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Fraser Health Authority

Strategic and Operational Plan

2014/15 – 2016/17

June 2014


For more information on the FRASER HEALTH AUTHORITY

contact:

FRASER HEALTH AUTHORITY Suite 400, Central City Tower

13450 – 102nd Avenue Surrey, B.C. V3T 0H1

or visit our website at www.FraserHealth.ca

http://www.fraserhealth.ca/


Strategic and Operational Plan of 90

MESSAGE FROM THE INTERIM BOARD CHAIR

On behalf of the board of directors and employees of Fraser Health, I am pleased to submit our Strategic and Operational Plan for fiscal years 2014/15 to 2016/17.

This plan was developed in accordance with the strategic and operational review commissioned by the Minister of Health in October 2013, and directly incorporates the findings and advice provided by the review committee convened by the Minister. The plan provides an analysis of the operating context of Fraser Health and sets out ten linked areas Fraser Health will prioritize and sustain focus on to achieve meaningful improvements in population and patient outcomes in the coming years. These priorities will be the basis on which Fraser Health Service and Budget Plans are developed and will be tracked by a balanced scorecard of indicators.

Most recommendations of the review committee are addressed in this plan, and the board is committed to considering and addressing all of the recommendations. However, findings and recommendations related to the review of duplication or redundancy in the delivery of health programs and services between Fraser Health and neighbouring health boards, and to whether the health needs of the region's population would be met more effectively or efficiently by changing the area of British Columbia that constitutes the region, are not included in this plan. As that review and findings are broader in scope than just Fraser Health, they have been presented to the Minister in a separate document for his consideration.

In 2014/15, Fraser Health has budgeted for total revenues of $3.3 billion, primarily through contributions from the Ministry of Health. Fraser Health is committed to a balanced budget throughout the three-year cycle of this plan and information on the budget plan is included in this document. The budget will be focused on meeting the needs of the population and supporting the highest priority actions outlined in this plan.

On behalf of our board and of Fraser Health as a whole, we look forward to working very closely with Government, as together we seek ways to meet the needs of those who live in Fraser Health in a responsible, responsive and sustainable manner.

G.W. (Wynne) Powell, CPA, FCGA, D.Tech. (Hon.) Interim Board Chair

June 2014



CONTENTS

Message From The Interim Board Chair ........................................................................................................................ 3

Organizational Overview ............................................................................................................................................... 7

Understanding Population Health Needs, Service Delivery and the Fraser Health Organization ................................. 8

Population and Patient Health Needs ....................................................................................................................... 8

Staying Healthy ...................................................................................................................................................... 9

Special Populations .............................................................................................................................................. 10

A Rising Burden of Chronic Disease and Disability............................................................................................... 11

Service Delivery ........................................................................................................................................................... 13

Population and Public Health Services .................................................................................................................... 13

Healthy Living ....................................................................................................................................................... 13

Maternal, Child and Family Health ...................................................................................................................... 13

Harm Reduction ................................................................................................................................................... 14

Immunization ....................................................................................................................................................... 14

Health Protection ................................................................................................................................................. 15

First Nations ......................................................................................................................................................... 15

Primary Care ............................................................................................................................................................ 16

Attachment to Primary Care ................................................................................................................................ 16

Accelerated Integrated Primary and Community Care Funding .......................................................................... 17

Aboriginal Health ................................................................................................................................................. 18

Conclusion – Primary Care ................................................................................................................................... 19

Mental Health and Substance Use .......................................................................................................................... 20

Home Care Services ................................................................................................................................................. 21

Residential Care ....................................................................................................................................................... 23

Acute Care ............................................................................................................................................................... 27

Occupancy Rates .................................................................................................................................................. 27

Patient Satisfaction .............................................................................................................................................. 28



Analysis of Acute Hospital Care Service Utilization ................................................................................................. 29

Age Standardized Rates for Selected Acute Care Services .................................................................................. 29

Comparison of Acute Care Service Utilization ..................................................................................................... 32

Emergency Department Utilization ......................................................................................................................... 32

Potential Drivers of Emergency Department Utilization ..................................................................................... 34

Surgical Services....................................................................................................................................................... 36

Patient Safety in Acute Services .............................................................................................................................. 37

Access and Flow in Acute Care ................................................................................................................................ 42

Acute Care Beds per 1,000 People ....................................................................................................................... 43

Actual Length of Stay vs Expected Length of Stay (ALOS/ELOS) .......................................................................... 44

Alternate Level of Care Rates............................................................................................................................... 45

Readmission Rates ............................................................................................................................................... 46

Ambulatory Care Sensitive Conditions ................................................................................................................ 46

Opportunities to Improve Quality in Fraser Health Hospitals ................................................................................. 48

Governance, Management, Human Resources and Finances ..................................................................................... 49

Governance, Leadership and Management ............................................................................................................ 49

Relationship With Physicians ............................................................................................................................... 51

Health Human Resources ........................................................................................................................................ 53

Overtime .............................................................................................................................................................. 53

Sick Time .............................................................................................................................................................. 54

Staff Injury Rate ................................................................................................................................................... 54

Difficult-to-Fill Vacancies ..................................................................................................................................... 55

Staff Deployment Opportunities .......................................................................................................................... 55

Staff Engagement ................................................................................................................................................. 55

Conclusion – Health Human Resources ............................................................................................................... 57

Finance and Funding ................................................................................................................................................ 58

Deployment of Regional Funds ............................................................................................................................ 60

Conclusion From Population Health Needs, Service Delivery and the Organization .................................................. 62



Priority Actions For Quality and Sustainable Service Delivery in Fraser Health .......................................................... 64

1. Capacity for Care Across All Sectors .................................................................................................................... 64

2. Quality and Safety ................................................................................................................................................ 65

3. Public Health Measures ....................................................................................................................................... 65

4. Accountability ...................................................................................................................................................... 66

5. Staff and Physicians ............................................................................................................................................. 66

6. Patient Centredness............................................................................................................................................. 67

7. Governance .......................................................................................................................................................... 67

8. Operational Organization and Management ....................................................................................................... 67

9. Lower Mainland Collaboration ............................................................................................................................ 68

10. Budget Accountability ........................................................................................................................................ 68

Financial Plan ............................................................................................................................................................... 69

Financial Planning Process ....................................................................................................................................... 69

Determine Service Volumes ................................................................................................................................. 69

Alignment With Strategic and Operational Plan .................................................................................................. 72

2014/15 Financial Considerations ........................................................................................................................... 74

Three Year Statement of Operations – Revenues, Sector Expenditures, Expenditures by Category and Budgets by Program/Portfolio .................................................................................................................................................... 75

Revenue ................................................................................................................................................................... 76

Sector Expenditures ................................................................................................................................................. 76

Expenditures by Category ........................................................................................................................................ 78

Net Budget by Program/Portfolio ............................................................................................................................ 80

Lower Mainland Consolidation and Health Shared Services BC .............................................................................. 83

Capital Asset Management Plan Summary.............................................................................................................. 83

Summary of Key Projects (Over $10.0 Million) ........................................................................................................ 86

Risks ......................................................................................................................................................................... 88

Appendix A .................................................................................................................................................................. 90



ORGANIZATIONAL OVERVIEW

As one of five regional health authorities in British Columbia, Fraser Health Authority (FH) organizes and operates a ‘system for health’ and delivers prevention, hospital, residential, community-based and primary health care services. Fraser Health’s legal authority is specified by the Health Authorities Act. Fraser Health partners with the two non-geographic health authorities (Provincial Health Services Authority and the First Nations Health Authority) on service delivery that transcends the geographic boundaries of Fraser Health.

The Ministry of Health appoints nine directors to the board to govern Fraser Health. Its governance approach is guided and assessed by Best Practice Guidelines and Governance and Disclosure Guidelines for Governing Boards of British Columbia Public Sector Organizations. The board provides oversight to ensure Fraser Health fulfills its vision and purpose and operates in accordance with its values.

Central to the vision and mission of Fraser Health is the optimization of the health status of its residents. Enjoying good health and a high quality of life throughout the course of one’s lifetime is a consequence of many factors, including access to quality education, meaningful employment, supportive family and friends, community environments and making healthy lifestyle choices.

Serving this mission are over 22,000 staff members, over 2,500 physicians and 6,500 volunteers working in partnership in very diverse work settings from hospitals, to mental health centers, public health units and services in ambulatory clinics and in homes.

In the fall of 2013, the Minister of Health directed that a strategic and operational review be undertaken of Fraser Health for the purpose of creating a Strategic and Operational Plan to be approved by the Minister. The regulation set out in Ministerial Order number M282 specified that the board must conduct a review with the assistance of a review panel. In section 4.2 subsection, A through H, of the regulation, the panel was to examine a range of matters including the population health needs, service delivery utilization and quality, as well as organization, leadership and governance. The review panel examined data and documents and conducted interviews with a broad range of internal and external stakeholders. The review panel produced working papers that included recommendations and areas for consideration.

This Strategic and Operational Plan directly incorporates the data, analysis and findings of the review and considers the recommendations and areas for consideration in setting priority actions. Importantly, this plan considers the broader context of the overall direction of the health system to ensure our actions are aligned with the direction set out by the Ministry of Health in Setting Priorities for the B.C Health System.

http://www.health.gov.bc.ca/library/publications/year/2014/Setting-priorities-BC-Health-Feb14.pdf




UNDERSTANDING POPULATION HEALTH NEEDS, SERVICE DELIVERY AND THE FRASER HEALTH ORGANIZATION

The health system is a complex network of interdisciplinary teams of skilled professionals, organizations and groups that work together to provide value for patients, the public and taxpayers. The key challenge facing the health system is to deliver a high-performing sustainable system (from prevention to end-of-life care) in the context of significant growth in demand.

This section of the plan provides analysis of factors that are considered in setting priority actions for Fraser Health. It is organized in three sections: Population and Patient Health Needs, Service Delivery, and Organization (Governance, Management, Human Resources and Finances). Incorporated throughout this section is the analysis undertaken as part of the strategic and operational review.

POPULATION AND PATIENT HEALTH NEEDS

Fraser Health serves approximately 1.70 million people in the Lower Mainland, accounting for just over one third of the total provincial population. Its geographical area runs west to east from Burnaby to Hope and south to north from the Canada/U.S. border to Boston Bar. It is the fastest growing health authority in British Columbia and has almost doubled in population since 1986. Between 2014 and 2019, the population is expected to increase by approximately 163,000 people to 1.86 million, or by approximately 10 per cent overall, with some communities growing at even faster rates.1 The Fraser Health population is generally younger than other health authorities, and has the lowest proportion of the population over 65 (13.8 per cent) and over 75 (6.2 per cent) except for the Northern Health Authority (NHA).

Fraser Health is divided into three Health Service Delivery Areas (HSDAs). As of 2012, Fraser Health South was the largest HSDA, with 738,107 people, or 45 per cent of the Fraser Health total. Fraser Health North is the second largest, with 623,357 people (38 per cent). Fraser Health East is less than half the size of either of the other two HSDAs, with 288,598 people (17 per cent).

The communities in Fraser Health are very diverse. Fraser Health has large Asian, Indo-Canadian, Korean, and Filipino populations. The region is home to the majority of B.C.’s South Asian population, with South Asians comprising 15 per cent of Fraser Health’s entire population (compared to three per cent for the rest of B.C.).

1 BC STATS, B.C. Ministry of Technology, Innovation and Citizens' Services, P.E.O.P.L.E. 2013 projections



The South Asian community is also growing rapidly, contributing close to half of the region’s population growth between 2001 and 2011. Fraser Health also has approximately 52,000 Aboriginal peoples, with 32 First Nations Bands in the region.

The following subsections describe some key population needs in Fraser Health.

STAYING HEALTHY

Population health indicators show Fraser Health residents are, on balance, as physically healthy as their counterparts in similar age and gender cohorts across the province. Life expectancy profiles are suggestive of a slightly healthier population on average. When compared to the provincial population, fewer Fraser Health residents perceive themselves to be in a poor or fair state of mental health and only a small portion of the population perceives itself to be in “quite a lot” of life stress. The social dimension of health, which addresses the complex interactions among people, their personal characteristics and the environment, is harder to describe than the physical and mental dimensions, as it often refers to the capacity to establish and maintain social bonds and to interact successfully with others and the broader community. The sense of community belonging reported in the Canadian Community Health Survey for Fraser Health is close to provincial norms.2

Using the most measured and accepted indicator of health status, life expectancy, Fraser Health is the second healthiest region in British Columbia at present, with a life expectancy of 82.3 years, compared to the provincial life expectancy of 82.0 years for both genders combined. Over the past decade, Fraser Health life expectancy gained 2.2 years; this is consistent with the provincial gain. Only the residents of the Vancouver Coastal Health Authority (VCH) live longer: 83.7 years at present and 80.3 years 10 years ago.3

Fraser Health’s standardized mortality ratio for all causes is somewhat better than B.C.’s average, the second best rate among the geographic-based authorities. Of the major causes of death, circulatory diseases and respiratory diseases have slightly higher (poorer) standardized mortality ratios, while the cancer ratio is better than for B.C. Cerebrovascular disease (stroke) and diseases of the digestive system have lower (better) than average standard mortality ratios. All of the external causes of death (accidents, suicides, drug-induced deaths, etc.) are better than B.C.’s average rate.

2 Canadian Community Health Survey 2012/13 3 Vital Statistics and Health Status Indicators, Annual Report 2011, British Columbia Vital Statistics Agency



These standardized ratios for the time period 2007 to 2011 have all improved relative to the provincial ratio since the 2004 to 2008 time interval. Fraser Health’s potential years of life lost (PYLL) before age 75 rate is 0.93, the second best behind Vancouver Coastal Health.

Among the health authorities, Interior Health, Northern Health and Island Health all have higher than average PYLL rates. The infant death rate is also the second best in the province, behind Interior Health.4

In 2012/13, over 200,000 people in Fraser Health did not use any health services, with a further 580,000 people only experiencing minor, episodic health needs. Helping people stay healthy contributes to overall quality of life and significantly decreases the overall demand on the health system.5

SPECIAL POPULATIONS

First Nations are an important population served through Fraser Health. Fraser Health is home to approximately 52,000 Aboriginal peoples (2011). There are 32 bands, with the majority of individuals living in urban settings. Approximately three per cent of Fraser Health residents self-reported as Aboriginal in the last census.6 At that time, Fraser Health was home to 19.4 per cent of the total provincial Aboriginal population; however, as a proportion of the total population, Fraser Health had the second lowest percentage of Aboriginal people in the province, behind Northern Health (17.5 per cent), Interior Health (6.7 per cent) and Island Health (5.8 per cent). At the HSDA level, the Aboriginal population in Fraser Health East accounted for 5.7 per cent of the total, compared to 2.1 per cent of Fraser Health South and 1.9 per cent of Fraser Health North.

In 2010, Fraser Health compiled a profile of Aboriginal people in the region in collaboration with Aboriginal leaders and the broader Aboriginal community. The profile has guided planning and service delivery in the region, and be can be viewed at: http://fraserhealth.ca/media/Aboriginal%20Profile_2010.pdf.

In Fraser Health, a significant portion of the population is of South Asian descent. Countries of origin include: Bangladesh, Bhutan, India, Maldives, Nepal, Pakistan and Sri Lanka. As mentioned earlier, the South Asian population comprises approximately 15 per cent of the population of Fraser Health.

4 Vital Statistics and Health Status Indicators, Annual Report 2011, British Columbia Vital Statistics Agency 5 Health System Matrix 5.0, Health Sector Planning and Innovation Division, Ministry of Health 6 Census 2006, Aboriginal Profiles, Health Authority Summary Tables, BC Stats

http://fraserhealth.ca/media/Aboriginal%20Profile_2010.pdf



Over the past decade, more than 90 per cent of the growth in the South Asian population of British Columbia occurred in Fraser Health. This group faces particular health challenges, including a diabetes prevalence rate estimated to be twice as high as that of the general population, earlier onset of diabetes, higher rates of cardiovascular disease, and a dialysis rate over one and a half times that of the general population.

There are also a number of socio-demographic, cultural and religious, economic and structural barriers for this group. Some barriers may include literacy and health literacy rates in their own language and English; difficulty accessing care due to transportation and translation; less knowledge regarding disease, risk factors and self-management; and some reluctance to change dietary habits due to custom and religious values attached to food.

A RISING BURDEN OF CHRONIC DISEASE AND DISABILITY

Chronic diseases are prolonged conditions such as diabetes, depression, hypertension, congestive heart failure, chronic obstructive pulmonary disease, arthritis, asthma and some cancers. People with chronic conditions represent approximately 44 per cent of the B.C. population and consume approximately 69 per cent of the combined physician payment, PharmaCare and acute care budgets.7 Chronic diseases are more common in older populations and it is projected that the prevalence of chronic conditions could increase 58 per cent over the next 25 years in British Columbia8 and be a significant driver of demand for health services. Chronic diseases can be prevented or delayed by addressing key risk factors, including physical inactivity, unhealthy eating, obesity, alcohol consumption and tobacco use. B.C. continues to experience success in implementing strategies which have prevented or delayed chronic disease and which Fraser Health needs to build on and accelerate for the years ahead.

In 2012/13, data shows that in Fraser Health 475,000 people experienced a low complex chronic condition, 136,000 experienced a medium complex condition, 68,000 experienced a high complex chronic disease, and 23,000 people accessed mental health and addiction services. An analysis of disease prevalence rates shows Fraser Health generally has modestly higher prevalence rates for selected chronic conditions than B.C. averages.9

7 B.C. Ministry of Health, Health System Matrix Version 5.0 May 2014 8 B.C. Ministry of Health, Medical Services Division, Chronic Disease Projection Analysis, march 2007, (2007-064); as cited in Primary Health Care Charter: a collaborative approach (2007), Ministry of Health Charter: a collaborative approach (2007), Ministry of Health 9 B.C. Ministry of Health, Health System Matrix Version 5.0 May 2014



Detailed Local Health Area analysis is available on Fraser Health’s web site at: http://www.Fraser Health.ca/about_us/reports/. These community-by-community reports provide comparisons of a very broad range of population health indicators, highlighting trends and important differences between communities.

http://www.fraserhealth.ca/about_us/reports/

http://www.fraserhealth.ca/about_us/reports/



SERVICE DELIVERY

Fraser Health delivers a full continuum of health services, from broad population health programs to specialized hospital treatment. This section provides an overview of service areas, current delivery of services and identified challenges or areas for focused improvement.

POPULATION AND PUBLIC HEALTH SERVICES

Public health services help keep people healthy by working to prevent disease and injury. Health promotion and prevention professionals provide health screening and assessment, referral, early treatment, and help to build public health capacity through community development and partnerships. Public health professionals are experts in immunization, communicable disease control, maternal and pregnancy health, speech therapy, audiology, nutrition, dental health, non-communicable diseases, health emergency management, and more.

