Hospital Improvement Plan Niagara Health System Staff Report – December 16, 2008

Hamilton Niagara Haldimand BrantLocal Health Integration Network

Question: Emergency Medical Services (EMS)•

The EMS stated (HNHB LHIN Board educational session) that if Fort Erie and Port Colborne are not designated as Emergency Departments, EMS will have to take the patients to either Welland or Niagara Falls. They stated they currently take approximately 4200 patients to Fort Erie and Port Colborne. EMS went on to state they will require more resources if they have to bypass these two sites. They mentioned as a minimum $3,000,000. How valid is this assumption?

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Answer: EMS•

EMS has confirmed the cost figure was an estimate and does not reflect the impact of the Niagara Health System Hospital Improvement Plan (NHS HIP)

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Full financial impact will be assessed when the HIP directions are confirmed and an implementation schedule developed

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The costs of any additional ambulance coverage will be assessed against other enablers: e.g. offloading improvement strategies, education about ambulance utilization

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Question: EMS•

What communication has there been to date for serious discussion with the EMS?

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Answer: EMS•

It is too early to assess what impact any NHS service distribution changes will have on EMS. It will be necessary for EMS to participate throughout the ongoing planning and implementation processes over the next three to five years and contribute to the solutions for > patient flow e.g. ambulance destination protocols, timely ambulance offload, NHS wide patient transfer protocols among sites, reduced fire dept. accompaniment, and advanced paramedic target

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Question: Funding Assumptions•

Re NHS funding assumptions:

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For the economic increase in expenses year over year, NHS appears to be using 3%, yet Joseph Brant Memorial Hospital mentions in their newsletter that costs are going up 4-5%. Which one is right?

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Answer: Funding Assumptions

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NHS inflationary cost assumptions:

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3% for salaries and wages;

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3.5% for supply costs.

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Base funding assumption: 3% annually.

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Answer: Funding Assumptions Cont’d•

Over the term of the Hospital Service Accountability Agreement (HSAA), 2008-10, inflationary pressures are outstripping funding increases.

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For 2008/09 NHS received about 2.5% and for 2009/10, the planning allocation is 2.2%.

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MOHLTC determined these adjustments. With > costs growing quicker than funding, it is challenging for a hospital to improve efficiency and service delivery processes for a balanced budget. Inflationary increases > than the assumption place > financial pressure on the hospital. 7

Question: Assumptions

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Some of the other assumptions the NHS is using to contain costs are beyond their control - how realistic are these savings?

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Answer: Assumptions•

Comments are provided on some of the key assumptions in the NHS financial outlook.

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The savings of 82 inpatient beds through diversion of Alternate Level of Care (ALC) is optimistic in the short term. Although the LHIN has implemented a number of strategies to reduce ALC, it will take time to see the benefits and some of the positive results may be offset by > demand. The opening of 96 Long term care beds in 2011 should provide relief.

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Question: Funds Follow Consumers?•

Will there be a transfer of funds from the Hamilton hospitals to NHS if Niagara residents currently being treated in Hamilton receive treatment locally?

Answer: Funds Follow Consumers

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The Clinical Services Plan (CSPlan) will determine the appropriate distribution of health services for hospitals in HNHB LHIN. As the outcomes of the CSPlan are implemented, it will be essential that funding follows any new siting of programs or volumes.

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Question: Enablers to alleviate shortfalls

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What specifically can be done in the short term to address the NHS shortfall-cuts in services for instance: help from MOHLTC, staffing adjustments, admin cost reductions? Will the introduction of the Health Based Allocation Model (HBAM) help?

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Answer: Enablers for Shortfalls•

The LHIN is working closely with NHS to manage fiscal pressures.

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NHS is implementing the recommendations of the HCM report. Implementation will generate nearly $6 million in savings for the current fiscal year. As HIP directions and recommendations from the "Review of the Reviews" is implemented, additional savings will materialize in base operations, however, immediate savings may be offset by one-time costs to enable change.

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The funding formula is not a solution. Planning targets for the 2009/10 fiscal year allocation have already been communicated, approximately 2.1%. 12

Question: ALC Impacts•

What predictions can we make about the impact of Alternative Level of Care reduction strategies and the resulting cost reductions for the NHS?

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Answer: ALC Impacts•

The LHIN, its stakeholders and the Ministry are working to identify immediate, short term and longer term strategies to alleviate ALC.

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Outcomes of early Aging at Home initiatives are pending

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Current ALC rate is approximately 21% and the LHIN and stakeholders are working to achieve 16% as per the Ministry LHIN Accountability Agreement (MLAA). 14

Question: Cardiac, Cancer and New Site•

If waiting times for cancer and cardiac treatment for Niagara residents in Hamilton are satisfactory, should the plans for the new hospital and the impact on the HIP be re-considered, especially given the apparent community satisfaction with the current situation?

