Hospital Improvement Plan Niagara Health System

Hospital Improvement Plan Niagara Health System Presentation to Hamilton Niagara Haldimand Brant Local Health Integration Network (HNHB LHIN) Board of Directors November 25, 2008 HNHB LHIN Staff

Health Improvement Opportunities Access Program and service distribution among the Niagara Health System sites Quality Commitment to quality improvement and tools and approaches Leadership Robust stewardship and relationship management for a well functioning health system Sustainability Sound financial management and balanced budget 1

HIP Review Framework Improvement The Challenge The Solution The Issues Access Quality Leadership Sustainability 2

Staff Review: Assumptions the HIP is a directional plan the directional plan is implemented over a 4-5 year period; some opportunities are building blocks; others require linkages at the LHIN level or sub LHIN level for refinement and feasibility assessment. an implementation schedule relies on a hand in glove relationship with MOHLTC, HNHB LHIN and NHS governance for fiscal management and financial health. 3

Setting the Stage: What are People Talking About? NHS Consultation Summary Report on the HIP The Media Other Submissions to LHIN 4

NHS Summary Report: Key Issues Sentiment in some communities that the NHS leadership lacks credibility and cannot be trusted. Credibility gap: Leadership competencies; calls for elected Board Trust Gap: Open and honest communication Response: The NHS commits to strong and visible leadership and to rebuild trust among staff and stakeholders 5

The Media: Key Issues The qualitative approach Scanned 118 media clips Oct 27 Nov 15 5 print 1 TV 1 radio Categories: Supportive (11%) Neutral (25%) Critical (64%) 6

The Media: Key Issues Percentages of issues covered by the media (Oct 27 - Nov 15, 2008) Change in Hospital 4% Change in Maternity service 5% Change in ER service 10% Dr. Kitts' recommendations 10% Trust 20% NHS Management 20% Overall HIP 30% 0% 5% 10% 15% 20% 25% 30% 35% 7

Submissions to LHIN: Key Issues After receipt of Dr. Kitts recommendations at its October 28 Board meeting the HNHB LHIN received approximately 15 letters from Niagara citizens. These are in addition to correspondence from Niagara s elected officials. The concerns expressed continue to focus on the site of the new hospital in St. Catharines, trust and confidence in the NHS leadership, and the provision of services at smaller community hospitals (in particular Fort Erie and Port Colborne). Many of these letters have been from citizens who have previously expressed their views to the HNHB LHIN regarding the NHS HIP. 8

Access: The Challenge 9

Access: The Challenge Demographic change Health system transformation Multiple sites Finite resources: human, capital, fiscal Quality Imperatives Meaningful relationships 10

Access: The Solutions A centre of excellence is a program seeking the highest standards of achievement. The centre of excellence brings together a critical mass of patients, providers and infrastructure to enable leading quality care. The centre of excellence may be virtual, supported by information communication technologies, or may be consolidated to a single site. The centre of excellence, as a program hub, shares its expertise with other sites, ensuring that all sites receive excellent quality care (Kitts, p. 8) 11

Access: The Solutions Re-organization of programs and services to support available, quality and sustainable services that together meet the needs of all residents in the Niagara Region Imperatives: Relationship Building Community commitment 12

Access: The Issues Stakeholder commitment to hospitals, not sites Perceived access barriers Distance, weather, health professionals, EMS Public AND private sentiment Sustained patient focus 13

Access: Port Colborne, Fort Erie Sites Neither site functions as a full service hospital today. Neither emergency department has the technology or specialist coverage to provide a full scope of emergency services. Specialists will not perform consults at either site; any patient requiring a specialist consult, or specialty diagnostics and treatment must be transferred to one of the 3 larger NHS sites. Buildings require significant renovation to meet modern care delivery standards. Until the recent retirement of the ophthalmologist at PCG Site, cataract surgery patients were given general anaesthetic, which is not the accepted standard. 14

Access: Port Colborne, Fort Erie Sites Current Utilization CTAS 1 and CTAS 2 (6 months 2008) Apr - Sept Arrival Port Colborne Douglas Memorial CTAS 1 CTAS 2 CTAS 1 CTAS 2 EMS 23 114 25 117 OPT 0 0 0 0 Walk in 16 486 9 361 Total 39 600 34 478 The CTAS data indicate that approximately 2300 ambulance visits would be diverted from Port Colborne and Douglas Memorial annually. 15