HEALTHY LIVING

Fraser Health has taken a strong approach to tobacco enforcement and has the highest rate of retailer inspections across all health authorities. They have also been proactive in addressing the potential harms of e-cigarettes by proposing policy direction to school districts in the region. There are strong relationships being established and visible success already achieved with schools and communities as part of the strategic integration of Healthy Families BC priorities, with local government to implement healthy living strategic plans, and across other sectors to integrate healthy built environment and healthy living mandates. Building on these successes, there are further opportunities to work with the Ministry of Health to more fully align food policy with healthy eating and food security priorities. Healthy eating resources and tools could reach wider audiences and enable sustainability to align with provincial messaging and standards that continue to be a focus in the new Healthy Families BC Policy Framework. There are opportunities to promote hospital-based tobacco cessation throughout FH and focus on fall prevention in hospitals to decrease hip fractures on site. Finally, there is an opportunity to extend the implementation of Surrey’s Healthy Schools BC pilot to other school districts in the FH region, while continuing to strengthen and build new community and Non-Governmental Organization partnerships.

MATERNAL, CHILD AND FAMILY HEALTH

Fraser Health has made substantive progress in the implementation of the provincial public health perinatal, child and family health service standards to support positive maternal-child health outcomes in the region.



Fraser Health is actively working to increase prenatal referrals to its prenatal registry, which is fundamental to the success of BC Healthy Connections. Furthermore, a dedicated lead has been established to advance breastfeeding initiation and duration, including implementation of the Baby-Friendly Initiative for both acute care and community settings. As Fraser Health has the highest birth rate in B.C., implementation and strong leadership for maternal and child health are essential to influence positive early childhood development and to reduce the risk of chronic disease later in life. Continued work to restructure maternal/child programming, increase recruitment to the BC Healthy Connections project, enhance programs to support social/emotional development and address early childhood oral health will help to build on current successes and ensure positive outcomes for major health indicators.

HARM REDUCTION

Fraser Health has made significant progress in harm reduction activities, particularly with changes to City of Abbotsford bylaws that previously prohibited harm reduction services. As year-one STOP HIV programming has been successfully implemented throughout the Fraser Health region, sustained efforts will help ensure positive results are realized. Additional capacity to reach and engage individuals and communities in HIV prevention and intravenous drug user harm reduction could be beneficial to prevent ongoing transmission. While the overall rates of hepatitis C have decreased significantly over the past decade at the same rate as the rest of the province, certain geographic areas within the Fraser Health region remain elevated. The distribution of safer sex and drug use harm reduction equipment could be increased to better match population density relative to other health authorities in order to help achieve provincial targets.

IMMUNIZATION

Of all the regional health authorities, Fraser Health has the highest overall percentage for HPV vaccine coverage rates for grade 6 girls (71 per cent) and is above the provincial average of 69 per cent. The coverage rate for two-year-olds has also been steadily rising. Additionally, the region met or reported above the provincial average for influenza immunizations during the 2012/13 flu season for healthcare workers and staff and residents in residential care facilities. In terms of outbreak response, the measles outbreak was declared over as of April 28, 2014, and was kept largely contained to the eastern regions of the Fraser Valley due to dedicated healthcare providers at Fraser Health and the increased uptake of vaccination at clinics held throughout the affected region. Ongoing attention to immunization is important to maintaining population health.



HEALTH PROTECTION

Fraser Health continues to place a strong emphasis on health protection and is doing significantly better than the rest of the province for rates of E. coli. Under regulations governing use, treatment and application of agricultural waste, Fraser Health can play a significant role in the review of agricultural land use issues through composting and waste regulations which help prevent contamination of ground water quality. It is important to continue to utilize inspection authority to identify and address illegal egg sales and help control salmonella outbreaks. Maintaining or increasing compliance with food safety plans and sanitation plans is also important to help guide food processors and environmental health officers in meeting the Food Premises Regulation food safety requirements. Finally, Fraser Health’s work with the Ministry of Agriculture continues to be a priority area to help address air quality pollutants and odours, particularly in the Fraser Valley area. For example, there are opportunities to help municipalities integrate land use and transportation planning to support physical activity and minimize air pollution that could be explored and will require support from other sectors.

FIRST NATIONS

Fraser Health was the first regional health authority to sign a Health Partnership Accord, with the Fraser Salish Caucus, in December 2011. Since then, sustained commitment and strong momentum have carried the relationship into implementation. The Aboriginal Health Steering Committee – with representation from First Nations, the board of directors, senior executive, clinical staff, and co-chaired by the FH CEO — has been very active in facilitating the transformation of health services to First Nations people. Priorities for collaborative action have been identified, and specific work is underway expanding access to primary care in First Nations communities, improving supports for mental wellness and substance use services, and striving to create a more culturally competent and representative health services organization. Specific focus has also been placed on targeted efforts to leverage resources and experience in broader partnerships against the tragedy of youth suicide.



PRIMARY CARE

The primary health care team in Fraser Health delivers primary care services through multiple clinics across the health authority. Many clinics serve vulnerable populations such as new Canadians and HIV/hepatitis clients, with all clinics providing primary care and chronic disease management. The clinics partner with other Fraser Health programs and physicians to deliver disease-specific interventions and education. The team works closely with family physicians, nurse practitioners and specialists throughout the region to deliver services, implement new systems and organize learning opportunities.

There are 10 Divisions of Family Practice (Divisions) in the Fraser Health region, which is the most comprehensive coverage of the population by Divisions of Family Practice in the province. Each Division has a Collaborative Services Committee (CSC), and senior staff representatives from Fraser Health participate actively on these committees. Fraser Health receives funding from the Doctors of BC for a Physician Support Program and is working to reorganize its primary care and Physician Support Program team to better align with the Divisions. A business plan has been submitted to increase resources to the Physician Support Program.

There is a growing partnership between the Divisions and Fraser Health to implement initiatives that improve outcomes for people living with chronic disease and mental health conditions, the frail elderly, and the perinatal population. These initiatives include the Surrey Diabetes Collaborative, South Asian Health Centre, Global Family Care Clinic, and the Chilliwack Primary Care and Seniors Clinic. Approximately 8,000 patients are now receiving new or revised targeted services through these initiatives. The spread and scaling up of these initiatives, using evaluative data from the work to date, will be a key area of system focus to shift away from hospitals to community and primary care.

ATTACHMENT TO PRIMARY CARE

“Attachment” to quality primary care for Fraser Health residents will be key to the spread and scaling up of these initiatives. Attachment occurs when a family physician or physician group agrees to take on the ongoing role of caring for a patient. This means maintaining a longitudinal patient record and providing and/or coordinating comprehensive medical care with other health care providers.

In 2012/13, FH had an estimated 77.9 per cent of its population associated with a primary care group, and 66.3 per cent associated with a particular family physician, very near the provincial average levels. Unattached plus attached rates do not add to 100 per cent, as individuals with fewer than three visits in 10 years are assigned to an “other” category which constitutes approximately



seven per cent of the population in B.C.10 Fraser Health North and Fraser Health South have moderately better rates of attachment than the provincial average, while Fraser Health East attachment levels are below the provincial average and the ratio is moderately deteriorating over time.

Attachment to primary care is particularly important for the frail elderly, chronic disease and mental health and substance use populations. In Fraser Health, the frail elderly group is more likely to be attached to a primary care physician than the population overall, although in Fraser Health South unattached status for the frail elderly seems to have increased in recent years.

More than 30 per cent of those with mental health and substance use issues do not have an identified GP, approximately 20 per cent are not attached to a primary care practice, and this number is rising.

To address the attachment issues evident across the region, Fraser Health and the Divisions of Family Practice have partnered to establish Rapid Access Clinics focused on mental health and substance use in White Rock, Langley, Abbotsford, Chilliwack and Burnaby, with plans underway to implement additional clinics in Surrey, New Westminster, and the Tri-Cities. A number of primary care clinics have been established in partnership with the Divisions, such as the Global Family Care Clinic in Burnaby, Primary Care Seniors Clinic in Chilliwack, and the South Asian Health Centre in Surrey. These are relatively new initiatives, with implementation occurring throughout 2013. The degree of partnership established to date varies from Division to Division, depending on both Fraser Health leadership capacity and the leadership in place at the Division level. Fraser East will warrant particular attention in the years ahead. However, despite attachment initiatives underway across Fraser Health the number of emergency department visits has not significantly decreased.

ACCELERATED INTEGRATED PRIMARY AND COMMUNITY CARE FUNDING

In 2012/13, Fraser Health received $14.4 million in Accelerated Integrated Primary and Community Care (AIPCC) funding to support initiatives targeted at improving health outcomes for those living with mental health conditions, one or more chronic conditions, and the frail elderly. In addition, Fraser Health received a one-time allocation of $2.5 million in 2012/13.

10 Unattached plus attached rates do not add to 100 per cent, as individuals with less than three visits in 10 years are assigned to an “other” category which constitutes approximately seven per cent of the population in B.C.



The projects underway from this funding include:

• BreatheWell (chronic obstructive pulmonary disease) – serving 450 patients • Psychosis Treatment Optimization Program (PTOP) – serving 248 patients • Home First – serving 419 patients • End of Life Care – serving 345 patients • Community REDi (Community Reintegration and Rehab Services) – serving 350

patients

An evaluation is underway to examine the impact of the PTOP, Home First and BreatheWell initiatives on acute care utilization. The evaluation suggests that all three projects have an impact in reducing hospital use. Early indicators suggest that the Community REDi project is not having the same expected impact on hospital utilization. In terms of the spread of these initiatives beyond the project phase, Fraser Health is implementing the BreatheWell initiative in residential care facilities across the region. Although it is early in the system design and implementation process, Fraser Health intends to use the learnings from these projects to inform system-level change.

ABORIGINAL HEALTH

Fraser Health also has a dedicated program, Aboriginal Health (AH), which has been in place for many years, with a director and a small team who provide planning and direct services to patients for navigation, advocacy, and partnership building. The program works closely with other Fraser Health programs and Divisions of Family Practice to ensure that AH needs are understood, supported and, where possible, that services are provided. Fraser Health has undertaken positive efforts in the area of Aboriginal health planning in the region; the 2007-2010 Aboriginal Health Plan was developed based on engagement with Aboriginal peoples in the region, and endorsed by many key First Nations and Aboriginal groups. Many specific action plans are underway that will focus efforts while building capacity for change. The extensive effort to involve partners and communities in the planning, delivery and alignment of services is noteworthy.

With respect to primary care for First Nations, Fraser Health is establishing integrated health teams in each First Nation community or groups of First Nations in the region to create closer linkages between community members and their health services. These team members include health staff, leadership, service providers, and staff of the First Nations Health Authority (FNHA) and Fraser Health. There has also been collaboration to determine various regional projects for Medical Service Plan funding based on the Tripartite Agreement. The Fraser Health Salish Partnership Accord implementation is well underway. Currently, the Fraser Health Salish First Nations are developing a Fraser Health Salish Regional Health and Wellness Plan (RHWP) that will be the



foundation for collaborative action on First Nations and Aboriginal health in the Fraser Health region. The RHWP covers off goals and priorities in a number of specified areas.

The partner organizations are also working together to develop measurable health indicators for the region. Other plans include the Aboriginal Health Operations Committee developing a strategy to enhance indigenous cultural competency training for review at a future Aboriginal Health Steering Committee meeting.

The implementation of these planning and partnership efforts holds significant promise for service improvements and continued advances in First Nations and Aboriginal health status. Continued efforts will deliver strong and responsive undertakings, most particularly in collaboration with the FNHA.

CONCLUSION – PRIMARY CARE

In summary, there are compelling reasons to focus the efforts of Fraser Health on improving its partnerships with primary care practitioners to deliver comprehensive, longitudinal and multidisciplinary care for people whose health condition would benefit from such coordinated care. The evidence suggests that both acute care and emergency department utilization could be positively affected by refocusing the system of services to the community sector.

Fraser Health has embarked on a number of initiatives and strategies to begin such a shift. However, many of these initiatives are in the very early stages of implementation and have not been fully evaluated, nor scaled up to fully inform system change. These initiatives must be linked to home and community care services.



MENTAL HEALTH AND SUBSTANCE USE

Mental health and substance use disorders impact all aspects of an individual’s life regardless of his or her age, social or economic situation, physical wellbeing and psychological functioning. Providing the necessary supports and treatments is a complex undertaking, as are other issues related to mental health and substance use. Services must address the unique needs of each individual within an integrated, collaborative and cohesive system across the developmental continuum.

Fraser Health is home to the highest number of residents affected by mental health and substance use, including a population of 50,000 severely addicted and mentally ill (SAMI) residents. An analysis of recent mental health and substance use data for British Columbia suggests that between 50 and 80 per cent of people aged 15 to 64 years who are receiving substance treatment services are also receiving mental health services. By 2020, it is estimated 160,000 to 200,000 people could be in need of withdrawal management or treatment services for substance use.

Approximately 230,900 people, or 17 per cent of the region’s adult population, live with some form of mental illness. This is projected to increase by 11.5 per cent to about 257,500 by 2020. Fraser Health is home to 40 per cent of the province’s young people under 18 years of age. An estimated 14 per cent of children and youth (aged 13 to 18 years) in Fraser Health experience mental health issues. In the older population it is estimated that by 2020 between 55,000 and 97,000 of those over 65 years of age could have a mental health disorder.

Fraser Health mental health and substance use services provide a continuum of care, with services ranging from health promotion, harm prevention and community-based care to more intensive services, such as inpatient/day treatment, tertiary care, and housing supports. This continuum is built on the need to provide integrated services that can meet the needs of those clients with concurrent mental health and substance use issues. It is also underpinned by the fundamental components of effective service delivery: integrated hospital and community services, respectful integration of mental health and substance use services, continuity of providers and treatments, family support services and culturally sensitive services.



HOME CARE SERVICES

Home Health services are designed to support an individual's independence whether the services are provided in the home, in clinics or in community settings. The type and amount of service depends on an assessment of each client's care needs – high, medium or low – based on a range of factors. Clients may access one or more of the following services for short or long term support: Home care nursing, rehabilitation, IV, nutrition, lung health (chronic obstructive pulmonary disease) and the BreathWell program, palliative care, social work, dental, ambulatory clinics for wound care, health services for the Community Living program, case management, day programs, home support, Meals on Wheels, and Lifeline.

Fraser Health has some of the lowest client rates in the province for home support, adult day services, home nursing care, and rehabilitation services for clients aged 75 and older (based on data from 2007/08 to 2011/12). In 2012/13, home support hours in Fraser Health were modestly lower than the provincial average level adjusted for age. Home nursing care client rates have decreased steadily year over year for the past decade.11

The table below tracks age standardized home support hour use in Fraser Health and its sub-regional components over a 10-plus-year period. As can be seen, home support use has consistently declined when standardized for age.

11 CCData Warehouse and Home and Community Care Minimum Reporting Requirements (HCCMRR) Data Warehouse, Health Sector Planning and Innovation Division, Ministry of Health Project 2014_0511



Home Support Utilization rate Over 10 years.

Fraser Health recognizes that an integrated approach to home and community care linked to the primary care initiatives will need to be strengthened and is critical if people living with chronic conditions and the frail elderly are to receive quality care in settings outside of the hospital.

As noted in the Primary Care section, Fraser Health implemented a Home-First initiative in 2012/13, funded through Accelerated Integrated Primary and Community Care funding. In addition, there is work underway in Fraser Health’s Home Health program to establish connections between case managers and family physicians.



RESIDENTIAL CARE

Residential care services are for adults who can no longer live safely or independently at home because of their complex health care needs. Fraser Health operates or funds many residential care facilities, which together accommodate more than 8,000 adults throughout Fraser Health communities. All residential facilities in British Columbia operate within and provide care that meets established standards.

Fraser Health’s residential care bed base has increased by 3.64 per cent since March 2010. However, population growth (6.2 per cent from 2009/10 to 2012/13) continues to outpace new residential care capacity. The tables below show the residential care bed base and capacity.

Fraser Health Residential Care Beds (2010 - 2014)

March 2010 March 2011 March 2012 March 2013 March 2014

Beds 7,886 7,871 7,881 8,007 8,184

Fraser Health Residential Care Capacity as of March 31, 2014

Residential Care Beds

Short Term Beds Long Term

RC Beds Temporary

Beds

Family Care

Home Beds

Total RC Beds Convalescent EOL Respite Flex

Beds

Fraser Health East 20 22 10 0 1501 49 1 1,603

Fraser Health North 0 36 16 0 2865 104 0 3,021

Fraser Health South 75 47 14 0 3229 98 9 3,560

FHA Total 95 105 40 0 7595 251 10 8,184

The operating model of Fraser Health’s 8,184 residential care beds is described in the table below. Fraser Health has the highest percentage of private-for profit beds in the province (43.8), well above the provincial average of 34 per cent. Interior Health has the second highest at 40.9 per cent, while Northern Health has the lowest percentage of private for-profit beds at 12.3 per cent.12

12 Residential Care Beds Source: Home and Community Care Beds Survey as provided by health authorities to Ministry of Health , Health Sector Planning and Innovation Division, Ministry of Health Project 2014_0460



Fraser Health will work with for-profit, not-for-profit and publically owned facilities, to accommodate the increased patient complexity mix that has developed over the last decade and promises to continue.

Fraser Health Residential Care Beds and Facilities by Owner Type

Health Authority Private for-profit Private not-for-profit Total

Beds 1677 3384 3123 8,184

Percentage 20.5 41.3 38.2

Facilities 15 39 35 89

Percentage 16.9 43.8 39.3

When comparing Fraser Health’s residential care beds per 1,000 population aged 75+ rate across B.C., it shows Fraser Health (77.20) has a slightly lower rate than the provincial average of 79.06. Ministry of Health analysis suggests that Fraser Health would require an additional 297 net new residential care beds to reach a per capita bed availability of 80 per 1,000 population aged 75+, which is approximately the provincial average.13

Residential Care Beds per Capita14

Health Authority Total Population, Aged 75+ Years (2013) Per Capita RC Bed Availability (per 1,000

persons, 75+)

FHA 106,013 77.20

IHA 70,918 80.80

NHA 14,307 80.94

VCHA 80,670 84.57

VIHA 73,512 73.65

BC TOTAL 345,420 79.06

13 CCData Warehouse, Home and Community Care Minimum Reporting Requirements (HCCMRR) Data Warehouse, Health Sector Planning and Innovation Division, Ministry of Health. Project 2014_0511 14 Population – P.E.O.P.L.E. 2013, Residential Care Beds Home and Community Care Beds Survey as provided by health authorities to Ministry of Health, Health Sector Planning and Innovation Division, Ministry of Health Project 2014_0460



Fraser Health’s client rates per 1,000 people have significantly decreased since 2001/02 for persons over ages 65 and 75, a trend that mirrors the provincial experience. In 2012/13, Fraser Health had the second lowest client rate (35.7) for populations over age 65 – only Island Health had a lower rate (35.3). For populations over age 75, Fraser Health has the third lowest rate amongst health authorities; Vancouver Coastal Health (74.9) and Island Health (75.2) had lower rates. However, Fraser Health North has higher utilization rates (82.8) than Fraser Health overall and the provincial rate.

