to reflect the impact of the plans on each hospital utilizing this pricing model. We do know that some of the accounting infrastructure (i.e. cost centres) to fully support this model would need to be built over the next year as several of our hospitals have limited structure in place to fully implement right now. However, we do see capacity to implement the model as the Regional Laboratory evolves. We do already collect the test data and LMS weights are accessible, which are the key building blocks of this approach. 33 P a g e

34 Anticipated Phasing Staging the projects is key to success implementation. We will learn and adjust as we move forward through the stages. Phase 3 Health Care Tomorrow project: Recruit key people to lead a transition team, and begin the process of filling the top positions of the new organizational structure. Create a detailed implementation plan and methodology to operationalize the Regional Laboratory. Year 1: Build Foundational project components IT and courier/transport network improvements, governance and leadership team development; and commence work on standardization and reference laboratory test repatriation. Work on quick win projects. Year 2: Continue standardization and reference Laboratory test consolidation and repatriation; and commence microbiology consolidation, limited pilot testing of histology/pathology opportunities, and POCT system development through regional electronic connectivity. Year 3: Complete microbiology consolidation and continue pilot testing of histology/pathology practices. Year 4: Create a new strategic plan for the Regional Laboratory to guide the next four years of development. Activities that can be done in parallel are: Costing model development; Clinical Advisory Committee development; Capital planning/standardization, HR issues, communication issue. 34 P a g e

35 Proposed service changes and related staffing Microbiology Microbiology changes including staffing LACGH No change already sending to KGH Blood cultures remain on site. All positive samples are sent to KGH. PSFDH BGH QHC Send microbiology work to KGH site Current staffing: 1.3 MLT FTE 0.53 MLA FTE Staffing changes: 0.77 MLT FTE reduction 0.53 MLA FTE reduction Send microbiology work to KGH site Current staffing: 3.0 MLT Staffing changes: 3.0 MLT reduction No changes in microbiology Blood cultures remain on site CSF and other fluids remain on site Blood cultures remain on site CSF and fluids remain on site Savings Staffing $306,600 Supplies and service agreements $100,000 Total: $406,600 Proposed Service Changes - Histology Histology changes have been put on hold at this stage pending further engagement with medical and operational staff. Key quick wins have been identified (e.g. Sending lymphoma cases to KGH) and these will be implemented in the first phase but still require detail work by the professionals involved in the work. Appendix C outlines potential service models for histology that could be considered in the future and for the team to review. 6.2 Stakeholder Impacts Good for our client services (provides customer service to participating hospitals and their laboratory users); 35 P a g e

36 Sustainable service - Sustainable microbiology service with reference level support; Sustainable histology services with shared medical level support; Patient does not have to travel; specimen can travel; Improved courier network to facilitate specimen and supply transport across the region; All sites connected through point to point interfaces; Cost savings for reagents and other supplies; Regional quality management approach; Shared SOPS and standardized equipment; Technology advancements not otherwise possible due to low volume; Better medical consultation. 36 P a g e

37 7.0 Regional Benefits of New Model Client services (provides customer service to participating hospitals and their laboratory users); Sustainable microbiology service with reference level support; Sustainable histology services with shared medical level support; Patient does not have to travel; specimen can travel; Improved courier network to facilitate specimen and supply transport across the region; All sites connected through point to point interfaces; Cost savings for reagents and other supplies; Regional quality management approach; Shared SOPS and standardized equipment; Technology advancements not otherwise possible due to low volume; Better medical consultation. 37 P a g e

38 8.0 Goals and Performance Measures The following areas are examples of performance measures that can be considered for the regional service delivery model that is proposed. The Laboratory Advisory council will consider which KPIs are essential to include as part of the quality management program. Goals for the Regional Laboratory Medicine program will be established at the operational, advisory council and governance levels. Appendix F provides additional examples of metrics that could be considered. Goals Description Measure Quality-Safety Customer engagement Service-Access Quality Stakeholders surveys (e.g. physicians and patients that use lab services) Test turnaround times for tests that are impacted by service changes (microbiology tests, histology tests e.g. CSF cell counts CSF Gram stain CSF Cultures Blood culture positive report Pathology report Unlabeled and mislabeled samples rates Specimen transport errors Blood culture utilization rate 3 surveys in calendar year as changes are being made (note as changes are being implemented, satisfactions levels may be lower until processes are stabilized) Check current TAT Check current TAT Check current TAT Check current state # specimen bags returned with specimens (should be returned empty) blood cultures per 1000 ICU Patient-days Learning and development Business development Blood culture contamination rate Training and development on key competencies Activity based costing <3% Metric to be established Costing model to be established 38 P a g e

