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AHW RHA Efficiency Review
Palliser Health Region
Governance and Accountability Overview Final Report
July 13, 2007
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AHW RHA Efficiency Review Palliser Health Region Property of Alberta Health and Wellness
Property of Alberta Health 2007 Deloitte Inc and Wellness
Governance and Accountability Overview
Key Components of Governance and Accountability
The province of Alberta uses a four part accountability framework that includes: 1) a three year Health Plan; 2) Annual Business Plans; 3)Quarterly Performance Reports; and 4) Annual Reports. This framework is to promote:
Governance and management of the health region Accountability to the Minister Keeping the public informed
For this assessment, Deloitte has focused on the Three-Year Health Plan to assess the degree to which there is demonstrable evidence that the direction is cascading to the operational level. In addition, Deloitte has applied a high level assessment of the Board's role related to:
Responsibilities and mandate Structure and organization Processes and information Performance assessment and accountability Organizational culture
Performance Assessment and Accountability Responsibilities and Mandate Organizational Culture Processes and Information Structure and Organization
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AHW RHA Efficiency Review Palliser Health Region Property of Alberta Health and Wellness
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PHR Three-Year Plan
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AHW RHA Efficiency Review Palliser Health Region Property of Alberta Health and Wellness
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Three Year Plan
PHR Strategy Mapping AH&W Goals & Legislated Responsibility
Deloitte's review of Palliser Health Region's strategies (2006 2009) mapped to health system goals and legislated responsibilities provides the following observations. Health System Goals 1 Albertans Choose Healthier Lifestyles Legislated Responsibility 1 Promote and protect the health of the population in the health region and work towards the prevention of disease and injury
Regional Strategic Focus 1: Promoting and Protecting Health
One corresponding strategy identified related to Wellness and Healthy Living. Our consultation process has identified the following: The 10 year Healthy Living Plan (2004) sets goals and strategies for increasing healthy behaviours and reducing chronic disease.
Deloitte Observations at the Operational Level
The recently completed community needs assessment provides a baseline from which to inform health care planning and monitor progress in achieving improvement in health status. Health Promotion utilizes a population health approach, with programs in community nutrition, smoke free communities, injury prevention, and other areas. Consultation findings indicated an opportunity to expand injury prevention services. The Chronic Disease Management, Living Healthy Program offers a number of programs aimed at enhancing healthy living and wellness. Public Health provides a full range of services but there is an opportunity to expand sexual health services. Overall, regional planning related to this strategy appears to be robust, and performance indicators are clearly identified for both three-year and longer-term targets for success.
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AHW RHA Efficiency Review Palliser Health Region Property of Alberta Health and Wellness
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Three Year Plan
PHR Strategy Mapping AH&W Goals & Legislated Responsibility
Deloitte's review of Palliser Health Region's strategies (2006 2009) mapped to health system goals and legislated responsibilities provides the following observations. Health System Goal 2 Albertans Health is Protected Legislated Responsibility 2 Assess on an ongoing basis the health needs of our region.
Regional Strategic Focus: Assessing the Needs of the Population
Although not separately identified as part of the region's four-part Strategic Focus framework, the region has identified this additional assessment focus as a key priority in its three-year health plan. Two corresponding strategies are identified: 1.1 Needs Assessment 1.2 Community Health Councils Both of these strategies are important elements to the ongoing health service planning and connection / responsiveness to communities served. The region conducts regular community health needs assessments, which significantly supports its ongoing planning and development of health services. The 2005 Community Needs assessment was developed through both community consultation and data gathering, and is providing information to inform health care planning in the Region. The region is currently in process of incorporating the findings from this assessment into planning. The region currently has three CHCs: Central, Northern and Western. Stakeholders report ongoing challenges with respect to the engagement of the Western CHC in regional vs. local issues.
4 AHW RHA Efficiency Review Palliser Health Region Property of Alberta Health and Wellness 2007 Deloitte Inc
Deloitte Observations at the Operational Level
Three Year Plan
PHR Strategy Mapping AH&W Goals & Legislated Responsibility
Deloitte's review of Palliser Health Region's strategies (2006 2009) mapped to health system goals and legislated responsibilities provides the following observations. Health System Goals 3 and 4
Improve Access to Health Services Improve Health Services Outcomes
Legislated Responsibilities 3 and 4
Determine priorities in the provision of health services in the region and allocate resources accordingly. Ensure that reasonable access to quality health services is provided in and through the health region
Five corresponding strategies identified: 3.1 Access to Services 3.2 Quality of Service 3.3 Primary Care 3.4 Mental Health 3.5 Continuing Care 3.6 Aboriginal Health Strategies/programs in Mental Health are integrated across the continuum of care, including the Child/adolescent program and Partial Hospitalization program. Community treatment plans Deloitte accompany inpatient admissions, which supports continuity of care. Observations Recent development of Quality Committees is a good strategy, however it has substantial work at the effort related to pulling all initiatives together and linking it to decision-making. Operational The Primary Care clinic offered at Bassano was one of the first programs offered in Alberta and Level is recognized as leading practice. The implementation of the Geriatric Assessment Program will positively impact quality of care provided to seniors through the seniors outreach (day hospital), vascular prevention clinic and the community outreach team. The regional Palliative Care Program supports continuity of care from acute to community. The implementation of the MDS tool will provide valuable information continuing care clients. Aboriginal health delivery is embedded in general care delivery. Other special target populations also warrant focus. Although several wait time measures are identified to support strategy 3.1 that still require performance indicators to drive and track progress to the strategy (e.g. Prostate Cancer)
5 AHW RHA Efficiency Review Palliser Health Region Property of Alberta Health and Wellness 2007 Deloitte Inc
Three Year Plan
PHR Strategy Mapping AH&W Goals & Legislated Responsibility
Deloitte's review of Palliser Health Region's strategies (2006 2009) mapped to health system goals and legislated responsibilities provides the following observations. Health System Goals 5 and 6 Health System Sustainability Create Organizational Excellence Legislated Responsibility 5 Promote the provision of health services in a manner responsive to the needs of individuals and communities and support the integration of services and facilities in the region.
Regional Strategic Focus 3: Adapting Technology and Resources Regional Strategic Focus 4: Improving Delivery and Efficiency
Three corresponding strategies identified: 3.7 Workforce 4.1 Information and Technology 4.2 Cost of Services The organization has developed a nursing workforce planning document and is in the process of working through the action plan. Once complete it will be rolled out to other professions. Innovative strategies include the use of supernumerary positions for new graduate nurses and the adoption of HPNet. Education skills days offered for nurses at Medicine Hat are now being expanded to the rural sites. Health Human Resource Plan (May 06) is developed, however it does not include the level of detail required for effective physician human resource planning. The region is planning to develop a comprehensive workforce plan in Fall 06 it is suggested that this include management, staff and physicians workforce needs throughout the region. The region is focused heavily on the Meditech implementation to drive strategy 4.1, with no specific measures or actions about other IT systems initiatives. The region's current lack of an IT strategic plan is an important missing input into the health plan. Although the region has identified cost of services as a strategic focus, no measures have yet been identified.
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Deloitte Observations at the Operational Level
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AHW RHA Efficiency Review Palliser Health Region Property of Alberta Health and Wellness
Three Year Plan
PHR Challenges and Opportunities Section Deloitte's review of Palliser Health Region's Three Year Plan (20062009) provides the following observations.
The plan identifies regional strategies and priorities in alignment to AHW's Health System Goals and legislated responsibilities, with clear performance measures and year-over-year targets to track progress to the tactical approaches for each strategic focus. Consultation findings across the strategic areas of focus and supporting tactical approaches have identified generally good progress towards the health plan. The establishment of a regular community health needs assessment for the region is an important input into planning, and should be maintained. An Annual Plan is not separately developed in PHR as it is in some of the other regions, and so commentary is incorporated into three-year plan observations.
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PHR Governance Assessment
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PHR Governance Assessment
Assessment Areas and Indicators
The high level assessment of the five areas of governance responsibility included:
Responsibilities and mandate Structure and organization Processes and information Performance assessment and accountability Organizational culture
Responsibilities and Mandate Performance Assessment and Accountability Organizational Culture Processes and Information Structure and Organization
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AHW RHA Efficiency Review Palliser Health Region Property of Alberta Health and Wellness
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PHR Governance Assessment
Responsibilities and Mandate
Performance Assessment and Accountability
Responsibilities and Mandate Organizational Culture Processes and Information Structure and Organization
Understanding of scope, authority and responsibilities (the difference between stewardship and management and setting policy vs. implementing policy) Involvement in multi-year strategic planning
Areas of Assessment
Involvement in annual planning and budgeting Involvement in establishing risk management process and aware of procedures to mitigate risk Ensuring management effectiveness and succession Communication with key stakeholders Board self reports to have good level of involvement in key areas of responsibility, with a focus on policy. Management is given a clear mandate to respond to operational issues.
Deloitte Observations
Board Chair reports that some members may not be completely familiar with their responsibilities and personal liabilities associated with their regional governance role, and that management is well-trusted to provide guidance to Board. This suggests an opportunity for further board development and education. Board has regular involvement with community stakeholders by rotating its meetings through each community twice per year, and through the Community Health Councils.
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AHW RHA Efficiency Review Palliser Health Region Property of Alberta Health and Wellness
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PHR Governance Assessment
Structure and Organization
Performance Assessment and Accountability
Responsibilities and Mandate Organizational Culture Processes and Information Structure and Organization
Appropriate number of members and meetings
Areas of Assessment
Appropriate representation of communities Committee structure Self assessment The Board currently has 13 members, with some members serving since 1995. The Board Chair reports a good mix of community representation. Board self reports effective working structure for board, with 11 scheduled meetings to address regular Board work and ongoing needs.
Deloitte Observations
The Board has established several committees to focus Board activities, with primarily reliance on the Corporate Services and Health Services Committees. A new Quality Improvement and Patient Safety Committee has been established in 2006-07 to better inform the Board on related issues. The Board conducts annual self assessment, with consideration of meetings, structure and committees to support board processes.
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AHW RHA Efficiency Review Palliser Health Region Property of Alberta Health and Wellness
2007 Deloitte Inc
PHR Governance Assessment
Processes and Information
Performance Assessment and Accountability
Responsibilities and Mandate Organizational Culture Processes and Information Structure and Organization
Board identification of information needs and receives required reporting Board meetings considered to be appropriate structured (length, frequency, advance circulation of materials, attendance, management ability to respond to enquiry)
Areas of Assessment
Documentation of meetings Identification of required skill sets / competencies for board members Formal orientation; ongoing education / development Board related policies (roles/responsibility; code of conduct; conflict of interest; ...) Board self reports good information flow between management and Board. All of senior management attends board meetings, and each provides a written or verbal report. All board meetings are reported as being documented, to support decision-making.
Deloitte Formal orientation process for new Board Members in place. Observations The Board Chair reports that there is a good mix of required skills and competencies
across the board, and that this is not a focus for recruitment. The Board operates under a set of by-laws and guidelines, which apply to the full Board and its committees.
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AHW RHA Efficiency Review Palliser Health Region Property of Alberta Health and Wellness
2007 Deloitte Inc
PHR Governance Assessment
Performance Assessment and Accountability
Performance Assessment and Accountability
Responsibilities and Mandate Organizational Culture Processes and Information Structure and Organization
Process to assess and monitor organization performance related to financial management, operations, people management, risk and safety
Areas of Assessment
Process to monitor achievement of strategic directions Self assessment of board performance Board understanding of liability issues Process to routinely assess performance of CEO/President The Board is compliant with required reporting. Board self reports that its ability to assess organizational performance is very strong, and that it regularly monitors the region's achievement of the strategic directions outlined in its 3-Year Health Plan. The Board has a structured process in place for annual self-evaluation of the Board, which is conducted and reviewed at its annual retreat. An evaluation of the Board as a whole is conducted, as well as individual self-evaluation by Board members. A separate Board evaluation of the CEO is also conducted annually by the Board, and Senior Management team feedback is also considered. The Board recognizes that it's primary employee relationship is through the CEO, and as such focuses on governance and policy vs. operations. The Board reports that risk management reporting is in place at a Board level. In part, this is supported by an annual briefing of liability insurance.