The table below illustrates the residential care client rate per 1,000 population over 75 for Fraser Health HSDAs:

Fraser Health Residential Care Client Rate per 1,000 Population Aged 75+

Residential Care Age Standardized Client Count Rate – 75+ Population

2001/02 2002/03 2003/04 2004/05 2005/06 2006/07 2007/08 2008/09 2009/10 2010/11 2011/12 2012/13

Fraser Health East

112.7 110.2 103.7 102.4 92.5 87.0 86.8 84.4 84.3 80.3 80.5 73.6

Fraser Health North

143.4 128.3 115.5 113.8 112.3 114.5 109.4 106.6 97.7 90.3 86.4 82.8

Fraser Health South

109.5 103.1 101.1 95.4 83.5 79.1 80.2 81.0 86.9 85.2 81.0 75.7

Fraser Health 121.2 112.2 106.0 102.4 94.5 91.6 90.4 88.6 87.8 83.8 80.6 75.4

BC 117.9 109.0 102.9 97.1 94.6 95.3 93.3 92.5 90.3 84.8 81.5 78.7

With respect to wait times for residential care, the Ministry of Health tracks the per cent of home and community care clients admitted to a residential care facility within 30 days of approval for services. Fraser Health’s performance over a two-year period is an average of 76.6 per cent of clients placed within 30 days from Q1 2010/11 to Q4 2012/13. This is above the provincial average of 66 per cent.15

15 CCData Warehouse, Home and Community Care Minimum Reporting Requirements (HCCMRR) Data Warehouse, Health Sector Planning and Innovation Division, Ministry of Health. Project 2014_0541



In terms of community care licensing and patient care quality, a review of Fraser Health licensing inspection reports shows that three of their facilities currently have a high risk rating. The Patient Care Quality Offices (PCQOs) in B.C. processed a total of 553 issues relating to residential care in fiscal year 2013/14. These 553 issues represent eight per cent of the 6,977 total issues received provincially for all sectors in 2013/14. Fraser Health received 187 complaints pertaining to residential care, representing 34 per cent of the provincial total. Four Fraser Health PCQO complaints were reviewed by Fraser Health’s independent Patient Care Quality Review Board.



ACUTE CARE

Fraser Health operates 12 acute hospitals, three of which are considered referral centers: Royal Columbian Hospital (RCH), Abbotsford Regional Hospital, and Surrey Memorial Hospital (SMH). Each of the hospitals forms part of a network and provides services to the local community and region. Each hospital has a unique blend of services complementing and supported by services within the network. Fraser Health also operates the Jim Pattison Outpatient Care and Surgery Centre, a large ambulatory care center offering a broad range of primary, acute and chronic disease services that do not require an overnight stay.

HSDA Hospital City

21 Fraser East

601 Chilliwack General Hospital Chilliwack 602 Mission Memorial Hospital Mission 606 Fraser Canyon Hospital Hope 609 Abbotsford Regional Hospital and Cancer Centre Abbotsford

22 Fraser North

109 Royal Columbian Hospital New Westminster

130 Burnaby Hospital Burnaby 136 Eagle Ridge Hospital Coquitlam 604 Ridge Meadows Hospital and Health Care Centre Burnaby

23 Fraser South

115 Langley Memorial Hospital Langley 116 Surrey Memorial Hospital Surrey 131 Peace Arch Hospital White Rock 134 Delta Hospital Delta

OCCUPANCY RATES

For fiscal years 2008/09 to 2012/13, Fraser Health had the highest occupancy rates of all HAs, regardless of whether alternate level of care (ALC) patients were included or excluded from the analysis. With the exception of Abbotsford Regional Hospital, the larger Fraser Health hospitals (Royal Columbian, Burnaby, Surrey Memorial and Delta hospitals) spent 2011/12 and 2012/13 with occupancy rates above 100 per cent.



Fraser Health Hospital Occupancy Rates

Hospital Occupancy Rate

2012/13 Year End, 2013/14 Q2 and Q3 Actual

Health Service Delivery Area Facility

2012/13 Year End

2013/14 Q2

2013/14 Q3

21 Fraser East 601 Chilliwack General Hospital 112.4% 106.5% 113.8%

602 Mission Memorial Hospital 136.7% 111.7% 131.6%

603 Matsqui-Sumas-Abbotsford GH 98.0% 97.8% 103.2%

606 Fraser Canyon Hospital 100.9% 91.0% 120.4%

609 Abbotsford Reg. Hosp & Cancer Centre

112.9% 111.4% 115.7%

22 Fraser North

109 Royal Columbian Hospital 111.3% 102.6% 103.3%

130 Burnaby Hospital 109.3% 106.4% 108.7%

135 Queen’s Park & Fellburn Care Centre 104.0% 97.4% 97.3%

136 Eagle Ridge Hospital 117.1% 103.7% 105.9%

604 Ridge Meadows Hospital 119.7% 104.3% 109.8%

23 Fraser South

115 Langley Memorial Hospital 104.7% 100.9% 103.1%

116 Surrey Memorial Hospital 105.3% 93.5% 102.2%

131 Peace Arch Hospital 111.9% 112.7% 116.8%

134 Delta Hospital 127.9% 111.4% 116.5%

In the context of the stress placed on the system by overcrowding (in addition to the long lengths of stay, significant ALC days and long admission times from the emergency department discussed later in this section), the review committee noted the issue of hospital occupancy rates at most major sites regularly exceed 100 per cent and as such warrants urgent attention and improvement.

PATIENT SATISFACTION

Fraser Health's per cent score in patient satisfaction survey results for the overall quality of care received at acute care facilities was 89 per cent in 2011/12, compared with the provincial average of 92 per cent. Fraser Health received slightly lower scores than other health authorities in all dimensions, including access to care, continuity and transition, coordination of care, emotional support, information and education, involvement of family, physical comfort, and respect for patient preferences. Although 89 per cent is not a significantly different number from that of the other HAs, it is important to note this is a drop in performance from earlier survey results.



ANALYSIS OF ACUTE HOSPITAL CARE SERVICE UTILIZATION

In preparing this plan Fraser Health, with the assistance of the Review Committee, has completed utilization comparisons between and among different geographic areas and different sectors of the system over time to augment its understanding of the Fraser Health delivery system and the use of services by Fraser Health residents. Fraser Health has used Vancouver Coastal Health as a relevant comparator for the purposes of this plan.

AGE STANDARDIZED RATES FOR SELECTED ACUTE CARE SERVICES

In comparing hospital admissions, the admission rate for all acute care clinical categories is higher for Fraser Health residents than for VCH residents. The largest discrepancies are for circulatory system diseases/disorders and for diseases/disorders of the kidney, urinary tract and male reproductive systems. The circulatory system age-standardized rate of acute care use (weighted caseload) for Fraser Health residents was 44 per cent higher than for VCH residents in 2012/13; the kidney, urinary tract and male reproductive system rate was 102 per cent higher. Over the entire spectrum of acute care, the admission rate (weighted caseload) for Fraser Health residents was 30 per cent higher than for VCH residents in 2012/13.



For circulatory system disorders and kidney disease, higher rates of utilization in Fraser Health should be expected based on the established profile of underlying need identified earlier. While the degree of expected elevation in use is impossible to quantify, the overall rate of utilization compared to the immediately adjacent health authority sharing the Lower Mainland geography and population is arguably higher than expected by a reasonable specification of the needs and pertinent preconditions for acute care.

The Medical Services Plan fee-for-service data (physician, lab, diagnostic) encounters per 1,000 people closely follows the acute care trajectory, with Fraser Health use exceeding VCH use per 1,000 people. It is important to note that VCH has a higher percentage of contracted rather than fee-for-service physicians, and that encounter-based data rates every encounter the same; this can be a distorting factor.

Age-Standardized Rates for Selected Services

Comparing the two largest population cohorts within Fraser Health to each other, an expected pattern presents (based on underlying chronic disease prevalence) for the acute care response to circulatory conditions: the South Fraser Health care usage rate is 19 per cent higher than that of Fraser Health North. The kidney, urinary tract and male reproductive system rate is 14 per cent higher for Fraser Health South residents than for Fraser Health North residents. However, overall acute care admissions are five per cent higher in the North compared to the South.



The acute myocardial infarction (AMI) hospitalization rate is often used as a marker for coronary artery disease in a population, with the ratio of AMI to cardiac surgery as an identified reference point. While hospitalization experience in Fraser Health is near the average level for B.C. for AMI, cardiac surgery for Fraser Health North exceeds the provincial rate by 29 per cent, and Fraser Health South exceeds the province by 37 per cent after adjustment for age. B.C. exceeds the national average rate of intervention, and the Fraser Health rate exceeds the B.C. intervention rate. This warrants further clinical review.



COMPARISON OF ACUTE CARE SERVICE UTILIZATION

In comparing use of acute care services, it is clear the utilization for the aged 70+ population is notably higher in Fraser Health when compared to VCH, particularly for medical (as opposed to surgical) patients. Fraser Health medical patient use over age 70 is 40 per cent higher than that of Island Health residents, while surgical use is only four per cent higher. Fraser Health surgical patient use over age 70 is 12 per cent higher than the rate of use by VCH residents.

Usage by FH residents under age 70 is very close to that of Island Health (four per cent lower on surgery and three per cent higher for medical cases). Compared to VCH residents, usage by Fraser Health residents under age 70 is 18 per cent and 27 per cent higher for medical and surgical patients, respectively.

Comparing utilization profiles for VCH, Fraser Health North and Fraser Health South between 2007/08 and 2012/13 also shows variation. Over the five-year time interval, Fraser Health North medical utilization by residents advanced from 16 to 23 per cent above provincial norms. Again for the aged 70+ population group, Fraser Health South moved from seven per cent higher than the provincial average to 13 per cent higher for medical care. Surgical care utilization for residents over age 70 advanced from five to eight per cent above the provincial average. Age-standardized utilization for population cohorts under age 70 is in line with the province overall. The focus on aged 70+ populations is important because of the exceptionally high rates of growth expected for this group over the next two decades.

EMERGENCY DEPARTMENT UTILIZATION

Emergency departments (EDs) are a critical component of the overall health care system. However, high levels of ED utilization have placed unsustainable pressure on health care systems worldwide. Within Fraser Health, the number of ED visits made by residents increased to over 550,000 visits in 2012/13.

ED utilization provides a picture of the effectiveness of the community and primary care service delivery system, as well as the effectiveness of patient flow inside the hospital. When patients present at emergency departments, they are triaged using the Canadian Triage Assessment Scale (CTAS). CTAS data for Abbotsford Regional, Burnaby, Royal Columbian, and Surrey Memorial hospitals is presented below.



Per Cent of Visits by CTAS Triage Level

CTAS level Hospital

2012/13 2013/14 1 2 3 4 5 1 2 3 4 5

Abbotsford Regional

0.5 16.7 45.3 31.4 6.0 0.5 16.8 46.6 31.0 4.2

Burnaby 0.2 10.7 41.9 44.4 2.7 0.3 11.7 45.0 41.3 1.3

Royal Columbian 1.2 12.2 54.1 28.6 3.7 1.6 14.1 57.4 24.1 2.3

Surrey Memorial 0.42 12.6 55.4 28.4 2.4 0.4 15.9 54.9 25.5 1.5

Patients triaged as CTAS level 4 and 5 generally could receive their care in a primary or community care setting. Although patients triaged as CTAS level 3 present to the ED with more complex needs, a proportion of the care needs of this group could also be provided in the community with intentional care coordination through primary care and a multidisciplinary team. In particular, those with co-morbid chronic conditions, the frail elderly, and those with mental health and substance use issues often fall into this group. The per cent of visits triaged as CTAS levels 3, 4, and 5 in Fraser Health’s hospitals in 2013/14 are outlined below.

Per Cent of CTAS Level 3, 4, and 5 Visits to Fraser Health Hospital in 2013/14

CTAS level Hospital CTAS 3 CTAS 4

& 5 CTAS level

Hospital CTAS 3 CTAS 4 & 5

Abbotsford 46.6 35.2 Chilliwack 42.0 48.4 Burnaby 45.0 42.6 Delta 45.3 34.2

Eagle Ridge 56.5 28.5 Fraser Health Canyon 22.9 69.7

Langley 45.0 36.5 Mission 43.2 42.8 Peace Arch 38.9 49.2 Ridge Meadows 38.3 55.2

Royal Columbian 57.4 26.4 Surrey Memorial 54.9 27.0

A recent population-level review of ED utilization by Fraser Health found that while trends of increasing ED visits were observed in other health regions, Fraser Health had the highest increase in the rate of ED visits in B.C. between 2008/09 and 2012/13. The annual growth rate in Fraser Health ED visits was 6.5 per cent per year while the annual population growth rate was 1.7 per cent per year.



ED rates increased by a minimum of 13 per cent across all age groups, and the greatest increase in ED rates was among middle-aged adults between 40 and 54 years of age (54.6 per cent increase), and Fraser Health East saw the largest increases. Approximately 13 per cent of ED visits resulted in hospital admission in 2012/13. Adjusted rates of ED visits resulting in hospital admission have remained steady between 2008/09 and 2012/13.

POTENTIAL DRIVERS OF EMERGENCY DEPARTMENT UTILIZATION

There is a group of frequent users that has grown over time and their rate of ED utilization has also increased. In 2006/07, frequent users (patients with four or more ED visits per year) made up 5.2 per cent of all patients and accounted for 19.1 per cent of total ED visits, compared to 8.1 per cent of all patients and 28.5 per cent of total ED visits in 2012/13. Frequent users are more likely to be older and severely ill. They also tend to have lower socioeconomic status, lack a regular source of care, have more co-morbid conditions, poorer health status, and are more likely to experience poor health outcomes. It appears ED visits are related to socioeconomic deprivation – that is, those who are the most socially deprived use the ED the most.

Attachment to a family physician is slowly declining in Fraser Health and is moderately correlated with high ED visit rates. While a low attachment rate does not completely account for the high ED visit rates, other factors such as barriers to timely physician access may undermine the benefits of having a regular source of care and play a role in driving the increasing volume of ED visits.

It remains unclear what the “best practices” are to reduce ED utilization. There have been difficulties in combining the findings from independent studies to estimate the overall intervention effect due to a combination of heterogeneity in reported outcomes, poor/fair methodological quality of studies, and the limited generalizability of studies conducted in the U.S. to the Canadian universal health care context. Thorough evaluation of the local setting is needed prior to development and implementation of potential interventions to reduce ED visits as the success of health programs is greatly affected by contextual factors. Efforts to better understand and characterize prominent frequent user subgroups, such as chronic frequent ED users who continually use the ED year after year, may aid in developing system-wide interventions to address their unmet health care needs.

It is likely, however, that attachment to a family doctor or other primary care provider, supplemented with focused, robust, community services and specialist services, will enable Fraser Health to have a positive impact on the high rate of ED admissions for the most complex.



The review committee noted that curtailing practices such as bringing patients back to the ED for follow-up, repeat IV antibiotics or suture removal requires a change in emergency physician culture and practice, development of better relationships with primary care physicians and community specialists, and often the establishment of appropriately resourced outpatient facilities to manage this non-ED workload.

The review committee further recommended that discontinuation of the fee-for-service model of emergency-physician remuneration should be explored, especially in the large EDs, since the fee-for-service model encourages physicians to bring back quick or relatively simple cases to the ED when treatment could be easily provided elsewhere.



SURGICAL SERVICES

Fraser Health’s wait times for elective surgery are comparable to the other regional health authorities. Like other health authorities, wait times can be impacted by a number of different factors, including funding allocated by the health authority and staffing (in particular, the availability of anaesthesia). In Fraser Health, almost a quarter of operating rooms (OR) are not regularly staffed and the highest OR closure period occurs in the summer, when 21 per cent of daytime OR capacity is closed. Annually, seven per cent of daytime OR capacity is closed in Fraser Health, which is the same as the B.C. average.

Fraser Health’s increase in surgical volumes is in line with the large population growth seen across the health authority. This is in contrast to Interior Health and Island Health, where increases in surgical volumes have significantly outpaced population increases.

The median and 90th percentile wait times for all completed surgical cases in Fraser Health have remained steady in the last five years. Fraser Health’s 2013/14 median wait time is five weeks (other health authorities range from four to five weeks) and Fraser Health’s 90th percentile wait time is 28 weeks (other health authorities range from 22 to 30 weeks). As of May 31, 2014, there were 20,965 surgical cases waiting in Fraser Health. The median wait time for cases waiting in FH is 11 weeks (other health authorities range from 10 to 14 weeks) and their 90th percentile wait time for cases waiting is 41 weeks (other health authorities range from 33 to 44 weeks). Looking at long waits, the per cent of patients waiting 52 weeks or longer was 4.6 per cent of Fraser Health patients at Q4 of 2013/14, compared with 9.3 per cent at Q1.

Fraser Health has led the province in a number of surgical quality improvement initiatives. For example, in 2012, Fraser Health updated their surgical program website and included the development of the Soonest Surgery Tool for patient and general practitioner education. This unique tool identifies the top five Fraser Health surgeons that might perform a patient’s surgery soonest. Fraser Health was also an early adopter of the National Surgical Quality Improvement Program16 (NSQIP) and is leading the province in the number of sites participating in front-line initiatives to improve perioperative performance. This work is part of a collaboration between the Ministry of Health, the BC Patient Safety and Quality Council and Doctors of BC.

16 NSQIP is a program from the American College of Surgeons designed to gather actionable data that can be used to determine where improvement efforts should be focused. The program uses clinical data from chart reviews and allows organizations to compare their outcomes with other participating sites.



PATIENT SAFETY IN ACUTE SERVICES

In assessing quality of care and patient safety in Fraser Health hospitals, three key indicators were examined: hospital standardized mortality rate (HSMR), hip fracture repair within 48 hours, and nursing-sensitive adverse events.

HOSPITAL STANDARDIZED MORTALITY RATE (HSMR)

Overall, Fraser Health’s HSMR is very near the B.C. average of 84 and shows a year-over-year reduction at a greater rate than other B.C. health authorities from the 2009 reference year when the Canadian average HSMR was 100. However, examining HSMR data more granularly reveals opportunities for more focused improvement. While the overall trend of HSMR by health service delivery area follows the trend for the whole of Fraser Health, there are differences in medical, surgical and intensive care unit (ICU) subgroup analysis. Overall, the HSMR for medical and surgical cases is trending downwards for each of the Fraser Health HSDAs, demonstrating improvement over the past three years. The review committee noted higher HSMRs for ICU cases in Fraser Health North. HSMR data for ICUs requires more in-depth study and understanding of case mix-adjusted analysis for better understanding of factors that may be driving these results. This can be done in conjunction with the provincial Critical Care Advisory Council.