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Answer: Cardiac, Cancer and New Site•

While the cardiac wait times for advanced cardiac services have decreased, this success was the result of a capital expansion at Hamilton Health Sciences (HHS) (new cardiac catheterization lab and operating room). HNHB LHIN population demographics and projected advanced cardiac service needs (cardiac catheterization, percutaneous coronary intervention (PCI), advanced arrhythmia services) indicate that the existing 4 cardiac cath labs at HHSC will not be sufficient to meet future demand 16

Answer: Cardiac, Cancer and New Site Cont’d

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Building cardiac catheterization capacity in Niagara (over further expansion in Hamilton) brings services close to home for a significant proportion of the LHIN’s population while allowing for the development of one LHIN advanced cardiac program operated at two sites (Hamilton and Niagara) to promote program quality and sustainability, optimize health human resources and expand the option of primary (PCI) for residents of Niagara.

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Answer: Cardiac, Cancer and New Site Cont’d•

The Ontario Cancer Plan supports bringing cancer services closer to home. The Functional Program for a Niagara Regional Cancer Centre, endorsed by Cancer Care Ontario and approved by the Ministry of Health and Long-Term Care, the Walker Family Cancer Centre will be a Centre of Excellence for cancer care, located at the new healthcare complex in St. Catharines.

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Question: Who Does What?•

Are there services being provided by NHS that could/should be transferred to another provider?

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Answer: Who Does What?•

There are questions across the Province as to the role scope for hospitals in addictions services. NHS and area addictions providers should plan together.

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NHS role in paediatric care and children's mental health should be planned with tertiary services in Hamilton.

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The respective roles of NHS and Hotel Dieu Shaver Health and Rehabilitation Centre (HDS) in rehab, complex continuing care, slow stream rehab and reactivation programs need to be more fully explored.

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NHS and Kitts’ Report concur: withdraw thoracic surgery

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Other opportunities may emerge in clinical services planning 20

Question: Maternal Newborn Services•

Would the maintenance of maternity services for routine births at Greater Niagara General Hospital (GNGH) and/or Welland County Hospital (WCH) and the creation of a centre for more complex cases at St. Catharine’s General Hospital (SGH) be feasible and sustainable?

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Why is a centre for excellence for maternity not feasible at either of GNGH or WCH, given the staff's concerns about the need for a pediatric centre at SGH? 21

Answer: Maternal Newborn Services

The case for consolidation

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Quality and economies of scale: 1500 births a year

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Space requirements: 50,000 sq. feet

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Existing three sites: significant renovations and considerable domino effect

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Answer: Maternal Newborn Cont’d

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The most important consideration for the maternal child program is quality. When women and children access obstetrical and paediatric care, it is critical that it be of high quality. Consolidation to the St. Catharines site is consistent with this priority (Kitts, 2008)

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Question: Rehab Capacity•

Can Hotel Dieu Shaver handle all of the rehab needs for NHS?

Answer: Rehab Capacity

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To be assessed pending LHIN-wide review of complex continuing care and rehabilitation

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Question: Urgent Care and Evaluation•

Urgent Care Centres (UCCs) - In what time frame will the evaluations take place and are they guaranteed for a specific time? If they are successful will every effort be made to keep them operational?

Answer: Urgent Care and Evaluation

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It would be appropriate for NHS to consult with other UCCs about their evaluation approaches and appropriate trend data for meaningful assessment. Likely the UCCs would remain available to the extent they are meeting level of care need. 25

Question: The HIP and Physician Retention•

Can we predict the impact on doctors' staying in their current communities if the hospital services change, particularly in Fort Erie and Port Colborne, given the prominent role family practitioners play in those hospitals?

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Answer: The HIP and Physician Retention• Recruitment and retention is strengthened

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when program and service directions are clear and committed

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with Centres of Excellence that support volume, equipment, coverage

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The HIP – no impact on Family Physicians and their role with learners/students

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Majority of new medical graduates seek opportunities that offer quality infrastructure, professional support, and reasonable workload

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Question: Inter-site Transit•

Inter-site transportation - In what depth has the cost of this service been explored and if so, are these costs figured into the five year budget?

Answer: Inter site Transit•

This initiative would be addressed by NHS in an implementation plan.

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Requirements of “H”Guidelines for Hospital Emergency Units in Ontario (1989)

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Guidelines developed by the MOHLTC to assist hospital boards in ensuring that emergency units are capable of providing rapid assessment and basic stabilization of patients with life, limb, or function threatening conditions, and when necessary, to admit such patients or arrange for their rapid transfer to other treatment facilities.

