Outstanding Care No Exceptions! Zero Based Budgeting Project Summary

Outstanding Care No Exceptions! Zero Based Budgeting Project Summary

Contents 1.0 INTRODUCTION... 2 1.1 EARLY ADOPTER OF CHANGE AND WORKING CAPITAL DEFICIT... 2 1.2 UNPRECEDENTED GROWTH... 2 1.3 ACCOUNTABILITY AGREEMENTS... 3 1.4 INCREMENTAL BUDGETING... 3 1.5 ZERO BASED BUDGETING... 3 1.6 ASSUMPTIONS FOR ZERO BASED BUDGETING... 4 1.7 IMPROVEMENTS IN PATIENT CARE PROCESSES... 4 1.8 IMPROVEMENTS IN DEPARTMENTAL OPERATIONS... 5 1.9 OPPORTUNITIES FOR IMPROVEMENT... 6 1.10 IMPLEMENTATION PLANS... 6 2.0 KEY ZBB INITIATIVES... 7 2.1 PAIN CLINIC SERVICES... 7 2.2 NICU... 8 2.3 RESPIRATORY THERAPY SERVICES FOR CCC & REHABILITATION... 9 2.4 PSYCHOLOGY SERVICES FOR CCC & REHAB... 11 2.5 CHRONIC VENTILATION SERVICES... 11 2.6 BED UTILIZATION MANAGEMENT PROGRAM... 13 2.7 TELEMETRY SERVICES... 14 2.8 PSYCHOGERIATRIC SERVICES... 15 2.9 OUTPATIENT DIAGNOSTIC IMAGING SERVICES... 16 Page 1 of 17

1.0 Introduction WRH is striving to create a culture of excellence and continuous improvement in operating effectiveness, efficiency and quality of care. Windsor Regional Hospital ( WRH ) determined that it needed to transform its patient care processes and operations to achieve dramatic breakthroughs in efficiency and significant reductions in operating costs. It needs to continue transforming the organization to create a culture of excellence and continuous improvement in operating effectiveness, efficiency and quality of care. WRH is committed to achieving its Vision Outstanding Care No Exceptions! 1.1 Early Adopter of Change and Working Capital Deficit The Windsor community was an early adopter of healthcare reform that resulted in WRH having to fund a substantial portion of that change Approximately 10-15 years ago WRH and the Windsor community was an early adopter of health system improvement initiatives the included the amalgamation of four Hospital corporations into two. As a result WRH was disadvantaged by being too early to fully benefit from Ministry of Health and Long Term Care ( MoHLTC ) funding policy changes. WRH had to draw down any cash reserves and incur debt to fund the improvements in facilities, programs and corporate structure. This also included being responsible for 30% for major capital facility projects which totalled more than $100 millions dollars. This has resulted in WRH having a $60 million dollar working capital deficit. This working capital deficit creates great strain on WRH s ability to renew and invest in medical equipment/capital program. 1.2 Unprecedented Growth During this same time period WRH has seen unprecedented growth in the provision of services. This has resulted in: WRH has experienced unprecedented growth and attempted to provide care to all who needed care (i) (ii) (iii) (iv) (v) 51% increase in emergency room visits 16% increase in acute care patient days; 92% increase in complex continuing care days 300% increase in operating budget of WRH 210% increase in provincial spending for healthcare WRH receives approximately 80% of its required operating funding from the MoHLTC and now with the Erie St. Clair Local Health Integration Network ( LHIN ). The remaining 20% comes from preferred accommodation revenues, parking revenues and community donations. Page 2 of 17