In addition to HSMR, the review committee identified 30-day in-hospital stroke mortality and 30-day in-hospital AMI mortality in Fraser Health East as areas for improvement. Improvement opportunities also exist at Royal Columbian, Burnaby, Abbotsford and Chilliwack hospitals for surgical re-admission rates. However, variation among peer group sites across the country is low.

HIP FRACTURE REPAIR WITHIN 48 HOURS

When a hip fracture is surgically repaired within 48 hours, a patient exhibits better health outcomes, including a reduced length of stay and a lower mortality rate. This indicator provides an important quality marker for hospitals to assess and improve performance.

The rate of hip fracture repair within 48 hours is a concern for the large community hospitals within Fraser Health, with six of the seven hospitals in this category performing below at least 80 per cent of peer hospitals. Of particular note is Surrey Memorial Hospital, which has been trending downwards over the past three years, with the most recent data showing a rate of 28.33 per 100 patients.



NURSING-SENSITIVE ADVERSE EVENTS

Nursing-sensitive adverse events (NSAE) are one of the indicators that the Canadian Institute for Health Information (CIHI) uses to assess quality of hospital care. They are usually divided into medical and surgical reports but the events that compose NSAE are the same, namely: urinary tract infections, pressure ulcers, in hospital fractures and pneumonia. These are used because they are caused by medical management not complications of disease.

Several Fraser Health hospitals perform very poorly when their NSAE rates are compared to those of their Canadian peer hospitals. With respect to NSAEs for surgical and medical patients in large community hospitals, Burnaby Hospital was the worst in Canada for two consecutive years (100 per cent of peer hospitals performed better in 2010/11 and 2011/12).

NSAEs for surgical patients (NSAE-surgical) are concerning for Fraser Health. Not only were NSAE-surgical rates for Surrey Memorial, Royal Columbian, Burnaby, Peace Arch and Ridge Meadows hospitals high in comparison to the per cent of higher performing peer group hospitals, but the actual rates were almost double the national average in Surrey Memorial, Burnaby and Ridge Meadows hospitals, with no demonstrated improvement over the past three years.

Surrey Memorial Hospital performed worse than 98 per cent of peer hospitals for each of the same years on NSAEs for surgical patients. Royal Columbian Hospital fared only slightly better, with 92 per cent of peer hospitals performing better in 2010/11 and 83 per cent performing better in 2011/12. These outcomes are particularly concerning, considering that the majority of surgeries that occur in Fraser Health are performed in these three hospitals. Peace Arch Hospital also performed significantly poorer on this parameter in 2011/12 than in the previous year (51 per cent of peer hospitals performed better in 2010/11 and 88 per cent performing better in 2011/12).



Source: Canadian Hospital Reporting Project 2013, Canadian Institute for Health Information

For NSAEs for surgical patients in medium community hospitals, Ridge Meadows Hospital performed in the bottom fifth percentile, with 99 per cent of peer hospitals performing better in 2010/11 and 96 per cent performing better in 2011/12.

The following three tables illustrate the performance of Fraser Health hospitals on NSAEs in comparison to Canadian peer group hospitals.

Domain: Patient SafetyIndicator: Nursing Sensitive Adverse Events for Surgical Patients (rate per 1,000)

2007-2008 2008-2009 2009-2010 2010-2011 2011-2012 Trend 2010-11 2011-12Community-Large

Abbotsford Regional 22.67 14.98 20.50 3 18Burnaby Hospital 72.07 67.52 69.23 100 100Chill iwack General 37.02 31.14 25.90 55 38Langley Memorial 45.69 36.27 32.97 68 60Peace Arch 42.40 30.15 46.99 51 88Royal Columbian 53.58 47.55 40.47 92 83Surrey Memorial 63.56 65.55 65.47 98 98Community-L Peer Group 32.05 32.64 32.14

Community-MediumDelta Hospital 28.97 25.41 13.10 53 25Eagle Ridge 33.83 28.02 20.89 61 42Ridge Meadows 71.25 71.03 61.76 99 96Community-M Peer Group 26.64 28.39 28.35

Fraser Health 52.27 46.71 45.40British Columbia 39.63 37.60 38.57Canada 35.59 36.15 35.99

Canadian Hospital Reporting Project

Needs Attention: BUH worst in Canada of Comm-L, SMH in worst 2% of Comm-L, RMH in Worst 4% of Comm-M, PAH in worst 12% of Comm-L and RCH in worst 17% of Comm-LNotable: ARH was in the best 19% of Comm-L

% of hospitals better in peer



Performance against Peer Group Hospitals: Nursing-Sensitive Adverse Events for Surgical Patients

The above table expresses surgical nursing-sensitive adverse events for these five hospitals from a different perspective, as a rate per 1,000 surgical patients.

Performance against Peer Group Hospitals: Nursing-Sensitive Adverse Events for Medical Patients

The above table expresses medical nursing-sensitive adverse events for these five hospitals from a different perspective, as a rate per 1,000 surgical patients.

0

10

20

30

40

50

60

70

80

ARH BH CGH LMH PAH RCH SMH DH ERH RMH

Nursing-sensitive Adverse Events for Surgical Patients (rate per 1,000) for 2011-2012

FH Hospitals Community-L Peer Group Community-M Peer Group FH Overall BC

0

10

20

30

40

50

60

70

80

ARH BH CGH LMH PAH RCH SMH DH ERH RMH

Nursing-sensitive Adverse Events for Medical Patients (rate per 1,000) for 2011-2012

FH Hospitals Community-L Peer Group Community-M Peer Group FH Overall BC



Nursing-Sensitive Adverse Events: Per Cent of Hospitals Performing Better in Peer Group

Hospital Medical 10/11 Medical 11/12 Surgical 10/11 Surgical 11/12

ARH 34 26 3 18

BH 100 100 100 100

CGH 45 49 55 38

LMH 62 65 68 60

PAH 40 63 51 88

RCH 82 94 92 83

SMH 97 98 98 98

DH 78 75 53 25

ERH 84 88 61 42

RMH 100 99 99 96

INDEX = worse than 90% of Canadian peer hospitals

= worse than 80-89% of Canadian peer hospitals = worse than 65-79% of Canadian peer hospitals = near or better than the median of Canadian peer hospitals

Fraser Health’s three largest sites show consistent concerns with multiple indicators of surgical quality. While Royal Columbian and Burnaby hospitals are demonstrating improvement in surgical HSMR data, these three sites show continued concerns based on NSQIP data: readmission, NSAE and hip fracture fixation within 48 hours. Additionally, Peace Arch Hospital’s NSQIP data highlight potential issues with its surgical orthopaedic program that warrants further investigation.

Medical and surgical adverse events need to be addressed in Fraser Health. A combination of strategies need to be employed. Education of both medical and nursing staff, ideally done in common settings, as to the best evidence based protocols for reduction in these events is needed. In addition, units need to make better use of safety huddles to bring to everyone’s attention potentential events as they arise. The best and most up to date practices regarding care without catheterrization, minimal use of sedatives and early mobility with support are needed. This needs to be site specific and particularly concentrated on areas where the current data demonstrate problematic results.



ACCESS AND FLOW IN ACUTE CARE

The previous sections have highlighted challenges in Fraser Health’s hospital system. It is well recognized that hospital overcrowding creates inefficient processes of care and compromises clinical care, which in turn leads to decreased morale and poor staff engagement. In an environment of overcrowding, it is almost impossible for care providers to shift their focus from day-to-day stress at work to implementing sustainable strategies to improve hospital access and smooth transitions of care, or flow.

The table below provides further evidence of the extent to which overcrowding in Fraser Health is contributing to poor access and flow. Data from 2008/09 to 2012/13 show that timely flow from the ED to in-patient beds is significantly below that of other regional HAs.

Source: Discharge Abstract Database, Planning and Innovation Division, Ministry of Health

The review committee cited several factors that have exacerbated hospital overcrowding in Fraser Health, including longer average length of stay (ALOS) than expected lengths of stay (ELOS), beds blocked by alternate level of care (ALC) patients, and unexpected readmissions. These factors in turn increase delays in admission from EDs and together make a significant impact on hospital in-patient bed congestion.



The review committee pointed to four potential solutions to the current overcrowding problem that can be explored: open more acute care beds, decrease ALOS/ELOS, expedite the movement of ALC patients out of the acute care setting, or admit fewer patients.

ACUTE CARE BEDS PER 1,000 PEOPLE

Based on P.E.O.P.L.E. 2013 data, 1.70 million people reside in the Fraser Health region. The Ministry of Health data from 2012/13 show that Fraser Health had 1.5 beds per 1,000 people, a rate that is lower than that of other regional health authorities in B.C. These data raise the question of whether Fraser Health is under-bedded compared to other health authorities. However, the review committee noted the number of hospital beds that are needed to serve a population depends on four main factors:

1. Age structure of the population: A population with a large proportion of seniors would generally require more beds per capita than an area with a small proportion of seniors. As noted in the population health needs section, FH has one of the lowest proportions of seniors.

2. Health status of the population: A healthier population would generally require fewer beds per capita than a population of people with poorer health. As noted previously, Fraser Health has a population with generally higher health status than do the other health authorities.

3. Location of tertiary services: Many tertiary services are accessed through Vancouver Coastal Health and the Provincial Health Services Authority, which provide care to all B.C. residents.

4. Isolation of the population: Because of the distance between communities, a region with isolated communities would require more hospital beds per capita than would urban regions. This is not a significant factor for Fraser Health.

As such, the in-patient beds per population measure is not meaningful when considering the underlying age structure and the amount of tertiary and provincial services provided in Vancouver Coastal Health or Provincial Health Services Authority facilities. The review committee suggested that a more appropriate measure for comparing regional bed rates is beds per catchment area population, adjusted for age and inter-regional flows (see table below).

Beds per 1,000 Population

IHA FHA VCHA VIHA NHA BC

Beds per 1,000 population (NOT age adjusted) 1.8 1.5 1.8 2.0 1.7 1.8

Beds per 1,000 catchment population (adjusted for age structure and inter-regional flows including to PHSA)

1.7 1.9 1.6 1.8 2.5 1.8

Source: DAD 2012/2013 and P.E.O.P.L.E.2013, (excludes NICU beds and population under 1 year old)



ACTUAL LENGTH OF STAY VS EXPECTED LENGTH OF STAY (ALOS/ELOS)

Comparing 2010/11 baseline data to 2012/13 actual performance, Fraser Health had the lowest percentage of all health authorities for cases where ALOS ≤ ELOS. In 2012/13, more than 35 per cent of admissions exceeded ELOS. This is significant in that a 35 per cent reduction of cases where ALOS ≥ ELOS would contribute significantly to increased acute in-patient bed capacity.

ALOS/ELOS data for medical cases, however, are even more compelling. For the five-year period between 2008/09 and 2012/13, Fraser Health had the lowest percentage among all health authorities of medical cases where ALOS was ≤ ELOS. Data from the fiscal years 2008/09 to 2012/13 show that Fraser Health has among the highest ALOS/ELOS in B.C. for patients with chronic medical conditions. Key outliers include patients with heart failure (second highest in B.C.), patients with stroke (second highest in B.C.), patients with COPD (highest in B.C.), and patients with sepsis (highest in B.C.).



Since the majority of medical patients and, specifically, patients with chronic medical conditions, in Fraser Health are admitted under hospitalists (hospital-based general practioners), the review committee explored a potential correlation between a hospitalist being the most responsible physician (or actively involved in patient care) and increased ALOS/ELOS. From this analysis, Burnaby, Royal Columbian and Surrey Memorial hospitals were major outliers. Patients admitted under hospitalists or who have had hospitalists involved in their care at these sites have had actual lengths of stay far in excess of those for patients admitted under other members of the medical staff.

ALTERNATE LEVEL OF CARE RATES

ALC patients are those patients admitted to hospital who no longer require acute care services but are waiting for discharge to a setting with an appropriate level of care. Through fiscal years 2008/09 to 2012/13, Fraser Health was not unusual compared to other health authorities for ALC days as a percentage of total in-patient days. For the same time period, however, Fraser Health had the second highest number amongst all health authorities for ALC days ≥ 30 days (where the first 29 days of an ALC stay are not counted) – second only to Island Health.



In 2012/13, the ALC rate in Fraser Health was 13 per cent and ranged from five per cent at Royal Columbian Hospital and seven per cent at Surrey Memorial Hospital to 18 per cent at Mission Memorial Hospital. During the same period, Vancouver Coastal Health’s rate was eight per cent, while the other health authorities’ rates ranged between 16 and 17 per cent. The provincial average of 12.7 per cent was marginally lower than the Fraser Health average of 13.1 per cent.

Fraser Health’s ALC in-patient days have continued to decline into the first half of 2013/14. If this downward trend were sustainable and progressive and if Fraser Health is able to reduce its facility ALC days from 13 per cent to 10 per cent, 36,700 inpatient days could be avoided. If ALC days were reduced to eight per cent, a further 18,300 days would be avoided.

As noted earlier in this document, for age groups over age 70 in Fraser Health, patient-day utilization, weighted cases, and admissions were higher than those of Island Health and Vancouver Coastal Health. This underscores the need to focus on options other than acute care for those over age 70 and the futility of adding acute care capacity as a primary response to the aging of the population.

READMISSION RATES

Readmissions to hospital for all causes within 30 days of discharge represent another opportunity to free up acute care beds. B.C. health authorities’ readmission rates ranged between 10 per cent and 10.8 per cent in 2012/13. Fraser Health’s readmission rate ranged from 9.1 per cent in 2008/09 to 10.2 per cent in 2012/13. While Fraser Health’s rate is consistent with that of the other health authorities, examining readmission data (risk-adjusted) more granularly by HSDA reveals opportunities for more focused improvement. Key areas for improvement include 30-day surgical readmission rates in Fraser Health East, 30-day obstetric readmission rates Fraser Health North and East, and 30-day AMI readmission rates in Fraser Health North and East.

AMBULATORY CARE SENSITIVE CONDITIONS

Ambulatory care sensitive conditions (ACSC) are one measure of conditions that can be managed in community settings and should not require admission to acute care. This measure includes the following conditions: chronic obstructive pulmonary disease, asthma, diabetes, heart failure, epilepsy, hypertension, angina, and pulmonary edema. Over the years 2008/09 to 2013/14 (partial year), the rate of ACSC admissions in Fraser Health improved. However, on a per capita basis, for every 100 Fraser Health ACSC admissions over age 75 in 2012/13, Vancouver Coastal Health had proportionately 82 and Island Health had 90. Similarly, for every 100 ACSC admissions under age 75 in Fraser Health in 2012/13, Vancouver Coastal Health had 75 and Island Health had 85.



If Fraser Health were to achieve an ACSC admission rate consistent with the other urban regions (Island Health and Vancouver Coastal Health) for those over aged 75 and under age 75, approximately 520 and 680 admissions could be saved, respectively. If Fraser Health assumes conservatively that each admission has an average length of stay of three days, 3,600 in-patient days per year could be avoided on a base of 1.04 million bed days. These calculations were made with reference to the acute and rehabilitation activity in Fraser Health facilities.



OPPORTUNITIES TO IMPROVE QUALITY IN FRASER HEALTH HOSPITALS

Fraser Health has made some significant improvements in quality of care over the past few years, in particular with regard to taking action on C. difficile infections, HSMR and medical device reprocessing. While improvements have been made in these areas, Fraser Health recognizes that they still warrant continued attention and effort to maintain results and make continued improvements. The strategic and operational review identified a number of site-specific opportunities. These are summarized as follows:

Site Opportunity: Surrey Memorial • Hip fracture fixation within the 48-hour benchmark

• Hospital standardized ICU mortality • Selected NSQIP indicators • Patient satisfaction with ED • Infection control (CDI, MRSA) • Nursing-sensitive adverse events (NSAE) • Readmission <19 years of age

Royal Columbian • Hip fracture fixation within the 48-hour benchmark • Hospital standardized ICU mortality • Selected NSQIP indicators • Readmission – surgical, medical, obstetric, and hip fracture • NSAEs • Infection Control (CDI, MRSA) and hand hygiene compliance

Burnaby • Hip fracture fixation within the 48-hour benchmark • HSMR in ICU and medicine • Selected NSQIP indicators • NSAEs • Readmission rates • Infection control • Patient satisfaction in the emergency department

Abbotsford • Hip fracture fixation within the 48-hour benchmark • Readmission rates

Chilliwack • Hip fracture fixation within the 48-hour benchmark

Ridge Meadows • Readmission rates for medical, obstetrics, stroke, and hip replacement

• NSAEs



GOVERNANCE, MANAGEMENT, HUMAN RESOURCES AND FINANCES

The delivery of services in Fraser Health is underpinned by the functioning of Fraser Health as an organization. This section provides an overview of the current state, key challenges and opportunities for Fraser Health in the areas of governance, management, human resources and finances.

GOVERNANCE, LEADERSHIP AND MANAGEMENT

Governance, leadership and management play a crucial role in advancing towards overall system goals as well as ensuring optimal performance. Accreditation Canada provides standards in these areas and tests compliance through on-site reviews. The board provides oversight through its committees and working groups, and conducts regular self-assessments of its own performance.

The strategic and operational review provided a number of additional insights to help strengthen the overall governance, leadership and management of Fraser Health. These included:

• focusing on four or five strategic service priorities in addition to more extensive operational objectives;

• revisiting the strategic plan annually in conjunction with management; • monitoring progress of the agreed-upon strategic agenda through regular management

updates; • strengthening support for clinical governance; • strengthening processes for management reporting; • strengthening CEO and executive evaluation; and • strengthening board member recruitment, orientation and ongoing development.

The review’s focus on operational management was aimed at assessing the organization’s structure and roles, the effectiveness of the reporting and accountability systems, and the relationships between programs and hospital site staff.

Fraser Health is organized through a matrix management structure built around programs and sites. The primary organizing structures are 19 programs, each with responsibility for its own budget and for developing a service plan to guide its activities. Fraser Health rolled out its current program management model approximately four years ago. Under this model, programs have accountabilities and responsibilities for services at each site (as compared to a site model, where site leadership has accountability and responsibility for all programs on each site). Programs are responsible for quality, planning and budgets. The strategic and operational review found that staff are supportive of the program model. Many indicated that conversion to a program model was



needed to achieve major change in the organization. However, it has taken time to implement and programs are at differing levels of maturity. Notwithstanding, the review committee noted that a great deal had been accomplished in achieving benefits related to standardization of care and the ability to move patients across sites.

Program management can facilitate quality oversight from a medical perspective through the program structure but only if sufficient resources are available within the program to undertake quality reviews and other initiatives. Larger programs have identified the need for increased dedicated resources within their programs, while smaller programs could benefit from additional support being provided through the corporate Patient Care Quality Office.