Deloitte Observations
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AHW RHA Efficiency Review Palliser Health Region Property of Alberta Health and Wellness
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PHR Governance Assessment
Organization Culture
Performance Assessment and Accountability
Responsibilities and Mandate Organizational Culture Processes and Information Structure and Organization
Board involvement in setting organization's values and philosophies
Areas of Assessment
Diverse representation from communities within Region Board serving role as policy advocates with government and key stakeholders Fosters effective board / management relations Board self reports significant involvement in value setting and strong relationship with management
Deloitte Observations
The region has three Community Health Councils, but the Western CHC is reported as being not effectively engaged in the region. The Board also reports good community representation in its own membership, which at times drives local vs. regional focus in Board discussions.
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AHW RHA Efficiency Review Palliser Health Region Property of Alberta Health and Wellness
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Concluding Comments
PHR
Strengths to build on include... Strengths to build on include...
Established process for regular Established process for regular Community Health Needs Community Health Needs Assessment Assessment Board commitment to regular Board commitment to regular rotation of meetings through rotation of meetings through regional communities regional communities Identification of need for renewed Identification of need for renewed health human resource workforce health human resource workforce planning planning
Areas for further development and Areas for further development and assessment... assessment...
Identification of measures to support Identification of measures to support Cost of Services strategic focus Cost of Services strategic focus Expansion of Information Technology Expansion of Information Technology tactical approaches to incorporate tactical approaches to incorporate regional IT strategic planning regional IT strategic planning Integration of physician human Integration of physician human resources strategy and workforce resources strategy and workforce planning into broader regional planning into broader regional initiative initiative Improved regional engagement of Improved regional engagement of Western CHC Western CHC
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AHW RHA Efficiency Review Palliser Health Region Property of Alberta Health and Wellness
2007 Deloitte Inc
Deloitte & Touche LLP and affiliated entities. Deloitte, one of Canada's leading professional services firms, provides audit, tax, consulting, and financial advisory services through more than 6,100 people in 47 offices. Deloitte operates in Qu bec as Samson B lair/Deloitte & Touche s.e.n.c.r.l. The firm is dedicated to helping its clients and its people excel. Deloitte is the Canadian member firm of Deloitte Touche Tohmatsu. Deloitte refers to one or more of Deloitte Touche Tohmatsu, a Swiss Verein, its member firms, and their respective subsidiaries and affiliates. As a Swiss Verein (association), neither Deloitte Touche Tohmatsu nor any of its member firms has any liability for each other's acts or omissions. Each of the member firms is a separate and independent legal entity operating under the names "Deloitte," "Deloitte & Touche," "Deloitte Touche Tohmatsu," or other related names. Services are provided by the member firms or their subsidiaries or affiliates and not by the Deloitte Touche Tohmatsu Verein. 16 AHW RHA Efficiency Review Palliser Health Region Property of Alberta Health and Wellness
Member of Deloitte Touche Tohmatsu 2007 Deloitte Inc
AHW RHA Efficiency Review
Palliser Health Region
Findings and Opportunities Final Report July 13, 2007
Property of Alberta Health and Wellness 2007 Deloitte Inc
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AHW RHA Efficiency Review Palliser Health Region Property of Alberta Health and Wellness
Table of Contents
Project Overview Clinical Resource Management Clinical Service Delivery Programs and Sites Physician Findings and Opportunities Clinical Support and Allied Health Corporate/Support Services Operational Trending and Analysis Human Resources Strategy and Management Infrastructure Cluster/Provincial Opportunities Moving Forward: Opportunity Prioritization and Mapping
1 AHW RHA Efficiency Review Palliser Health Region Property of Alberta Health and Wellness 2007 Deloitte Inc
Project Overview
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AHW RHA Efficiency Review Palliser Health Region Property of Alberta Health and Wellness
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Project Overview
Scope, Objectives and Business Drivers
Scope: Alberta Health and Wellness is undertaking an RHA Efficiency Review to identify potential efficiencies and opportunities for improvement within each of the RHAs in the province. To achieve this purpose, this Review is focusing its scope on improvements to deployment across five key dimensions:
Increases to productivity Improvements to patient flow Improvements to patient outcomes Improvements to financial stewardship Exploration of province-wide opportunities
The review does include voluntary organizations, but will not be reporting to the voluntary boards. Project Objectives There are three primary objectives that direct the activities of this Review:
Identify performance improvement issues and opportunities. Identify productivity and performance improvement strategies and solutions. Provide recommendations to optimize: available resources, operational efficiency, service delivery, safety and quality.
3 AHW RHA Efficiency Review Palliser Health Region Property of Alberta Health and Wellness 2007 Deloitte Inc
Project Overview
Approach and Timelines
The diagram below outlines the project approach, and key activities of the review. The review started in June 2006, and was completed in June 2007.
AH&W Launch
Phase 0:
AH&W Contract Management and Risk/Benefit Assessment
RHA Cluster Efficiency Review Activities by Phase
Phase 1:
Project Launch
AH&W Closure
Phase 6
Project Evaluation and Go-Forward Risk/Benefit Assessment with AH&W
Phase 2:
Global High Level Review
Phase 3:
Opportunity Identification and Preliminary Reporting
Phase 4:
Opportunity Prioritization Support
Phase 5:
Recommendations and Final Report
Administrative and Support Services Allied Health and Clinical Support Services Clinical Nursing Services Clinical Resource Management Governance and Performance Management Technology
Workstreams
Scope Definition, Workplan and Information Collection
Project KickOff Meeting with Steering Committee
Qualitative Analysis, Profile Review, Data Analysis Consultation On-Site Consultation Integrated Collect Data Review to and Develop Information Comprehensive Regional Findings Conduct Risk Assessment Quantitative Analysis and Benchmarking Comparison
Region Assessment Overview
Opportunities Prioritized
Insights from Phases 2 and 3
Final Report and Recommendations
Opportunity Identification Workshops
Working Session with each RHA to Identify Priorities for Action
Final Report
AH&W Project Evaluation and GoForward Risk Assessment Workshop
Infrastructure
RHA Cluster Observations
Opportunity Prioritization from Phase 4
Deliverables
Project Management, Quality and Risk Management, Knowledge Management and Transfer, Stakeholder Engagement and Communication
Project Scope Project Contract Risk/Benefit Assessment Project Workplan Stakeholder Consultation Plan
Current State Assessment Governance Performance Management Diagnostic Technology Assessment
RHA High-Level Opportunities RHA Cluster HighLevel Opportunities
Project Evaluation Prioritized Opportunities Final Report with Recommendations Go-Forward Risk/Benefit Assessment
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AHW RHA Efficiency Review Palliser Health Region Property of Alberta Health and Wellness
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Project Overview
Reporting
This report presents the findings and opportunities identified through the region's review. Findings and opportunities are organized into 10 categories of reporting:
1. 2. 3. 4. 5. 6. 7. 8. 9.
Clinical Resource Management Acute Care Continuing Care Community Health Services Physician Findings and Opportunities Clinical Support and Allied Health Corporate and Support Services Operational Trending and Key Metrics Human Resources Strategy and Management
10. Infrastructure
Following the identification and validation of findings and opportunities for each region, two additional activities were completed for this review, which are summarized in the final two sections of the report:
Identification of opportunities at a cluster / provincial level. An opportunity prioritization and mapping exercise to support regional planning and goforward monitoring.
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AHW RHA Efficiency Review Palliser Health Region Property of Alberta Health and Wellness
Clinical Resource Management
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AHW RHA Efficiency Review Palliser Health Region Property of Alberta Health and Wellness
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Clinical Resource Management
Overview
Clinical resource management analysis includes CIHI analysis (internal trending of complexity and utilization data and external comparison of utilization data for each program) and the results of the MCAP review. In conducting an internal review of the complexity and utilization data, a drilldown approach is used to understand changes in utilization efficiency (volume, complexity and utilization efficiency).
Analysis is based on 2003-04, 2004-05 and 2005-06 Q3 data. A straight-line projection on 2005-06 Q3 data was used to project patient volumes.
In conducting an external comparison of utilization data, the goal is to identify potential opportunities to improve utilization in relation to CIHI ELOS and peer performance.
A drill-down approach is utilized, which begins with a "gross" assessment of utilization and potentially "conservable days" opportunities by comparing Palliser's acute ALOS by CMG to the CIHI acute ELOS. The analysis is based on the 2004-05 data. This analysis is then fine tuned to determine the more realistic opportunities related to improved utilization management. A filter is applied that specifies the number of cases required and the minimum variance in ALOS required before an opportunity can be considered realistic. For example, if there were fewer than 10 cases or the conservable days for the CMG are less than .5, it is not considered to be a realistic opportunity.
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Top 10 Patient Services (2003-04 to 2005-06 Projected)
CIHI Abstract Data (Region)
The Top 10 Patient Services accounts for the 74% of the region's total caseload. Comparison over the past three fiscal years suggests a fairly consistent distribution of key patient services: Gastroenterology represents 13%, Newborn and Obstetrics each represent 10%, Cardiology represents 9% and Psychiatry represents 8% of current volume Patient Service
Gastroenterology Newborn Obstetrics Delivered Cardiology Psychiatry Traumatology General Medicine Respirology Urology Dentistry
2003-04
1,722 1,271 1,259 1,196 1,098 803 796 703 595 563 10,006 2,558
2004-05
1,824 1,272 1,258 1,259 1,027 832 664 763 641 490 10,030 2,848
2005-06 Proj.
1,764 1,360 1,351 1,260 1,151 900 777 632 667 492 10,353 3,725
Variance
2% 7% 7% 5% 5% 12% -2% -10% 12% -13% 3% 46%
Top 10 Patient Services Total Other Patient Services Total Region Patient Services Total
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12,564
12,878
14,079
12%
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AHW RHA Efficiency Review Palliser Health Region Property of Alberta Health and Wellness
Top 10 Patient Services (2003-04 to 2005-06 Projected)
CIHI Abstract Data (Medicine Hat Regional Hospital)
The Top 10 Patient Services accounts for the 73% of the hospital's total caseload, and 56% of the region's caseload. Comparison over the past three fiscal years suggests an increase in several key patient services: Orthopedics, Traumatology and General Medicine. Patient Service
Gastroenterology Newborn Obstetrics Delivered Cardiology Psychiatry Traumatology General Medicine Urology Orthopedics Dentistry
2003-04
1,296 953 939 864 840 606 461 459 332 504 7,254 2,089 9,343
2004-05
1,382 992 974 883 801 658 431 468 441 420 7,450 2,258 9,708
2005-06 Proj.
1,325 1,037 1,025 961 901 709 516 503 436 429 7,844 2,951 10,795
Variance
2% 9% 9% 11% 7% 17% 12% 10% 31% -15% 8% 41% 16%
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Top 10 Patient Services Total Other Patient Services Total MHRH Patient Services Total
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AHW RHA Efficiency Review Palliser Health Region Property of Alberta Health and Wellness
Patient Volume, Weighted Cases and Patient Acuity
(Region)
Patient Volume
Weighted Cases Inpatient Weighted Case Volume
15,000
Inpatient Case Volume
15,000
10,000
10,000
5,000
5,000
0 2003-04 2004-05 2005-06 Projected
0 2003-04 2004-05 2005-06 Projected
1.2
Patient Acuity
Overall patient acuity for the region has declined by 8% since 2003-04. Although patient cases have increased by 12% over this same period, this decline in acuity has resulted in only a moderate change in weighted cases.
Average RIW
1 0.8 0.6 0.4 0.2 0
2003-04
2004-05
2005-06 Q3 YTD
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AHW RHA Efficiency Review Palliser Health Region Property of Alberta Health and Wellness
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Patient Volume, Weighted Cases and Patient Acuity by Plx
(Region)
12,000 10,000 8,000 6,000
Cases by Plx
2003-04 2004-05 2005-06 Projected
12,000 10,000 8,000 6,000 4,000
Weighted Cases by Plx
2003-04 2004-05 2005-06 Projected
4,000 2,000 0 Plx Level I/II Plx Level III/IV Plx Level IX
2,000 0 Plx Level I/II Plx Level III/IV Plx Level IX
Acuity by Plx
4.5 4 3.5 3 2.5 2 1.5 1 0.5 0
Plx Level I/II Plx Level III/IV Plx Level IX
2003-04 2004-05 2005-06 Q3 YTD
The majority of patients for the region are Plx level I/II. Patient volumes have increased for Plx I/II and Plx IX while there has be a 14% decrease in Plx III/IV. Acuity decreased across all Plx levels, with the greatest decrease in Plx III/IV (16%).