39 9.0 Savings 9.1. Future Frontline Staffing and Costs by Major Business Functions Overall Savings Microbiology $406,000 Histology $50,000 (target that shows commitment to make histology more efficient. Further engagement with medical and operational staff is required) Leadership $314,000 Standardization and contract management $100,000 Reference laboratory repatriation and contract consolidation* $160,000 Total $1,030,000 Deduct operating requirements ongoing ( transport system/travel ) $420,000 (includes needs for beyond 2020, would require full RFI and RFP) Annual savings $610,000 ROI A little over 2 years to realize savings on the one-time investment of 1.3 M (if histology proceeds with investigated level of consolidation and this results in savings, the ROI will be shorter) *Note: Reference laboratory approx. 1.3 M estimated to save 20%. Estimated $160,000 (estimated through consolidation, test repatriation to new SELHIN Regional Laboratory and single reference lab provider. This is a very large project and will require time and effort to fully investigate current spending, and to prepare a RFI/RFP). 39 P a g e

40 10.0 Transformation Costs One Time and Ongoing Costs Item One time cost Ongoing cost Transition Team $300,000 IT integration $590,200 TBD Incudes regional level document control software Specimen transport system improvements $400,000 Implementation support $50,000 Additional travel costs to support Regional Laboratory $20,000 LEAN resource $75,000 Subtotal $1,015,200 $420,000 Contingency 25% $250,000 Total $1,265,200 $420,000 Note: Project management support will be required from the Health Care Tomorrow project office. Suggest this resource has a lab background. Future technology development for consideration: Expansion of histology tracking system between sites if histology consolidation occurs in the future; Urine screening and transport; Semi-automated microbiology system for microbiology; Explore technology for incubating blood cultures on site at QHC collection sites; Explore methods for pre-incubation of blood cultures; Tele-medicine including tele-pathology and tele-microbiology; Facility development; Labels produced at bedside for specimen collection; Inventory management control system; 40 P a g e

41 Voice recognition. As a Regional Laboratory we see having the scale to adapt some of these new technologies more quickly and therefore being about to benefit from the efficiency and improvements more quickly Labour Adjustments Labour adjustment is very difficult to estimate until final staff counts are established, a full HR review is done and potential for retirement, early retirement, and other related severances are determined and costed. An estimated range of potential costs for severance are $300,000-$800,000 (this is very difficult to estimate at this time and is only provided to remind stakeholders of the need to budget for these costs. We see the changes in the laboratory being evolution, not revolution and therefore see attrition as a major part of labour changes. Sites are already starting to use temporary positions to fill roles to help mitigate the impact on staff and leadership. 41 P a g e

42 11.0 Human Resource Plan 11.1 HR Principles Open and Transparent; Communicate often; Keep union leadership well informed; Work towards single employer model over time; It will likely be a hybrid ; Leadership should be hired as early as possible once project is approved to proceed; 11 collective agreements complex LR environment; Need dedicated HR consultant for laboratory project; 3 unions Labour Relations Overview Governed by employment standards act and common law; Governed by Public Sector Labour Relations Transition Act (PSLRTA); Governed by collective agreement language related to employment stability; Avoid implications related to constructive dismissal; Open and transparent process; Where possible keep transition period as short as possible; o o Impact on morale; Can lose employees due to uncertainty. 42 P a g e