The review committee undertook some assessment of how effectively the program model is operating and its impacts on quality and budget. Early focus in implementing the program model centred on standardization benefits and implementation of new responsibilities associated with the structure. The focus was to build strength in the programs. Many of those interviewed by the review team acknowledged this initial approach was necessary to achieve the degree of change needed. However, in retrospect, there has not been enough focus on the importance of site management. About 18 months ago, Fraser Health further strengthened site integrity by decentralizing infection control practitioners and access/flow staff to individual sites. Fraser Health’s board and executive recognize further action is needed to rebalance and review communication between these two streams.

Executive directors have senior responsibility for 14 sites and communities. The review committee noted that site directors, who are accountable to executive directors, have limited authority to make decisions at their respective sites. Site directors do not have visibility into budgets for programs operating at their site. The role relies on relationships and an ability to influence in order to effect the desired changes and decisions. Often this approach is a slow one, because of the need to involve many decision-makers at the director or executive director level. In addition, site-specific plans do not exist. There is no information source that documents anticipated program changes, patient volumes and initiatives at a site. The lack of a site plan hinders the site’s ability to prepare adequately for change.

The review committee also suggested some weaknesses in the integration between acute sites and community-based programs. Goals across the hospital-community continuum need to be better aligned to establish effective transitions, and residential care-emergency department-residential care transitions need to be seamless to ensure the patient returns to an appropriate facility upon discharge from the hospital setting. Currently the five community-oriented programs report to three vice presidents of clinical operations. This may run counter to a more fully integrated and system-level approach.



In addition, the review committee noted that at the mid-management level, routine operational workloads have increased, which, combined with multiple program initiatives and inadequate change management support, is creating stress, engagement issues and a slow pace of actual change.

RELATIONSHIP WITH PHYSICIANS

There are approximately 4,000 physicians practising in the Fraser Health region, with more than half having privileges with Fraser Health. Most of the physicians are independent practitioners and as such have no contractual relationship with Fraser Health, apart from being granted privileges and the requirement to be bound by the medical staff bylaws and rules. This degree of independence has a bearing on the nature of the working relationship between Fraser Health and physicians, and must be considered in any determination of how best to engage physicians and collaborate with them.

The introduction of program management within Fraser Health is a significant factor influencing how physicians can be engaged and become part of the decision-making processes within Fraser Health. The review committee recognized the work of Fraser Health in the creation of the program medical director (PMD) position. The PMDs’ involvement in service delivery leadership throughout the organization is an important component of the engagement process, as is the active involvement of regional and local department heads, regional division heads, and hospital medical coordinators in the management process.

The ‘dyad’ approach of PMDs having joint leadership with executive directors of a Fraser Health program is an evolving one and is meaningful if the dyad works well together. The strength of this approach is highly dependent upon the working relationships developed within the dyad – a focus of current work is to define the respective roles and responsibilities more clearly.

The review committee noted strong support of dyads from the vice presidents of clinical operations, and this provides an opportunity to influence the decision-making process at the senior management level. However, dyadic accountability to the vice presidents of clinical operations reduces the opportunity for the PMD to interact with the vice president of medicine, other than on professional matters.

Program management has resulted in a significant shift away from local site/community management. This change, while having the benefit of driving improved quality through standardization, has reduced the opportunity for significant physician involvement/responsibility for addressing local issues and the use of resources. Hospital medical coordinators (HMC) at the local sites were intended to enhance local medical involvement.



There is a need to further strengthen the HMC role and the dyadic site leadership with the site, work that is underway alongside the work with the PMD/ED dyads to define respective roles and responsibilities more clearly.

In ensuring there is effective collaboration with physicians throughout Fraser Health, it is important that the medical community understands their opportunities to interact with not only senior management, but also with the board of directors. It is recognized that the Health Authority Medical Advisory Committee (HAMAC) is the primary vehicle for interaction between the board and medical community on professional affairs (credentialing and discipline) and quality. The review committee reported HAMAC has become successful in focusing on quality matters (in addition to its credentialing and disciplinary responsibilities) although its HA-wide collaborative focus makes it cumbersome (40+ members).

In addition to the regular quality reporting mechanism to HAMAC for physicians, the introduction of regular quality reporting from programs to the board’s Quality Performance Committee was considered to be a positive step in strengthening the opportunity for physicians to interact with the board on quality improvement within Fraser Health.

There has been significant engagement of general practitioners through the development of collaborative working relationships with the Divisions of Family Practice. These Divisions, even though in varying stages of development, are serving as vehicles for interaction with general practitioners in the local communities. They provide an excellent opportunity for Fraser Health and Fraser Health specialists to engage with those physicians who may have limited involvement in the acute and community programs being offered. There are 10 Divisions of Family Practice within the Fraser Health region. The Divisions and Fraser Health work in partnership to achieve common goals related to improving the health and health outcomes of vulnerable populations who may be poorly served, maximizing use of community-based services and primary care clinics for the benefit of the patient and the health system and improving access through the GP4ME initiative. Today, there are several active initiatives and all Division interviewees pointed to the successes they have achieved. They have made significant progress on attachment initiatives by attracting local physicians to their Division and providing opportunities for physicians to connect amongst themselves and with specialists. There are many examples of Divisions and Fraser Health together establishing a health centre (South Asian Health Centre) and a primary care and seniors clinic (Chilliwack).



HEALTH HUMAN RESOURCES

Fraser Health has advanced to become B.C.’s largest employer of nursing staff, and is one of the top 10 (and perhaps top five) employers of nurses in Canada.

From the mid-point of 2010 to the mid-point of 2013, Fraser Health was the largest provincial employer of nursing staff by a considerable margin, with over 50 per cent more paid hours than Vancouver Coastal Health, the second largest employer of nurses. Fraser Health’s nursing hours, including licensed practical nurses, grew by 17.4 per cent over the three years up to 2013, while the provincial nursing hours grew by 12 per cent. During this period, the health sciences group of employees grew by 10.5 per cent against a provincial rate of 8.5 per cent; the community bargaining unit staff grew by 15.1 per cent against a provincial growth rate of 8.6 per cent; and the facilities bargaining unit staff grew by 6.1 per cent against a provincial average of 3.2 per cent.

Collective agreement tracking information for the health authorities and Providence Health Care confirms that both straight time hours (vacation/other paid leave included) and productive hours have been growing at a faster pace in Fraser Health than in the province overall. This is largely due to the expansion of services at Abbotsford Regional Hospital and Cancer Center as well as the opening of Jim Pattison Outpatient Care and Surgery Center.

From 2008 to 2012, non-contract (excluded) staff grew by 19.1 per cent in Fraser Health. The provincial average growth rate was 18.6 per cent over the same five-year period. Overall, Fraser Health has experienced both the opportunities and challenges associated with an expanding workforce. The productivity of this workforce can be analyzed by examining overtime, sick time, staff injury, and staff vacancy rates.

OVERTIME

Overtime is often the result of temporarily high patient volumes, permanent service demand growth or inefficient work processes. The overcapacity issues in many Fraser Health sites described earlier are likely a contributor to nursing overtime rates experienced in several sites across Fraser Health.

Despite these growth pressures, Fraser Health made progress on the management of overtime during the mid-2010 to mid-2013 time period. Nursing overtime hours grew by only two per cent per full-time equivalent (FTE), or 30.4 hours per FTE compared to a provincial average growth of 31.6 hours per FTE in the same period. Although nursing overtime is an ongoing challenge for all health authorities, Fraser Health’s progress in managing nursing overtime is significant, particularly given the 17.4 per cent increase in nursing hours over the same time frame.



Generally, a relatively rapid expansion of nursing hours coupled with an aging workforce demographic is accompanied by growth in overtime per FTE.

By mid-2013, overtime hours began to increase, placing Fraser Health near the midpoint in overtime use per FTE among health authorities. Remedial measures were introduced at Fraser Health and overtime as a percentage of productive hours again started to decline. As of February 2014, overtime use in Fraser Health was at 2.29 per cent of productive hours, compared to 2.68 per cent for the corresponding 2013 fiscal year-to-date period.

At a more granular level, the Fraser Health nursing overtime percentage is at 3.35 per cent this year, compared to 3.93 per cent last year. Nursing overtime use at several Fraser Health hospitals exceeded four per cent in 2013/14. These sites include Abbotsford Regional, Eagle Ridge, Langley, Mission, Royal Columbian, and Surrey Memorial hospitals. However, all of these sites, with the exception of Surrey Memorial Hospital, experienced a drop in nursing overtime in 2013/14 compared to 2012/13. Royal Columbian Hospital experienced a significant decline, with nursing overtime dropping from 6.98 per cent to 4.89 per cent.

SICK TIME

Fraser Health’s sick time hours per regular FTE are constant or nearly constant over the past three years. Overall, sick time is up 3.5 per cent for nurses, up 1.1 per cent for the facilities bargaining unit, down 9.4 per cent for the health sciences sector, and up 13.8 per cent for the community bargaining unit. In all cases, Fraser Health is at or moderately above provincial norms in sick time use.

Attendance management is an area that requires consistent attention in all health authorities and is not unique to Fraser Health. Generally, there is a growing proportion of the workforce that exhausts their sick banks and utilizes unpaid sick time. Unpaid sick time is not captured in the above workforce statistics.

STAFF INJURY RATE

Using the WorkSafe BC (WSBC) definition of ‘non-health care only’ claims, the Fraser Health staff injury rate per 100 FTEs increased from 4.3 to 5.3 claims per 100 from 2009 to 2012 inclusive. Fraser Health’s experience is the second highest rate among health authorities between 2009 and 2012 and, at 17.5 claims per 100, the Fraser Health long term care experience was the highest rate of all health authorities in 2012. However, in 2013, Fraser Health was able to drop its ‘WSBC claims with cost’ by over eight per cent from the average of the previous three years. The long term care experience also declined by 17 per cent over the past three-year average.



Claims duration is a particular focus for all health authorities. The WSBC rolling average calculation positioned Fraser Health at 43 days per claim in 2013, the lowest average duration among the HAs. As with overtime control, Fraser Health‘s track record on staff injury duration shows an ability to focus on results, identify effective remedial and preventive measures, and improve organizational performance.

DIFFICULT-TO-FILL VACANCIES

Difficult-to-fill vacancies are those vacancies that have been posted externally and remain unfilled after 90 days. These vacancies declined steadily in B.C. from 2008 to 2011 with all health authorities experiencing relief from near-crisis levels. By the third quarter of 2012, the rate had again started to climb, with province-wide vacancies in the health sciences sector increasing by 31 per cent by Q2 in 2013 from Q4 in 2012. This was offset by a 10 per cent decline in nursing vacancies overall.

Fraser Health is experiencing challenges, though not at 2008 levels, in difficult-to-fill health-sciences positions, which include such professionals as pharmacists, physiotherapists, occupational therapists, social workers, and lab and imaging technologists. Difficult-to-fill nursing positions in Fraser Health are at the provincial average level.

STAFF DEPLOYMENT OPPORTUNITIES

Overtime use and difficult-to-fill position pressures are influenced by staff mix and the rate of program growth. Fraser Health, with known population growth and demand pressures, will continue to add staff in the years ahead. Staffing at the B.C. median level of productive hours per patient-day in Fraser Health facilities could reduce the demand for nursing positions somewhat, and staffing with a higher ratio of nursing support staff could also reduce the potential for difficult-to-fill situations if the Lower Mainland pool of available nursing staff continues to tighten. By some estimates, a redesign of care processes and staff mix could redirect as many as 70 nursing positions. This would require significant staff engagement and an effective redesign process, such as the ‘releasing time to care’ model used by Vancouver Coastal Health. Health sciences vacancy management can be an even more difficult challenge, suggesting the need for careful control of the pace of program expansion.

STAFF ENGAGEMENT

Improving quality of care and services requires attention to three areas: care processes, structures, and culture. Culture exists at the unit level. A culture focused on quality reflects characteristics such as feeling safe to speak up about quality issues and a willingness to challenge the status quo,



perceptions of management, and the quality of team relationships. Staff engagement is an important aspect of building such a culture. Also critical is how the changes necessary to achieve a quality culture are led and implemented.

The Gallup Q12 engagement survey is one method available to health authorities to gain insight into organizational culture. B.C. health authorities have participated in three Gallup Q12 staff engagement surveys. Fraser Health had a 17 per cent improvement in participation in the 2013 Gallup Q12 survey, with 67 per cent of staff participating and the grand mean improving by 0.07 to 3.52. The Fraser Health grand mean compares favourably with the other health authorities as outlined in the table below.

Grand Mean by Health Authority in 2013

Health Authority Grand Mean Health Authority Grand Mean

Providence Health 3.58 PHSA 3.49

Northern Health 3.55 Interior Health 3.41

Vancouver Coastal 3.54 Island Health 3.39

Fraser Health 3.52 OVERALL 3.49

The grand mean for B.C. health authorities overall in 2013 is 3.49. This represents a small improvement from 3.44 in 2010 and compares to a grand mean of 4.11 in Gallup’s overall healthcare database. B.C. health authorities’ staff-engagement performance is in the bottom 25th percentile in Canada. The ratio of engaged to actively disengaged staff in B.C. is 0.9 to 1, as compared to 2.3 to 1 in the Gallup Canada database and 4.5 to 1 in the Gallup healthcare database (international). Gallup states that the staff engagement tipping point occurs at 4.0 engaged to 1 actively disengaged.

The Gallup survey results for Fraser Health, while not significantly different from the rest of the province, require attention. An overview of the Gallup grand mean by site in Fraser Health is summarized in the table below. All sites showed improvement in 2013 over the grand mean in 2010, with the exception of Mission. In Fraser Health overall, two out of 10 staff are engaged and six out of 10 are not engaged. There is a higher percentage of bargaining unit staff who are actively disengaged versus engaged. The survey results also point out that there was weak follow-through after the 2010 survey.



Gallup Q12 Grand Mean by Site in 2010 and 2013

Site 2010 2013 Site 2010 2013

Abbotsford 3.46 3.58 Burnaby 3.43 3.49

Chilliwack 3.29 3.39 Delta 3.51 3.55

Eagle Ridge 3.39 3.48 Fraser Health Canyon 3.30 3.50

Langley 3.28 3.42 Mission 3.47 3.30

Peace Arch 3.29 3.57 Ridge Meadows 3.29 3.46

Royal Columbian 3.36 3.47 Surrey Memorial 3.47 3.58

CONCLUSION – HEALTH HUMAN RESOURCES

Forecasting the need for the Fraser Health workforce provides the basis for the creation of recruitment, retention and workforce development initiatives. Service growth and an aging workforce continue to have the biggest impact on Fraser Health’s workforce projections and Fraser Health’s ability to maintain an adequate supply and mix of health professionals and providers. When coupled with the needs of the emerging, younger workforce, it is evident that a multi-pronged strategy is critical to ensuring system sustainability and an engaged, skilled, well managed and healthy workforce.

While ensuring that Fraser Health has the required number of qualified health service providers entering the workforce is important, it is equally important Fraser Health retain the people they already have. Through building and maintaining healthy, supportive workplaces that enhance working and learning conditions, Fraser Health has the opportunity to both attract and retain the workforce it needs to provide high quality services. Fraser Health also needs to continue focusing on ensuring care delivery models are fully utilizing the skill sets of its professionals, including creating and supporting inter-professional care teams.

The future work environment will be built around interdisciplinary, collaborative teams of health professionals and providers. Workflow models that identify best practices regarding staff utilization and new disciplines and positions are being considered to deal with population-based changes and services across the continuum of care.



FINANCE AND FUNDING

Since Fraser Health’s projected deficit for 2013/14 played a significant role leading up to Ministerial Order M282, the operating budget was an area of focus for the review committee and warrants comment in this document.

The Ministry of Health provides annual funding allocations to health authorities at the beginning of the three-year budget cycle. The review committee noted that raw per capita funding comparisons are not particularly helpful as they:

• Ignore inter-regional flows (e.g. patient referral patterns between Fraser Health and Vancouver Coastal Health)

• Provide insufficient recognition of the cost of complex services (e.g. patient referrals to Vancouver General Hospital or Saint Paul’s Hospital)

• Ignore factors such as remoteness, underlying health status, the cost of remote care delivery, and age make-up of the population served

The Ministry of Health funds health authorities with a mixed approach, using the Population Needs-Based Funding (PNBF) model, supplemented by a targeted funding approach (capital substitution needed for public private partnerships among other things) and activity-based funding to provide specific incentives in support of expected outputs from the system. The PNBF model is a tool for allocating available funding.

PNBF allocations among health authorities are based on:



The review committee acknowledged that all health authorities have issues with the PNBF model from their respective local perspectives. The PNBF model attempts to balance these competing expectations with a transparent system that is subject to periodic review and adjustment. To this end the review committee recommended that the Ministry of Health should continue to advance its detailed examination of PNBF methodology and outputs to ensure funding system consistency and responsiveness.

Adding the one-time provisions allocated to Fraser Health over the past year confirms that Fraser Health funding has consistently slightly exceeded the articulated PNBF model allocation for the past several years. When new facilities have been brought on stream, the incremental cost exposure to Fraser Health has been funded concurrently (or even in advance).

Fraser Health’s PNBF share and relative ranking has steadily increased in recognition of its expanding population and changing demographics, moving Fraser Health from the second largest funding allocation in 2010/11 to the largest since 2011/12. The 2015/16 allocation forecast would position Fraser Health with 30.5 per cent of funding, compared to 26.8 per cent for Vancouver Coastal Health (the second largest allocation).

Impact of Various Steps in the PNBF Allocation Process

IHA FHA VCHA VIHA NHADistribution by Pop only 16.1% 35.8% 25.1% 16.6% 6.3%2: After Demographics 17.7% 34.7% 23.8% 18.3% 5.5%3: After adding Health Status 19.0% 34.5% 21.5% 18.7% 6.3%4: After Interregional Flows 17.6% 30.9% 27.8% 18.9% 4.8%5: After Remoteness 18.2% 29.7% 26.9% 18.5% 6.8%6: After Complexity 16.8% 28.9% 28.8% 19.2% 6.4%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

40.0%

HA PNBF Share of Acute Care 2013/14



On balance, the review committee concluded that Fraser Health has funding consistent with provincial policy, given the age structure of the population, chronic disease prevalence and cross-regional patient flow dynamics and is treated equitably in comparison to the other health authorities. The analysis of the funding allocations since 2010/11 confirmed a rate of growth in funding exceeding that of all other health authorities, recognizing the pressures of population growth and aging. At present, Fraser Health receives its full share of PNBF and slightly more through one-time adjustments. From 2001/02 to 2012/13, the Fraser Health share of the total health authority funding lift was 32.6 per cent, and in the current cycle (2013/14 to 2015/16) the share of growth will exceed 40 per cent.

A key issue identified by the review committee and noted earlier in the service delivery and utilization section is that Fraser Health residents have relatively high rates of use relative to their overall demographics and health status. As previously illustrated, Fraser Health patient-days for the population over age 70 were substantially higher than Island Health and Vancouver Coastal Health averages in 2012/13. Appropriately moderating over age 70 acute care use through the development of well-considered options will be a priority for Fraser Health in the years ahead.