Part of this may be driven by an increase in MNRH volumes. A challenge in understanding acuity for 2005-06 is the reported backlog in coding and abstracting.
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AHW RHA Efficiency Review Palliser Health Region Property of Alberta Health and Wellness
Import/Export Inpatient Volumes for Palliser
By Complexity for 2004-05 (Region)
As a % of Total Cases for each Plx % Imports % Exports 2004-05 Plx I/II 4% 15% Plx III/IV 1% 28% Plx IV 2% 9% Total 3% 14%
In examining the impact of import/export on inpatient volumes for 2004-05, an overall average of 3% of patients were imported into Palliser in 2004-05. Overall, 14% of inpatient volumes were exported from Palliser in 2004-05
Plx III/IV patients demonstrated the highest level of export, at 28%. Further examination suggests that 87% of exported patients are sent to the Calgary Health Region.
Although not demonstrated here, analysis suggests that imports/exports as a % of total cases has not changed significantly for Palliser over 2003-04 and 2004-05.
Further the proportion of import/export by Plx level has also been comparable over the two-year period.
Source: Alberta Health & Wellness CIHI DAD, 2003-04 and 2004-05 12 AHW RHA Efficiency Review Palliser Health Region Property of Alberta Health and Wellness 2007 Deloitte Inc
Average Length of Stay vs. Expected Length of Stay
(Region)
Palliser Health Region 7 6 5 4 3 2 1 0 2003-04 Average LOS 2004-05 2005-06 Q3 Average ELOS
Length of Stay analysis reveals that Palliser's average length of stay (ALOS) is consistently higher than the CIHI expected length of stay (ELOS). However, progress in effectively managing LOS is noted in that the ALOS ELOS gap across all Plx categories has been decreasing over the trended period, which suggests the benefits in the usage of the Continuum Solutions system and other regional utilization management processes. The chart below shows that the patients in Plx I/II and III/IV are driving the ALOS ELOS gap.
PLx Level I/II Fiscal Year ALOS 2003-04 2004-05 2005-06 Actual
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Plx Level III/IV ALOS 20.0 14.3 16.0 ELOS 14.2 13.6 14.1
Plx Level IX ALOS 5.4 5.0 5.2 ELOS 4.9 4.6 4.7
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ELOS 4.0 4.0 3.9
6.0 5.1 5.4
AHW RHA Efficiency Review Palliser Health Region Property of Alberta Health and Wellness
Average Length of Stay vs. Expected Length of Stay
By Site
Palliser 2005-06 Q3 YTD ALOS vs. ELOS by Site 10 9 8 7 6 5 4 3 2 1 0 Bassano Health Centre Big Country Hospital (Oyen) Average ALOS Bow Island Health Centre Brooks Health Centre Medicine Hat Regional Hospital
Average ELOS
All facilities demonstrated a higher ALOS relative to ELOS. The greatest gap between ALOS and ELOS is at Big Country Hospital in Oyen, however MHRH is the primary driver of the regional ALOS to ELOS gap, given higher patient volumes.
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AHW RHA Efficiency Review Palliser Health Region Property of Alberta Health and Wellness
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Top 10 CMGs by Potential Days Savable in 2004-05
(Region)
CMG 851 773 294 783 847 253 512 784 237 536 CMG Description Other Factors Causing Hospitalization Dementia with or without Delirium without Axis III Diagnosis Esophagitis, Gastroenteritis and Miscellaneous Digestive Disease Psychoactive Substance Dependence Other Specified Aftercare Major Intestinal and Rectal Procedures Other Transurethral or Biopsy Procedures (MNRH) Psychoactive Substance Abuse Arrhythmia Urinary Obstruction (MNRH) Total Cases 276 61 734 96 126 52 107 73 203 192 1,920 10,958 12,878 Average CIHI Expected Length of Stay Length of Stay 11.0 22.0 3.8 9.3 12.2 15.2 4.8 6.4 4.7 3.3 6.2 10.8 3.1 4.4 9.1 9.4 2.1 2.5 3.3 1.9 ALOS ELOS Gap 4.8 11.2 0.6 4.9 3.1 5.8 2.7 3.9 1.4 1.4 Potential Days Savable 1,324 685 471 469 391 302 292 284 283 274 4,775 6,718 11,493
Top 10 Region CMGs Total Other 320 Region CMGs Total Total Region CMGs
Leading CMGs for savable days are "Other Factors" and "Other Specified Aftercare", which suggest a cumulative opportunity of almost 5 beds savable. Although not shown here, 2005-06 analysis suggests that the opportunity for these two CMGs has increased to almost 7 beds savable. This suggests further analysis and potential coding improvements may be required to identify appropriate strategies for LOS management. Mental Health also shows opportunity across CMGs 773, 783, and 784, which suggests potential opportunity for expanding community-based mental health resources. Similar findings were observed in 2005-06 analysis.
The savable days calculation includes only those cases where the gap between actual length of stay was greater than 0.5 of a day, and the number of cases per CMG was greater than 10.
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Beds Savable in 2004-05
(Region)
Potential Days Savable
45 40 35
5 1 1 3
30 25 20
1 2 4
Comparison of Palliser ALOS to CIHI ELOS suggests that the Region could save as many as 41 beds (total of 15,086 potential savable days). When compared to peers, using the filter process, the region's potential bed savable reduces to 12 beds (4,272 potential days), the majority of which are located at Medicine Hat Regional Hospital, suggesting a focus for opportunity for the region.
1 2
15 10
31 25
2 1 1 14
5 0 CIHI Comparison Without Filter CIHI Comparison With Filter
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Peer Comparison Peer Comparison Without Filter With Filter Brooks Health Centre Big Country Hospital
Medicine Hat Regional Hospital Bow Island Health Centre Bassano Health Centre
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Note: The filter excludes cases where the gap between actual length of stay was less than 0.5 of a day, and the number of cases per CMG was less than 10.
AHW RHA Efficiency Review Palliser Health Region Property of Alberta Health and Wellness
2007 Deloitte Inc
Top 10 CMGs by Peer Potential Days Savable in 2004-05
(Medicine Hat Regional Hospital)
CMG 783 512 784 354 781 536 138 237 609 253 CMG Description Psychoactive Substance Dependence Other Transurethral or Biopsy Procedures (MNRH) Psychoactive Substance Abuse Knee Replacement Alcohol Induced Organic Mental Disorders without Axis III Diagnosis Urinary Obstruction (MNRH) Respiratory Neoplasms Arrhythmia Vaginal Delivery with Complicating Diagnosis Major Intestinal and Rectal Procedures Total Cases Average Length of Stay Potential Days Savable 63 107 44 141 15 97 31 132 247 52 929 8,779 9,708 10.5 4.8 8.9 7.9 18.9 4.2 16.6 5.5 3.2 15.2 282 243 231 220 168 156 153 134 129 128 1,844 1,648 3,492
Top 10 CMGs Total Other 313 CMGs Total Total CMGs
Mental Health CMGs 783, 784 and 781 show a cumulative opportunity close to 2 beds, which suggests potential opportunity for expanding community-based mental health resources. Opportunity for CMGs 512 and 536 suggest the need to shift to a day procedure model, which could potentially yield approximately 1 bed savable. The region also has several CMGs which are uncommon among peers for inpatient admissions, such as CMG 93 Tonsillectomy (in 2005/06 Q3, there were 265 cases). The remaining days savable for MHRH are distributed across multiple CMGs, and may be difficult to achieve.
The savable days calculation includes only those cases where the gap between actual length of stay was greater than 0.5 of a day, and the number of cases per CMG was greater than 10.
17 AHW RHA Efficiency Review Palliser Health Region Property of Alberta Health and Wellness 2007 Deloitte Inc
MCAP Review
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MCAP Overview
Process
An MCAP review was conducted to:
Gain a better understanding of patients' required levels of care and their specific care needs and the impact these needs have on inpatient bed utilization Identify system issues why patients are not at appropriate level of care.
MCAP is a utilization management tool that uses rigorous scientifically researched and validated criteria to review the intensity of services required for any given patient and determine the appropriate level of care required. The tool uses a "service-driven methodology" and focuses on the treatment plan/services ordered for that day. By avoiding the placement of patients at too high or low of a care level, health care managers can be assured that patients will receive the highest possible care quality and will move through the health care system in the shortest possible time. The review was conducted by a Registered Nurse certified in MCAP. She reviewed the charts of all admitted inpatients in the Acute Care settings between July 10 to July 13, 2006. Using the MCAP criteria, the following three key questions were answered for each admitted patient:
Does the patient require the level of care (i.e. Long Term Care, Acute Care, Intensive Care, etc.) they are receiving? If not, what level of care does the patient require? Why is the patient not at the level of care they require?
19 AHW RHA Efficiency Review Palliser Health Region Property of Alberta Health and Wellness 2007 Deloitte Inc
Patient Profile
PHR Acute Care
191 patients were reviewed at the acute care sites within the Palliser Health Region. This represents 76% of the total number of acute care bed capacity (250) within these sites. The average age of patients was 63 years. Medicine Regional Health Centre, with an average age of 63, clearly drives this average - the average age at Brooks is 41 years whereas the other centre's average is 70-88 years. 58% of patients were female and 42% were male.
Total Number of Beds 178* 36 10 Number of Beds Reviewed 160 16 8
Site
Proportion of Beds Reviewed
Big Country Hospital (Oyen) 4% Bow Island Health Centre 3% Bassano Health Centre 1%
Medicine Hat Regional Hospital Brooks Health Centre Big Country Hospital (Oyen) Bow Island Health Centre Bassano Health Centre Grand Total
10 4 238
6 1 191
Brooks Health Centre 8%
Medicine Hat Regional Hospital 84%
*Medicine Hat Regional Hospital closed 12 beds during the2006 summer season. Typically, MHRH has a total of 190 beds. 20 AHW RHA Efficiency Review Palliser Health Region Property of Alberta Health and Wellness 2007 Deloitte Inc
Patient Profile by Site and Service
PHR Acute Care
Site Patient Service Medicine Brooks Health Centre Obstetrics Paediatrics Brooks Health Centre Total Big Country Hospital (Oyen) Combined Medicine-Surgery Number of Beds Reviewed 8 7 1 16 8 8 ICU Bow Island Health Centre Combined Medicine-Surgery 6 6 1 1 31 Regional Total 191 Gynaecology NICU Medicine Hat Regional Hospital Total 4 3 2 160 Medicine Hat Regional Hospital Site Patient Service Medicine Combined Medicine-Surgery Psychiatry Obstetrics Paediatrics Number of Beds Reviewed 76 41 17 12 5
Big Country Hospital (Oyen) Total
Bow Island Health Centre Total Bassano Health Centre Combined Medicine-Surgery
Bassano Health Centre Total Regional Site Total
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Patients Who Meet Clinical Criteria for Admission
PHR Acute Care
Site
Medicine Hat Regional Hospital Brooks Health Centre 14 2 134 26
Percent at Appropriate Level 100% 75%
Bassano Health Centre Big Country Hospital (Oyen) Bow Island Health Centre Brooks Health Centre
20 40 60 80 100 120 140 160
Bow Island Health 42 Centre Big Country Hospital (Oyen) 6 2
67% 88% 84% 83%
Bassano Health 1 Centre
0
Meet Admission Criteria Do Not Meet Admission Criteria
Medicine Hat Regional Hospital Total for Region
For the patient charts reviewed across PHR, 159 out of 191 patients (or 83%) met clinical criteria for admission to the service they were on. Our experience with other regions and hospitals in Canada suggest that PHR is performing above average. The observed average for Canadian facilities ranges between 65-75% of patients in the most appropriate care setting. This performance supports stakeholder reports of good success with the implementation of the Continuum Solutions system and the region's utilization management initiatives.