Access: Port Colborne, Fort Erie Sites EMERGENCY VISITS (CTAS 1 & 2) BY DISPOSITION APRIL TO SEPTEMBER 2008 TRIAGE LEVEL INPATIENT ADMIT TO SITE DIED PORT COLBORNE GENERAL SITE LEFT WITHOUT BEING SEEN TRANSFERS TO NHS SITES TRANSFERS TO OTHER ACUTE TRANSFERS TO NON ACUTE HOME TOTAL VISITS CTAS 1 7 5 0 15 3 0 9 39 CTAS 1 % 17.9% 12.8% 0.0% 38.5% 7.7% 0.0% 23.1% 100.0% CTAS 2 58 0 9 79 6 2 446 600 CTAS 2 % 9.7% 0.0% 1.5% 13.2% 1.0% 0.3% 74.3% 100.0% DOUGLAS MEMORIAL SITE TRIAGE LEVEL INPATIENT ADMIT TO SITE DIED LEFT WITHOUT BEING SEEN TRANSFERS TO NHS SITES TRANSFERS TO OTHER ACUTE TRANSFERS TO NON ACUTE HOME TOTAL VISITS CTAS 1 2 9 0 13 8 0 2 34 CTAS 1 % 5.9% 26.5% 0.0% 38.2% 23.5% 0.0% 5.9% 100.0% CTAS 2 48 2 14 58 16 1 339 478 CTAS 2 % 10.0% 0.4% 2.9% 12.1% 3.3% 0.2% 70.9% 100.0% 16

Access: Urgent Care Urgent Care Centers provide services to unscheduled patients seeking treatment for non-life threatening conditions such as eye injury, fractures, lacerations etc. during the day, in the evening and on weekends. The Clinics must have the capacity to treat Canadian Triage and Acuity Scale [CTAS] Level III patients. The services must be supported by a range of on-site diagnostics and laboratory tests, as well as by the ability to administer intravenous and other drug treatments. 17

Access: Urgent Care UCCs must have the capacity to initiate immediate resuscitation efforts. UCCs must be able to make arrangements to transfer and refer patients requiring this level of care to hospital ER. UCCs are staffed primarily by ER physicians working in cooperation with the local ER, providing opportunities for ER physicians at all stages in their career and training for family physicians, as a means to facilitate enhanced ER coverage, as well as residency training. (MOHLTC, November 18, 2008) 18

Access: Kitt s Report Poor quality services located within the community does not equate to excellent access. Residents of Fort Erie and Port Colborne will have to travel further for some services, but those services will be of higher quality. The proposed model is safer. The DM Site and the PCG Site will only offer services that have the necessary supporting human and physical infrastructure. 19

CTAS Levels CTAS Levels Physician Reassess (RN) Level 1 Resuscitation Level 2 Emergent Level 3 Urgent Level 4 Less Urgent Level 5 Non-Urgent Immediate aggressive interventions Rapid medical intervention by physician or medical directive Serious problem requiring Emergency intervention Benefit from intervention or reassurance within one or two hours could be delayed or even referred to other areas of the hospital or health care system Continuous nursing care Every 15 minutes Every 30 minutes Every 60 minutes Every 120 minutes 20

Quality: The Challenges Higher than average hospital standardized mortality rates High rates of readmission for some illnesses MSRA and VRE infection issues Focus on quality assurance, less on quality improvement No unified approach to quality of care indicators Care practices vary across sites Insufficient volumes in some programs to support quality care 21

Quality: The Solutions Engage an advisor Develop an implementation schedule Implement a robust quality measurement framework Develop HIP evaluation framework Expedite re-development of operating rooms at Greater Niagara site 22

Quality: The Issues Advisor role builds capacity for quality leadership for health transformation, accountability and sustainability Successful, staged change requires a roadmap of parallel and sequential strategies Performance tools CQI Monitoring the HIP how are we doing? 23