1.3 Accountability Agreements WRH s operating funding will only increase 2.25% and 1.95% over the next two fiscal years Starting in 2005 WRH has been a signatory to an annual Accountability Agreement with the Ministry of Health and Long Term Care ( MoHLTC ) and now with the Erie St. Clair Local Health Integration Network ( LHIN ). The Accountability Agreements provide, among other things, that WRH must balance its budget and operate with a margin sufficient enough to fund its capital/equipment requirements. For the 2008-2009 operating year the LHIN has announced WRH will only receive a 2.25% increase to its funding and 1.95% in 2009-2010. WRH cannot expect the LHIN or Province to provide additional funding in the form of increased operating dollars. WRH has to build and sustain its own financial health. 1.4 Incremental Budgeting WRH needs to reexamine its operations from the bottom up and not from the top down During the last ten years, similar to many organizations, both public and private, WRH used traditional incremental budgeting to set its budget from year to year. In traditional incremental budgeting, departments justify only increases over the previous year budget and what has been already spent is generally automatically sanctioned. 1.5 Zero Based Budgeting ZBB at WRH has focused on developing approaches to eliminate unnecessary activity, restructure inefficient processes, better balance workload and staffing, improve quality of worklife, maintain or improve quality of care and reduce costs. As part of a process of organizational transformation WRH s medical/dental staff ( professional staff ) and clinical and nonclinical administrative staff ( administrative staff ) has supported a Zero Based Budgeting exercise across all programs, services and hospital departments designed to improve the performance of the organization by rethinking the budgets necessary to deliver high quality hospital services. The focus has been on rethinking approaches to providing and supporting care so as to eliminate unnecessary activity, restructure inefficient processes, better balance workload and staffing, improve quality of worklife, maintain or improve quality of care and reduce costs. The process has involved both medical leadership and the managers of hospital departments. The work of the medical leaders and department managers should be recognized and their willingness to challenge the status quo should be commended. As a result of their efforts there are innovative ideas being pursued throughout the organization in order to realize Page 3 of 17

Windsor Regional Hospital s vision of Outstanding Care - No Exceptions. 1.6 Assumptions for Zero Based Budgeting The following key assumptions have guided the Zero Based Budgeting Exercise: Patient volume (Measured in Episodes of Care) will be the same from year to year. Patient days will be the same or be reduced from year to year. Patient mix will be the same from year to year Range of medical services will be the same from year to year Work content per episode of care will be the same or be reduced from year to year Departmental workload will be the same or be reduced from year to year. There will be no reductions in salary or wage rates for staff 1.7 Improvements in Patient Care Processes Medical leadership has identified opportunities to improve care for patients by providing more focused, more timely and more appropriate patient care Through a series of workshops and workbooks the hospital s medical departments have worked to define anew the hospital s approach to providing an episode of patient care. ZBB applied to medical departments and programs has involved considering all elements of the hospital s care processes extending across providers, medical departments and hospital functional centres throughout the Hospital. This has included consideration of: Admission Decisions, Most Responsible Physician Service Delivery Models, Content of Care, Work Flow, Delays in Care, Discharge Planning, Discharge, Post Discharge Care, and ALC days Page 4 of 17

The ZBB process has led to the identification of opportunities to improve these elements of the patient care process which will lead to improved care for patients by providing more focused, more timely and more appropriate patient care. Realization of these opportunities will provide for reduced operating costs when they are translated into reduced workload for hospital functional centres (fewer patient days, fewer meals, fewer diagnostic tests, fewer therapy attendances, etc.). These new workload estimates have been the input into the Zero Based Budgeting of the hospital s functional centres. 1.8 Improvements in Departmental Operations Departmental managers have identified opportunities to improve service delivery, improve quality of worklife, more efficient operations and reduced costs. Through a series of workshops and workbooks we have worked with the directors and managers of all hospital departments and functional centres to rethink their approaches to delivering departmental services in support of the patient care processes of the hospital and to use ZBB approaches to developing departmental budgets for these new models for service delivery. This has included consideration of: Services Offered Work-Content of Services Service Delivery Models Staff Mix Opportunities for Alternate Care Providers Opportunities for Work Intensification Managing Scheduling Workload Staff Scheduling: Balancing Workload with Staffing Benefit Hours; Sick Time Volumes of Service/Workload Expectations Labour Productivity Targets Staffing Requirements Considering Material Content and Sourcing Materials, Supplies and Service Requirements Budgets Considering these elements of organizing, delivering, staffing and supplying departmental services has identified opportunities for Page 5 of 17