22 AHW RHA Efficiency Review Palliser Health Region Property of Alberta Health and Wellness 2007 Deloitte Inc
Patients Who Meet Clinical Criteria for Admission
Medicine Hat Regional Hospital Acute Care
5E Surgery-Main 5W Surgery-Main 5W Surgery-Sub ICU 4W Medicine-Main 4W Medicine-Sub 6W Medicine-Main 6W Medicine-Sub NICU 3N Gynecology 3N Ante Partum 3N Post Partum LDR 4N Pediatrics 5N Psychiatry 2N GAU
0 5
9 11 12 3 1 15 3 2 15 16 2 3 1 9 2 5 13 15
2 5 2
Service
Unit
Percent Meeting Clinical Criteria for Admission
5E Main Surgery Surgery Total ICU 4W Main Medicine 4W Sub 6W Main 6W Sub Medicine Total NICU 3N Main
4 10
82% 69% 86% 78% 75% 100% 60% 100% 100% 95% 100% 100% 100% 100% 100% 100% 100% 76% 60% 84%
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5W Main 5W Sub
Perinatal and Pediatrics
20 25
3N Main Ante Partum 3N Main Post Partum
10
15
Meet Admission Criteria Do Not Meet Admission Criteria
LDR 4N Pediatrics Perinatal and Pediatrics Total Psychiatry Geriatric Assessment Grand Total 5N Main 2N GAU
Further examination of the MHRH revealed that overall, 134 out of the 160 patients reviewed (84%) meet the clinical criteria for admission demonstrating a small opportunity for improvement.
23 AHW RHA Efficiency Review Palliser Health Region Property of Alberta Health and Wellness
Patients Identified as Requiring a Different Level of Care
PHR Acute Care
Site Medicine Hat Regional Hospital
19 7
Percent Identified as Requiring a Different Level of Care 100%
Brooks Health Centre
2
Big Country Hospital (Oyen) Medicine Hat Regional Hospital Bow Island Health Centre 5 10 15 20 25 30 Brooks Health Centre Total for Region
Bow Island Health Centre 11
73%
Big Country Hospital (Oyen)
2
50%
0
0% 69%
Identified
Not Identified
Of the 32 patients who did not meet clinical criteria across the region, 22 (69%) of this group were already identified by the facilities as requiring a different level of care. This suggests that only 10 patients of the 191 patient charts reviewed did not meet clinical criteria and were not identified as such.
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Required Level of Care for Patients
PHR Acute Care
Required Level of Care Long Term Care Home care Outpatient Psychiatry Alternative Level of Care Acute (see below) Rehabilitation Home Grand Total 2 2 1 2 26 Big Country Hospital (Oyen) 2 Bow Island Health Centre 1 1 1 Brooks Health Centre Medicine Hat Regional Hospital 8 8 4 3 2 1 Grand Total 11 9 5 3 2 1 1 32
Of those patients who did not meet clinical criteria for acute care admission, the most frequently observed level of care required was Continuing Care and Home Care. Of the patients who required a different level of Acute setting, one patient in ICU required a private surgical room due to MRSA and the other patient required acute care in a "closer to home" acute hospital.
25 AHW RHA Efficiency Review Palliser Health Region Property of Alberta Health and Wellness 2007 Deloitte Inc
Reasons Patients Did Not Meet Clinical Criteria
PHR Acute Care
Of the 32 patients who did not meet clinical criteria, 34% were due to a physician delay in discharging the patient. The second most common reason was due to challenges in accessing an ALC bed within the region (31%).
Brooks Health Centre
1 1
Bow Island Health Centre Medicine Hat Regional Hospital Big Country Hospital (Oyen) 0
2
8
1 1 1
9
2
1
3
2 5 10 15 20 25 30
ALC Bed Availability No ALC Status Identified Physician Delay in Discharging Patient No Documented Plan by Physician
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Awaiting Physiotherapy Evaluation Private room for MRSA No Discharge Order Sociodemographic
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PHR Acute Care Profile Summary: July 10 13, 2006
Met Clinical Criteria for Admission
Long Term Care
159
11
Home Care
Reviewed Beds
191
Did Not Meet Clinical Criteria for Admission Vacant Beds
9
Outpatient Psychiatry
Acute Care Bed Capacity
32
5
Alternative Level of Care
250
47
3
Summer Closed Beds Other
12
4
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Clinical Resource Management Opportunities
Opportunities Findings
CMG analysis revealed several CMGs with uncommon admissions relative to peers, typically being classified as MNRH. Examples include tonsillectomies and other ENT procedures, biopsy procedures, and several urinary-related procedures.
1.Continue to develop strategies for LOS management focused on the following:
Consultation findings support observations related to a high level of inpatient admissions of tonsillectomy procedures, which Develop and implement is out of line with peer practice. policies to increase use of
day procedures across identified areas to achieve improved bed utilization.
Assess need for improvements to regional Additional coding and abstracting focus is required to help the region more discretely identify and manage this patient volume. coding and abstracting. Continue planning efforts to increase continuing care capacity.
Analysis identified CMG 851 (Other Factors Causing Hospitalization) and CMG 847 (Other Specified Aftercare) as having a high potential days savable to both ELOS and peers.
Improve discharge planning and coordination Based on the CMG analysis relative to peers, PHR has an across continuum for mental health population opportunity to reduce length of stay across several CMGs, to reduce mental health particularly in mental health. related LOS targets.
The MCAP review found that 11 out of 32 patients in PHR who did not meet acute care criteria for admission that required long term care or assisted living services and facilities.
The MCAP review found that several admitted patients required out-patient mental health services.
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Clinical Service Delivery Programs and Sites
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Clinical Service Delivery Review
Introduction
Regional Acute Care Opportunities Our review of the clinical programs and facility-based care across PHR has focused on identifying key findings and opportunities related to service delivery and staffing. The clinical service delivery findings and opportunities will be reported on in the following order: Acute Care Site and Program Opportunities
Regional Acute Care Findings and Opportunities Acute Care Site and Program Findings and Opportunities Community Health Services Findings and Opportunities
Community Health Services Opportunities
This filter approach to reporting is intended to streamline findings and opportunities, such that where a given opportunity exists across all three levels of reporting, it will only be highlighted in the most appropriate section. As a result, the Clinical Sites Findings and Opportunities will report only on those items related to local staffing resource, and other key locally-specific opportunities.
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Clinical Opportunities for PHR
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Regional Acute Care Findings and Opportunities
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Region Acute Care Findings and Opportunities
Opportunities
1. Review and determine desired organization model such as program management and corresponding structure, with consideration of:
MHRH-based vs. regional Health Continuum (e.g. acute only, cross-continuum) Leadership (nursing/medical coleads) Extent of Authority (budget vs. planning)
Findings
The organizational structure is in transition on several fronts, specifically related to the evolution to program management and the shift to Patient Care Managers. In addition, there have been a number of vacancies in supervisory and management positions. This combination of factors has resulted at times in unclear or split lines of accountability (e.g. Medicine) and opportunities to improve resource management (e.g. ICU/ER). Stakeholder consultation in the allied health areas report a preference to stay in current organization model, and not shift to program-based delivery.
2. Conduct regional assessment of Consultation findings suggests several issues related to CTAS in the rural sites, including: CTAS use in the ER to determine resources, education support, Physical plant does not support CTAS standards (e.g. first and policies and procedures point of contact is a triage desk, staffed by nursing, waiting room not visible to nurses) required to standardize use across the region. Varied compliance to CTAS recording
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Region Acute Care Findings and Opportunities
(continued)
Opportunities
Nursing Education Palliser provides an extensive array of professional development (including orientation) opportunities to staff. Of particular note are the skill review and nursing education days which provide staff access to a number of topics within one day, A rural education day was piloted in Brooks in June and one was scheduled in Oyen for the fall. 3. Continue to support the roll out of full scope of practice for RNs and LPNs. An Education Passport has been developed which allows staff a simple but effective way of tracking education completed. The organization is to be commended on its regional nursing practice committee and its move to standardized regional documentation systems and processes. Nursing staff are moving toward a modified primary care model, with LPN and RN staff functioning at full scope with individual patient assignments. An educational process was provided by the Regional Educators, consisting of 2 classroom days and 2 days individual unit based buddying and support for LPNs, as well as sessions for RNs on change, and charge nurse responsibilities. Nursing staff will continue to require support as this change rolls out. RNs continue to require support in moving from traditional roles (e.g. med nurse) to taking a full patient assignment, including expanded discharge planning and patient education.
33 AHW RHA Efficiency Review Palliser Health Region Property of Alberta Health and Wellness 2007 Deloitte Inc
Findings
Region Acute Care Findings and Opportunities
(continued)
Opportunities Findings
Skill Mix analysis indicates that in many units the percentage of Registered Nursing staff is lower than peer practice. According to CARNA, the more complex and unpredictable the environment, the more qualified the provider needs to be to provide the full range of potential care requirements, assess changes, re-establish priorities and recognize the need for additional resources as required
Most medical/surgical nursing units at MHRH have health care aides, many of who were absorbed after the CCC beds were closed. Consultation findings indicated that these individuals are involved in patient care, including bathing, simple dressings, etc. Peer experience indicates that when health care aides move from CCC to acute care, they may continue to perform similar care activities with more acute patients. Employers and registered nursing staff are responsible for determining what tasks are appropriate for unregulated care providers (UCPs) and ensuring that on a daily basis there is an assessment of each client's situation and condition, the activity and associated risk, and the environmental supports available. Employers are responsible for ensuring client safety when UCPs are allowed to perform tasks without considering the context of the client's situation.
4. Review skill mix, including the roles of health care aides to ensure that they are operating within an appropriate scope of practice within the acute care setting.
Source: College & Association of Registered Nurses of Alberta. Guidelines for Assignment of Client Care and Staffing Decisions, March 2004
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Region Acute Care Findings and Opportunities
(continued)
Opportunities
5. Palliser should implement medical protocols, as opposed to standing orders. CARNA states that
Findings
There are 167 Standing Orders in place across the region. They require physician signature but consultation findings indicate " Medical protocols apply to a range of clients that sometimes this is a telephone order or who meet certain conditions or criteria... Medical protocols are evidence-based and is obtained after the fact, which presents a pre-approved by the appropriate medical and risk to the organization. This is a particular nursing authority within an agency, and are concern in ICU as nurses report reluctance supported by agency and nursing policy. to call certain Internists at night. Medical protocols should be reviewed on a regular basis to ensure that they continue to CARNA does not recommend standing reflect best practice knowledge. Medical orders for the following reasons:
protocols must identify the specific medication(s), condition(s), and circumstances(s) that must be present before being implemented." "In contrast to medical protocols, standing medication orders are not developed from a multidisciplinary perspective, are not evidencebased, and provide limited information to care providers. Because they do not specifically identify the conditions and circumstances that must be present before being implemented, they are not considered as representing best practice knowledge"
Source: College & Association of Registered Nurses of Alberta. Medication Administration: Guidelines for Registered Nurses, December 2005.
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Region Acute Care Findings and Opportunities
(continued)
Opportunities Findings
Current schedules and staffing/scheduling processes cause challenges at times: 6. Review staffing and scheduling processes as well as schedules to ensure adequate baseline staffing, consistent staffing patterns, and sufficient replacement staff.
Mix of 8 and 12 on some units causes difficulty in finding replacement. As a result, 4 West has recently moved to all 8 hour shifts which has caused some staff unrest. Several units report that staffing is different (unplanned) on days of the week/weekend due to contractual issues. For example, 2 of 4 weekends on 5 West there are 3 RNs and 3 LPNs, on the other 2 weekends there are 4 RNs and 2 LPNs. Some units do own replacement staffing, others request it of Staffing Office Consultation findings indicate that while there is a small float pool, there are inadequate numbers of staff available for replacement and as a result there is an increasing use of mandatory overtime to cover staff shortages, sick relief and workload. This is a vicious cycle. The organization is nowhere near the 70% FT mix, which is generally seen as leading practice.
The organization should perform an analysis of their nursing human resources, including age, expected retirements, and satisfaction with current position, in order to determine if there are opportunities to increase the number of FT positions.
7. Investigate potential of adding additional resources to infection control.
36
Infection Control resources are low (1.8 FTEs in total), when compared to external standards. For example, APIC standards require:
1 FTE per every 150 acute care beds. 1 FTE per every 250 long term care beds.
Additionally there is little or no clerical support provided.
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AHW RHA Efficiency Review Palliser Health Region Property of Alberta Health and Wellness
Region Acute Care Findings & Opportunities
Medicine Hat Regional Hospital (MHRH)
Opportunities
8. Review MHRH unit clerk model and roles, and align resources appropriately. See housekeeping for further opportunities.
Findings
Services at MHRH to support nursing and patient care, including portering, clerical support and bed making are challenged at times. Portering services are reported as limited within MHRH, especially noted within Surgery. MHRH Unit Clerk hours vary by unit All the 36 bed units have the two desk areas which is challenging for 1 clerk to manage.
There is a new float unit clerk on evenings from 1600 0000, which is reported to be very positive.
