North East Local Health Integration Network: INTEGRATED HEALTH SERVICE PLAN LABORATORY SERVICES DECEMBER 2006 Sommaire en français inclu. ISBN 1-4249-2747-1 (PDF)
T A B L E O F C O N T E N T S Executive Summary / Sommaire 1.0 Inroduction... 1 2.0 Current State... 2 Four Pillars Supporting Change... 2 North East Ontario... 6 Other Regional Initiatives...14 Partnership Between Sectors...18 Public Health Laboratories...19 3.0 Issues and Opportunities...20 4.0 Resources...22 North East LHIN: Laboratory Services
EXECUTIVE SUMMARY The integration of laboratory services in North East Ontario is being driven by a number of factors including: The Ontario Regional Laboratory Services Planning Initiative (2000); Increasing difficulty in recruiting and retaining pathologists and laboratory technologists; Technological advancements in laboratory medicine and laboratory information systems; Service demand pressures associated with an aging population; and Increasing expectations by the public and government for service standards and performance measures. The 2003 Strategic Plan for the North East Ontario Laboratory Region (the Strategic Plan) documented that there were 387 fulltime equivalent staff employed in clerical, technical and managerial capacities within laboratory services in the region at that time. This Strategic Plan forecasts a decrease in the work force by 19% over the next five years, as a result of pending retirements, with greater attrition in the five years following the initial period. Some employers within are already experiencing difficulty recruiting staff for vacant positions. In North East Ontario, medical laboratory services were provided in 2004 by nineteen pathologists. More than half were general pathologists. Sault Ste. Marie and Timmins each report one vacancy for a pathologist at present, according to the most recent listing of vacancies posted by the Ministry of Health and Long-Term Care through the Underserviced Area Program. Despite the stable or declining population in North East Ontario, the increasing age of the population places a higher burden on health services in general, including requirements for diagnostic laboratory tests and other laboratory services. In 2003, 6.4 million laboratory tests were performed for the region s residents by hospital laboratories and another 2.7 million tests were performed by community laboratories on behalf of North East Ontario residents. Test volumes and costs are forecast to grow by 1.5 to 4.5% annually. Laboratory services are currently being provided throughout North East Ontario by 28 independent hospital laboratories and eighteen community- based specimen collection centres. The 2003 strategic plan for laboratory services in North East Ontario was developed to address the challenges facing this service system. It called for a network of five service hubs, with clusters of community hospital laboratories linked to each service hub through shared laboratory information systems. It was anticipated that this system would take three years to implement fully, and that it would save $9.8 million during the first five years of operation, net of one-time capital and operating costs. By the end of this period, savings are forecast at $5.3 million annually, rising dramatically as time passes. More importantly, the recommended system would be able to meet the needs of North East Ontario residents for laboratory services with fewer technological human resources, adapting to the impact of the attrition of staff anticipated over the next decade. Many of the enablers for the integration of laboratory services are already in place: North East LHIN: Laboratory Services
EXECUTIVE SUMMARY The Ontario Laboratories Information System will result in common nomenclature for laboratory tests and a shared data repository for the entire province. The ICT Blueprint for Northern Ontario has documented the information systems technical requirements and costs required to augment existing laboratory information systems in order to create a comprehensive data sharing network for all of Northern Ontario. The Quality Management Program for Laboratory Services has defined the standards and processes required to support excellence in laboratory services. The initial plan for system integration within North East Ontario has already been developed and supported by the participating hospitals. Independent initiatives by some laboratory clusters within the region have already begun to follow the path laid out in the 2003 Strategic Plan, offering experience and learning from which the rest of the region can benefit. Integration initiatives by laboratories in other regions within Ontario have already achieved significant advances and their experience and learning can also benefit North East Ontario. The North East LHIN has the mandate to support and encourage integration initiatives that will benefit the population and that have been supported by service providers. To move forward with the integration of laboratory services within North East Ontario at this time makes good sense. It will result in a more efficient and effective system of services that will be better able to meet the needs of the population served. However, to advance this initiative from a plan to reality will require significant effort, time and resources. The first steps required in this transformation include the following: 1) To resume the process of laboratory integration requires the participation of a wide variety of stakeholders. All hospitals must be engaged in this integration process. As well, representative laboratory medicine physicians, private laboratory partners, and other groups are required to ensure that the system considers all views and addresses all identified needs. Dedicated human resources are required to facilitate this process and to do the behind the scene s work required on behalf of the group, in liaising with the MOHLTC, developing the documents and agreements required to reflect understandings, researching how to best meet the needs of participants in relation to accounting, etc. 2) The service delivery model for laboratory services for North East Ontario must be revisited to consider the impact on the model of the assignment of the Muskoka hospitals to a different LHIN subsequent to the development of the Strategic Plan. 3) If funding for both private and hospital laboratories is to be flowed through the LHIN, then the planning process should continue to formally consider and assess the opportunities that are possible from greater collaboration with, and appropriate integration of, private sector laboratories. North East LHIN: Laboratory Services