improved service delivery, improved quality of worklife, more efficient operations and reduced costs. In addition to the facilitated workshops and support for completion of workbooks, best practices were identified and opportunities for improvement in a number of key areas such as the operating room, birthing/obstetrics, complex continuing care/rehab, NICU and registration/health records. 1.9 Opportunities for Improvement Medical leadership and departmental managers have identified over 250 viable opportunities for improvement From this work, the organization was able to identify over 250 viable opportunities for improvement. These opportunities have been reviewed by the Hospital s Executive Committee. The Committee assigned relative priority to each initiative and a time frame for implementation. Hospital programs and departments will develop detailed implementation plans for each initiative including plans realizing the operational benefits and cost savings. The impact of these initiatives will form the basis for zero-based budget allocations to each program, department and cost centre. This report presents recommendations of the Board of Directors regarding the appropriate course of action regarding nine key potential initiatives for the hospital In reviewing these initiatives, it has been determined by WRH that some of them could have significance for the provision of health care services in the Windsor community. In its ongoing commitment to accountability and transparency WRH determined it was best to share these modifications with the community it serves. 1.10 Implementation Plans The Board has directed the medical and administrative leadership to develop implementation plans that will minimize any permanent job loss The Board of Directors has asked the ZBB Steering Committee along with the medical and administrative leadership to develop implementation plans for each of the Initiatives outlined later in this document. The Board has directed the medical and administrative leadership to develop implementation plans that will minimize any permanent job loss along with ensuring the Initiatives are implemented systematically to minimize impact on patients and families. Page 6 of 17

2.0 Key ZBB Initiatives 2.1 Pain Clinic Services WRH will advocate for the development of a comprehensive, regional pain program. There is currently a waiting list for patients who require medical intervention for the management of their pain. The key point in the provision of pain management is that these patients are in need of a comprehensive pain management program that includes multimodal and interdisciplinary assessment and therapy. At the present time Windsor Regional Hospital and others in the community are providing a pain clinic, but not a comprehensive pain management program. The pain clinic services that are being provided at the hospital have been externally reviewed and have been deemed to be in need of significant enhancement. In considering the pain clinic there are four central issues to be considered. 1. There is a risk in continuing to offer services to patients when there is documented evidence that there is a need to make changes to the policies, procedures and practices of the existing pain clinic. The hospital should not assume this risk to patient care. 2. The WRH pain clinic has no specific funding envelop and so the costs associated with both the relocation of the clinic, the resources required to operate the clinic would have to be absorbed by the hospital. 3. The pain clinic is currently conducted within the physical space of operating room. Its presence is causing delays to start times for surgical cases. These delays in turn result in overtime costs for nursing staff and/or result in cancelled surgical procedures. The effective and efficient running of the operating room is being negatively impacted by the presence of the pain clinic within its space. These inefficiencies are increasing the operating costs of the OR, decreasing the hospital s ability to meet its wait time targets and thus reducing its revenues and impacting negatively on the morale within the surgical program. 4. However, there is and will continue to be a need for pain management for those people in our community that are suffering from acute and chronic pain. The LHIN needs to work with WRH and others to create an effective pain program for the region; but the program is likely more appropriately located in a community setting. Page 7 of 17

Decision: 2.2 NICU It has been decided that: (1) WRH will discontinue its pain clinic and advocate for the development of a comprehensive, regional pain program. The Women s and Children s Program is a lead program for Windsor Regional Hospital and the integrity of the program must be maintained and supported. Neonatal Intensive Care is an integral component of the program. There is an undeniable need to continue to provide clinical services for neonates within our LHIN and local community. The current services being provided are meeting the care needs of babies and their families and the hospital should be proud of its accomplishments. The program, as a result of its leadership, has been successful in recruiting physicians from a broad spectrum of specialties including neonatologists, maternal fetal medicine and obstetrics and gynecology. However there is concern regarding the volume and scope of service being provided by the NICU. The decision point is not driven by quality of care or questions regarding the need to provide the services but rather the costs of associated with caring for critically ill babies. The NICU at WRH is funded in relation to the scope of services, service volume and operating costs that were transferred from Hotel Dieu Grace Hospital in December 2006. The WRH NICU should limit its census to its current funding level of 14 bassinets. The WRH NICU should reduce the number of low acuity, low risk babies admitted to the unit. The funding that was transferred to WRH, inflated to 2007/08 values, would support the provision of care for approximately fourteen (14) critically ill babies. However, because the WRH NICU has capacity for 23 bassinettes; and there is often demand for the use of the NICU that exceeds 14 bassinettes, and the program is reluctant to turn away or transfer babies referred to the NICU, the census of the unit most often exceeds its funded level of 14 babies. The Hospital has been providing this extra volume of care without any additional funding. It has been suggested that the volume could be reduced by reducing the number of low acuity / low risk neonates admitted to the unit. The external review of the NICU has suggested that the program should review its current admission policies to the NICU. Page 8 of 17