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Acute Care Site and Program Findings and Opportunities
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Acute Care Site and Clinical Program Review
Introduction
Our review of the clinical programs and facility-based care across PHR has focused on identifying key findings and opportunities related to service delivery and staffing. Clinical programs and services will be reported on in the following order: MHRH and Regional Clinical Programs
MHRH Medicine, Critical Care and Emergency Services MHRH Surgical and Perioperative Services MHRH Obstetrics and Pediatrics Services MHRH Emergency Department and Ambulatory Care Services Geriatric Assessment unit/Senior Services (2 North) Regional Mental Health Services Homecare Population Health
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Acute Care Site and Clinical Program Review
Nursing Staffing Process Overview
The relative efficiency of patient/resident care services was assessed based on a comparative analysis of staffing levels and skill mix for each inpatient care unit using three key inputs:
GRASP Systems International Database Deloitte Peer Database Unit Staffing Schedule/Pattern
As an indicator of variance from the benchmark, the difference in hours per patient day/case/visit (HPPD/C/V) is reflected using an FTE estimate for illustrative purposes. To gain an understanding of the clinical requirements and environment on each unit, profiles were completed and consultation was conducted with clinical leadership. For each patient care unit, the following analysis was then conducted:
Total nursing unit producing personnel (UPP) worked hours per patient day/visit (HPPD). Nursing UPP Worked Hours include direct patient care hours provided by RNs, RPNs, and certain percentage of Health Care Aides. UPP hours include regular worked, relief, and overtime, and exclude benefit hours (i.e., vacation and absenteeism). HPPD were calculated for 2004-05 and 2005-06 then compared to the comparable peer units based on the profiles completed by each program/unit. All units are shown at the 50th percentile. In some units, adjustments have been made to better reflect patient mix/care requirements.
40 AHW RHA Efficiency Review Palliser Health Region Property of Alberta Health and Wellness 2007 Deloitte Inc
MHRH Medicine, Critical Care and Emergency Departments
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Acute Care Site and Program Findings and Opportunities
PHR Emergency Department Volumes by Triage Level
Triage Level I II III IV V IX Resuscitation Emergency Urgent Semi-Urgent Non-Urgent Unavailable Total Visits 2003-04 PHR Emergency Visits 198 3,007 11,933 26,861 28,175 5,718 75,892 2005-06 Proj. PHR Emergency Visits 169 2,357 12,545 34,603 25,928 3,693 79,295 % of Total PHR Emergency Visits Volume (2005-06) 0.2% 3.0% 15.8% 43.6% 32.7% 4.7% 100% CTAS National Averages: Weekday 0.4% 9.9% 37.9% 41.9% 9.5% 0.0% 100% CTAS National Averages: Weekend 0.2% 8.5% 38.9% 45.3% 6.7% 0.0% 100%
Source: Alberta Health & Wellness ACCS Database; ECH Triage Data
A review of Palliser's emergency visits found good alignment to national CTAS averages for triage levels I and IV, but a high level of Non-Urgent and Unavailable visits is observed that is disproportionate to national averages. A decrease in the number of visits with an "Unavailable" triage level suggests improved compliance with CTAS since 2003-04, or may indicate an outpatient coding change, however the 2005-06 volumes in this category suggest opportunity for continued improvement.
Consultation findings also suggest challenges in maintaining consistency in CTAS coding across the region, which may also be impacting reported triage volumes.
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Acute Care Site and Program Findings and Opportunities
MHRH Emergency Department Volumes by Triage Level
Triage Level I II III IV V IX Resuscitation Emergency Urgent Semi-Urgent Non-Urgent Unavailable Total Visits 2003-04 MHRH 2005-06 Proj. Emergency MHRH Visits Emergency Visits 149 2,294 7,984 16,763 7,962 2,432 37,584 121 1,648 8,008 18,505 6,939 1,401 36,623 % of Total MHRH Emergency Visits Volume (2005-06) 0.3% 4.5% 21.9% 50.5% 18.9% 3.8% 100.0% CTAS National Averages: Weekday 0.4% 9.9% 37.9% 41.9% 9.5% 0.0% 100% CTAS National Averages: Weekend 0.2% 8.5% 38.9% 45.3% 6.7% 0.0% 100%
Source: Alberta Health & Wellness ACCS Database; ECH Triage Data
A specific review of MHRH's emergency visits also found good alignment to national CTAS averages for triage levels I, but variation across the other triage levels. A decrease in the number of visits with an "Unavailable" triage level is observed at MHRH, supporting observations at regional level, however the 2005-06 volumes in this category suggest opportunity for continued improvement. A high level of `Semi-Urgent' and `Non-Urgent' visits suggests that the regional hospital is still receiving a larger than average ambulatory visit population to the ED.
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Acute Care Site and Program Findings and Opportunities
MHRH Emergency
Opportunities Findings
1. Target potential staffing investment with focus on:
Separating Triage from Charge Nurse positions during the day and evening shifts. Reviewing nurse assignment practices to ensure equitable workloads and alignment between patient needs and nurse staffing. Removing patient care responsibilities from paramedic.
Consultation findings suggest the need to realign roles and responsibilities consistent with peer practice.
Paramedic takes full patient assignment and is in regular nursing rotation. This is a challenge to care delivery, and a a risk to patient safety, as skills do not align to required nursing competencies. Triage and charge roles are combined. Nurse assignments are not equal in terms of workload. ICU staff are not cross trained to Emergency (see Critical Care)
Unit/Area Description
Actual FTEs 2004-05
Actual FTEs 2005-06
Actual HPPV 2004-05
Actual HPPV 2005-06
Recom'd HPPV
Recom'd FTE (Effic.)/ Re-Invest. 2005-06
Skill Mix 2005-06
ER
24.3
24.1
1.0
1.0
1.3
5.8
98%
Source: PHR 2004-05, 2005-06 Payroll, Deloitte Database, Grasp Database 44 AHW RHA Efficiency Review Palliser Health Region Property of Alberta Health and Wellness 2007 Deloitte Inc
Acute Care Site and Program Findings and Opportunities
MHRH Emergency (continued)
Opportunities Findings
The hospital has determined that a fast track system in the ER would not be effective at the present time.
We recommend that this be reviewed on a regular basis, considering patient waiting time, adherence to triage standards, etc.
2. Explore options to improve management of workflow for CTAS 4 and 5 patients with consideration of:
Review benefit of a dedicated fast track area. Shifting of Triage 4/5 volumes to PCN to improve ER flow. Involvement of physicians to ensure alignment of practice to process, which may require a shift in funding model. Continue to liaise with both Day Medicine and Home Care to reinforce continued support for shifting nonemergency patients out of the ER.
There appears to be some inappropriate utilization of the ER:
ENT and Plastics doing procedures in ER vs. outpatient setting. Consultation findings suggest that some patients who could be served better elsewhere are being referred into Emergency (patients with dressings, IV meds, and patients requiring a second opinion). The hospital has established a Day Medicine program which is reported to be effective. Some of this may be reduced with the newly formed Primary Care Network. Patients that could be served by home care come into the ER after hours.
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Acute Care Site and Program Findings and Opportunities
MHRH ICU
Opportunities
1. Redefine definitions for ICU admission and discharge criteria with the goal of appropriate utilisation of this resource.
Findings
10 bed combination ICU/CCU, all rooms are private; only one with capacity for negative pressure isolation. Average census is 4.5 beds, and MCAP findings suggest 1 of 4 patients is not appropriate for an ICU bed.
Baseline staffing is 4 RNs/24 hours. It is rare that all 10 2. ICU nursing staff should be beds are being utilized, and occupancy averages 46%. cross trained and expected to While nursing staff are the Code Blue Team for the support ER during times of low hospital (with the exception of ER and OR), they are not occupancy. cross-trained or expected to support ER during times of 3. Consideration should be given low occupancy. based on the number of Nursing staff monitor up to 16 telemetry packs on 4 West. telemetry packs to empower Pediatric patients over 16 are admitted under the Pediatrician, the 4 West nurses through children under 16 and neonates are transferred to Calgary. education to be responsible Although staffing comparison indicates potential and accountable for the opportunity for savings, it is suggested that this needs to telemetry patients. be achieved through ICU staff cross-training with the ER.
Unit/Area Description Actual FTEs 2004-05 Actual FTEs 2005-06 Actual HPPD 2004-05 Actual HPPD 2005-06 Recom'd HPPD Recom'd FTE (Effic.)/ Re-Invest. 2005-06 Skill Mix 2005-06
ICU
22.6
22.6
23.2
22.3
15.7
(6.7)
100%
Source: PHR 2004-05, 2005-06 Payroll, Deloitte Database, Grasp Database 46 AHW RHA Efficiency Review Palliser Health Region Property of Alberta Health and Wellness 2007 Deloitte Inc
Acute Care Site and Program Findings and Opportunities
MHRH Medicine 6 West
Opportunities
1. Examine management structure for Medicine and Critical Care units, in relationship to regional program model considerations. 2. Review schedules and assignment practices with the goal of leveling day and night staffing.
Unit/Area Description
Findings
The Medicine units management structure is fragmented. Responsibility for medical units is shared between the PCM of Critical Care and the PCM of Medicine, with shared responsibility for Ambulatory Care/Day Medicine. 6 West The mix of adult medicine, geriatric medicine and palliative care results in a heavy workload. The physical layout of the unit impacts workload as staff are geographically separated. While overall HPPD are in line with peers, the staffing pattern is focused more heavily on the day shift. In addition, the skill mix (% RN) is 51% which is quite low when compared to peers. (similar to 4 West). Stakeholders report that patient Care is impacted by the lack of physiotherapy on the evenings and weekends (e.g. patients recovering from stroke). Consultation findings indicated that nursing staff do not devote sufficient time to discharge planning and patient education.
Actual FTEs 2005-06 Actual HPPD 2004-05 Actual HPPD 2005-06 Recom'd HPPD Recom'd FTE (Effic.)/ Re-Invest. 2005-06 Skill Mix 2005-06
Actual FTEs 2004-05
6 West
36.3
37.9
4.9
5.2
5.2
-
51%
Source: PHR 2004-05, 2005-06 Payroll, Deloitte Database, Grasp Database 47 AHW RHA Efficiency Review Palliser Health Region Property of Alberta Health and Wellness 2007 Deloitte Inc
Acute Care Site and Program Findings and Opportunities
MHRH Medicine 4 West
Opportunities
1. Conduct a review of Medicine unit telemetry practices and develop evidence based indications for the initiation and discontinuation of telemetry.
Findings
Consultation findings show no clear protocols or guidelines for the practice of monitoring and discontinuing telemetry care on the unit. Current HPPD are in line with peer practice, although consultation findings indicated that 2. Review admission and discharge criteria the unit is operating over budget by involving the Medicine/ICU staff. approximately 2 FTEs. In addition, the skill mix (% RN) is 51% which is quite low when 3. Continue to support LPN move to full compared to peers. scope of practice, as part of move to LPNs are not yet at full scope of practice on modified primary care model. this unit. Some are reportedly not comfortable 4. Consider enhancing the skill mix, as well doing orders and as a result, some RNs do as increasing the budget to reflect not take a full patient assignment. actual HPPD.
Unit/Area Description
Actual FTEs 2004-05
Actual FTEs 2005-06
Actual HPPD 2004-05
Actual HPPD 2005-06
Recom'd HPPD
Recom'd FTE (Effic.)/ Re-Invest. 2005-06
Skill Mix 2005-06
4 West
34.8
35.5
4.7
5.0
5.0
-
51%
Source: PHR 2004-05, 2005-06 Payroll, Deloitte Database, Grasp Database 48 AHW RHA Efficiency Review Palliser Health Region Property of Alberta Health and Wellness 2007 Deloitte Inc
Acute Care Site and Program Findings and Opportunities
MHRH Day Medicine, Ambulatory Clinics and Palliative Care
Opportunities Findings
Day Medicine/Ambulatory Clinics Consists of Day Medicine (chemo, blood transfusions, dressing changes, IV antibiotics, urology, etc.), Pain Clinic, Ophthalmology Clinic, Urodynamics, Neurology Clinics. Currently only open during from 0900 until 1900 Monday to Friday, which impacts ER after hours and on weekends. Palliative Care Regional Palliative Care program works out of 6 West with 4 Palliative Care Nurse Consultants located out of Medicine Hat Regional Hospital who provide support to the community and region. One Palliative Care Resource Nurse is located out of Brooks Health Centre. Program staff provide service on a consultative basis to patients in acute, continuing care and home care. Staff report that the ability to follow patients from acute to the community supports continuity of care.