DEPLOYMENT OF REGIONAL FUNDS

An additional area of focus for the review committee was the distribution of funding by service sector in Fraser Health, specified as: acute care; residential care; community care; mental health and substance use (MHSU); population health and wellness (PHW); and corporate services. The table below provides a comparison of expenditure percentages. The percentages have remained very consistent since 2007/08, with sector coding changes over time as expenditure definitions have been refined in a joint Ministry of Health/health authority effort to reach consistency.

Regional Health Authority Sector Expenditures in Millions by Sector Allocation 2012/13

FHA % IHA % NHA % VCHA % VIHA %

Acute Care 1,693.1 57 1,014.5 55 430.8 59 2,047.5 60 1,092.2 55 Residential Care 521.5 18 356.7 19 95.9 13 442.8 13 343.4 17

Community Care 258.6 9 183.6 10 49.2 7 240.9 7 227.1 11

MHSU 209.8 7 107.8 6 50.6 7 282.8 8 143.2 7

PHW 73.6 2 54.5 3 37.2 5 99.9 3 55.5 3

Corporate 201.8 7 131.2 7 61.4 8 289.6 9 131.3 7

Total 2,958.5 100 1,848.2 100 725.0 100 3,403.5 100 1,992.7 100



The review committee noted, however, that while on the surface the Fraser Health expenditure distribution appears reasonably comparable to the pattern of other health authorities, the use of Vancouver Coastal Health services by Fraser Health residents should be a material consideration for planning. If the Vancouver Coastal Health costs associated with Fraser Health residents using their services (now funded by the Ministry of Health outside of Fraser Health) is factored into the Fraser Health envelope and removed from Vancouver Coastal Health, then:

• the acute care percentage would increase to just under 60 per cent, while the Vancouver Coastal Health allocation would shrink, placing Fraser Health with the highest percentage of acute care investment despite a younger than average population;

• Fraser Health residential care would shrink to 17 per cent; and • the aggregate of community care, mental health and substance use, and population health

and wellness would shrink to 17 per cent, the lowest among health authorities.

As such, the review committee recommended that Fraser Health should examine its sector allocation strategy, seeking opportunities to reinvest outside of the acute care sector.



CONCLUSION FROM POPULATION HEALTH NEEDS, SERVICE DELIVERY AND THE ORGANIZATION

The analysis of service delivery linked to an understanding of population and patient needs provides the basis for a strategic refresh of Fraser Health services, building on the platform put in place over the past number of years.

Vital statistics including life expectancy, standardized mortality, infant death rate and potential years of life lost prior to age 75 all position Fraser Health as the second healthiest health authority – healthier on average than the province overall.

Over the past decade the opening of new capacity has kept up with population growth and ageing; however, standardized for age, Fraser Health residents experience greater rates of admission, patient day use, and weighted patient day use than their counterparts elsewhere in urban British Columbia. The review committee analysis suggests that Fraser Health is close to the provincial average in acute care beds available, yet acute care occupancy pressures persist in the health authority. The overall rate of acute care service use in 2012/13 appears higher than the measured underlying health conditions would warrant.

Specifically, acute care use by Fraser Health residents, particularly for medical patients and for patients 70 years of age or older, is increasing relative to provincial norms. Fraser Health residents over age 70 account for 22 per cent more weighted patient cases and 16 per cent more admissions per 1,000 than the average of Vancouver Coastal Health and Island Health. Fraser Health utilization for the under 70 population is comparable to other urban regions of the province, but much higher than Vancouver Coastal Health, which historically has the lowest admission rates for this age group.

The analysis completed by Fraser Health with support from the review committee points to the need to rebalance service delivery across the care continuum – from primary, home and community care services, through to supported living and residential care access – to appropriately reduce demand and utilization of hospital services. Fraser Health must manage its acute care sector more effectively and efficiently in order to reduce length of stay, alternate level of care days and readmissions to hospital. Appropriately moderating acute care usage for patients over age 70 through the development of well-considered community options must be a priority for Fraser Health in the coming three years.

Fraser Health hospital sites vary greatly in the quality of care delivered, as measured by such indicators as hospital standardized mortality ratio and nursing-sensitive adverse events. Fraser Health must take urgent action to bring hospitals and sites which are outside a normal range into line with those sites which are performing well.



The strategic and operational review provided a number of insights to help strengthen the overall governance, leadership and management of Fraser Health. Given the complexity of modern health service delivery, Fraser Health needs to enact the kind of governance changes recommended by the review, including defining a focused and actionable set of priorities for the next three year cycle.

Oganizationally, Fraser Health needs to review whether a program based organizational model facilitates or hinders the provision of patient care across the continuum. If and or where it is found to be problematic, managers and care givers will need to be provided with the tools to enable more seamless and effective care.

Fraser Health also needs to renew its partnership with the physician community. Both Fraser Health and physicians will need to develop accountability principles and structures that enable the organization to succeed in providing the best care to its patients and clients.

Finally, the review found that Fraser Health’s share and relative ranking of provincial health funding has steadily increased in recognition of its expanding population and changing demographics. Fraser Health must believe that it has the appropriate funding to maintain a balanced budget throughout the next three year cycle and that it has the management tools to effect change and to develop a robust accountability structure.

In alignment with and supported by the Ministry of Health’s strategic priorities outlined in Setting Priorities for the B.C. Health System, and building on a range of initiatives already underway, Fraser Health will pursue specific actions to address these areas starting immediately. Fraser Health will engage and work with all parts of the organization including the board, senior management, physicians, nurses and nurse practitioners, health professionals and staff to maximize the functioning of our organization to improve the quality of services for Fraser Health residents.





PRIORITY ACTIONS FOR QUALITY AND SUSTAINABLE SERVICE DELIVERY IN FRASER HEALTH

This section of the plan details ten linked areas on which Fraser Health will prioritize and sustain focus to achieve meaningful improvements in population and patient outcomes in the coming years. These priorities will be the basis on which Fraser Health Service and Budget Plans are developed and will be tracked by a balanced scorecard of indicators, applied across and identified by HSDA and individual sites throughout Fraser Health.

1. Capacity for care across all sectors (efficiency and effectiveness) 2. Quality and safety 3. Public health measures 4. Accountability 5. Staff and physicians 6. Patient centredness 7. Governance 8. Operational organization and management 9. Lower Mainland collaboration 10. Budget accountability

1. CAPACITY FOR CARE ACROSS ALL SECTORS

Fraser Health will increase its capacity to support growth and aging of its population through developing efficiencies in the acute sector, and as a result increase investment in the community and residential care sectors.

A focus will be on reducing the actual length of stay for hospitalized patients to less than the expected length of stay as calculated by the Canadian Institute for Health Information, with specific emphasis on the work carried out by hospitalists. Anticipating and planning for discharge on admission, regular use of iCare rounding, and improved initial communication between the acute and community sector will be instituted with an aim to reducing alternative level of care days (patients who no longer require acute care). Better coordination of care with family physicians, nurse practitioners, other primary care givers and more robust community supports will lead to reduction of readmission rates.

Any organizational changes will be made as necessary to enhance the continuum of care for our patients, clients and residents, particularly in home and community care and residential care.



2. QUALITY AND SAFETY

Fraser Health will concentrate on the indicators of access and safety while looking at the entire spectrum of quality activity across all sectors. The provincial targets related to timing of scheduled surgery, wait times for CT and MRI and admission from emergency departments will be met.

In addition, the health authority will concentrate on a number of nursing-sensitive adverse events in medicine (falls, pneumonia, urinary tract infections and pressures sores). Attention will also be focused on complications identified in the National Surgical Quality Improvement Program (NSQIP), which include: post operative site infections, pneumonias, urinary infections, and blood clots.

Hospital Standarized Mortality Rates (HSMR), will be studied across the organization on a site by site basis so that poor performance can be eliminated and good performance emulated. Control measures that have been successful at some sites to reduce stubborn infections such as C. difficile outbreaks will be implemented throughout the organization. The organization will re-double efforts to achieve hand hygiene rate goals.

Improvement of these measures will require close work with medical, nursing and other health care professionals, and efforts to increase engagement with those professionals will be furthered.

3. PUBLIC HEALTH MEASURES

Fraser Health has a relatively young population, and its public health initiatives need to reflect this through indicators such as immunization rates for MMR (measles, mumps, rubella), and rate of low birth weight infants.

Fraser Health also has a number of separate and distinct communities. Programs specific to meeting population and public health needs will be expanded. Indicators such as number of communities with enhanced tobacco reduction bylaws, number of communities with a municipal alcohol policy, and number of communities with a healthy living plan will measure our efforts.

Fraser Health will also focus on the rapidly growing older population with targeted measures including active leisure in those 75 years of age or greater, and number of falls in residential care facilities.



4. ACCOUNTABILITY

FH will create a balanced scorecard of key performance measures and will report quarterly at the health authority, health service delivery area and site level.

Members of the senior team will be responsible for reporting on specific measures, however the development of action plans to successfully achieve targets are an organization wide responsibility. The balanced scorecard will be made available on the Fraser Health website.

5. STAFF AND PHYSICIANS

Fraser Health will review its employee and physician engagement plans. A robust exchange of ideas and best practices with other health authority vice presidents of human resources will occur, and Fraser Health is committed to adaptation of “best in class” programs.

Overall staff engagement has been measured provincially using the Gallup scores. These scores can be broken down by unit, and leadership programs will be designed for those that are not performing as well. Other human resource management measures will include the monitoring of sick time, nurse overtime, nursing productive hours of care per patient and staff safety.

In addition, Fraser Health recognizes the above average number of nursing hours in recent years, and will work with staff and unions to maximize quality and efficiency using the most successful methodologies in the province.

Since some measures are particular to certain physician groups, specific discussion will be undertaken in areas such as, but not limited to:

• Ambulatory Care Sensitive Conditions admissions, which will be discussed with emergency department physicians and specialists; and

• ALOS/ELOS and hospital readmission rates, which will be discussed with hospitalists, general practitioners and specialists

Fraser Health recognizes that improvement in the areas identified above will need to be realized through a proactive and collaborative relationship and dialogue between the health authority, physician community and services in the community. The effectiveness of this engagement including measures to streamline the Health Authority Medical Advisory Committee (HAMAC) will be examined.

Fraser Health commits to making whatever changes are needed to improve the care of the patients, clients and residents we serve.



6. PATIENT CENTREDNESS

While patient centredness was not a specific focus area from the strategic and operational review, it is core to Fraser Health’s strategy. Fraser Health will build on current work to implement a framework and toolkit that includes the diverse nature of its population. This means putting the patient and family at the heart of every decision and ensuring that we systematically examine the patient experience when redesigning services and care. It also means measuring the patient experience in a more robust manner.

7. GOVERNANCE

Suggestions for improvement to Fraser Health board operations emerged from the review and changes are underway including:

• Streamlined presentations to the board based upon key indicators described in this section; • Increased frequency of board meetings, including telecommunication as necessary • Creation of a robust senior leadership development plan, including succession planning for

senior leaders

In addition the board will follow best governance practices in its own self-evaluation, development and succession planning.

8. OPERATIONAL ORGANIZATION AND MANAGEMENT

Extensive analysis of the Fraser Health organizational model was performed as part of the review. The current FH model emphasizes horizontal programmatic themes through 14 programs.

Suggestions have been made to increase site or health service delivery area components in order to enhance the continuum of care from primary care to acute care to residential care. Fraser Health will undertake a careful analysis of portfolios and competencies, and examine the functional relationship between site leaders and the senior team.

The enhanced use of the various indicators identified in this plan, aggregated by site, will be used to identify areas requiring attention. These areas will be examined by the Fraser Health leadership team and acted upon in an expeditious manner.



9. LOWER MAINLAND COLLABORATION

Health authorities, with the assistance of the Ministry of Health, have been engaged in the consolidation of various non-clinical and clinical areas over recent years.

As noted in the review, there are a number of patients from Fraser Health that use the facilities of Vancouver Coastal Health and the Provincial Health Services Authority. In some ways this decreases demand on Fraser Health but it also makes it necessary to pursue increased collaboration between the three entities.

While the review examined primarily cardiac care, trauma and critical care, Fraser Health will engage in collaborative planning with its Lower Mainland partners for those services and other clinical areas such as stroke care planning, to enable the local population to realize the best value out of existing and planned specialized services and facilities.

10. BUDGET ACCOUNTABILITY

Fraser Health is committed to a balanced budget throughout its three-year cycle. The high level elements of the budget plan are included in this document. Indicators that will be used to measure this performance at a health authority level and also at a site and HSDA level will include: average cost per stay, acute productive hours per patient day and total system utilization.



FINANCIAL PLAN

FINANCIAL PLANNING PROCESS

Fraser Health’s 2014/15 to 2016/17 planning process is guided by the goals and objectives set out in the Ministerial Order M282 and addresses current and future population needs. The Financial Plan supports Fraser Health’s overall operational planning process.

Within the context of a balanced budget, the 2014/15 to 2016/17 Financial Plan is intended to support the health service delivery goals in the Strategic and Operational Plan. The financial planning process includes the following steps:

1. Determining service volumes for predicted demand growth; 2. Identifying resources to improve and re-prioritize services and reduce costs consistent with

the priority actions in the previous sections of the Strategic and Operational Plan; and 3. Preparing a detailed three year financial plan.

DETERMINE SERVICE VOLUMES

The process of identifying the workload, staffing, and financial resources needed to address this level of service includes:

• Build volume growth into the plan to preserve the current level of services based on the past four years of historical growth; and,

• Align the service capacity (population/patient day) provided by Fraser Health to meet the needs of the population as described in the Strategic and Operational Plan; and,

• Identify impacts on other areas such as clinical support (lab, pharmacy, etc.) and corporate support services (housekeeping, food services, etc.)

2 - Clinical Services

• Acute Care• Community Care• Public Health• Mental Health &

Substance Use• Residential Care

3 - Clinical Support Services

• Laboratory• Medical Imaging • Pharmacy

4 – Corporate Support Services

• Housekeeping• Food Services• Laundry/Linen• Systems Support• Facility Costs• Health Records• Material Management• Registration• Other

1 – Estimate Clinical Demands

• Historical Growth• Population Projections



2014/15 to 2016/17 Clinical Volumes

Fraser Health began the 2014/15 planning process with a review of historical workload volumes and the expected population growth. The first step was to forecast workload volumes based on the average growth over the past four years, including the new capacity that will come with the Surrey Memorial Hospital Critical Care Tower opening in June 2014, the Mission Memorial Hospital Campus of Care, the Langley Memorial Hospital maternity expansion, and the Residential Request for Proposal.

New Investments

This phase of the planning process identified the financial impact of those initiatives/services that were previously approved and had a cost impact in 2014/15 to 2016/17, including:

Colorectal Cancer Screening – $6.5 million annual cost for this provincial program, which started in 2013/14.

Langley Memorial Hospital Maternity – $1.6 million to open four of the seven newly constructed single room maternity beds. These beds will facilitate the consolidation of maternity services in Fraser Health.

Mission Campus of Care – Includes the opening of 175 beds out of the 200 new residential beds located on the Mission Memorial Hospital site. Included in 2014/15 is $2.4 million in start-up costs and $1.8 million ongoing costs. The remaining 25 beds will be opened at a later date.

Residential Request for Proposal – In April 2015 Fraser Health will open 92 new residential beds and 107 replacement beds, with an additional 311 new and 45 replacement beds opening in October 2015, at a cost of $11.3 million in 2015/16 growing to $32.8 million in 2016/17. In addition to these residential care beds, Fraser Health will open 24 new mental health and substance use beds for $0.8 million 2015/16, growing to $1.8 million in 2016/17.

Surrey Memorial Hospital Critical Care Tower and Expansion Project – Includes a new and expanded emergency department and a critical care tower at Surrey Memorial Hospital, which adds 151 acute care beds, establishes a centre of excellence in care for high-risk newborns, provides a larger adult intensive care unit. The emergency department opened in October 2013 and the tower opened in June 2014. Included in the 2014/15 Financial Plan is the incremental funding increase of $82.4 million.

SAMI – this project addressed the FH proportion of the severely addicted and mentally ill population that are being addressed in the entire Lower Mainland. This will likely lead to more enhanced Assertive Community Treatment Teams (ACT) for Fraser Health clients.



The results of this forecast are provided in the table below.

4 Yr Avg2010/11 2011/12 2012/13 2013/14 % Chg 2014/15 % Chg 2015/16 % Chg 2016/17 % Chg

Acute CareAdult & Children ActivitiesSeparations 111,081 115,118 118,975 122,245 2.5% 129,252 5.7% 133,755 3.5% 137,570 2.9%Patient Days 917,985 966,548 991,011 1,014,178 2.6% 1,072,794 5.8% 1,110,164 3.5% 1,141,831 2.9%Length of Stay 8.3 8.4 8.3 8.3 0.1% 8.3 0.0% 8.3 0.0% 8.3 0.0%

NewbornSeparations - Newborn & NICU 15,187 15,205 15,558 15,203 0.0% 15,922 4.7% 15,922 0.0% 15,922 0.0%Patient Days - Newborn & NICU 45,747 47,959 47,726 47,012 0.7% 50,958 8.4% 54,571 7.1% 55,064 0.9%

Emergency Visits 546,079 574,788 599,561 624,726 3.6% 653,150 4.5% 678,520 3.9% 705,290 3.9%

Operating Room (1)In-patient Visits 31,127 31,047 31,605 31,792 0.5% 32,100 1.0% 32,588 1.5% 33,075 1.5%Day Surgery Visits 52,545 53,346 51,589 52,532 0.0% 53,500 1.8% 54,313 1.5% 55,125 1.5%

Diagnostic ServicesLaboratory Procedures (1) 17,830,932 19,292,780 19,791,961 20,769,853 4.1% 21,816,000 5.0% 22,558,700 3.4% 23,182,700 2.8%Diagnostic Imaging Exams 1,010,018 1,136,431 1,163,513 1,190,908 4.5% 1,234,300 3.6% 1,263,100 2.3% 1,292,200 2.3%

Ambulatory CareSurgical Visits 204,142 244,730 264,329 285,548 10.0% 286,873 0.5% 291,574 1.6% 296,491 1.7%Medical Visits 307,742 341,357 363,186 407,024 8.1% 426,394 4.8% 457,178 7.2% 491,059 7.4%

Residential CareTotal Resident Days 2,833,413 2,879,771 2,904,006 2,954,549 1.1% 2,992,686 1.3% 3,009,152 0.6% 3,009,288 0.0%

Mental Health & Substance Use (Owned & Operated)Community Based Days 66,509 73,901 83,132 99,519 12.4% 118,600 19.2% 118,600 0.0% 118,600 0.0%

Home & Community Care (HCC)Home Support Hours 1,855,524 2,073,142 2,468,566 2,785,000 12.5% 2,896,400 4.0% 3,012,200 4.0% 3,132,400 4.0%

Notes:

(1) Workload statistics excludes the tests/visits for the Colorectal Cancer Screening fit test. This information will be added as soon as it is available.