Leadership: The Challenges NHS has little explicit public support Lack of public trust Felt lack of engagement Legacy of turmoil in Niagara re the area hospital system Deficit a lightning rod Variable relationships between management and physicians, and among sites leadership 24

Leadership: The Solutions Relationships, Relationships, Relationships Rebuild trust and credibility with medical leadership health professionals communities 25

Leadership: The Issues Can the NHS and its stakeholders build a collaborative working relationship with Niagara communities for a successful Niagara Health System? Can Niagara stakeholders sustain a focus on residents and patients? Walking the talk 26

Sustainability: The Challenges People Short supply Asset Renewal Maintaining facilities, technology and equipment Money Finite 27

Sustainability: The People Challenge Official nursing vacancy rates are 8 percent ONA has censored the NHS since 2002 Several medical positions vacant Looming retirements in 2013: RNs 41% RPNs -44% Leadership 53% 28

Sustainability: The People Challenge Implications of Challenges Curtail services, close beds (temporary), transfer patients Increased overtime costs; > $5M > Sick time, burn out, < work life balance Safety issues 29

Sustainability: The Renewal Challenge Buildings are Aging Maintaining facilities, technology and equipment difficult Multi site equipment purchases is costly 30

Sustainability: Fiscal Health NHS posted an operational deficit of 17.9M (2007-08) > working capital deficit 31

Sustainability: Fiscal Health Implementation Schedule 4+ Years Improvement Foundational LHIN wide Niagara wide Access Urology Opthamology Urgent Care Mat newborn (other clinical programs) Tertiary MH Vascular, thoracic Children s Health ALC diversion MH + Addictions planning Quality Leadership Advisor Quality Metrics HIP evaluation Relationships Shared metrics Links with LHIN CEO s Sustainability Implementation Schedule Fiscal Plan Parallel Activities and Enablers MOHLTC Priorities Provincial Children s Health Council Clinical Services Plan, IHSP Aging at Home, Family Health Teams, Nurse led clinics Niagara wide MH and Addictions Planning 32

Draft Financial Outlook Niagara Health System Hospital Improvement Plan (November 20, 2008 Amendment) 33

NHS Financial Outlook On a budget of $360 million, the NHS is forecasting a deficit for : 2008/09 of $17.8 million 2009/10 of $14.9 million NHS engaged Health Care Management (HCM) Consulting, in an operational improvement process to identify cost savings without reducing funded service levels, impacting patient access or quality 34

Efficiencies HAPS Savings 2008-10 The NHS is currently below the 25th percentile with respect to administration and support costs After implementing the estimated HCM savings identified, the NHS will be one of the most efficient hospitals in its peer group HCM analysis identified approximately $12 million in operational savings inadequate to achieve a balanced budget 35

Efficiencies HAPS Savings 2008-10 Savings of $12.3 million over the next two years. $9 million of savings identified through the HCM Operational Improvement Process An additional $3.3 million through other savings initiatives including revenue generation The $9.0 million in cost savings identified through the HCM undertaking is made up of more than 100 different individual initiatives across all programs, services and hospital sites The forecast deficits for the next two years takes into account the $12.3 million in savings identified 36

HCM Summary of Savings Overall Benchmarking Results 2007/08 Budget Net Total $ NHS Net Operating Costs $351,580,034 Calculated (Theoretical) Screening Targets @ Best Quartile ($30,420,534) Percentage Change -8.7% Total Operational NHS Operational Improvement Target Savings/Revenues Improvement Initiatives Labour Related ($6,994,201) Non-Labour Related ($4,037,822) Potential Recoveries/Revenues ($1,941,832) Total Potential Savings/Revenues ($12,973,855) One-Time Costs Identified $1,534,828 % of Calculated (Theoretical) Targets Achieved 42.6% At 25 th percentile for all functional centres, NHS would perform better than 85% of recent HCM clients (based on 06/07 data) If planned savings attained, NHS would exceed the % savings achieved by other hospitals who completed similar projects over the past four years Percentage Change in 2007/08 Budgeted Net Operating Costs -3.7% 37