The WRH NICU should continue to care for premature and critically ill newborns 26 weeks gestation and older. Although the WRH NICU is recognized as a modified Level 3 nursery that should be caring for babies with a gestational age of 29 weeks or greater. However, the unit is often caring for babies younger than 29 weeks and in these instances functions like a full Level 3 nursery. These very young, very low birth weight babies are born in WRH, are transferred from other hospitals within the LHIN and, because of limited Level 3 NICU capacity in the province, are often transferred from elsewhere in the province. Often these babies are cared for at WRH because there is no other place for them to go. It will be important to the communities served by WRH and for the province as a whole for the WRH NICU to be designated as a Level 3 NICU. This designation will allow the Maternal Newborn Program in general and the Neonatal Intensive Care Program in particular to expand its scope and meet the future needs of the community. Decision: It has been decided that: (2) The WRH NICU will limit its census to its current funding level of 14 bassinets. (3) The WRH NICU will reduce the number of low acuity, low risk babies admitted to the unit. (4) The WRH NICU will continue to care for premature and critically ill newborns 26 weeks gestation and older. (5) WRH will aggressively pursue Level 3 designation and funding for its NICU. (6) WRH will formally request that the LHIN approve and fund the expansion of the NICU from 14 to 23 bassinets. 2.3 Respiratory Therapy Services for CCC & Rehabilitation WRH should reduce respiratory therapy service coverage at the Western Campus from 24 hours per day, seven day per week to 8 hours per day, seven days per week. Respiratory therapy services at the Western Campus Tower Building are currently provided 24 hours per day, seven days per week. This level of service was established to provide back-up for the chronic ventilator patients at the Western Campus and to be available in case of medical emergencies. However the service is under utilized; and it has been found that peer hospitals do not have the same level of respiratory therapy coverage. The recommendation is to reduce the level of respiratory therapy staffing and to refocus the work of the therapists on the rehabilitation needs of patients while still being Page 9 of 17

available, as needed, to support the remaining patients on chronic ventilation. There are some considerations that will need to be addressed if RT staffing is to be reduced and redirected: The nursing staff would have to be educated to facilitate a return to utilizing their full scope of practice in identifying and handling medical emergencies. There would be a need for an increased number of portable defibrillators for the units and this is a capital purchase. The site would be a 911 facility and Emergency medical services need to alerted to the change in staffing. There would need to be a new position description for the respiratory therapist that would include a more active role as a member of the allied health team for the rehabilitation of patients. Respiratory therapists would still be able to monitor the chronic ventilation patients and provide assistance to the nursing staff in their continuing education related to response to medical emergencies. Both the expert reviewer for CCC and the clinical staff of the hospital have indicated that these changes will not compromise patient safety or quality; will enhance the effectiveness and quality of rehabilitation services and will significantly reduce operating costs. Decision: It has been decided that: (7) WRH will reduce respiratory therapy service coverage at the Western Campus from 24 hours per day, seven day per week to 8 hours per day, seven days per week. (8) WRH will refocus the work of respiratory therapy at the Western Campus from emergency response and support to chronic ventilation patients to support for rehabilitation patients. Page 10 of 17