1. Investigate feasibility of extending hours of Day Medicine into evenings and weekends.
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MHRH Surgical and Perioperative Services
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Acute Care Site and Program Findings and Opportunities
MHRH Surgery
Opportunities Findings
The Surgical management structure is in transition to a 1. Examine management regional model. structure for Surgery, in relationship to regional During the consultation, the structure consisted of 2 program model considerations. PCMs, 1 with responsibility for inpatient, day surgery, As part of this, realign frontline pre-admission and Endoscopy, and the other with manager positions to two responsibility for OR and PARR . The Inpatient PCM is positions - 1 for OR/PARR/DS/ supported by a Supervisor while the OR/PARR PCM is Preadmission and Endoscopy; supported by an Assistant Manager. Both the Inpatient 1 for the inpatient units. PCM and Supervisor were vacant effective mid July. 2. Explore a dedicated area for medication preparation within the unit to decrease interruptions. Medication distribution is currently in the hallway and nurses are frequently interrupted causing potential medication errors.
3. Review clinical rationale for Consultation findings indicated that despite the increase admission of some colonoscopy in hours of Endoscopy, some patients are still being patients the night before the admitted for colonoscopy. procedure. (See Endoscopy).
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Acute Care Site and Program Findings and Opportunities
MHRH Surgery (continued)
Opportunities Findings
There is opportunity to revise the care delivery model on 5 West to address role overlap between Care Coordinator and Team Leader on 5 West. With full scope of practice the Team Leader role should not be required. Staffing on evenings and particularly on nights is low in comparison to the day shift. With the OR extended hours patients are frequently being admitted back to the unit on evening shift. Staffing comparison finds that both inpatient surgical units have small efficiency opportunities. Day Surgery and PAC were physically co-located in fall 2004. The budgets were combined for the 05/06 year. Staffing is in line with peer practice.
Actual HPPD/V 2004-05 Actual HPPD/V 2005-06 Recom'd HPPD/V Recom'd FTE (Effic.)/ Re-Invest. 2005-06 Skill Mix 2005-06
4. Revise the care delivery model on 5 West to eliminate the Care Coordinator role, shift some resources to the evening and night shift and enhance skill mix.
Unit/Area Description
Actual FTEs Actual FTEs 2004-05 2005-06
5 East 5 West Day Surgery/PAC
52
19.4 33.6 7.9
19.3 35.2 6.9
5.9 5.5 2.3
6.0 5.8 2.1
5.5 5.5 2.1
(1.5) (1.9) 0.0
69% 59% 96%
Source: PHR 2004-05, 2005-06 Payroll, Deloitte Database, Grasp Database AHW RHA Efficiency Review Palliser Health Region Property of Alberta Health and Wellness 2007 Deloitte Inc
Acute Care Site and Program Findings and Opportunities
MHRH Perioperative Services
Opportunities Findings
MHRH has 6 OR theatres in total, one of which is latex free. Physical plant is not optimal, with small theatres and lack of sufficient equipment storage space. 1. Explore the conversion of all OR's to latex free. MHRH has a Surgical Suite Advisory Committee comprising of the Senior VP Health Services, VP Medical, 4 Chiefs of Services, the Regional Program Manager Surgical Services, and the OR Manager. The committee meets monthly, or as necessary.
2. Formalize an interdisciplinary Leading Practice is to have a shared interdisciplinary leadership team for team for this function, which meets on a regular (i.e. monthly) Perioperative basis with responsibility to oversee planning as well as quality, Services that access and ensure efficient use of resources. oversees planning as OR documentation is being revised in preparation for moving well as quality, to electronic systems. Moving towards standardization access and efficient across the region, including prompts and legends. use of resources. New Manager has developed a stronger process for capital equipment . For example, the process now requires signatures of all members of service before capital requests are submitted to the regional review committee.
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Acute Care Site and Program Findings and Opportunities
MHRH Perioperative Services (continued)
Opportunities Findings
Utilization 3. Regular audit of reasons for late starts Staff start at 0700 with a team meeting to review slate, etc. First and turnaround case is booked till 745 am but consultation indicated that they are practice to develop frequently late due to tardiness of Surgeons and/or Anesthetists. targeted strategies Regular hours until 1715 pm. There is an evening on call line of 4 for improvement. RNS for add-ons and urgent/emergent. 4. Organization policy to Surgeons responsible for determining urgency -some abuse is admitted. clearly define what Avg 8 10 hours on Saturdays, less than that on Sundays. cases are appropriate They did a cost benefit analysis of permanent evening and weekend for off-hours and a shifts vs. overtime and concluded overtime was more cost effective. regular process to The OR/PARR Scorecard contains some information on utilization review. Surgeons including utilization rate, number of emergency and add-on cases should be involved in and wait times for hip, knee and cataracts. While some indicators the review and are collected, there is no consistent process to review and manage negotiation results on a regular basis: processes. Utilization of assigned OR time is monitored. 4th quarter 05/06 results 5. Expand performance measurement report to support decision making and quality monitoring (see page 55).
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was 97% of assigned time and 78% of block booking time. A more appropriate measure of utilization would be of % of total operative time available which would provide a more accurate measure of capacity. A review of 05/06 turnaround time indicates it ranges between 7 and 13 minutes. Community hospital peer benchmarks are approximately 14 minutes so this is an excellent result. Other utilization data is collected although it not all rolled up into the Performance Scorecard.
2007 Deloitte Inc
AHW RHA Efficiency Review Palliser Health Region Property of Alberta Health and Wellness
Acute Care Site and Program Findings and Opportunities
MHRH Perioperative Services (continued)
Opportunities
Quality & Safety Have several patient safety initiatives underway including clipping vs. shaving; timely administration of pre-op antibiotics and temp on arrival and recovery. While staff do not conform to surgical pause as it is defined, they do a comprehensive check while the patient is awake, involving all staff. Surgeon signs the right side of patient prior to surgery.
Findings
6. Consider Have a transfer checklist which is used upon transfer of patient from expanding the PARR to the inpatient units. use of regularly collected Regularly collected quality indicators include wait times, complaints and incidents. quality indicators as Wait time (50%) is higher than Alberta median for presented on Cataract surgery (single provider) 21 vs. 11.6 weeks the following Knee replacement 26 vs. 22.4 weeks page.
Urological (single provider) 8 vs. 4.9 weeks General Surgery: 7 vs. 4 weeks Gynecological: 13 vs. 7.1 weeks Gall Bladder and Hip Replacement are at provincial median
Have adopted several strategies to improve staff culture, teamwork and communication, which was reported to be having a positive improvement.
55 AHW RHA Efficiency Review Palliser Health Region Property of Alberta Health and Wellness 2007 Deloitte Inc
Acute Care Site and Program Findings and Opportunities
Suggested Performance Indicators: OR/PARR Quality
Wait Times Post Surgical Mortality Intra-operative Mortality Complications Infection Rates Unexpected Admission to ICU Unexpected Admission of Outpatients Patient Satisfaction Cancelled Cases Unplanned Return to Surgery
Utilization
Service and Surgeon Utilization Percentage of Outpatients Night Time and Weekend Activity PACU Time and By Pass Rates Standardization of Supplies Post-Operative Length of Stay Variance to Targets
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Acute Care Site and Program Findings and Opportunities
MHRH Perioperative Services (continued)
Opportunities Findings
7. Increase utilization of Staffing model is consistent with leading practice including an regularly scheduled hours all RN staff, cross trained between OR and Recovery, and able to improve staffing to work in all the specialties. efficiency. Staffing HPPV are higher than peers due in part to utilization Ensure regular hours issues including downtime and the use of after hours for and staffing matches urgent cases. Staffing efficiency is also impacted by the surgical demand. practice of having 3 RNs per theatre plus Team Leader 8. Expand Educator support (100%) and Charge Nurse (25% relief). to include OR. 9. Consider requiring nurses Absenteeism was lower than budgeted in 05/06 (1565 vs. 2391 hrs). to obtain C.N.A Perioperative Have Educator support for PARR but not OR. Certification, in the Do own 3 month in house education and orientation for nurses absence of a formal OR as there is no local OR Course available. course.
Actual HPPC/V 2004-05 Actual HPPC/V 2005-06
Unit/Area Description
Actual FTEs 2004-05
Actual FTEs 2005-06
Recom'd HPPC/V
Recom'd FTE (Effic.)/ Re-Invest. 2005-06
Skill Mix 2005-06
OR/PARR
29.3
31.2
7.0
6.5
6.1
(1.9)
100%
Source: PHR 2004-05, 2005-06 Payroll, Deloitte Database, Grasp Database 57 AHW RHA Efficiency Review Palliser Health Region Property of Alberta Health and Wellness 2007 Deloitte Inc
Acute Care Site and Program Findings and Opportunities
MHRH Perioperative Services
Opportunities Findings
The OR has a porter from 0700-1815h, 3 days per week and 0700-1500h, 2 days a week. However, nursing See portering opportunity in and/or clerical staff are often required to deliver Housekeeping. stretchers/beds to the OR or to assist in patient transport to and from the OR. 10.Trial the use of wheelchairs to transport patients to the The OR Manager has a plan to trial use of wheelchairs Operating Room. This could instead of stretchers but this is reported to have been be expanded to include met with some resistance by Surgeons. walking appropriate patients to the OR.
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MHRH Perinatal and Pediatric Services
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Acute Care Site and Program Findings and Opportunities
MHRH Perinatal Services
Opportunities
1. Explore the concept of "Rooming in" 24/7 to keep in line with evidence-based practice, and as a staging toward LDRP. 2. Conduct a review to determine feasibility of moving to an LDRP model of care, with consideration of care model, staffing and facilities. 3. Examine Perinatal Services management structure in relationship to regional program model considerations. 4. Ensure that all ambulatory visits are consistently captured and reported in regional statistics (e.g. NSTs).
Findings
Program consists of acute services (antenatal, LDR, postpartum, normal newborn, level 2 NICU and gynecological surgery) as well as the Family Medical Maternity Clinic (FMMC) located on 6 East. Approximately 1000 births per year Gynecology averages 3 5 cases per day 8 bed NICU (average census 3.4) staffed by 2 nurses 24/7 19 bed normal newborn nursery with all babies in nursery at night is not consistent with leading practice. The C-Section rate is approximately 24% which is lower than provincial average Sections are performed on the unit, with OR and NICU staffing attending. After hours emergencies are covered by the anesthetist on call. In process of implementing MOREob program.
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Acute Care Site and Program Findings and Opportunities
MHRH Perinatal Services (continued)
Opportunities
5. Continue to promote cross training between all areas e.g. so that all staff have a major and a minor focus. 6. Link with Calgary for preceptorship program to maintain NICU skills. 7. Explore planning opportunities for future co-locating of Perinatal services.
Unit/Area Description Actual FTEs 2004-05
Findings
Nurse Staffing LDR and NICU are all RN staffing which is appropriate 1 RN during days is responsible for NSTs Some nurses float between L&D and Mat/Child and between NICU and L&D, which is consistent with leading practice. Nurses are senior and experienced staff which will create recruitment challenges in the future as they retire. The physical plant impacts care delivery and efficiency of operations with 3 separate areas patient units Low NICU occupancy may lead to risk of maintaining skill sets should link with Calgary for preceptorship model to maintain skills. All 3 areas have staffing efficiency opportunity when compared to peer practice. However, required minimum staffing levels will impact ability to achieve savings with the current physical plant and volumes.
Minimum staffing requirements exist for LDR, 3 North and NICU, however, which suggests that there is no realistic opportunity for staff savings.
Actual FTEs 2005-06 Actual HPPV/ HPPD 2004-05 Actual HPPV/ Recom'd Recom'd FTE (Effic.)/ HPPD 2005-06 HPPV/HPPD Re-Invest. 2005-06 Skill Mix 2005-06
LDR 3 North NICU
61
14.5 17.1 11.5
13.1 18.5 12.3
24.6 6.6 21.5
21.2 7.7 16.5
9.5 5.4 10.2
(7.2)
See Above
100% 64% 100%
(5.4)
See Above
(4.7)
See Above
Source: PHR 2004-05, 2005-06 Payroll, Deloitte Database, Grasp Database AHW RHA Efficiency Review Palliser Health Region Property of Alberta Health and Wellness 2007 Deloitte Inc
Acute Care Site and Program Findings and Opportunities
MHRH Pediatrics
Opportunities
1. Consider combining management of obstetrics and paediatric services, with relationship to regional program model considerations. 2. Consider crosstraining staff between Paediatrics and NICU. 3. Review ENT services in the Region to align service to needs, and consider ambulatory service delivery model to align to best practice.