EXECUTIVE SUMMARY 4) The governance model and organizational structure for laboratory services for North East Ontario must be determined in order to proceed with the integration of laboratory services throughout the region. 5) Business plans and financial modeling for laboratory services for North East Ontario must be revisited to update the information and assumptions made in 2003 and to provide the additional detail required to advance progress. regional laboratory service system will take at least three years, with the cultural changes requiring a longer period of time to implement than either the technical or process changes. The sooner this transition begins, the sooner the residents of North East Ontario will begin to benefit from the more efficient, more effective service system that will result. 6) The regional level health human resources responsibilities outlined in the North East Region Laboratory Services Strategic Plan should be fostered and supported in their development and implementation. The portion of the North East Ontario Health Human Resources Plan that addresses laboratory health human resources should incorporate the elements defined in the North East Region Laboratory Services Strategic Plan. As part of broader health human resources planning in the IHSP action plan, #6 has been identified as a specific opportunity for LHIN attention between 2007/2008 and 2009/2010. It is anticipated that transforming the current array of laboratories into the recommended North East LHIN: Laboratory Services
SOMMAIRE L intégration des services de laboratoire dans le Nord-Est de l Ontario est motivée par divers facteurs, dont les suivants : le Projet de planification des services régionaux de laboratoire de l Ontario (2000); la difficulté croissante de recruter et de garder en poste des pathologistes et des technologues de laboratoire; les progrès technologiques en médecine de laboratoire et le perfectionnement des systèmes d information de laboratoire; les pressions exercées par les besoins en services d une population vieillissante; les attentes croissantes du public et du gouvernement concernant les normes de service et le rendement. Selon le plan stratégique 2003 des services laboratoires pour le Nord-Est de l Ontario, les services de laboratoire de la région comptaient 387 employés à temps plein affectés à du travail technique, de bureau et de gestion. Le plan prévoit une diminution de 19 % de la main-d œuvre d ici cinq ans en raison des prochains départs à la retraite. Le phénomène d attrition devrait s accentuer dans les cinq ans qui suivront cette période initiale. Certains employeurs ont déjà de la difficulté à combler les postes disponibles. En 2004, dans le Nord-Est de la province, 19 pathologistes offraient des services de laboratoire médical, plus de la moitié étant des pathologistes généraux. Selon la liste des postes disponibles produite par le ministère de la Santé et des Soins de longue durée (MSSLD) dans le cadre du Programme des services aux régions insuffisamment desservies, les secteurs de Sault Ste. Marie et de Timmins cherchent actuellement à combler un poste de pathologiste chacun. Même si la population du Nord-Est se stabilise ou qu elle décline dans certains secteurs, son vieillissement impose un lourd fardeau sur les services de santé en général, y compris les tests d analyses diagnostiques et d autres services de laboratoire. En 2003, les résidants de la région ont subi 6,4 millions de tests de laboratoire dans les hôpitaux du Nord-Est, et 2,7 millions d autres tests ont été effectués par les laboratoires communautaires pour des patients d ici. Or, le volume et le coût des tests devraient croître de 1,5 % à 4,5 % annuellement. On peut aujourd hui obtenir des services de laboratoire dans 28 laboratoires hospitaliers indépendants et 18 centres de prélèvement communautaires de la région. Le plan stratégique 2003 des services laboratoires pour le Nord-Est de l Ontario a été produit en réponse aux défis que le système doit relever. Il préconise la formation d un réseau de cinq carrefours de services, chacun étant lié à un regroupement de laboratoires hospitaliers communautaires par le biais d un système commun d information de laboratoire. On s attend à ce que la mise en oeuvre complète du système prenne trois ans et que celui-ci permette des économies de 9,8 millions de dollars dans les cinq premières années, après déduction des coûts ponctuels des immobilisations et du fonctionnement. À la fin de cette période, les économies devraient atteindre 5,3 millions de dollars annuellement et augmenter considérablement avec le temps. Mais surtout, le système recommandé répondrait aux besoins des résidants du Nord-Est en matière de services laboratoires tout en exigeant moins de ressources humaines en technologie et en réduisant l effet de l attrition prévue au cours de la décennie à venir. RLISS du Nord-Est : Services de laboratoire
SOMMAIRE Bon nombre des outils clés permettant l intégration des services de laboratoire sont déjà en place. Le Système d information de laboratoire de l Ontario permettra de créer une nomenclature commune des essais en laboratoire et un dépôt de données commun pour toute la province. Le Projet de planification de la TIC dans le Nord de l Ontario a permis de documenter les exigences techniques des systèmes d information et les sommes nécessaires pour renforcer les systèmes existants afin de créer un réseau étendu de partage des données dans tout le Nord de l Ontario. Le Programme de la gestion de la qualité Services de laboratoire a défini les normes et les processus nécessaires au maintien de l excellence dans les services de laboratoire. Le plan initial d intégration des systèmes dans le Nord-Est ontarien a déjà été mis au point et adopté par les hôpitaux participants. Des initiatives menées de façon indépendante par des regroupements de laboratoires de la région suivent déjà la voie tracée par le plan stratégique de 2003. Elles offrent de l expérience et des connaissances dont le reste de la région peut profiter. Des initiatives d intégration lancées par des laboratoires d autres régions de l Ontario ont déjà permis des progrès importants. L expérience et les connaissances ainsi acquises peuvent aussi profiter au Nord-Est de l Ontario. Le RLISS du Nord-Est a