43 12.0 Change Management We understand that most transformation projects fail to meet expectations. 70% of merger/integration initiatives do not live up to the goals. We also understand that: % of re-engineering projects fail in business re-engineering projects; In IT only 9% of large IT projects are on time and on budget. Even then only 42% of promised features are actually delivered; It is hard work to prevent distinctive and siloed work environments and culture; In a multi union environment, single employer can help by minimizing various union locals and differences in collective agreements; Need commitment from HR, Finance and IT to ensure the regional lab success as we rely on these services and until there are regional services of this nature, one of the hospitals will need to support us; Significant process, resource and facility variation has been noted to leads to bigger change management issues 3 unions, 11 collective agreements; To help mitigate we need: o o o o o Strong regional leadership; Clear role clarity; Need strong change management plan to mitigate Lack of trust/fear of losing role identity and control ( Phase 3 to develop); Need team to build consistent and clear work flow practices; Consider succession planning as we develop new structures, particularly as current laboratory staff members are able to retire within 10 years. Staff & Culture From site specific to integrated/coordinated/regional care; Foster a sense of purpose for the shared service team; Establish a regional identity and team while maintaining a connection to the individual hospitals and clinical staff. 43 P a g e

44 Customer & Service Governance From provider/customer centric to patient focused; From local lab physician service to regional medical service; Partner with clinical staff to enable change associated with introduction of regional standards. Strategy & Governance Transition from service provider to strategic partner; Lab governance as a strategic component of the overall hospital strategy(s); Interim strategy for active projects and planned projects Client and Staff Engagement An overall engagement plan for Phase 2 of the Health Care Tomorrow Hospital Services project created opportunities for the working group to gather input from stakeholders from October 2015 and June 2016, to inform the planning and decision-making process. This ongoing engagement helped to support the client and staff engagement process by involving stakeholders as early as possible in the future-state design. This process will continue into Phase 3, Implementation Planning of the project, to help advise how the Regional Laboratory will evolve and build on the existing strengths of each of the hospital sites. The following engagement activities informed the development of the business cases/ models: a Regional Patient Advisory Committee was provided updates by SECHEF representatives which helped ensure the patient/family voice was part of the HCT planning process; Hospital/organization(s) each kept their leadership informed and involved in the Hospital Services project through their regular leader meetings; A survey to all regional staff and physician in November 2015 had more than 900 respondents; Department meetings Local hospital leaders provided face-to-face updates on the current thinking of the Laboratory Medicine working group to all available staff in this area in April; Summaries of the draft proposed future state and compelling case for change were shared with all regional staff and physicians in April An open-ended survey tool was included to allow input, with 633 people responding and 74 specifically on the Laboratory Medicine working group summary; 44 P a g e

45 The working group solicited input in each of the hospitals in May 2016 from physician and staff representatives to gather input on the proposed future state, as the users/internal clients of our service; Three regional forums for physicians were held during late May/early June 2016 to invite physician feedback into the key concepts proposed in this and other business cases; Union leaders have been updated through written summaries and face-to-face meetings. The stakeholder input that was compiled from the above engagement activities has been reviewed and discussed at working group meetings in order to inform the development of this business case Communication A communications plan will be developed consistent with the communications principles of Health Care Tomorrow: Hospital Services i.e. to provide clear, regular and timely communication that is respectful of those most affected or most likely affected by proposed changes. A specific communications strategy will be required to support Laboratory Medicine Services following approval by the Boards to help ensure clarity about what has been approved and next steps. Similarly, communications strategies will support implementation planning and delivery. This will include communication and engagement with stakeholder groups and unions Learning Opportunities As noted in the introduction, the ADKAR model has been used throughout the Health Care Tomorrow: Hospital Services project to manage change. It will be important to ensure that there is solid knowledge of the skills required to implement this business case. Many users will require coaching and training to adopt standardized approaches, and/or access staff who now may be located in different areas and create understanding on how to work with new positions created and a new management structure. Similarly, staff who currently support only one site may, in future, require orientation to and familiarization with new sites in order to support newly expanded roles. The learning opportunities and needs will be more fully considered as part of implementation planning Ongoing Support As in prior phases of Health Care Tomorrow: Hospital Services, leaders will have an important role in coaching and supporting staff. The need for ongoing support will be carefully considered by the working group, in consultation with the HR Advisory Group and the Change Management Steering Committee as part of implementation planning. 45 P a g e