Unit/Area Description Actual FTEs 2004-05
Findings
The Paediatric Program consists of 14 inpatient beds (including 2 high observation rooms & 4 negative pressure), PAC, 10 bed Day Surgery plus Day Medical (IV therapy, diabetes education program, eating disorder clinic, outreach clinics, telehealth, etc.)
Average inpatient occupancy is 50% Matrix reporting to both SVP and VP Community Health Nursing staff cross-trained to work the inpatient unit and the clinic area Member of the Southern Alberta Child & Youth Network
Paediatrics is a separate program from Perinatal and is not regional, although the Manager shares policies and procedures with Brooks. ENT practice appears inconsistent with best evidence
Tonsillectomies are performed as inpatient procedures, typically during one OR block. Because most patients are admitted, this results in a number of admissions to the inpatient unit at the same time.
Nurse Staffing
Nurses are all certified in PALS and function to full scope of practice 0.8 Team Leader does not have a patient assignment, but spends 50% of her time in direct care (e.g. admissions, discharges) Senior and experienced staff which will create future recruitment challenges.
Staffing efficiency opportunity in comparison to peer practice will be difficult to achieve with current model and volumes.
Actual FTEs 2005-06 Actual HPV 2004-05 Actual HPV 2005-06 Recom'd HPV Recom'd FTE (Effic.)/ Re-Invest. 2005-06 Skill Mix 2005-06
Paeds
62
18.7
18.7
12.9
12.3
9.7
(3.9)
See Above
73%
2007 Deloitte Inc
Source: PHR 2004-05, 2005-06 Payroll, Deloitte Database, Grasp Database AHW RHA Efficiency Review Palliser Health Region Property of Alberta Health and Wellness
MHRH Geriatric Assessment Unit
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Acute Care Site and Program Findings and Opportunities
MHRH Geriatric Assessment Unit/Senior Services (2 North)
Opportunities Findings
GAU Program currently consists of:
A 30 bed unit, with a mix of acute, geriatric assessment, rehabilitation and ALC beds. Patients are assigned priority for admission based on level of need; Seniors Outreach (Day Hospital); Vascular Prevention Clinic (3 Geriatricians and 1 Psychiatrist staffed M-F for both inpatients and outpatients); and A Community Outreach team (under development), which is consistent with leading practice.
1.Continue planning for the reconfiguration of 2N, to establish:
clear vision role model of care Admission/dischar ge criteria associated nursing and allied health resourcing
Utilization
Staff report challenges in providing care for psycho-geriatric patients due to lack of an area that can be locked, combined with difficulty in accessing beds on psychiatry Active discharge planning, starting on admission
Nurse staffing is not appropriate for an acute/geriatric assessment/rehab unit with a high number of HCAs.
Staffing on nights is a particular concern with only 1 RN and 2 NAs
While the majority of staff are long term, there are recruitment challenges for RNs, LPNs and HCAs. The unit is currently in transition to an increased proportion of rehabilitative care on the unit, however planning for this was still underway at the time of review.
64 AHW RHA Efficiency Review Palliser Health Region Property of Alberta Health and Wellness 2007 Deloitte Inc
Mental Health
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Mental Health Outpatient Activity
PHR Overview
As presented below, PHR Enrolments and Events increased by 12% between 2002-03 and 2004-05. Enrolments have increased most significantly at Medicine Hat Mental Health Clinic between 2002-03 and 2005-06, while Brooks demonstrates the most significant increase for Event volumes over the same period. Where variances between Event and Enrollment increases exist (e.g. Brooks), this may be due, in part, to information capture capacity, but may also speak to changes in programming.
Enrolments Clinics 2002-03 2003-04 2004-05 Events 3-Year 3-Year 2002-03 2003-04 2004-05 Variance Variance
Brooks Mental Health Clinic Medicine Hat Mental Health Clinic Grand Total
66
486
399
489
1%
3,281
3,661
4,004
22%
1,957 2,443
2,133 2,532
2,258 2,747
15% 12%
42,921 46,202
45,671 49,332
47,724 51,728
11% 12%
Source: ARMHIS Database 2002-03 to 2004-05 AHW RHA Efficiency Review Palliser Health Region Property of Alberta Health and Wellness 2007 Deloitte Inc
Mental Health Outpatient Activity
PHR Events by Type
Type of Event Type of Activity Assessment Face-to-Face Consultation Group Work Therapeutic Intervention Face-to-Face Total Telephone Videoconference Not Specified Grand Total
Source: ARMHIS Database 2002-03 to 2004-05
2002-03 1,744 998 964 25,937 29,643 4,683 11,876 46,202
2003-04 1,518 1,224 39 26,634 29,415 5,731 16 14,170 49,332
2004-05 2,003 2,061 23 26,215 30,302 7,400 64 13,962 51,728
3-Year Variance 15% 107% -98% 1% 2% 58% n/a 18% 12%
As demonstrated above, outpatient mental health activity in PHR has been increasing over the past three years by 12% - driven primarily by face-to-face consultations and telephone interventions. Group work as a type of activity has seen a significant decline in volume since 2003-04, which may be due in part to a change in coding.
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Mental Health Outpatient Activity
PHR Top 10 Diagnoses Driving Enrolments Year over Year
Diagnoses Major Depression Parent-Child Relational Problem Adjustment Disorder Relational Problem NOS Unspecified Mental Disorder Bipolar Disorder Anxiety Disorder Attention-Deficit Hyperactivity Disorder Sexual Abuse of Child Substance Abuse Related Diagnosis Top 10 Diagnoses Total PHR Total
Source: ARMHIS Database 2002-03 to 2004-05
2002-03 440 360 175 69 382 109 70 40 105 47 1,868 2,443
2003-04 456 383 236 147 180 109 91 80 111 40 1,893 2,532
2004-05 485 357 236 184 170 150 119 111 76 75 2,026 2,747
3-Year Variance 10% -1% 35% 167% -55% 38% 70% 178% -28% 60% 7% 12%
The top 10 diagnoses driving enrolments have increased by approximately 7% over the past three years, and represent approximately 74% of total enrolments in 2004-05. Notable increases are observed for Attention Deficit Hyperactivity Disorder (178%), Relational Problem NOS (167%), Anxiety Disorder (70%), and Major Depression (10%). An decrease in "Unspecified Mental disorder" (-55%) indicates an improvement in coding for submitting clinics.
68 AHW RHA Efficiency Review Palliser Health Region Property of Alberta Health and Wellness 2007 Deloitte Inc
Mental Health Outpatient Activity
PHR Top 10 Referral Sources
The top 10 referral sources for mental health enrolments in PHR represent almost 97% of total enrolments. From these top 10 sources, the main referral source for Mental Health enrolments in PHR was Self-Referral, at 27% in 2004-05 Overall regional average time between referral and intake call for PHR in 2004-05 was 13.2 days, which is a 2% increase from 2003-04. This increased intake time is driven by Medicine Hat Mental Health Clinic. The time between intake call and initiation of services is not available. Referral source data for 2002-03 was not used due to the high number of unidentified referral sources.
PHR Top 10 Enrolment Referral Sources
RHA Community & Outpatient Services 4% Other Agency 4% Physician 2% Legal System 2% Crisis Services 1% Self 28%
Mental Health Clinics
Average Days Between Referral & Intake Call 2003-04 2004-05 11.6
Brooks Mental Health Clinic Medicine Hat Mental Health Clinic
12.0
Physician / Psychiatrist 8% Significant Other 11% RHA Hospital 16%
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13.0 12.9
13.5 13.2
Educational Facility 27%
PHR Average
Source: ARMHIS Database 2003-04 and 2004-05 2007 Deloitte Inc
AHW RHA Efficiency Review Palliser Health Region Property of Alberta Health and Wellness
PHR Mental Health Program
Regional Findings and Opportunities
Opportunities Findings
Regional Program consisting of a 31 bed adult inpatient unit supported by Family Practice & Psychiatry. Programs include child/adolescent; access/early intervention, seniors mental health, and a wide range of community programs and teams (adult team, children's team, parenting, ACT, crisis response, etc.) Expanding services to the Region.
Last year had 1st annual regional workshop for staff. In process of developing a mental health crisis service in Brooks.
1. Opportunity to create stronger links with AADAC for community addictions support. 2. Monitor MHRH inpatient bed utilization.
Received innovation funding for several new programs, including Rural Family Mental Health Nurse, Concurrent Disorder Treatment Centre Liaison Coordinator, Regional Mental Health and Wellness Program, etc. These programs are not sustainable however without additional base funding. 3. Continue to expand 45% of MHRH inpatients have concurrent substance use and mental community-based disorders. Currently there is no addictions treatment available in the mental health region, thus patients are referred outside. services to In new Master plan there is a plan for an additional 12 14 beds for assessment & referral of patients with concurrent disorders. This will build support inpatient on the use of 12 of the existing unit beds for addictions residents. activity. CRM/MCAP findings at MHRH indicate some opportunity to save Mental Health beds through improved outpatient service availability, but not enough to meet this identified bed expansion by the region.
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There is a provincial psychiatric bed utilization review in process.
2007 Deloitte Inc
AHW RHA Efficiency Review Palliser Health Region Property of Alberta Health and Wellness
PHR Mental Health Program
MHRH Findings and Opportunities
Opportunities Findings
Perception raised during consultation that MHRH Psychiatry is not consistently responsive to receiving geriatric mental health patients. 1. Clarify MHRH Mental Health role and mandate with respect to other hospital services, including clarification and communication of admission criteria.
Philosophy is to treat the geriatric patients where they are and support them in place with mobile resources. Interdisciplinary case/treatment/discharge conferences are conducted weekly for inpatients, supported by outpatient program staff. Several programs are integrated across the continuum of care, including Child/adolescent program, Partial hospitalization program, etc. Community treatment plans accompany inpatient admissions. Innovative Farm Stress Line program offered in partnership with Saskatchewan government.
Care Delivery has many innovative elements including:
MHRH Mental Health Nurse staffing In process of implementing full scope of practice for all LPNs and RNs. Primary Care Nursing Model in place which is consistent with leading practice. Small efficiency opportunity in comparison to peer practice.
Actual FTEs 2005-06 Actual HPPD 2004-05 Actual HPPD 2005-06 Recom'd HPPD Recom'd FTE (Effic.)/ Re-Invest. 2005-06 Skill Mix 2005-06
Unit/Area Description
Actual FTEs 2004-05
MHRH 5N Mental Health
71
29
29.5
5.2
5.3
4.9
(2.4)
91%
Source: PHR 2004-05, 2005-06 Payroll, Deloitte Database, Grasp Database AHW RHA Efficiency Review Palliser Health Region Property of Alberta Health and Wellness 2007 Deloitte Inc
Bow Island Health Centre
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Acute Care Site and Program Findings and Opportunities
Bow Island Health Centre
Opportunities Findings
The ER sees patients for procedures or treatments due to the lack of community based alternatives, particularly during off hours and weekends.
1. Explore alternative service setting for clinic visits seen in the Acute care beds are being used for day medical or to ER. provide treatment to outpatients seen in ER, which is an effective use of empty beds. CTAS standards are 2. Additional clinical educational not consistently met support required, with consideration of use of simulators Some patients not triaged by nursing to train teams for the rare Patient first point of contact is not an ER nurse emergencies that develop. The waiting area is not visible to ER nursing staff Stakeholders report that although regional education 3. Move to full ACLS and TNCC exists, access is limited. training for all staff. Some ER nursing staff have ACLS and TNCC, but these certifications are not mandatory.
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Acute Care Site and Program Findings and Opportunities
Bow Island Health Centre
Opportunities Findings
Clinical placements are provided for both nursing and medical students interns/residents. Recruitment and retention challenges are:
Limited access to human resource support Nursing staff shortages result in the use of overtime and double time to cover replacement Projected senior nurse staff retirements (4)
See HR section for targeted Regional Recruitment & Retention Strategy.
Pharmacy has limited services and no pharmacist available on site. Nurse Staffing Many staff are cross trained which is appropriate for a health centre of this size. No opportunity identified.