Selected Workload Statistics Plan2014/15 to 2016/17

PlanActual

Before Average Length of Stay Reductions and Quality Improvements



ALIGNMENT WITH STRATEGIC AND OPERATIONAL PLAN

The second step was to forecast the workload volumes associated with the specific priorities described in the Strategic and Operational Plan that will have a direct impact on workload volumes:

Acute Care Average Length of Stay (ALOS), Utilization, and Quality – reduce the ALOS by 0.7 by focusing on decreasing complications (nursing adverse events, national surgical quality improvement program), following key protocols, and implementing best practices (estimated annual savings of $130 million). Reducing the ALOS, improving utilization of some services and improving quality will allow Fraser Health to manage the same number of inpatients with fewer acute care beds.

Alternative Level of Care (ALC) – reduce the number of ALC patients in acute care by investing in residential care (community/mental health/addictions) and in community care (home support hours/mental health/addictions). The 2016/17 annualized investment included in this Financial Plan is approximately $50.0 million in residential care and $15.0 million in community care.

Repurpose Acute Sites – consolidate some services and repurpose some sites to improve the quality of care through specialization, allow the health authority to provide more appropriate care in patients’ residential or home setting, and realize estimated annualized cost savings of $10.0 million. The repurposed sites have the potential to become centres of excellence for highly specialized activity within Fraser Health, while the additional community capacity will allow the health authority to provide care that is more comfortable for patients and cost effective for the health authority.

Physicians – work with the Ministry of Health to create incentives/disincentives in physician contracts.

Benchmark Services – align Fraser Health’s service delivery costs with other health authorities. Where Fraser Health can apply lessons learned/experiences of other health authorities in operating services at lower cost with appropriate levels of quality and service, Fraser Health will attempt to apply similar practices to reduce costs (i.e. care hours/patient day).

The impact of these changes on Fraser Health workload statistics is shown in the following table. As shown Fraser Health expects to reduce inpatients in 2014/15 by 20,700 and 2016/17 (annualized impact) by 83,950. In addition, emergency visits will decrease by 2,500 in 2014/15 and by 10,000 in 2016/17 (annualized impact). The investment made into community and/or mental health residential care will add 8,300 resident days in 2014/15, which will annualize to 30,000 by 2016/17. In addition, this plan includes an increase of 8,760 resident days for mental health and substance use and an increase in home support hours of 420,000 annualized hours (140,000 in 2014/15).



The last step in this part of the planning process was to pull together the workload statistics for the growth identified in step one and the volume changes identified in step two. The results are shown in the following table.

Annualized Impact of

ALOS/ELOS

2014/15 Impact

Acute CareAdult & Children ActivitiesSeparations - - Patient Days (83,950) (20,700) Length of Stay 7.6 8.1

Emergency Visits (10,000) (2,500)

Residential CareTotal Resident Days 30,000 8,300

Mental Health & Substance Use (Owned & Operated)Community Based Days 8,760 -

Home & Community Care (HCC)Home Support Hours 420,000 140,000

2014/15 to 2016/17 Planned ChangesSelected Workload Statistics

4 Yr Avg2010/11 2011/12 2012/13 2013/14 % Chg 2014/15 % Chg 2015/16 % Chg 2016/17 % Chg

Acute CareAdult & Children ActivitiesSeparations 111,081 115,118 118,975 122,245 2.5% 129,252 5.7% 133,755 3.5% 137,570 2.9%Patient Days 917,985 966,548 991,011 1,014,178 2.6% 1,052,094 3.7% 1,026,214 -2.5% 1,057,881 3.1%Length of Stay 8.3 8.4 8.3 8.3 0.1% 8.1 -1.9% 7.7 -5.7% 7.6 -0.9%

NewbornSeparations - Newborn & NICU 15,187 15,205 15,558 15,203 0.0% 15,922 4.7% 15,922 0.0% 15,922 0.0%Patient Days - Newborn & NICU 45,747 47,959 47,726 47,012 0.7% 50,958 8.4% 54,571 7.1% 55,064 0.9%

Emergency Visits 546,079 574,788 599,561 624,726 3.6% 650,650 4.1% 668,520 2.7% 695,290 4.0%

Operating Room (1)In-patient Visits 31,127 31,047 31,605 31,792 0.5% 32,100 1.0% 32,588 1.5% 33,075 1.5%Day Surgery Visits 52,545 53,346 51,589 52,532 0.0% 53,500 1.8% 54,313 1.5% 55,125 1.5%

Diagnostic ServicesLaboratory Procedures (1) 17,830,932 19,292,780 19,791,961 20,769,853 4.1% 21,816,000 5.0% 22,558,700 3.4% 23,182,700 2.8%Diagnostic Imaging Exams 1,010,018 1,136,431 1,163,513 1,190,908 4.5% 1,234,300 3.6% 1,263,100 2.3% 1,292,200 2.3%

Ambulatory CareSurgical Visits 204,142 244,730 264,329 285,548 10.0% 286,873 0.5% 291,574 1.6% 296,491 1.7%Medical Visits 307,742 341,357 363,186 407,024 8.1% 426,394 4.8% 457,178 7.2% 491,059 7.4%

Residential CareTotal Resident Days 2,833,413 2,879,771 2,904,006 2,954,549 1.1% 3,000,986 1.6% 3,039,152 1.3% 3,039,288 0.0%

Mental Health & Substance Use (Owned & Operated)Community Based Days 66,509 73,901 83,132 99,519 12.4% 118,600 19.2% 122,980 3.7% 127,360 3.6%

Home & Community Care (HCC)Home Support Hours 1,855,524 2,073,142 2,468,566 2,785,000 12.5% 3,036,400 9.0% 3,306,200 8.9% 3,552,400 7.4%

Notes:

Including Average Length of Stay Reductions and Quality Improvements

Selected Workload Statistics Plan2014/15 to 2016/17

(1) Workload statistics excludes the tests/visits for the Colorectal Cancer Screening fit test. This information will be added as soon as it is available.

Actual Plan



2014/15 FINANCIAL CONSIDERATIONS

Staffing Strategies – This Financial Plan includes the following strategies: • Overtime: maintain overtime costs at a rate that is lower than the rate experienced in

2013/14 ($3.0 million). Overtime as a percentage of worked time in 2013/14 was 2.3 per cent compared to 2012/13 at 2.7 per cent.

• Staffing Model: develop and implement program specific standardized staffing model across the acute care sites.

• Position Control: implement a more expansive position control process to ensure no unbudgeted positions are hired.

• Health Sector Compensation Information System (HSCIS): benchmark FH to other health authorities.

Achieve Pay for Performance Measures:

The Ministry of Health has advised the health authorities that Pay for Performance (P4P) funding will continue into 2014/15. Under P4P, the Ministry of Health has frozen a portion of health authority base funding, which will be released based on performance (activity and outcome-based measures) to maintain and improve system access and quality.

Pay for Performance funding in 2014/15 is $12.05 million and allocated to specific measures as follows:

Measures Holdback • Emergency admissions from triage • Elective patients waiting greater than 52 weeks for surgery • Hip fractures fixations within 48 hours • Nursing-sensitive adverse events • Data compliance (Home and Community Care) • Long Length of Stay

16.7% = $2.01M 16.7% = $2.01M 16.7% = $2.01M 16.7% = $2.01M 16.7% = $2.01M 16.7% = $2.01M 100% = $12.05M

Surrey Memorial Hospital Critical Care Tower Opening: the successful opening of the new Critical Care Tower will create acute care capacity, offset demand pressures, and relieve congestion. The costs associated with the Surrey Memorial Hospital Critical Care Tower were allocated to the programs / portfolios in alignment with the opening of the tower in June 2014.



THREE YEAR STATEMENT OF OPERATIONS – REVENUES, SECTOR EXPENDITURES, EXPENDITURES BY CATEGORY AND BUDGETS BY PROGRAM/PORTFOLIO

Fraser Health’s forecast Statement of Operations by Sector provides the 2013/14 year end results and the budget for 2014/15 to 2016/17. Included in the gross revenues and expenditures is approximately $64.0 million for the Lower Mainland Consolidated services that Fraser Health leads.

The Statement of Operations with expenditures by sector is shown in the following table. As per the Strategic and Operational Plan, Fraser Health has included targeted funding increases for residential and community services with growth in the acute sector essentially limited to the SMH Critical Care Tower.

The following section provides an analysis of the significant changes from 2013/14 to 2016/17 in the revenues and expenditures included in the above schedule.

Statement of OperationsExpenditures by Sectors

($000's)

2013/14 2013/14 2013/14 ChangeAudited ARHCC Actual 2014/15 2015/16 2016/17 from %

Statements Consolidation Results Budget Budget Budget 2013/14 ChangeRevenue:

Provincial Sources $2,977,806 $9,667 $2,987,473 3,119,589 3,167,791 3,205,628 218,155 7.3%Non-Provincial Sources 139,739 - 139,739 133,980 132,535 132,635 (7,104) -5.1%

Total Revenue 3,117,545 9,667 3,127,212 3,253,569 3,300,326 3,338,263 211,051 6.7%

Expenditures:Acute Care 1,781,069 9,667 1,790,736 1,883,175 1,871,495 1,856,329 65,593 3.7%Home & Community Care- Community 280,139 - 280,139 289,533 309,500 318,807 38,668 13.8%Home & Community Care - Residential 535,891 - 535,891 547,697 564,372 589,926 54,035 10.1%Mental Health & Substance Use 218,142 - 218,142 225,901 234,372 235,153 17,011 7.8%Population Health 77,878 - 77,878 80,159 81,206 81,091 3,213 4.1%Corporate 197,177 - 197,177 227,104 239,381 256,957 59,780 30.3%

Total Expenditures 3,090,296 9,667 3,099,963 3,253,569 3,300,326 3,338,263 238,300 7.7%

Net Surplus / (Deficit) $27,249 $0 $27,249 $0 $0 $0 ($27,249)



REVENUE

Provincial Sources ($218.2 million increase – 2016/17 over 2013/14): Includes the increase in Ministry of Health global funding, revenue from other provincial organizations such as other health authorities ($64.0 million from Lower Mainland Consolidation (LMC) services that FH leads), Medical Services Plan (MSP) for physicians, and the amortization of deferred capital contributions.

Included in the $218.2 million (7.3 per cent) increase in provincial sources of revenue is targeted Ministry of Health funding for SMH Emergency and Critical Care Tower ($87.8 million), Ministry of Health global funding allocation ($162.1 million), other targeted funding ($3.9 million) and an increase in the amortization of deferred capital contributions of $9.0 million (due to the SMH CCT).

Refer to the analysis on provincial sources of revenue in Appendix A for a detailed breakdown on the sources in this category.

Non-Provincial Sources ($7.1 million decrease): Includes Room Differential, Non-Residents, Fees and Licenses, Gain on Sale of Capital Assets, Endowment Contributions, Donations and other revenue. The $7.1 million (5.1 per cent) decrease in non-provincial sources of revenue includes a small reduction in interest revenue with the remaining reduction due to one-time revenue recognized in 2013/14 that is not expected to occur in future years including, $1.0 million for the sale of land in Mission, endowment contribution of $0.7 million, donations of $2.4 million, and union leave recoveries at $2.8 million. Any one-time funding of this type that is received in future years would have an offsetting expenditure or in the case of a land sale be shown as a surplus.

SECTOR EXPENDITURES

Expenditures in the sectors include known wage and benefit rate increases, such as step increments and the municipal pension plan rate changes. There may be some reallocation of expenditures between the sectors as implementation of the Strategic and Operational Plan progresses.

Acute Care ($65.6 million increase): This sector includes all of the services provided in the acute hospitals and in the Jim Pattison Outpatient Care and Surgery Centre, the diagnostic and therapeutic clinical support services (e.g. pharmacy, laboratory, medical imaging, physiotherapy, etc.) and corporate support services (e.g. food, housekeeping, laundry, infection control, etc.). Included is the SMH Critical Care Tower and the forecast growth which is essentially offset by the planned savings in the reduced length of stay, reduction in the number of Alternative Level of Care (ALC) inpatients (transferred to more appropriate care), and the consolidation and repurposing of acute care services.



Home and Community Care (HCC) Residential ($54.0 million increase): This sector includes owned and operated residential facilities and health service provider facilities. The 3 year financial plan includes $19.3 million for growth and $34.7 million for increased capacity to be implemented though a Residential Request for Proposal (RFP) process.

Home and Community Care (HCC) Community ($38.7 million increase): This sector includes services that are provided in the community or in the home (i.e. home health care, home support, primary health care, community dialysis clinics, chronic disease management, case management, and adult day care). These services are provided by Fraser Health employees and/or by health service providers. The three year financial plan includes $12.4 million growth in home support services, $8.0 million in home health services, and $3.3 million in primary care. The $15.0 million increase in this sector will be allocated to support the reduction in ALOS and ALC patients in acute care.

Mental Health and Substance Use ($17.0 million increase): This sector includes all services related to mental health and substance use, such as acute inpatient psychiatric services, community residential, case management, group therapy, outpatient clinics, and emergency psychiatric liaison. These services are provided by Fraser Health employees or health service providers.

Included in this Financial Plan is growth in acute psychiatric care ($6.4 million), residential care ($1.5 million), tertiary care ($1.6 million), and community and other services ($7.5 million). In addition, there may be funding currently allocated to Home and Community Care that will be transferred into this sector as needed to support the reduction in ALOS and ALC inpatient days.

Population Health ($3.2 million increase): This sector includes medical health officers, environmental health, public health nursing, health promotion, and other community services such as audiology, speech pathology, and dental. This plan includes a $3.2 million increase in population health ($0.6 million is targeted for highly active antiretroviral therapy for HIV).

Corporate ($59.8 million increase): The corporate sector includes administrative services such as human resources, finance, information management/information technology, supply chain, planning, and undistributed depreciation.

The following table provides a breakdown of the significant changes in the Corporate sector from 2013/14 to 2015/16.

2013/14 ChangeActual 2014/15 2015/16 2016/17 from %

Corporate Results Budget Budget Budget 2013/14 ChangeCorporate 229,777 208,904 217,481 235,057 5,280 2.3%Corporate HBT LTD (32,600) - - - 32,600 -100.0%Corporate Surrey Critical Care Tower - 18,200 21,900 21,900 21,900 0.0%

$197,177 $227,104 $239,381 $256,957 $59,780 30.3%



Included in 2013/14 is a Healthcare Benefit Trust Long Term Disability valuation adjustment that lowered the 2013/14 costs by $32.6 million. The 2014/15 to 2016/17 budget includes a cost increase of $21.9 million to operationalize the SMH Critical Care Tower (includes Public Private Partnership (P3) financing and facility management costs of $18.0 million; information management costs of $2.9 million; biomedical costs at $1.0 million). Also included in this financial plan is a $5.3 million (2.3 per cent) increase over the three year plan, primarily for information technology support ($3.0 million) for desk top services and the Kamloops Data Centre, and $2.7 million increase for Health Shared Services BC (HSSBC) Tech Services. These increases are partly offset by targeted reductions.

EXPENDITURES BY CATEGORY

The following schedule provides Fraser Health’s revenues and expenditures by category.

i. Revenues

Refer to the revenue analysis included in the Revenue, Expenditure by Sector section above and to Appendix A for the detailed schedule on provincial sources of revenue.

ii. Expenditures

The following section explains significant changes in each expense category from 2013/14 to 2016/17:

Statement of OperationsExpenditures by Category

($000's)

2013/14 2013/14 2013/14 ChangeAudited ARHCC Actual 2014/15 2015/16 2016/17 from %

Statements Consolidation Results Budget Budget Budget 2013/14 ChangeRevenue:

Provincial Sources 2,977,806 9,667 2,987,473 3,119,589 3,167,791 3,205,628 218,155 7.3%Non-Provincial Sources 139,739 - 139,739 133,980 132,535 132,635 (7,104) -5.1%

Total Revenues 3,117,545 9,667 3,127,212 3,253,569 3,300,326 3,338,263 211,051 6.7%

Expenditures:Compensation 1,718,577 59 1,718,636 1,832,413 1,846,384 1,816,723 98,087 5.7%Supplies 252,894 - 252,894 260,872 261,015 258,107 5,213 2.1%Sundry 104,248 12 104,260 93,549 89,608 90,410 (13,850) -13.3%Referred Out Services 814,896 2,385 817,281 838,781 871,351 943,341 126,060 15.4%Buildings and Grounds 99,240 4,685 103,925 113,054 113,068 112,782 8,857 8.5%Amortization of Capital Assets 100,441 2,526 102,967 114,900 118,900 116,900 13,933 13.5%

Total Expenditures 3,090,296 9,667 3,099,963 3,253,569 3,300,326 3,338,263 238,300 7.7%

Net Surplus / (Deficit) $27,249 $0 $27,249 $0 $0 $0 ($27,249)



Compensation ($98.1 million increase): Includes salaries and wages for Fraser Health employees, purchased service personnel and physician fees. The $98.1 million (5.7 per cent) increase in compensation costs is due to staffing increases for the SMH Critical Care Tower, the Mission Campus of Care, known wage (step progression) and benefit rate increases (includes wage sensitive benefits and the municipal pension plan) and the hospitalist program.

Supplies ($5.2 million increase): Includes all supplies, such as medical/surgical supplies, drugs, food, laundry and linen, and housekeeping, and stationary supplies. Increases in supplies at $5.2 million (2.1 per cent) includes 1.5 per cent for inflation and the costs associated with increased volumes for planned new programming such as the SMH Critical Care Tower and the Mission Campus of Care and the growth required to sustain existing service levels.

Sundry ($13.9 million decrease): Includes facility lease costs, patient transport, equipment purchases, equipment maintenance and repairs, bad debt expense, and miscellaneous expenses such as bank charges, travel, and professional fees (legal and audit).

The $14.0 million decrease in expenditures is due to the actual results for 2013/14 included one-time equipment purchases for the Mission Campus of Care and the SMH Critical Care Tower Project.

Referred Out Services ($126.1 million increase): Included in this expense category are health service providers in residential, community (i.e. home support), mental health and substance use (residential and community services), Lower Mainland Consolidated services, HSSBC services, and Facility Management services (P3 contracts, housekeeping, etc.).

Included in the $126.1 million is $50.0 million for planned growth in residential capacity (community and/or mental health/additions), $35.0 million for home health/home support and/or mental health community services, $27.7 million related to the SMH Critical Care Tower ($18.0 million SMH P3 contract, $2.9 million Information Management, $1.0 million Biomedical, $4.8 million Laboratory & Medical Imaging, and $1.0 million HSSBC Supply Chain), $5.0 million for contractual obligations (housekeeping, food services, security, facilities etc.), and $5.3 million for HSSBC Information Technology Services.

Buildings and Grounds ($8.9 million increase): Includes building and grounds service contracts, utilities, rent/leases, and interest on mortgages or long term debt. The $8.9 million increase includes $3.6 million for leases and $5.3 million for utility rate increases.