46 13. Implementation Strategies The reality of Laboratory Medicine being a wave 1 initiative raises the question as to how to govern and oversee the development of the new regional operation before the new Shared Service Organization (SSO) is ready. Concerns have been raised about the impact on cost of operations of the Regional Laboratory if it has to carry the cost of SSO operation before other services are included, and in respect the preparedness of the SSO to oversee a clinical operation. An alternative solution that has been discussed, if the SSO is not ready, is that the Regional Laboratory be overseen and operated by an existing hospital governance and executive leadership, therefore avoiding additional overhead and allowing time for the development of infrastructure to support a regional diagnostic service. Once more services are ready and approved to transfer into the SSO and the SSO is deemed to be ready by the Hospital s CEO s, the Regional Laboratory would be transferred into the service under a new SSO executive lead. The selection of Hospital to govern and lead the Regional Laboratory Medicine Services or the executive responsible in this transition period have not been discussed to date and would be part of a process to be overseen by SECHEF CEOs in the Implementation Phase for Wave 1 projects. It is also our recommendation to the Hospital CEOs that dedicated resources will be required by the Regional Laboratory Medicine Working Group to complete Phase 3, Implementation Planning, as part of the project team. We will require the ongoing support of the Project Secretariat used in Phase 2, but we see the need for the leads to be dedicated in this next phase and more aligned to Regional Laboratory with subject matter expertise. The working group has accomplished a lot of work this past year on the time allocated by staff across the hospitals but more focused work is needed in this next stage. As soon as possible we would like to move to formally filling the Director roles for the Regional Laboratory to lead the role out of the implementation planning. We appreciate that CEO approval for these positions may need to wait until after the first point of check-in with the Boards in Phase 3, but if we are moving forward these positions will be critical to preparing the plans for implementing Year 1 of the Laboratory Medicine Services Business Case. 46 P a g e

47 14 Risk Assessments and Mitigation Issue IT connectivity not completed Courier / transport systems not established Effectiveness of re-designed specimen transport system will need to be monitored and measured to ensure quality of specimen integrity and related testing is not compromised. Sufficient technology investment Availability of scalable platforms from vendors Buy in and support from management and staff Job security and impact on retention and recruitment Each site not having an equal voice Funding for capital timing of available funds 47 P a g e Risk mitigation A plan has already been established for site connectivity. Detailed planning for this is pending business case approval. We expect to roll out site by site and build on past successes. Initial assessment has been completed and pending business case approval, a RFI and then a RFP can be issued to facilitate improvements in this area. Quality metrics will be established to monitor effectiveness of the transport system. The laboratory Advisory Council will review metrics and ensure specimen testing and related patient care is not compromised. A transformation plan has been completed and initial investment is being sought as part of the business case. The regional plan will incorporate standardization where it makes sense and where technology will allow. A full scale change management plan, engagement plan and communication plan is being developed to support information sharing and to help garner support from laboratory staff. As above. It is expected any job loss would be through attrition and natural retirement options. Each hospital will have representation to ensure their concerns and issues are addressed. The approach to decision making and the governance to support the regional decision making will be planned and established during the implementation phase (HCT phase 3, the next phase) Pending business case approval, a capital plan will be developed to ensure timing for the purchase of new equipment and corresponding funding will be made

48 available. Shift in practice for medical staff For any POCT changes, transfer of costs to nursing Laboratory licensing impact The change management and engagement planning will include medical staff. Any plans to expand POCT will be done in collaboration with nursing and any impacted stakeholders. Any relevant regulatory bodies such as OLA, MOH etc will be engaged. Notes: Transfer of costs to nursing for POCT Create capacity to add new services Review costing model Lab license changes 48 P a g e

49 Appendices Appendix A: Integration Estimate 1 KGH, HDH, and Providence Care currently have access to full HIS integration (only Providence Care is using the HIS in this way). For the purposes of Lab IT, orders from Providence Care flow to KGH LIS and results flow back via interface to Providence Care patient chart. Since these 3 sites share a common HIS platform (two facilities on one instance of QuadraMed), the patient s chart can be visible to clinicians at all 3 sites. Providence Care is using this to its full potential but KGH and HDH have not given all clinicians access to this full integration yet. Example: Dr. Frank at Providence Care, when visiting a possible admission to Providence Care at KGH, can see all aspects of client s record that are in PCS. These results are all trended and graphed together since they share a common testing platform at KGH. 2 LACGH existing interface is for transmission of microbiology orders from LACGH to the LIS at KGH and the results back. Results from LIS at KGH flow back via interface to LACGH meditech. There is no sharing of the rest of the record between sites. 3 The interfaces being proposed for PSFH, BGH, and QHC will be for orders from each of these sites into KGH and the flow of results back from KGH to each of these sites. This eliminates the need for a paper requisition and sets a scalable framework for future Lab IT expansion. This solution does not enable the sharing of the rest of the client record between sites. For QHC this interface is for the repatriation of some tests that are currently sent out to Dynacare. 49 P a g e