le mandat de soutenir et de promouvoir les initiatives d intégration qui bénéficieront à la population et qui ont reçu l appui des fournisseurs de services. À l heure actuelle, tout indique que l intégration des services de laboratoire du Nord-Est est pleine de bon sens. En effet, cette initiative permettra d établir un réseau de services plus efficace et efficient, qui pourra mieux répondre aux besoins de la population. La réalisation de ce projet exigera toutefois une bonne somme de travail, de temps et de ressources. Les premières étapes de ce renouvellement sont notamment les suivantes : 1) La poursuite du processus d intégration des laboratoires exige la participation d un large éventail d intervenants. Tous les hôpitaux doivent contribuer à cette initiative. En outre, il faut faire appel à des spécialistes de la médecine de laboratoire, à des partenaires de laboratoires privés et à d autres groupes représentatifs pour que le système tienne compte de tous les points de vue et de tous les besoins identifiés. Il s avère aussi nécessaire d y affecter des ressources humaines afin de faciliter le processus et d accomplir le travail «en coulisse» pour le compte du groupe, c est-à-dire, de faire la liaison avec le MSSLD, de produire des documents et des ententes qui reflètent les points de vue exprimés, de chercher les meilleures façons de répondre aux besoins des participants en respectant les responsabilités applicables, etc. RLISS du Nord-Est : Services de laboratoire
SOMMAIRE 2) Le modèle de prestation des services de laboratoire du Nord-Est doit être révisé pour qu il tienne compte de l effet que produirait l affectation d hôpitaux de la région de Muskoka à un autre RLISS à la suite de l élaboration du plan stratégique. 3) Si le financement des laboratoires privés et hospitaliers doit être versé par l entremise du RLISS, le processus de planification devrait être maintenu pour que l on puisse envisager et évaluer formellement la possibilité d établir une collaboration plus étroite avec des laboratoires privés et de procéder à une intégration appropriée de ces laboratoires. 4) Le modèle de gouvernance et la structure organisationnelle des services de laboratoire du Nord-Est doivent être fixés pour que l intégration puisse aller de l avant. Dans le cadre du processus général de planification des ressources humaines en santé décrit dans le plan d action du PSSI, le RLISS devra porter son attention sur l étape n 6 entre 2007-2008 et 2009-2010. On s attend à ce que l intégration des laboratoires actuels dans le réseau régional de services de laboratoire proposé nécessitera au moins trois ans. À cet égard, la culture sera certainement plus longue à transformer que la technique et les processus utilisés. Cependant, pour que les résidants du Nord- Est profitent dans un proche avenir d un réseau de services plus efficace et plus efficient, la transition devra commencer le plus tôt possible. 5) Il faut réviser les plans d activités et le modèle financier des services de laboratoire du Nord-Est afin de mettre à jour les renseignements et les hypothèses établis en 2003 et de fournir les précisions supplémentaires requises pour faire progresser l initiative. 6) Il convient de favoriser et de soutenir l élaboration et l application des responsabilités régionales en matière de ressources humaines en santé, exposées dans le plan stratégique de services laboratoires pour le Nord-Est. La section du plan de ressources humaines en santé du Nord-Est qui concerne les services de laboratoire devrait renfermer les éléments définis dans le plan stratégique régional des services de laboratoire. RLISS du Nord-Est : Services de laboratoire
1.0 INTRODUCTION In 2003, the Strategic Plan for North East Region Laboratory Services (the Strategic Plan) articulated a vision for laboratory services in the region to: Provide effective, high quality laboratory services; Be efficient at the provision of laboratory services; Provide an environment for excellence; and Provide exemplary and elegant service. To achieve this vision requires the development of a system that will enhance patient care and address the critical factors present in the industry. The objectives of this document are to: Provide an overview of the current state of laboratory services in North East Ontario; Identify the key integration opportunities and local priorities recommended as a focus for LHIN activities over the next three years; and Estimate the readiness for action in relation to identified priority areas. A brief resource list is included at the end of the document for further reference. 1 North East LHIN: Laboratory Services
This section of the document provides information about the current state of laboratory services in North East Ontario. It begins by describing four pillars supporting change within laboratory services. A description of the proposed model for the integration of the services within the North East region is provided, based on the Strategic Plan approved by the region s hospitals in 2003 and submitted to the MOHLTC. A summary of the activity undertaken subsequent to this proposal follows. Finally, a summary of select laboratory integration efforts in other regions is included to provide a sampling of the lessons learned from the experience of others. Four Pillars Supporting Change There are four significant change drivers currently influencing Laboratory Services throughout Ontario: Ontario Laboratory Information System (OLIS); Ontario Laboratory Accreditation (OLA); Laboratory Reform; and Laboratory Physicians and Technologists Ontario Laboratories Information System The Ontario Laboratories Information System (OLIS) is a project designed to link the information arising from the millions of orders and results from laboratory tests carried out by community, hospital and public health laboratories each year for each person. When fully implemented, OLIS will electronically link 35,000 health care practitioners with the province s 650 specimen collection centres and laboratories so that all laboratory information can be exchanged electronically between practitioners and laboratory service providers. It will provide the Ministry of Health and Long-Term Care (MOHLTC) and other payers with program management information. Patients will have faster service with less duplication of tests. OLIS will be implemented in three phases over a two-and-a-half year period. Phase 1 involves the creation of a transaction delivery system to handle the