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A hospital emergency unit is considered to be a unit within a hospital that is specifically designated, staffed and equipped to care for persons requiring immediate or urgent assessment, diagnosis, and treatment of illness and injury.

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Requirements of “H” Cont’dQuality of Care•

The Emergency Department (ED) must be covered by a physician 24/7 and if on-call must respond within 15 minutes (most ED’s have on-site physicians).

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Emergency unit medical/nursing personnel must possess knowledge and skills in emergency medicine sufficient to perform triage, evaluation, and resuscitation of emergency patients with life, limb, or function threatening conditions

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Mandatory skills include airway management; cardiac defibrillation; cardiac monitoring, initiation of critical IV solutions; administration of drugs for life threatening conditions

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Requirements of “H” Cont’dQuality of Care Cont’d

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Equipment and supplies must be immediately available

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Pharmacologic interventions must be immediately available

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Clinical lab and diagnostic imaging should be available.

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Requirements of “H” Cont’dQuality Assurance Programs

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The emergency unit should have programs to evaluate the quality of care provided to patients. Examples provided include physician/nurse audits; mortality review; random chart audit; outcome reviews; specific entity review; documentation of continuing medical education

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Requirements of “H” Cont’dPatient Transfer

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The staff must be aware of specialized treatment centers and critical care facilities within their region.

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Staff should be familiar with the Provincial Guidelines for Transferring Critically Ill Patients between hospitals.

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Transfer of an emergency patient must not occur until appropriate evaluation has been completed and stabilization procedures have been instituted.

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Consultation with specialized treatment centers regarding management and/or early transfer is indicated for severe and /or multiple trauma; spinal cord injury; severe or extensive burns; acute renal failure; high risk obstetrics, etc. 33

Ambulance RedirectsCurrently

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Approx 284 people (CTAS 1 and 2) arrive at Douglas Memorial site by ambulance annually

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Approx 274 people (CTAS 1 and 2) arrive at Port Colborne site by ambulance annually

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Hence, the current HIP Plan suggests that approximately 274 people would be taken directly to one of three sites for emergency care (~ 23 a month)

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Current Utilization CTAS 1 and CTAS 2 (6 months 2008) Apr- Sept

Arrival Port Colborne Douglas Memorial

CTAS 1 CTAS 2 CTAS 1 CTAS 2 EMS 23 114 25 117OPT 0 0 0 0Walk in 16 486 9 361 Total 39 600 34 478

Source: NHS, 2008

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CTAS Levels CTAS Levels Physician Reassess (RN)

Level 1 Resuscitation

Immediate aggressive interventions Continuous nursing care

Level 2 Emergent

Rapid medical intervention by physician or medical directive

Every 15 minutes

Level 3 Urgent

Serious problem requiring Emergency intervention

Every 30 minutes

Level 4 Less Urgent

Benefit from intervention or reassurance within one or two hours

Every 60 minutes

Level 5 Non-Urgent

could be delayed or even referred to other areas of the hospital or health care system

Every 120 minutes

Source: Beveridge, R. et al CTAS-Canadian Emergency Department Triage and Acutiy Scale: Implementation Guidelines. CJEM 1999, Oct Special Supplement.

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Sustainability

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People

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Assets

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Financial Health

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Sustainability: People

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Health human resources - people – are stretched across multiple sites

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Nurse (ONA) vacancy rate is 6.85%; overall vacancy rate is 5.29% (October 31, 2008)

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Ontario Nurses Association has censored NHS since 2002

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Physician recruitment a challenge 38

Sustainability: Finances

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Draft Financial OutlookNiagara Health System

Hospital Improvement Plan(December 10, 2008 Amendment)

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NHS Financial Outlook

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2007/2008 Actual

2008/2009 Forecast

2009/2010 Plan

2010/2011 Plan

2011/2012 Plan

2012/2013 Plan

REVENUE MOHLTC Base Allocation 284,039,781 291,634,700 298,211,700 307,158,100 316,372,800 325,864,000 MOHLTC Allocation - Interest Carrying Costs 2,570,000 3,055,000 3,085,000 2,985,000

MOHLTC Additional Funding 3,004,500 PCOP-New Hospital and Rehab 2,600,000 2,600,000 65,482,500 One-time payments 15,256,845 8,275,150 8,275,150 9,275,150 10,275,150 11,275,150 Paymaster 8,837,100 9,448,250 9,903,950 10,382,450 10,884,850 11,381,850 Other Revenue from MOHLTC 6,779,284 7,269,850 7,269,850 7,269,850 7,269,850 7,269,850 Sub total MOHLTC 314,913,010 316,627,950 326,230,650 339,740,550 350,487,650 427,262,850 Other Revenue-Patient/Differential/Recoveries/Amortization 56,580,502 54,646,850 54,924,350 55,401,850 55,879,350 56,356,850 TOTAL REVENUE 371,493,512 371,274,800 381,155,000 395,142,400 406,367,000 483,619,700