50 Appendix B: Leading Practices and Benefits Leading practice QHC lab consolidation QHC POCT technology implementation Microbiology MALDI-TOF technology Microbiology equipment standardization Specimen tracking for Histopathology* Decision support data mining capabilities at QHC * Reduction of specimen collection errors (KGH site) * Benefits Quinte Health Care has already consolidated all laboratory testing services to a single brand new laboratory at Belleville General Hospital. Point of Care Testing (POCT) is utilized for testing at Picton, Trenton and Bancroft. All other testing including blood bank and microbiology/histopathology testing is sent into Belleville. Physicians are now very satisfied with POCT testing at the non-belleville sites as it helps with short turnaround time results for key clinical decision making and other non-urgent tests are still available at the larger Belleville site. QHC has a well-designed POCT program meeting the needs of clinicians and patients. All testing devices are tracked and connected to the LIS using middleware technology. All results are included in the patient medical record. Quality management is performed across all sites with a team of POCT specialists supporting this program, taking care of monitoring volumes, quality management, training and technology development. KGH site and QHC site have new technology for the microbiology departments. This has provided a standardized approach for mass spectrometry technology which allows same day identification of microorganisms and contributes to earlier diagnosis and treatment of infectious diseases. This has saved money and improves patient care. SELHIN microbiology department equipment is already standardized to the Biomerieux platforms using Vitek and Bacti-Alert. Bar code-based tracking solutions, are now being used in pathology (AP) laboratories. Tracking of AP "assets" (specimens, blocks, slides, reporting) enhances laboratory efficiency, promotes patient safety, and improves patient care. The goal is to reduce specimen processing errors as close to zero as possible. QHC has a very strong decision support team with the tools to data mine and produce high quality informative reports to help make important clinical and operational decisions. It has been recognized that this model should be propagated across the LHIN to support broader regional decision support needs. KGH has successfully reduced specimen collection errors with a focused effort to improve the collection process using value stream analysis. Laboratory results provide essential data for diagnostic, monitoring and treatment of patients. Delays in laboratory tests can be the result of specimens received in the laboratory that are unlabeled or mislabeled. In either case this means unnecessary delay in treatment or decision making. From a regional perspective it will be imperative to have specimens correctly labelled. 50 P a g e

51 Chemistry automation KGH site -large track system KGH has introduced a new state of the art automated track ( TRACK ) effective May Laboratory results are used to make clinical decisions around admissions, discharges and diagnosis so it is imperative that results are available in a timely manner. There were several specific goals with the implementation of the TRAC, those being; cost savings for laboratory testing; improved quality with respect to results turn-around-times; improved staff and patient safety. Transfusion Safety officer* (currently at KGH only, needed for other sites) Standardization of coagulation instrumentation/ processes/standard operating procedures The Transfusion Safety Officer is accountable for collaborating with Medical, Technical and Para-Medical and nursing personnel to identify, implement and evaluate strategies for blood conservation, safety and quality assurance associated with the transfusion of blood and blood products. The Regional inter-laboratory Hemostasis program ensures that all laboratory equipment and reagents are standardized in the region reducing unnecessary costs and supplies and the continuity of patient care. This was done by; purchase of same family of laboratory instrumentation; sequestering of the same reagent lot numbers; sharing of policies and procedures. Lennox Addington hospital sends microbiology and histo-pathology to KGH* site This has helped to maximize the standardization of laboratory equipment, reagents and supplies to achieve improved quality, cost savings through economies of scale, through regional purchasing of reagents and supplies. Perth Smiths Fallss hospital sends histo-pathology to KGH site QHC sends cytology and reference pathology work to KGH site Auto-verification Auto-verification is partially implemented at QHC, is implemented in chemistry and hematology at KGH site. This electronic decision tool can be further rolled out at all SELHIN hospital lab sites. This software tool is used to send out normal lab results without technologist input and review. This speeds up the release of normal lab test results. This is now considered industry best practice. 51 P a g e