messaging and transaction processing for all laboratory test orders and results including online validation of practitioner, patient, laboratory and service data. It requires the development of data repositories to store clinical laboratory data and laboratory utilization data, and processes to record and maintain patient consent. The system will function as a web-based application. Two sites are currently involved in alpha level testing of this system. Phase 2 involves the development of the MOHLTC adjudication application and orders repository for services that are publicly funded. Phase 3 provides for a comprehensive MOHLTC financial management and reporting subsystem including a repository for laboratory financial data, and demographic information from external sources. Ontario Laboratory Accreditation In the fall of 2000, the MOHLTC authorized the Ontario Medical Association (OMA) to lead the development of its Quality Management Program for laboratory services. This initiative is intended to provide the public with assurance of the highest standards of laboratory service. North East LHIN: Laboratory Services 2
Formerly, the OMA provided proficiency testing through its Laboratory Proficiency Testing Program (LPTP) while laboratories were routinely inspected by the MOHLTC. The introduction of the Quality Management Program (QMP) expanded the mandate of the OMA to develop a peer group accreditation program and process over a five-year period. As a result, LPTP became the Quality Management Program Laboratory Services (QMP LS). Ontario Laboratory Accreditation (OLA) was implemented in 2003 and is a mandatory program for all of Ontario s licensed medical laboratories. The accreditation process involves self-assessment against a set of standards and criteria, followed by an on-site peer review assessment process. Through this process, an authoritative body ensures that laboratories meet explicit quality management criteria in order to give formal recognition that the laboratory is competent to carry out the testing that it performs. Ontario Laboratory Reform Throughout the province, laboratory services are facing a number of challenges including increasing demand for services related to population growth and aging, technology innovation and new tests, and shortages of laboratory physicians, scientists and technologists. The MOHLTC initiated the Ontario Regional Laboratory Services Planning Project (ORLSP) to follow the guidelines established by the Provincial Group on Laboratory Reform in 2000. In order to design a system that would ensure quality and access to services and optimal utilization of scarce human and technological resources, input was required from all stakeholders affected by the system. The resulting Strategic Plan for North East Region Laboratory Services was developed following extensive consultation and input from stakeholders throughout the region. This Strategic Plan was approved by hospital CEOs in 2003 and submitted to the MOHLTC. The issues and specific model proposed, as a result of this process, are detailed later in this report. Laboratory Physicians and Technologists Laboratory Physicians The Ontario Physicians Human Resources Data Centre indicates that there were 432 laboratory physicians actively working in Ontario in 2004. This represents a decrease of 3% over a six-year period. Five out of every six laboratory physicians is either a general pathologist or an anatomical pathologist. Within this group, over the six-year reference period, there has been a significant decrease in the number of general pathologists and a corresponding increase in the number of anatomical pathologists. Volumes of all other specialties are small with just 33 medical microbiologists, 21 hematological pathologists, and 17 medical biochemists practicing in Ontario. The numbers of individuals who complete postgraduate training in Ontario in each of these areas is very small too annually 2 medical microbiologists, 12 hematological pathologists and 8 medical biochemists. In North East Ontario, medical laboratory services were provided in 2004 by 19 pathologists, more than half of which were general pathologists. Sault Ste. Marie and Timmins each reported one vacancy for a 3 North East LHIN: Laboratory Services
pathologist at present, according to the listing of vacancies posted most recently by the MOHLTC through the Underserviced Area Program. The three tables included below provide detail concerning laboratory physicians in Ontario and North East Ontario. Active Laboratory Physicians in Ontario 1998 1999 2000 2001 2002 2003 2004 Change General Pathology 153 146 135 121 118 118 115-25% Anatomical Pathology 207 218 233 239 233 252 246 19% Hematological Pathology 23 21 17 18 18 20 21-9% Medical Biochemistry 24 26 24 22 21 18 17-29% Medical Microbiology 38 40 38 35 34 33 33-13% Total 445 451 447 435 424 441 432-3% Ontario Physicians Human Resources Data Centre, 2005 Postgraduate Laboratory Medicine Trainees in Ontario 1999 2000 2001 2002 2003 2004 Change General Laboratory Medicine 0 0 0 0 2 4 n/a General Pathology 10 11 8 6 8 9-10% Anatomical Pathology 39 33 43 46 66 76 95% Hematological Pathology 4 2 5 6 9 12 200% Medical Biochemistry 2 2 2 2 2 2 0% Medical Microbiology 5 1 4 9 12 8 60% Neuropathology 2 1 1 2 3 4 100% Total 62 50 63 71 102 115 85% Ontario Physicians Human Resource Data Centre, 2005 General Pathology Anatomical Pathology Algoma Sudbury RM Active Physicians in North East Ontario, 2004 Manitoulin Sound Parry Sudbury Cochrane Nipissing District Timiskaming Total 3 0 0 3 0 0 5 0 11 0 0 0 1 1 0 6 0 8 Total 3 0 0 4 1 0 11 0 19 Ontario Physicians Human Resources Data Centre, 2005 North East LHIN: Laboratory Services 4