2.4 Psychology Services for CCC & Rehab WRH should change its psychology support for CCC and Rehabilitation patients to a Psychology by Consult model of care. Comparisons with peer hospitals suggest excess staffing of psychologists for the Rehabilitation and Complex Continuing Care (CCC) programs. Windsor Regional Hospital (WRH) has more psychologists on staff than other community CCC and Rehabilitation hospitals. The psychologists are treating all Rehabilitation and CCC patients without a consult request from the physician. Best practice for community hospitals and programs such as WRH is to have fewer numbers of psychologists on staff, and that the psychology staff are utilized on a consultation basis for special needs patients only. What s more, it is felt that the unusual involvement of psychology is contributing to an unusually high cost per patient day for CCC care at WRH. Both the Rehabilitation and CCC physician leadership and the functional centre managers have suggested that there is a need to rethink the deployment and use of psychology services at WRH. They have suggested a reduction in the number of psychologists on staff and movement to a Psychology by Consult approach to care. What s more, they have suggested that a neuro-psychology position should be created to better support the Rehab and CCC patients with stroke and acquired brain injury. The changes would reduce the number of full time psychologists and clerical support staff. There would be an increase in psychometry and neuron-psychology hours. It was determined that these changes would provide for a reduction from 5.2 FTEs to 2.6 FTEs. Decision: It is decided that: (9) WRH will change its psychology support for CCC and Rehabilitation patients to a Psychology by Consult model of care including the provision of neuro-psychology services. 2.5 Chronic Ventilation Services WRH should discontinue chronic ventilation care except for its two long-stay patients requiring chronic ventilation The CCC program at Windsor Regional Hospital is currently caring for patients requiring chronic ventilation. There are currently four patients receiving chronic ventilation in WRH Complex Continuing Care. Two of these patients have been in the hospital for an extended period of time and will potentially remain in hospital for many years; the other two patients is potentially more short term. Page 11 of 17

The hospital does not receive any additional funding to provide this service and the service is contributing to the high cost of Complex Continuing Care at WRH. There are multiple issues to be considered in considering the delivery of chronic ventilation services. They are: There is and will continue to be a growing need for this service in the community. The number of people requiring chronic ventilation will continue to grow as people with neuromuscular disabilities are living longer due to advances in medical care. The closest beds that are funded by the MOHLTC for care of patients requiring chronic ventilation are in London and Toronto For most patients requiring chronic ventilation, it is not best practice to remain in hospital. A better quality of life can be established for these patients in the community with appropriate support services. There are currently two people in the Windsor community on ventilators and they are doing very well. Reducing access to inpatient chronic ventilation in CCC could delay discharge from acute care beds and block their use for patients requiring acute care. A better approach to care for patients requiring chronic ventilation would involve reducing reliance on inpatient service and expanding support for chronic ventilation in the community. The Erie St. Clair LHIN, the CCAC and the MOHLTC will need to be approached to help with funding for these beds and for the further development of a comprehensive community program. During the transition to a community program WRH will continue to care for its patients who are currently receiving chronic ventilation. However, WRH should actively look for placement opportunities for existing patients and any new patients requiring chronic ventilation will have to be relocated to another Hospital that is specifically funded for this service. Decision: It is been decided that: (10) WRH will discontinue chronic ventilation care except for its two long-stay patients requiring chronic ventilation plus continue care for the third & fourth chronic vented patients until the patients can be placed in an alternative facility or program. Page 12 of 17