Amortization of Capital Assets ($13.9 million increase): Includes $17.0 million increase for the SMH Critical Care Tower less $3.0 million depreciation reduction for Abbotsford Hospital assets that were fully depreciated in 2013/14 (five year depreciation).



NET BUDGET BY PROGRAM/PORTFOLIO

The following schedule provides a high-level summary of the Financial Plan by program/portfolio services and includes the past two years of history and the 2014/15 to 2016/17 budget. The financial information provided in this schedule is the net amount (portfolio expenditures less portfolio specific revenues).

VP/Program 2012/13 Actual

2013/14 Actual

2014/15 Budget

2015/16 Budget

2016/17 Budget Note

Clinical Operations LDMedicine (includes Hospitalists) 180,833 196,937 198,613 172,036 160,772 1 MHSU 190,368 197,570 203,680 211,005 212,241 2 Rehab & Older Adult (incl PT & SW) 91,171 97,387 101,400 100,817 97,927 Residential 469,767 480,338 490,478 504,375 531,024 3 Other 499 377 383 383 383

Subtotal 932,639 972,610 994,554 988,616 1,002,347

Clinical Operations VGCritical Care 93,137 97,840 114,973 119,383 118,278 4 Cardiac & Renal 74,989 76,299 77,136 81,833 84,681 Emergency (excludes SMH Peds & MH) 93,237 104,602 105,692 108,916 114,618 5

MICY 84,445 89,951 97,384 98,574 99,801

Surgery (includes SPD & Portering) 270,924 280,226 282,731 286,830 283,018

SMH Lag Savings - - (8,000) - - Other (ARH & Community, Staffing Office, etc) 7,003 8,882 16,655 16,465 16,465

Subtotal 623,735 657,800 686,571 712,001 716,861

Clinical Operations MPeHome Health & End of Life (incl PATH) 212,576 237,248 245,297 262,756 272,663 6

Laboratory 69,109 74,301 80,066 79,191 81,323

Medical Imaging 50,331 55,487 58,764 58,197 60,712 Pharmacy 33,254 38,404 45,113 45,809 47,587 Other 678 3,588 528 528 528

Subtotal 365,948 409,028 429,768 446,481 462,813

Clinical Operations CHClinical Ops & Professional Practice / Access 20,306 19,248 26,818 27,022 27,248 Primary Healthcare 16,950 17,986 18,124 20,536 20,862

Subtotal 37,256 37,234 44,942 47,558 48,110

VP Public Health & CMO 59,906 70,787 65,336 65,976 66,019

Net Expenditures by Program/Portfolio2012/13 to 2016/17

($000's)



VP/Program 2012/13 Actual

2013/14 Actual

2014/15 Budget

2015/16 Budget

2016/17 Budget Note

VP Medicine 18,768 16,938 16,948 16,948 16,948

Information ManagementHealth Information Management 30,135 30,871 30,768 30,819 31,445 Biomedical Engineering 13,701 14,483 15,881 16,469 16,835 Information Management 44,895 49,963 52,395 54,867 56,088 7 HSSBC Technology Services 25,718 27,973 29,731 30,617 31,370

Subtotal 114,448 123,290 128,775 132,772 135,738

Chief Financial OfficerBISS 88,964 90,704 93,447 92,108 94,087 Finance & Corporate Services 14,526 15,253 15,199 15,286 15,325 HSSBC Materials Mgmt & Supply Chain 16,905 17,375 17,825 18,426 18,426 HSSBC Accounts Payable 989 920 966 966 966 P3 Facility Management / Planning 22,746 23,936 32,957 33,412 33,591 8 RCH Planning - 2,263 3,000 3,000 -

Subtotal 144,130 150,451 163,394 163,198 162,395

People & Organization Development 25,896 25,415 25,595 25,661 25,661

Communications 2,229 1,913 2,323 2,323 2,323

CEO 2,402 2,308 2,328 2,328 2,328

Capital Projects, Real EstateCapital Projects, Real Estate 76,348 83,262 85,414 87,955 90,523 9 Parking (9,377) (9,953) (10,187) (11,173) (11,173)Protection Services 7,561 7,887 8,137 8,137 8,137

Subtotal 74,532 81,197 83,364 84,919 87,487

Accounting Centres / Undistributed (2,427,128) (2,590,388) (2,668,398) (2,713,281) (2,753,530)Ministry of Health - One Time - - - -

(Surplus) / Deficit before Amortization (25,242) (48,407) (24,500) (24,500) (24,500)

Amortization 24,922 21,158 24,500 24,500 24,500

(Surplus) / Deficit after Amortization (321) (27,249) - - -

Net Expenditures by Program/Portfolio2012/13 to 2016/17

($000's)



The following are notes for clinical programs/portfolios with changes over $10.0 million and non-clinical portfolios over $5.0 million:

1) Medicine: includes $13.2 million for the SMH Critical Care Tower less targeted savings of

$47.0 million for cost reductions related to the ALOS and ALC patients by 2016/17 ($8.0 million in 2014/15, $24.0 million in 2015/16, and $15.0 million in 2016/17).

2) Mental Health and Substance Use: growth over 2013/14 is primarily due to the annualizations of Timber Creek and the SMH Mental Health Emergency.

3) Residential Care: includes the $50 million for growth to transition acute services to the community.

4) Critical Care: includes $24 million in growth for the SMH Critical Care Tower less ALOS targeted reductions of $4.5 million by 2016/17 ($2.0 million in 2015/16, and $2.5 million in 2016/17).

5) Emergency: includes the annualizations of the SMH emergency department with minor growth in emergency departments in the other acute sites less $5.0 million targeted volume reductions by 2016/17 ($1.0 million in 2014/15, $2.5 million in 2015/16, and $1.5 million in 2016/17)

6) Home Health and End of Life (includes Palliative and Therapeutic Harmonization (PATH)): includes the loss of $10.0 million reduction in accelerated AIPCC revenue, $12.2 million in planned growth in home support (approximately 4 per cent per year), $9.0 million growth in home health services, and $4.2 million in other services (includes Choice in Supports for Independent Living (CSIL), Community Living BC (CLBC), hospice, and community services).

7) Information Management: includes the ongoing costs for information systems associated with the SMH Critical Care Tower ($2.9 million) and desk top services/Kamloops Data Centre ($3.0 million).

8) P3 Management: increase is primarily due to SMH Critical Care Tower facilities management contract ($8.0 million).

9) Capital Projects, Real Estate: increase is primarily due to leases and utility rate increase.



LOWER MAINLAND CONSOLIDATION AND HEALTH SHARED SERVICES BC

To advance the goal of financial sustainability, Fraser Health is a partner participating in two major initiatives: LMC and HSSBC to deliver both clinical and corporate support services under a shared services model. Launched in August of 2009, the net value of the services managed by the LMC is $1.0 billion with Fraser Health’s portion amounting to $370.0 million for 2013/14.

In addition to collaborating with the other Lower Mainland health authorities, Fraser Health has consolidated certain services under HSSBC, including supply chain, technology services, and accounts payable. In addition, HSSBC through technology services manages key contracts for Fraser Health, including technology refresh, desk top management services, and the Kamloops Data Centre. For 2014/15 the net value of Fraser Health’s budget that is managed by HSSBC is $62.0 million.

Key areas of focus for the period covered by this Financial Plan include: • Revise the current budget model; • Bring shared services into financial balance; • Work with the Ministry of Health to expand the scope of shared services.

CAPITAL ASSET MANAGEMENT PLAN SUMMARY

Fraser Health’s Capital Plan supports the Strategic and Operational Plan and Fraser Health’s efforts to improve innovation, productivity, and efficiency in the delivery of health services through the optimization of technology and infrastructure.

2014/15 -2016/17 Capital Plan

Fraser Health’s 2014/15 to 2016/2017 Capital Plan includes investments in facilities, equipment, and information management/information technology. Capital needs are prioritized by the Capital Planning & Steering Committee against available funds. In August 2013 the Ministry of Health allocated Restricted Capital Grants (RCG) for Routine Capital Investments with cash flow from 2012/13 to 2016/17. The following table shows the amounts allocated for 2014/15 to 2016/17, the funds already committed and the balance remaining for new investments.

2014/15 2015/16 2016/17 TotalRestricted Capital Grants 20,700 20,700 27,400 68,800 Committed (19,644) (12,349) (4,275) (36,268) Total uncommitted 1,056 8,351 23,125 32,532

($000's)



For the 2014/15 Capital Plan, Fraser Health has $32.5 million of unallocated RCG funding, based on a three year period from 2014/15 to 2016/17. In addition, consistent with previous years, there is $9.2 million of non-RCG funding available, which is restricted for capital projects and equipment that cost under $0.1 million. The following table shows Fraser Health’s new project additions to the Capital Plan in 2014/15 by investment category and their associated cash flow and sources of funds.

Fraser Health’s total sources and application of capital funds for 2014/15 to 2016/17 is shown in the following table. Included in the planned capital cash flow is the 2014/15 capital plan shown above and projects approved in prior years that remain underway.

Cash Flow Source of Funds

2014/15 2015/16 2016/17 Total

Project RCG

(note 1)

Foundation /Auxiliary

Working Capital

Non-RCG

Facility ProjectsRoutine Capital Investment (unallocated) 32,532 1,056 8,351 23,125 32,532 32,532 - - - Subtotal Projects Under $5.0 million 32,532 1,056 8,351 23,125 32,532 32,532 - - - Projects under $100K 1,925 1,925 - - 1,925 - 25 - 1,900 Total Facility Projects 34,457 2,981 8,351 23,125 34,457 32,532 25 - 1,900

Equipment2013/14 Equipment under $100K 11,000 11,000 - - 11,000 - 3,675 - 7,325 Total Equipment 11,000 11,000 - - 11,000 - 3,675 - 7,325

Information Management Information Management Allocation 9,004 8,835 169 - 9,004 - - 9,004 - Information Technology Allocation 7,000 7,000 - - 7,000 - - 7,000 - Total IM/IT 16,004 15,835 169 - 16,004 - - 16,004 - Total Capital Plan 61,461 29,816 8,520 23,125 61,461 32,532 3,700 16,004 9,225

2014/15 Capital Plan

2014/15 Capital

Plan

($000's)



The $47.6 million in 2014/15 working capital (FH internal capital funds) includes $21.1 million for the SMH North Parkade, $23.3 million in IM/IT projects, with the remaining $3.2 million allocated to various facility projects.

The $20.7 million foundation funding includes support for the SMH Critical Care Tower ($16.0 million), equipment acquisitions between $5,000 and $100,000 ($3.7 million), and a number of smaller facility projects.

2012/13 to 2016/17 Capital Cash Flow ($000's)

Sources of Funds 2012/13 Actual

2013/14 Actual

2014/15 Plan

2015/16 Plan

2016/17 Plan

Total Plans

Ministry of Health ServicesRestricted Capital Grants 131,324 89,161 52,356 28,976 33,663 114,995 Ministry of Health Services under $100K 8,266 4,160 9,225 9,225 - 18,450

Total Contributions from the Province 139,590 93,320 61,581 38,201 33,663 133,445 Foundation 7,222 11,569 20,721 1,740 - 22,461 Regional Hospital District 12,531 10,282 - - - - Working Capital 3,069 21,689 47,589 - - 47,589 Other Internal Sources w ith DCC 8,302 23,596 11,337 402 - 11,740

Total Sources of Funds 170,714 160,457 141,229 40,344 33,663 215,236 Government Debt (note 1) 90,274 20,871 - - - Total 260,988 181,328 141,229 40,344 33,663 215,236

Application of FundsFacilities 227,734 150,444 95,137 30,217 29,388 154,741 Equipment 25,521 18,517 18,187 9,725 4,275 32,187 Information Management/Information Technology 7,733 12,367 27,905 402 - 28,308 Total Application of Funds 260,988 181,328 141,229 40,344 33,663 215,236

Notes: (1) Government debt reflects the liability build up of Fraser Health's P3 projects. Includes all facility, equipment and information management projects w ith confirmed funding Includes all approved Information Management / Information Technology projects



SUMMARY OF KEY PROJECTS (OVER $10.0 MILLION)

This section provides an overview of the major capital projects underway in Fraser Health and major projects with a business plans currently under review by Government.

i. Projects underway:

Surrey Memorial Hospital Critical Care Tower and Expansion Project, $486.4 million – Investments in the new emergency department and Critical Care Tower at Surrey Memorial Hospital will help reduce emergency room congestion, increase the number of acute care beds, establish a centre of excellence in care for high-risk newborns, provide a larger adult intensive care unit, and create a clinical academic campus for Surrey to help attract and retain health care professionals. The expansion at SMH will also include renovations to the existing hospital which will add inpatient beds, create an expanded family birthing unit, including a second dedicated maternity operating room, and expand the pharmacy and sterile processing unit. The emergency department opened in October 2013 and the tower opened in June 2014. The funding sources for the $486.4 million investment are RCG funding ($286.8 million), P3 debt ($179.6 million) and foundation funding ($15.0 million) and child health ($5.0 million).

Surrey Memorial Hospital Parkade, $29.0 million - The project involves demolition of the existing parkade and construction of a new 750 stall parkade to provide optimal access to the new SMH emergency department and Critical Care Tower. Space for an eight bay (increased from existing three bays) replacement ambulance station is also included in the project scope. Completion date is targeted for October 2014. The funding source is Fraser Health working capital.

ii. Business Cases under review by the Ministry of Health:

Peace Arch Hospital Emergency Renovation and Expansion17, $20.0 million – The project will address current infrastructure deficiencies that result in congestion and risk to patient and staff safety due to an emergency department that is critically undersized and overcapacity. The Peace Arch Hospital Foundation will contribute $15.0 million and Fraser Health will contribute the remaining $5.0 million from working capital funds.

17 Facilities Replacement/Renewal Opportunities, Board Briefing Note, October 31, 2013, page 1



Delta Hospital Medical Imaging and Laboratory Renovation and Expansion18, $12.5 million – The project will provide appropriate space for medical imaging and laboratory services. Completion of the project will improve patient care, address infection control issues currently in the hospital, eliminate laboratory accreditation issues and enable the implementation of new innovations in clinical practice, medical technologies and support systems in the hospital. The Delta Hospital Foundation will contribute $7.5 million and Fraser Health will contribute the remaining $5.0 million from working capital funds.

Matsqui-Sumas-Abbotsford (MSA) Site Redevelopment, $35.2 million – The project will replace 119 non-compliant residential care beds at the existing MSA site and add 81 new beds for a new 200 bed complex care facility that meets or exceeds current guidelines and capacity. Fraser Health will own and operate these beds. In addition to the Campus of Care, this project will consolidate existing community health programs into one location at the MSA site which Fraser Health will lease. This project is pending Government approval and is at the Request for Proposal stage. Construction completion is planned for 2017/18.

The Fraser Valley Regional Hospital District will contribute $14.1 million and Fraser Health will contribute the remaining $21.1 million from the proceeds of redevelopment and working capital funds.

Royal Columbia Hospital (RCH) Redevelopment Component A, $258.9 million – Component A of the RCH Redevelopment includes a 75 bed mental health and substance use facility (45 net new beds), the infrastructure for a new energy centre (excludes equipment) to support the RCH campus, new parking and replacement of existing parking stalls, relocation of the heliport, relocation of staff and services in areas impacted by construction, renovation and demolition, demolition of the Sherbrooke building, the development of an integrated IM/IT infrastructure, conversion from a steam to hot water system, linkages and transportation corridors to the remaining campus buildings, and the building services required to support the mental health and substance use building and the existing campus. The funding sources are the Ministry of Health ($249.8 million) and the Royal Columbian Hospital Foundation ($9.1 million).

18 Facilities Replacement/Renewal Opportunities, Board Briefing Note, October 31, 2013, page 6.



RISKS

To achieve the financial and operational plan, the following risks need to be considered: 1. Quality Improvement Plans: this Financial Plan is at risk if is the quality improvement plans

are not successfully implemented, or the plans are implemented slower than anticipated.

2. Surrey Memorial Hospital: generating additional volume which is not offset by reductions at other Fraser Health sites.

The new emergency department opened on October 1, 2013, with significantly higher volumes than anticipated. Some of this volume came from other Fraser Health sites which experienced a marginal decrease in visits. Overall, the growth at Surrey Memorial Hospital has been more than what can be explained by the decrease in other Fraser Health sites.

The following chart compares the number of visits to the SMH emergency department from 2011/12 to 2013/14 and forecasts that volume for 2014/15 by fiscal period. The significant increase in visits experienced since it opened has continued into 2014/15 and is expected to continue into the future.

Note: the difference between the 2013/14 P13 visits and 2014/15 P01 visits is due to the number of days in the period. 2013/14 P13 had 32 days (average number of visits per day at 357) and 2014/15 P01 had 24 days (average number of visits per day at 353).



The Critical Care Tower opened in June 2014, adding 151 net new beds to the Surrey site. This additional capacity has been factored into plans to manage acute care demand pressures. However, actual demand may exceed this additional capacity.

3. Pay for Performance Measures: Fraser Health may not achieve all of the Pay for Performance measures and as such may not fully earn available Pay for Performance funding.

4. Shared Services: This plan is at risk if the Lower Mainland Consolidation and Health Shared Services of BC increase costs and we are not able to refine the budget to address these external pressures.

5. Culture: Fraser Health will need to focus on proven actions to achieve meaningful impact on this plan. This needs to be driven in a timely manner to focus on prevention, primary care, home and community care and hospitals for the health system to ensure maximum value for the tax payers while providing maximum benefits to taxpayers. We will need to work within the existing budget and in partnership with staff, physicians and community.

6. Implementation: to ensure success of this plan, Fraser Health needs to consider if modifications to its structure are necessary to support the successful outcomes of the plan.



APPENDIX A

Provincial sources of revenue included in the Financial Plan are detailed in the following schedule.

2013/14 Actual Results

2014/15 Projection

2015/16 Projection

2016/17 Projection

GRE Revenue:Contributions From GRE - Province - MOH (Regional) (Note 3) 2,589,674 2,717,253 2,764,010 2,801,947 From GRE - Other Ministries 4,621 4,739 4,739 4,739 From GRE - Health Authorities 62,793 64,118 64,118 64,118 From GRE - Other Gov't Org & SUCH Entities 108 108 108 108 MSP - Fee for Service 84,312 84,599 84,599 84,599 MSP - Alternative Payments Program 47,078 47,544 47,544 47,544 MSP - Rural Health 244 44 44 44 MSP - MOCAP and Other 26,016 26,012 26,012 26,012 Pharmacare 1,320 914 914 914 Amortized Revenue - Deferred Operating Contributions 408 - - - Amortized Revenue - Deferred Capital Contributions 63,753 71,598 73,043 72,943 Sales to GRE - Gov't Org and SUCH 107,146 102,660 102,660 102,660 Total GRE Revenue 2,987,473 3,119,589 3,167,791 3,205,628

Provincial Sources of Revenue($000's)

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