One of the strategies currently being explored in the region to assist with the shortage of pathologists is e-pathology, or electronic pathology reporting. Through scanning technology, a digital image of the entire tissue slide is created and transmitted over a secure internet connection to a pathologist for interpretation. The product and service bundle could include such things as: standardized report formats tailored to different needs (primary care physician, cancer specialist, patient), electronic links to past pathology reports, images and graphical output. It could enable the needs of the North East region to be supported to a greater extent by pathologists located outside the region. Medical Laboratory Technologists The College of Medical Laboratory Technologists of Ontario (CMLTO) includes 7,757 registrants throughout Ontario as of their 2004 Annual Report. Registration with this College declined slowly from 1998 through 2001, falling from 8,000 to 7,500 members. However, membership has climbed steadily from this low point to the current level. Roughly 6% of CMLTO s membership is inactive (not working in the profession), consistent throughout the seven-year reference period. The majority of Ontario s medical laboratory technologists are employed by hospitals (65%), with private laboratories employing 14% of the College s registrants and public laboratories employing another 8%. The MOHLTC has increased the number of entry level training positions in medical laboratory science from 70 in 2000, to over 200, meeting its target for new training positions for medical laboratory science. As of April 13, 2006, 444 CMLTO members were registered in North East Ontario with 411 of these recorded as actively practicing. The ratio of medical laboratory technologists in Ontario, per 100,000 population, is virtually the same as the Canadian average, at 59. In North East Ontario, this ratio appears to be substantially higher at 72 per 100,000 people. One explanation for this disparity may relate to the large number of small hospital and community hospital laboratories distributed throughout North East Ontario and the Age Distribution of North East Ontario Medical Laboratory Technologists College of Medical Laboratory Technologists of Ontario, 2006 5 North East LHIN: Laboratory Services
diseconomies of scale associated with staffing facilities of this size. The age profile of medical laboratory technologists in North East Ontario is provided in the following figure. Just over one-third of the medical laboratory technologists employed in North East Ontario are working on a part-time basis. The 2003 Strategic Plan for the North East Ontario Laboratory Region documented that there were 387 full-time equivalent staff employed in clerical, technical and managerial capacities within laboratory services in the region. This report forecasted an 18% decrease in the number of hospitalbased technologists and a decrease of 39 technologists in community laboratories, as a result of retirements, by the year 2012. It also noted that laboratory staff positions were configured, in 2003, in a ratio of three medical laboratory technologists for every one technician or laboratory assistant. North East Ontario The current state of hospital sector laboratory services in North East Ontario was last documented in February 2003. This document summarized key operating statistics by sector. In the hospital sector, in 2003, there were 28 hospital sites, each with a laboratory, organized into 25 corporations; 6 different laboratory information system (LIS) platforms providing laboratory test results; 6.4 million laboratory tests provided per annum; 387 full-time equivalent technical, clerical and management staff; 24.6 full-time equivalent laboratory physicians, including 2.0 budgeted vacancies1 1.7 full-time equivalent PhD resources; and $42.8 million annual operating costs. In the community sector, in 2003, there were: 18 specimen collection centres operated by community laboratories; 15 active community laboratory licenses; Over 560,000 patient collections resulting in 2.7 million laboratory tests; and Approximately 10,500 house call services and 89,000 courier pick ups per year. In addition to supporting the needs of hospitals, North East Ontario s laboratory services were required, in 2003, to support the needs of: 38 long-term care facilities with 4,347 beds; 5 public health units; 7 community care access centres; and 540 general practitioners and 340 specialist physicians. The Region s Model The model of laboratory services for North East Ontario was documented in November 2003, as approved by the Chief Executive Officers and Executive Directors of the hospitals in the region. At that time, the North East included both the Districts of Muskoka and Parry Sound, however, the North East LHIN does not include the District of Muskoka. The service delivery model for laboratory services for North East Ontario should be revisited to consider the impact on the model of the assignment of the District of Muskoka to another LHIN. North East LHIN: Laboratory Services 6
Service Hubs and Clusters The service model approved in 2003 included five service hubs, each with a group or cluster of affiliated community or member hospitals. Sudbury Regional Hospital was identified as the regional referral hub for all hospital laboratories in North East Ontario for particular types of tests and expertise. This arrangement is documented in the following table. Hub Hospital (Cluster) North Bay General (18% of test volume) Sault Area (11% of test volume) Timmins and District (21% test volume) Sudbury Regional (36% of test volume) None (14% of test volume) Member Hospitals Mattawa General, West Nipissing General North Algoma Health Organization Anson General, Bingham Memorial, Lady Minto, Notre Dame, Sensenbrenner, Smooth Rock Falls, Hornepayne, Englehart and District, Kirkland and District, Temiskaming, Moosonee, James Bay General St. Joseph s (Elliot Lake), Blind River, Manitoulin Health Centre, Espanola General, Chapleau General West Parry Sound, South Muskoka, Huntsville District Note: In the case of Chapleau, there continues to be debate about whether it should be aligned with Sudbury or Timmins. This was to be determined in Phase 2 of the work. As an integrated part of the North East health care system, the regional hospital cluster model was envisioned to be a not-for-profit laboratory organization with the mission to provide appropriately integrated access to laboratory services and laboratory medicine specialists. Governance In the process of developing the model, the Working Groups were directed by hospital CEOs and Executive Directors to spend less time on governance in favour of devoting more time to determining how to make the service delivery model work. Consequently, recommendations concerning governance were not developed other than to reach agreement concerning the following principles: Some mix of the partnership and joint executive committee models would be most effective in the North East; All hospitals and clusters would join into a formal agreement; Decision-making and implementation roles and powers would be split between the clusters and the region; The new organization would be responsible and accountable to each member hospital for the provision of services; and The selected governance structure must be attractive to the medical and technical staff so that they will stay with the organization. The consultants who supported the North East Ontario hospitals in developing the Strategic Plan recommended that the hospitals adopt a joint executive committee (JEC) form of governance. Through this structure: Each hospital would appoint a delegate to the JEC and would delegate to the Committee, the power to make governance and management decisions related to laboratory decisions on its behalf; 7 North East LHIN: Laboratory Services