52 Appendix C: Proposed draft Histology changes for future consideration Note: These are not proceeding at this time. Further medical and operational management and staff engagement is required to determine if there is agreement to proceed. Send select histology specimens/cassettes after grossing to KGH for technical processing. Send slides back to QHC and Brockville for pathologist interpretation and report generation. Possible IHC consolidation Grossing technologists, pathologists remain at QHC and Brockville locations. Before any change would occur in this area the physicians and staff would need to validate and test any model so no assumptions can be made at this time about this model. Consolidate to KGH site, currently performed at both KGH and QHC site. Brockville sends to KGH. Might not save $ as cost per test is approximately the same at the two sites. Vendor discussions would be needed. LACGH PSFH No change already sending to KGH site No change already sending to KGH site BGH Send Histology specimen processing work to KGH site Current staffing: 3.4 MLT to 1.2 Staffing changes: 2.2 MLT reduction QHC Current staffing 6.0 MLT/MLA Staffing changes: 3.0 MLT/MLA Potential Savings Staffing $240,000 Supplies and service agreements $100,000 Total: $340, P a g e

53 Appendix D: Capital Costs Annualized Amount FY 11/12 FY 12/13 FY 13/14 FY 14/15 FY 15/16 Earned Hours 550, , , , ,464 EARNED HOURS - MANAGEMENT 69,887 67,858 67,408 74,326 71,270 AND OPERATIONAL SUPPORT (MOS) EARNED HOURS - MED 6,172 6,779 12,610 6,617 6,830 EARNED HOURS - UNIT 474, , , , ,364 PRODUCING PERSONNEL (UPP) Functional Centre Profile 38,671 38,334 40,653 40,595 80,740 OPERATING DAYS 4,604 4,266 4,486 4,418 4,364 WORKLOAD SYSTEM 34,067 34,068 36,167 36,177 76,376 S Diagnostic and 34,067 34,068 36,167 36,177 76,376 Therapeutic Workload System Personnel Profile - Earned Hours 551, , , , ,752 Earned Hours Details MED 6,172 6,779 12,610 6,617 6,826 Earned Hours Details MOS - 69,909 67,888 67,422 74,391 71,310 Earned Hours Details UPP 474, , , , ,616 Personnel Profile - Head Count MED HEAD COUNT - BY OCCUPATIONAL CLASS - BY EMPLOYMENT STATUS MOS HEAD COUNT - BY OCCUPATIONAL CLASS - BY EMPLOYMENT STATUS UPP Head Count - by Occupational Class - by EMPLOYMENT STATUS Service Recipient Activity 7,304,692 7,606,973 7,501,841 7,209,289 7,554,202 Accounts Autopsies Performed CLINICAL LAB IN-HOUSE 6,449,862 6,727,769 6,460,817 6,202,640 6,555,124 INTERVENTIONS LAB CLINICAL CONTRACTED 854, ,958 1,040, , ,356 OUT INTERVENTIONS MEDICAL IMAGING IN-HOUSE EXAMS 13,067 12,482 Specialty and Priority Program 6,952 7,350 6,536 6,985 6,154 Profile GENETICS 6,952 7,350 6,536 6,985 6,154 Workload 21,199,845 23,905,623 24,821,42 25,777,154 24,453,484 5 CLINICAL LABORATORY 13,780,591 14,012,214 14,342,86 14,484,344 14,495,468 SERVICE RECIPIENT WORKLOAD 9 DIAGNOSTIC STANDARD TIME 330, , , , ,978 SERVICE RECIPIENT WL NON-SERVICE RECIPIENT 7,089,250 9,563,405 10,281,47 11,085,836 9,751,038 WORKLOAD UNITS 6 Grand Total 29,652,437 32,674,307 33,473, ,134,511 33,156, P a g e

54 Appendix E: Courier/Transport Requirements 54 P a g e