(11) WRH should work with the CCAC and the LHIN to help develop a fully functioning community program. 2.6 Bed Utilization Management Program WRH should develop and implement a utilization management program WRH should eliminate its fourteen (14) flex beds Windsor Regional Hospital needs to establish strategies and processes to utilize its resources in a more efficient and effective way. A number of challenging actions need to be taken to address the root cause of financial and patient safety issues being faced by the Hospital because of the inefficient use of its inpatient resources. First, the Hospital can not financially afford the unfunded flex beds it operates. The Hospital has historically opened and closed unfunded flex beds to deal with increases in patient volumes. These fourteen (14) unfunded beds are utilized on an ad hoc basis and are costing the organization approximately $600,000 annually. The physical capacity to open the flex beds has created an interesting dilemma for the Hospital in that larger volumes of patients who require acute care can be admitted to the available beds but there is no funding for these beds. Removing the beds from circulation is the best solution. If the beds are not available they cannot be used. More importantly not having the flex beds will provide the opportunity to escalate the shortage of beds issue to the LHIN in a more immediate and concrete way. Second, Windsor Regional Hospital has above average lengths of stay in most of its clinical services. The associated staffing and operating costs of keeping patients in beds longer than expected is a major cause of the hospital s high costs. The Hospital must reduce its cost per weighted case and striving to be a high performing hospital with respect to length of stay will help to achieve this objective. The hospital should strive to exceed provincial benchmarks for lengths of stay. This will require an aggressive approach to managing the utilization of inpatient beds. The approach suggested in the relevant workbooks should be pursued vigorously. WRH should schedule surgical procedures to balance demands for post procedure services including PAR, Day Surgery and inpatient beds. Third, as is true for many community hospital operating rooms, Windsor Regional Hospital must work diligently to smooth its OR schedule. There should be a daily balance of the number of inpatient and out-patient surgeries so that in-patient beds are utilized in a planned and consistent manner. Irregular patterns of admission to inpatient surgical beds make it very difficult to efficiently utilize those beds with demand exceeding supply on some days and under utilization on others. What s more, irregular patterns of admission make balancing of nursing staffing with nursing workload on Page 13 of 17

surgical units exceedingly difficult. Similarly, the inefficient scheduling of surgical cases negatively impacts day surgery and the post anesthesia care units. All of this is unnecessarily increasing the cost of providing surgical services at WRH. Decision: It is been decided that: (12) WRH will develop and implement a utilization management strategy that minimally incorporates three key elements: Creation of a corporate clinical utilization management team Elimination of fourteen (14) flex beds Scheduling surgical procedures to balance demands for post procedure services including PAR, Day Surgery and inpatient beds. 2.7 Telemetry Services WRH should transfer its telemetry beds to an inpatient medical unit WRH should create a rapid access cardiology and internal medicine clinics to facilitate early discharge from inpatient beds and to avoid inappropriate admissions from the ED. Appropriate and timely access to patient beds is essential in today s healthcare environment. Windsor Regional Hospital has been struggling to place patients in the right bed at the right time and needs to take steps to more aggressively resolve it patient flow issues. It is not uncommon, especially in the winter months, to have patients in the emergency department waiting for a telemetry bed that is not available in a timely fashion. Integrating the telemetry beds within a medicine unit will increase the compliment of monitored beds from thirteen (13) to sixteen (16). The monitored beds could then be utilized by either telemetry or medicine patients as required. Another significant advantage of relocating the telemetry beds is the potential to free up of the space that will be vacant as a result of the move. The space made available could be used to provide urgent cardiology and internal medicine clinics. These clinics would be implemented to avoid admission from the emergency department and also provide follow-up visits that would facilitate more timely discharges. The Hospitals NACRS and DAD data show that patients are being admitted to in-patient beds as a way for the emergency room physicians to be certain patients are seen by an appropriate specialist e.g. cardiologists and internists within twenty four (24) hours. Creating urgent cardiology and internal medicine clinics will obviate the need for admission because the ED physician will be Page 14 of 17