A JEC Agreement would be written to cover items such as mandate, accountability, decision-making process, scope of decision-making, privileges, responsibilities, etc.; The JEC would be responsible to its member hospitals; Decisions would be supported by a majority of the participating hospitals; Operating and capital funds would flow to the JEC from the hospitals; The scope of the role of the JEC would be limited to laboratory services and would not impinge on the role of the Boards of the individual hospitals; The JEC would be responsible for developing and implementing management structures as needed to effectively implement the new regional organization; Each hospital would remain the employer of record for laboratory staff; and Effective region-wide mechanisms for achieving an effective and efficient laboratory system would be put in place. The governance model and organizational structure for laboratory services for North East Ontario must be decided in order to proceed with the integration of laboratory services throughout the region. Operational Structure The following section of the document briefly highlights the role of select staff and committees in the operational structure of the laboratory service system as envisioned for North East Ontario. Laboratory Medical Directors According to the model, the laboratory medical directors and medical staff would be hired or contracted by individual hospitals, as regular members of that hospital s medical staff with full medical privileges. Each physician would remain accountable to their hospital s Board of Directors and Medical Advisory Committee in the usual way. The consultants recommended that each cluster should have one laboratory medicine physician leader who would coordinate and manage the medical and scientific activities of that cluster. Collectively, these cluster leaders would coordinate and manage the medical and scientific activities for the region. Specifically, they would: Ensure the quality of the medical, scientific and technical activities Develop fair, effective and uniform guidelines for the allocation, integration and coverage of medical human resources; and Develop a regional continuing medical education program. Region and Cluster Level Staff It was recommended in the Strategic Plan that there be a small management team constituted at the regional level, responsible to the JEC. The Strategic Plan did not document this structure in any detail but suggested that the team might include an operations manager, a quality coordinator, and a medical leader. Their responsibilities would include: North East LHIN: Laboratory Services 8
Providing coordination and guidance to the committees; Region-wide business planning; Providing input to, and developing, proposals for the JEC to consider; and Planning and negotiation with the MOHLTC. In each cluster, it was anticipated that the management structure would consist of one operations manager, one medical director and, possibly, one quality coordinator. Each individual laboratory site within the cluster would be overseen by a charge technologist. As envisioned, multi-cluster cross-functional committees would do much of the work in coordinating, investigating and making recommendations to the JEC, focused in areas such as: quality management, test siting and referral, human resources, information connectivity, standardizing and consolidating equipment purchasing and implementation, and regional programs. Individual hospitals would contract with each cluster and, possibly, with Sudbury Regional Hospital as the regional referral centre. Laboratory Information Systems Integrated information and communication technology is required to make information available to all health care providers in the circle of care about a patient s laboratory tests. To accomplish a regional laboratory information system, as envisioned by the Strategic Plan, four separate layers of implementation are required: 1) Establish LIS connectivity within each cluster; 2) Establish LIS connectivity between the clusters and Sudbury Regional Hospital s laboratory; 3) Establish LIS connectivity with the private sector laboratories; and 4) Provide access to community physicians and provincial laboratories, long-term care homes and community care access centres. The implementation of connecting laboratory information systems for North East Ontario is a key enabler to the integration of laboratory services. System requirements are discussed in greater detail as part of two different projects. They are documented as part of Phase II of the regional electronic health record as envisioned in the ICT Blueprint for Northern Ontario. They are also the focus of the Ontario OLIS project, mentioned previously in this report. Progress on either or both of these initiatives will support the development of a laboratory information system for North East Ontario. Human Resources Committee The Strategic Plan made a number of recommendations in relation to human resources, dividing these responsibilities between regional and subregional groups, according to the following chart. 9 North East LHIN: Laboratory Services