EXPENSECompensation and Benefits 244,168,679 244,281,700 245,640,200 252,847,500 256,982,900 308,280,800 Medical Staff Remuneration 35,173,312 33,817,600 33,367,600 33,367,600 33,367,600 33,367,600 Supplies and Other Expenses incl med/surg/drugs/amortization 108,330,340 109,104,700 111,115,500 114,427,000 117,772,800 138,986,300 Interest - short term 1,676,789 1,900,800 2,570,000 3,055,000 3,085,000 2,985,000 TOTAL EXPENSE 389,349,120 389,104,800 392,693,300 403,697,100 411,208,300 483,619,700

SURPLUS/(DEFICIT) FROM HOSPITAL OPERATIONS (17,855,608) (17,830,000) (11,538,300) (8,554,700) (4,841,300) -

Change in Financial Position 25,608 6,291,700 3,233,600 3,720,900 1,882,900 Ratio: Total Margin as % of Revenue -4.8% -4.8% -3.0% -2.2% -1.2% 0.0%Working Capital Deficit (116,800,000) (134,630,000) (146,168,300) (154,473,000) (159,056,800) (161,757,700)

MOHLTC One Time Funding - $3.5 million•

in 2007-08, the MOHLTC provided NHS with a $3.5 million one-time payment•

funds recorded as revenue - reducing deficit from $21.3 million •

if all else remained the same the 2008-09 deficit would be greater by this amount, hence the need to add it back to the forecast

Base Funding and Economic Increase •

base funding % increases less than inflationary increases•

difference impacts hospital’s deficit

Interest Carrying Costs – $11.71 million•

assumed interest cost incurred on the annual bridge financing will be funded by the LHIN on a one-time annual basis

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cash advances are basically interest free loans that help reduce the carrying costs of working capital deficits

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ministry has not funded these costs historically nor is expected to in the future•

hospital expected to manage costs of borrowing

NHS Financial Outlook – LHIN Comments

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Additional Base Funding Required - $3.0 million

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2012-13 financial outlook revised to remove savings related to inpatient and emergency services at the Fort Erie site

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Net impact on the deficit is $4.4 million. •

Revised financial position at March 31, 2013 is a deficit of $3.0 million

NHS Financial Outlook – LHIN Comments

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2012-13 HIP Surplus as per Addendum dated November 18, 2008 1,395,500$ Removal of Funding Assumed for Port & Fort ER - end state vision comprehensive primary care and monitored beds (4,900,000) Removal of costs related to Fort Erie monitored beds 500,000

Revised Deficit at 2012-13 (3,004,500)$

HCM Initiatives - $14.3 million

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NHS has started to implement the recommendations from HCM

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expected savings in 2008-09 is $6.72 million

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these savings enable NHS to hold their deficit to $18 million - without these savings, the forecast deficit would be $24.72 million.

ALC Reduction - $9.75 million

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as a result of the AAH initiatives $9.75 million of savings projected from the reduction in ALC beds – may be overly optimistic estimate

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difficult to quantify a reduction in ALC beds as a result of the initiatives being implemented under AAH

NHS Financial Outlook – LHIN Comments

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Sustainability: Quality Challenges

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Demographic Change

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Health System Transformation

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Multiple Sites

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Finite Resources

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Quality Cooperative

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Meaningful Relationships 45

On the HIP: Response to Recent Correspondence

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There is no hospital closure

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Quality trumps cost for long-term gain

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War of words over emergency access and the implications for the most urgent of cases

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Kitts’ Review: Requirement for champions to “step up”

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In Closing: Niagara Health System Responsibility•

Hospital Boards are required to ensure that hospital administrative and medical leadership develop plans to deal with situations that could place a greater than normal demand on the services provided by the hospital and disrupt the normal hospital routine (Public Hospitals Act)

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Hospitals are responsible to deliver and manage programs and services effectively and efficiently, safeguard protected services and roll out provincial strategies (HAPS Guidelines)

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Hospitals are required to “improve access to high quality health services, coordinated health care and effective and efficient management” (LHSIA)

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In Closing: Niagara Health System Responsibility Cont’d

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The LHIN requires health service providers and their partners to advance health improvement solutions that are

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in the public interest

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collaborative

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coordinated, and

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focused on the needs of residents and patients.

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