confident that the patient will have timely access to the necessary specialist care. Increased lengths of stay are also noted and attributable to concerns by the most responsible physicians are that if they discharge a patient then the patient may not receive the follow-up care from the required specialist in coordinated and timely manner. Creating urgent cardiology and internal medicine clinics will facilitate earlier discharges because the most responsible physician will be confident the patient will have timely access to the necessary specialist care. Windsor Regional Hospital should take steps to improve access to appropriate beds and out patient services. The current patient flow problems could be addressed in part by: first, expanding the number of monitored beds on an in-patient unit to provide more flexibility, and second, by offering out patient clinics that support admission avoidance and prompt discharges. Decision: It is been decided that: (13) WRH will transfer its telemetry beds to an inpatient medical unit (14) WRH will utilize the space freed up by relocating its telemetry beds to house a rapid access cardiology and internal medicine clinics to facilitate early discharge from inpatient beds and to avoid inappropriate admissions from the ED. 2.8 Psychogeriatric Services The psychogeriatric unit should be closed, temporarily, until the completion of the new construction of the mental health building. The 14 bed inpatient psychogeriatric unit is a very small, geographically isolated unit at the Western campus. It was over 40 beds until 29 beds were transferred to Hotel Dieu Grace Hospital in May 2007 as a result of reconfiguration. There is a lot of concern for patient and staff safety due to the isolation and staff skill set. It is not cost effective to run the unit in its configuration of only 14- beds. There was an attempt to increase the size of the unit by getting an early transfer of some beds from St. Thomas however that did not occur. There is limited and varying demand for the services of the unit; on occasion this year the unit has had a daily census of only 4-6 patients, leaving 8 to 10 beds and associated staffing unused. The thought is that the unit should be closed until the new mental health building is completed and operational. If it is not closed, the unit will have to be re-located in December 2010, when the rest of the Western Tower is evacuated in order to facilitate construction. Page 15 of 17

However, if the unit is closed and the service no longer offered, there could be increased need for acute psychiatric beds at HDGH and there could be pressures on the area Emergency Rooms. There are currently limited alternatives for care in the community if a geriatric patient has a psychosis or severe dementia with aggressive behaviors. Closing the unit could mean a loss of staff that may be needed for the new mental health beds opening in 2011. And, the psychiatrists will lose some billing opportunities and stipends which could be addressed through alternative stabilization measures that would also ensure psychiatric coverage for patients being cared for in the complex continuing care program. Decision: It is been decided that: (15) The psychogeriatric unit will be closed temporarily, until the completion of the construction of the new mental health building. 2.9 Outpatient Diagnostic Imaging services WRH Diagnostic Imaging Department should increase the volume of profitable ultrasound and nuclear medicine procedures. WRH Diagnostic Imaging Department should limit the provision of unprofitable X- Ray procedures to WRH inpatients, ED patients, Cancer Centre patients and patients referred from WRH outpatient clinics For many years, the net benefit of providing outpatient diagnostic imaging services in return for the OHIP fees paid to the Hospital has been questioned but the issue has not been fully investigated or reviewed. To answer this question definitively, a costing analysis was prepared to compare the current work activity, costs and revenues of the Diagnostic Imaging (DI) department against an alternative model that would limit DI work activity, costs and revenues to ONLY addressing the needs of the hospital s inpatients and ED patients. Through this analysis for each testing modality (Ultrasound, Nuclear Medicine and General X-ray) WRH has been able to determine the financial benefit of providing outpatient diagnostic imaging serves for physician office referrals (walk-ins) or referrals from WRH s own ambulatory clinics and the cancer centre. The findings of this review are: 1. The OHIP fees are greater than the cost of labour and supplies for: ultrasound procedures nuclear medicine procedures thus it is to the financial benefit of WRH to provide outpatient ultrasound and nuclear medicine procedures. It would be beneficial to increase the volume of these procedures. It is estimated that increasing outpatient Ultrasound and Nuclear Page 16 of 17

Medicine services can provide additional operating profits of $200,000. 2. However, the OHIP fees are less than the cost of X-Ray procedures. Thus it would be financially beneficial if WRH discontinued outpatient X-rays. However, X-Ray services are required in support of the hospital s ambulatory clinics and Cancer Centre. Thus, it would be best if the hospital could focus its outpatient X-Ray service testing on ED Patients, Cancer Centre patients and Ambulatory Clinic patients in order to minimize the operating losses from providing this service. It should be noted that if there are opportunities to shift ambulatory care visits, such as the fracture clinic, to a community setting, then diagnostic support services could also be shifted to community labs. Decision: It is been decided that: (16) WRH Diagnostic Imaging Department will develop and implement strategies to increase the volume of profitable ultrasound and nuclear medicine procedures. (17) WRH Diagnostic Imaging Department will develop and implement strategies to limit the provision of X-Ray procedures to WRH Inpatients, ED patients, Cancer Centre patients and patients referred from WRH Outpatient Clinics Page 17 of 17