Regional and Subregional Responsibilities in Relation to Laboratory Services Human Resources Regional Level Develop the Human Resources Plan Develop approaches and policies concerning recruitment and retention Implement a shared approach to developing skills and acquiring knowledge Consider the development of policies concerning compensation Represent the concerns of the region to the MOHLTC, colleges and universities (e.g. degree requirement by 2010, foreign applicants) Coordinate clinical placements Hire central laboratory resources Cluster and/or Hospital Level Provide input concerning regional responsibilities Implement regional initiatives Implement regional CME and training plans Hire Quality Coordinators Manage employees and oversee day-to-day operations including performance management and expectations It was recommended that the regional human resources plan for North East Ontario be developed as soon as possible during the design phase of laboratory restructuring. Elements of this plan were to include: Specification of the number and type of health professionals required to deliver services; Coordinated recruitment and retention strategies; Provisions for skills development through training and education; Increasing the number of shared human resources policies throughout the region (e.g. incentive programs); and Developing key indicators for human resources. The regional level health human resources responsibilities outlined in the North East Region Laboratory Services Strategic Plan should be supported in their development and implementation. The portion of the LHIN s proposed regional health human resources plan that addresses laboratory services should incorporate the elements defined in the Regional Laboratory Strategic Plan. Quality Committee The management of quality within Ontario hospital laboratories is an exacting and time-consuming process that is required to produce the reliable test results that physicians and patients have come to rely on. There are significant gains to be made by adopting a shared approach to quality management within clusters and across the region. Among other things, these benefits relate to efficiencies with respect to time and standardization, the benefit of specifically dedicating resources to quality, and the ability to seek out and adopt or adapt best practices. The region s Quality Committee would be accountable for developing, implementing and monitoring of a number of elements of service quality including: quality improvement, quality control, licensing and accreditation, staff credentialing, compliance North East LHIN: Laboratory Services 10
with QMP-LS standards and other compliance standards (e.g. Canadian Blood Standards), benchmarking, and quality management policies and guidelines. Test Siting Committee Determining the location where different types of laboratory tests are performed is always a contentious issue when creating systems of laboratory service providers. In some instances, it means discontinuing local testing in favour of referral of specimens to another laboratory site. This can have an Regional Level Develop a broad overview plan and strategy (including business case) Make macro decisions re: test siting and referral (e.g. What special tests are sited in only one place? What tests are currently referred out of the region that can be brought back?) Develop and maintain minimum STAT testing menu laboratory profiles Review and recommend new tests and implementation strategies Act as a resource centre for testing guidelines, new directives, licensing requirements, reference ranges, test selection, methodology, clinical practice guidelines, and utilization impact on the number and type of employees who work in the laboratory, the immediate availability of test results, and perceptions by medical staff. Committees at both the regional and cluster level would have roles to play in relation to test siting with responsibilities assigned in accordance with the following table. At a high level, one suggestion made during the strategic planning process to rationalize testing within the North East region would have the impact represented in the second table. Cluster Level Determine local testing needs based on current clinical practices at each site Implement test menus locally Participate on the regional committee Validate new tests (when needed) Develop and share performance criteria Implement regional directives as appropriate Test Type Current Number of Sites Proposed Proposed Key Change Biochemistry, Immunology and Haematology 25 25 25 n/c Immunoassay 18 4 4-14 Immunohaematology 24 24 4-20 Bacteriology 19 19 5-14 Parasitology 9 0 0-9 Cytology GYN 5 4 4-1 Cytology non GYN 23 4 4-19 Histology (blocks) 9 5 5-4 Genetics 1 1 1 n/c Molecular 1 1 1 n/c Uncoded 4 4 4 n/c 11 North East LHIN: Laboratory Services
This suggested test siting plan would significantly reduce the number of hospital laboratories performing immunoassay, immunohaematology, bacteriology, parasitology, and non-gynecological cytology. There would also be adjustments within categories as specific tests in any given test category may be referred out by community hospitals to the cluster s hub laboratory. Finance and Purchasing Committee According to the approved model, the MOHLTC would still continue to flow funding to each hospital individually where it would be allocated to the laboratory s budget. While the budget for the entire laboratory service system would be focused at the region and cluster level, each hospital would maintain its own laboratory budget. There would be regional- and cluster-level accountabilities and activities in relation to finance and purchasing as detailed in the following table. During 2005, hospitals in North East Ontario received approximately $2 million, through the MOHLTC s Diagnostic Medical Equipment Fund, for the purpose of purchasing laboratory equipment. Results of System Implementation Some of the most significant arguments made in the Strategic Plan in relation to support for transforming laboratory services in North East Ontario relate to concerns over system sustainability in the face of declining numbers of human resources. In 2003, it was projected that there would be significant reductions in the number of both technical (61 FTEs or 16%) and medical staff (1.9 FTEs or 7%) over the next ten-year period. At the same time, it was forecast that test volumes would continue to increase at current rates, growing by 16% over the same ten-year period. Additionally, the cost of tests to Regional Level Cluster Level Review centrally-funded items such as information technology, some elements of human resources, and transportation Accountable to the clusters for spending money well Develop broad plans Allocate costs for shared services to clusters based on agreed formulas Apply for funding grants for regional improvements Recommend major regional capital projects Manage the flow of dollars Facilitate purchasing arrangements Develop a cooperative model to identify key operational issues that require direct funding and coordinate funds from each facility Flow funds to the region for shared resources (e.g. transportation, information technology, regional management, etc.) Participate on the regional committee North East LHIN: Laboratory Services 12