NHS Financial Outlook NHS Summary - 5 Year Financial Outlook ($M) 2008/2009 Plan 2009/2010 Plan 2010/2011 Plan 2011/2012 Plan 2012/2013 Plan Deficit from previous fiscal year (17.86) (17.83) (11.78) (9.06) (5.39) Less: MOHLTC One Time Funding not renewed (3.50) Add: One Time Expense in Prior Year 0.50 Opening Deficit (20.86) (17.83) (11.78) (9.06) (5.39) MOHLTC Base Funding Increase 7.59 6.58 8.95 9.21 9.49 Economic Increase on expenses (10.83) (10.73) (10.75) (10.50) (10.24) Net Economic Impact (3.24) (4.15) (1.80) (1.29) (0.75) MOHLTC One Time Funding - Interest Carrying Costs on Working Capital Deficit 2.57 3.06 3.09 2.99 MOHLTC Additional Base Funding Required - Kitts Recommendation - Port/Fort 24/7 Urgent Care and Monitored Beds 4.90 MOHLTC PCOP Funding - New services at the St. Catharines Hospital Complex and new inpatient rehabilitation beds at the GNG site - offset by equivalent increase in costs 2.60 65.50 HCM Initiatives 6.72 5.60 Implementation of Monitored Beds at Port/Fort Urgent Centre as per Kitts Report (0.50) (0.50) Savings through closure of 82 inpatient beds dependent on the reduction in ALC days through community investments, Aging at Home. Total Savings over 4 years is $9.75 million 3.00 3.00 3.00 0.75 Reduction in ED visits and avoidance of inpatient admissions at the three large sites dependent on investment in community chronic disease prevention management (CDPM) and primary care. This assumes that additional Family Health Teams and Comprehensive H 2.00 1.50 1.00 Program Consolidations- Maternal/Child,Opthamology,Orthodics,Urology. Total savings over 4 years is $1.7 million 0.40 0.30 0.30 0.70 Growth due to increased demand on the NHS caused by population aging (2.70) (2.70) (2.70) Increased costs offset by PCOP funding for new services to be provided by NHS. This includes new inpatient rehabilitation beds at the GNG site and new regional services at the new St.Catharines healthcare complex. All of these new services will only be i (2.60) (65.50) Amortization of new equipment (0.20) (0.20) (0.20) (0.20) (0.20) Additional Interest Cost on Working Capital Deficit (0.25) (0.67) (0.43) (0.03) 0.10 SURPLUS/(DEFICIT) before One Time Items (17.83) (11.78) (9.06) (5.39) 1.40 One Time Costs tbd tbd tbd tbd tbd SURPLUS/(DEFICIT) after One Time Items (17.83) (11.78) (9.06) (5.39) 1.40 Change in Financial Position 0.03 6.05 2.73 3.67 6.79 Ratio: Total Margin as % of Revenue -4.8% -3.1% -2.3% -1.3% 0.3% Working Capital Deficit (134.63) (146.42) (155.48) (160.84) (159.45) 38

NHS Financial Outlook LHIN Comments MOHLTC One Time Funding - $3.5 million in 2007-08, the MOHLTC provided NHS with a $3.5 million one-time payment funds recorded as revenue - reducing deficit from $21.3 million if all else remained the same the 2008/-09 deficit would be greater by this amount, hence the need to add it back to the forecast Base Funding and Economic Increase base funding % increases less than inflationary increases difference impacts hospital s deficit Interest Carry Costs $11.71 million assumed interest cost incurred on the annual bridge financing will be funded by the LHIN on a one-time annual basis cash advances are basically interest free loans that help reduce the carrying costs of working capital deficits ministry has not funded these costs historically nor is expected to in the future hospital expected to manage costs of borrowing 39

NHS Financial Outlook LHIN Comments Additional Base Funding Required - $4.9 million NHS identified additional revenue to offset the cost of the running the Urgent Care Centres ($3.9 million) and the monitored beds ($1.1 million) HCM Initiatives - $12.32 million NHS has started to implement the recommendations from HCM expected savings in 2008-09 is $6.72 million these savings enable NHS to hold their deficit to $18 million - without these savings, the forecast deficit would be $24.72 million. ALC Reduction - $9.75 million as a result of the AAH initiatives $9.75 million of savings projected from the reduction in ALC beds may be overly optimistic estimate difficult to quantify a reduction in ALC beds as a result of the initiatives being implemented under AAH 40