hospital laboratories was projected to continue increasing at a rate of at least 1.5% per year. In the absence of improved system effectiveness and efficiency, the magnitude impacts of the combination of staff attrition and increased test volume and cost is expected to result in a reduction in service levels. Benchmarking productivity performance indicators (laboratory tests per full-time equivalent staff per day) against the actual productivity levels in North East Ontario laboratories indicates that there is the potential to significantly increase efficiency within a redesigned laboratory system. Even without reaching best practice performance levels, the service system for North East Ontario, once redesigned, should be able to perform the number of laboratory tests forecast for the region without replacing the number of staff expected to leave the system over the next ten years. In the Strategic Plan, the creation of the regional laboratory system was calculated to save $9.8 million in the first five years. Net cash outflows are forecast for the first two years of the project, reflecting one-time costs of $2.3 million. These relate to development of the laboratory information system, renovation and rebuilding costs, staff retraining, and legal and consulting fees. By the fifth year, annual savings amount to $5.4 million and are expected to rise dramatically beyond this point. It is anticipated that transforming the current array of laboratories into the planned regional service system would take at least three years with the cultural changes requiring a longer period of time to implement than either the technical or process changes. In order to proceed with the recommendations of the Strategic Plan, business plans and financial modeling for laboratory services for North East Ontario must be revisited in order to update the information and assumptions made in 2003 and to provide the additional detail required to advance progress. Cluster Level Activity Within North East Ontario, since the development of the Strategic Plan, other priorities have dominated the hospitals agendas so that there has been little progression toward advancement of the regional laboratory vision and model. These priorities have included a focus on balancing budgets and adapting to the Ministry s transformation agenda. Despite these issues, unique circumstances and conditions propelled the Timmins- Cochrane-Timiskaming (TCT) laboratory services cluster to move forward independently in implementing a shared approach to laboratory services, in line with the vision and plan put forward through the regional model. Within this cluster, a number of hospitals had been organized for some years as the Cochrane Regional Laboratory Program (CRLP), with a pathologist from Sudbury serving as the medical director for all laboratories in this group. This physician announced his intention to retire, providing many months of advance notice to the CRLP hospitals. Timmins and District Hospital is the hub hospital that would support the CRLP hospitals according to the region s model for laboratory services. The Timmins-Cochrane- Timiskaming cluster decided to move forward and further detail the service model required to support the needs of the cluster. The CRLP hospitals brought to the process their 13 North East LHIN: Laboratory Services
experience in working together collaboratively over the years, sharing a medical director and quality manager. Working groups, including representatives from hospitals throughout Timiskaming and Cochrane Districts, met throughout 2004 and focused on: human resources, test sizing and siting, and quality management. As a result of this process, the TCT cluster developed a set of plans and commitments to: Standardize equipment purchasing and purchase as a group; Standardize point of care testing; Select and implement a common laboratory information system or interface across existing systems; Ensure necessary transportation networks; Collaborate on quality management principles and practices; and Realign testing (most notably microbiology) and consolidating testing for microbiology from five sites to one or two. Letters of intent were provided by each of the hospitals participating in the TCT cluster although the legal document that will bind the group in sharing services has not yet been executed. The operating model selected by this cluster includes provisions for one medical director, one general manager, one quality manager and one transfusion medicine specialist, in line with the vision laid out for the clusters within the Strategic Plan. In order to address the immediate need for medical directorship, the cluster contracted with the Toronto Medical Laboratory/University Health Network (TML/UHN) which now supports the needs of the cluster with laboratory medicine specialists. One laboratory physician regularly attends on site, on a rotational basis, throughout the cluster hospitals while the expertise of other TML/UHN laboratory physician specialists remains available to the group on a consultative basis. Simultaneously, Timmins and District Hospital established a relationship with MDS Laboratories for management of its own laboratory operations. MDS has been adopted as the laboratory courier service and referral laboratory by all hospitals in the cluster. A general manager has been hired to lead the work of the cluster laboratories and a quality manager will be selected within the second quarter of 2006. The transfusion medicine specialist is expected to be recruited by the summer of 2006. In addition to the ambitious agenda that the TCT cluster has adopted, they are actively exploring e-pathology technology, seeking to build on the infrastructure in place through NORrad that connects each of the cluster hospitals at present. (Sault Area Hospitals is also exploring the use of e-pathology.) The managers or coordinators working in each of the TCT cluster hospitals meet regularly to work through shared issues in a collaborative fashion and to advance the agenda of the cluster. Other Regional Initiatives Regionalization of laboratory services is progressing at various rates in different regions within Ontario. This section of the document highlights activity from three different regions and summarizes the lessons learned by others. North East LHIN: Laboratory Services 14