Nursing staff rotate between acute and LTC ER RN responsible for LTC
Efficiency opportunity of 1.9 FTEs is not achievable given minimum staffing requirements.
Unit/Area Description Actual FTEs 2004-05 Actual FTEs 2005-06 Actual HPPD/V/C 2004-05 Actual HPPD/V/C 2005-06 Recom'd HPPD/V/C Recom'd FTE (Effic.)/ Re-Invest. 2005-06
Combined Inpatient Acute/ER/OR LTC
74
13.1 12.7
13.2 12.5
7.0 3.0
9.5 2.8
8.1 2.8
(1.9) See Above 2007 Deloitte Inc
Source: PHR 2004-05, 2005-06 Payroll, Deloitte Database, Grasp Database AHW RHA Efficiency Review Palliser Health Region Property of Alberta Health and Wellness
Big Country Hospital (Oyen)
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Acute Care Site and Program Findings and Opportunities
Big Country Hospital (Oyen)
Opportunities Findings
10 Bed acute centre with a 70% occupancy. 1. As part of regional education strategy, explore on-site continued education or access through telehealth to support current specialized skills and knowledge in obstetrics. 2. Monitor LTC staffing relative to 2006/07 target.
Patients wait in an acute bed for LTC bed as limited access to lodge or assisted living option is available in the community. During consultation, a concern was raised regarding inconsistent approaches to placement as a result of the lack of standardized processes, as well as social work hours are not available to assist with social issues/placement concerns.
ER visits are increasing due in part to lack of community alternatives for after hours care. The ER/OPD area is slated for construction to facilitate ambulatory care service delivery. Maternity cases have increased in 05/06 and are expected to double this year. In process of implementing MOREOB , all staff are NRP trained. Good co-location with physicians clinic, enables easier ER coverage and flow. However, the community recently lost one physician in Oyen, and now has only 2 physicians for the town. Nurses in acute care are cross trained to enable flexibility in coverage. Comparison of acute care 2005/06 staffing relative to peer practice shows that Big Country is in line. Although there are no vacancies, stakeholders report recruitment is an ongoing challenge. Little clerical support was noted as a challenge by stakeholders, as was limited access to onsite education. An efficiency opportunity exists in LTC relative to peers, however this must be considered relative to 2006-07 funding.
Actual FTEs 2004-05 Actual FTEs 2005-06 Actual HPPD/V 2004-05 Actual HPPD/V 2005-06 Recom'd HPV Recom'd FTE (Effic.)/ Re-Invest. 2005-06
Unit/Area Description
Combined Acute/ER LTC
76
10.5 17.0
11.4 17.6
8.4 2.8
6.8 2.7
6.9 2.4
0.1 (2.0)
2007 Deloitte Inc
Source: PHR 2004-05, 2005-06 Payroll, Deloitte Database, Grasp Database AHW RHA Efficiency Review Palliser Health Region Property of Alberta Health and Wellness
Brooks Health Centre
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Acute Care Site and Program Findings and Opportunities
Brooks Health Centre
Opportunities Findings
Brooks currently has 3 supervisor positions plus a Site Manager, which is higher than expected for a Centre of this size. May be impacted by limited clerical support. The hospital has made progress in improving utilization and has decreased ALOS while holding admissions stable. 1. Revisit the administration structure and administrative clerical support.
Surgical services has additional unused capacity. Volumes declined by 24% from 01/02 to 03/04, due primarily to discontinuation of the ENT service.
Additional resources have been added to the ER to support the triage function, however, even with planned renovations, patients arriving for an ER visit will not have first point of contact with a triage nurse.
On call ER physician will see office patients in department. Further, stakeholders report challenges exist in differences in physician practice about call, and variability in which physician to call for ER coverage. The use of part time staff in OR enhances efficiency and flexibility. Nursing is responsible for all portering, for housekeeping after 9 pm; clerical support is limited and non existent in ER. Reinvestment opportunity in Emergency.
Actual FTEs 2005-06 Actual HPPD/C/V 2004-05 Actual HPPD/C/V 2005-06 Recom'd HPPD/C/V Recom'd FTE (Effic.)/ ReInvest. 2005-06
Nurse Staffing
Unit/Area Description
Actual FTEs 2004-05
Combined Inpatient OR/RR ER LTC
78
34.7 2.8 12.4 40.5
35.6 2.7 13.2 41.7
5.4 5.0 0.8 2.5
5.8 4.6 0.8 2.6
5.8 4.1 0.9 2.8
(0.3) 1.9 2.5
2007 Deloitte Inc
Source: PHR 2004-05, 2005-06 Payroll, Deloitte Database, Grasp Database AHW RHA Efficiency Review Palliser Health Region Property of Alberta Health and Wellness
Bassano Health Centre
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Acute Care Site and Program Findings and Opportunities
Bassano Health Centre
Opportunities Findings
Management has taken steps to support efficient operations in a small facility.
All nursing staff are 0.63 base, with extra as required/desired Nursing staff are cross-trained to work more then one area. No opportunity to achieve peer staffing efficiency opportunity due to minimal staffing
While all nurses have ACLS and TNCC, there is no formalized mentoring or orientation program in place.
No opportunity identified.
Only one RN on duty per shift During consultation it was raised that Bassano nursing staff received limited educational support from the Regional Educators. Some challenges in recruiting nursing staff
The PCN clinic (available without referral) is staffed by physicians, dieticians, social worker, RN and mental health services.
Patients are seen by the ER physician when the clinic is closed.
Could benefit from point of care testing, and access to an on site pharmacist support (provided out of Brooks, with local pharmacy available for supplying after hours medication.
Every morning there is an inter-professional team meeting, which is consistent with leading practice and promotes patient flow and discharge planning. Physical plant is aging, and security has been a concern after hours.
Unit/Area Description Actual FTEs 2004-05 Actual FTEs 2005-06 Actual HPPD/V 2004-05 Actual HPPD/V 2005-06 Recom'd HPV Recom'd FTE (Effic.)/ Re-Invest. 2005-06
Combined Acute/LTC/ER
80
10.6
12.3
19.0
25.6
16.8
(4.2)
See above
Source: PHR 2004-05, 2005-06 Payroll, Deloitte Database, Grasp Database AHW RHA Efficiency Review Palliser Health Region Property of Alberta Health and Wellness 2007 Deloitte Inc
Community Health Services Findings and Opportunities
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Regional Continuing Care, Home Care and Coordinated Access
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Continuing Care Activity Analysis
PHR Weighted Cases by Facility
As depicted below, PHR had 53,108 continuing care weighted cases in Spring 2006, which represents an overall decrease in weighted cases by 4% from Fall 2003.
Regional continuing care beds increased by 18% for the same period (from 540 beds to 635 beds), but cases decreased by 26%. Given the overall large decrease in cases, PHR's weighted case decline was minimized by an increase in the region's average CMI from 71 to 92 over this same period, an increase of 30%. In part, this reduction in weighted case volumes reflects traction in the region's efforts to shift the care model from tradition long-term care facility-based services to a DAL model.
16 14 12
Thousands
10 8 6 4 2 0 South Ridge Villa: Bow Island Health South Ridge Villa: CPL - Riverview Retirement Res Bassano Health Nursing Home South Country Brooks Health Leisure Way Big Country Sunnyside NH Club Sierra at Regional Hospital Orchard Manor South Country Meadowlands River Ridge Valleyview Care Centre Hospital Medicine Hat GSS - DAL Village Centre Centre Village
Centre
Fall 2003
Source: Alberta Health & Wellness LTC Database 83
Spring 2005
Spring 2006
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AHW RHA Efficiency Review Palliser Health Region Property of Alberta Health and Wellness
GSS
Continuing Care Activity Analysis
PHR Weighted Cases by Classification
Spring 2006 Continuing Care Weighted Cases 247 1,988 2,984 6,708 10,659 21,550 8,972 53,108 Spring 2006 Proportion of Total Cases 0% 4% 6% 13% 20% 41% 17% 100% Proportion Variance Fall 2003 to Spring 2006 300% 21% 6% 22% -20% -4% -8% -4%
Source: Alberta Health & Wellness LTC Database
Proportion of Weighted Cases by Classification
G 17% A 0% B 4%
Classification
C 6% D 13%
A B C D E F G PHR Total
F 41%
E 20%
Approximately 78% of PHR's continuing care weighted cases are distributed across classifications E, F and G as of Spring 2006.
Overall proportion of F and G weighted cases has remained relatively stable from 58% in Fall 2003 to 57% in Spring 2006, while E weighted cases have declined by 4%. The overall proportion of B, C & D cases have increased slightly, with the greatest increase in D cases from 10% in Fall 2003 to 13% in Spring 2006.
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Coordinated Access
Opportunities Findings
Coordinated Access is not a regional service and each site is responsible for coordinating the placement of individuals into DAL (Medicine Hat and Brooks) and LTC (all sites). 1. Consider the balance of regional vs. local policy and service delivery to create consistent criteria, processes and equitable access. 2. Ensure all staff have access to Continuum solutions software
Each site has a separate waitlist of clients Coordinated Access/Patient Placement coordinator reports to the Regional Program Manager Home Care/Continuing Care Placement Coordinator Brooks reports to the Nursing Supervisor Brooks Home Care Coordinated Access for Bow Island and Oyen is handled through the local Home Care offices.
Limited clerical support (0.34 FTE in Medicine Hat) which necessitates Coordinators spending time in clerical and administrative functions. Coordinated Access staff and transition nurses in Medicine Hat have access to Continuum solutions and are able to both view and input patient information. The Home Care nurse in Brooks does not have access.
Facilities are limited for young disabled and brain injured clients, for clients with addictions and for clients with mental health conditions.
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Home Care
Opportunities Findings
Home Care is programmed regionally, but managed locally. Supervisors in each area report to respective Directors. The Regional Program Manager in Medicine Hat is responsible for policy and program direction overall, but responsibility for local operations and budgets is with respective Directors. 1. Consider Transition Nurses are assigned to acute care in Medicine Hat and options to Brooks to facilitate flow from acute to community, consistent with increase service leading practice. In Bow Island and Oyen, the Home Care Nurse works delivery, with emergency and acute care staff to identify clients requiring including the placement. potential for:
additional respite beds expanded day programs expanded evening and weekend home care service.
Service Delivery There is no wait list for home care in the region. ER referrals are taken on the weekend day shifts, with some evening and weekend coverage. During consultation it was reported that existing day programs cannot manage clients with heavy care needs, and since respite services are limited, this impacts family caregivers. Limited social work services (0.63 FTE). No Home Physiotherapy available in Oyen. Limited dietician services. All clients with difficult wounds are referred to Calgary due to lack of enterostomal therapy nurse.
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Public Health, Health Promotion, Chronic Disease Prevention and Environmental Health
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Public Health
Opportunities Findings
Public Health is a regional program providing a full of services including immunization, prenatal/mother and baby, school health, communicable disease control, travel health, newcomers health, genetics outreach and sexual health: 1. Consider expanding sexual health /STD clinic hours to 6 hours per week. Provide some hours in regional facilities as well as MHRH.
Sexual Health is a new clinic offered since April 06 2 hrs per week. Ontario standards are 8 hours per week (4 for SH and 4 for STD) per 150,000 population. Needle exchange is partially grant-funded through the HIV/AIDS Network. Offer some extended hours clinics for well child, adult and travel immunization. Provide some services outside of Region boundaries, including yellow fever immunization to Chinook Region and immunizations for some Saskatchewan residents due to proximity.
The recently completed community health needs assessment will be analyzed to determine if any changes are required in service delivery. Have recently moved from a generalist model to specialized teams of nurses who have the ability to cross cover one another. Utilization and workload are monitored as are performance indicators (immunization standards achievement, teen birth rates, communicable diseases, satisfaction, etc.) Despite the use of Language Lines are challenged by the number of new immigrants into region who do not understand English. Currently in process of developing and implementing electronic documentation through the RSHIP program, which is resource intensive as Meditech Public Health module was not well developed.
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Health Promotion
Opportunities Findings
Health Promotion works closely with Public Health & Chronic Disease Prevention in designing primary population based health promotion. The service also provides some individual service in the areas of dental health and nutrition for paediatric and perinatal populations All programs are planned and coordinated regionally and are driven from the community health needs assessment as well as the 10 year Healthy Living Plan completed in December 2004.
1. Examine health promotion Due to resource constraints, services are focused on prenatal clients, resources relative infants, toddlers and school age children and families. Programs to required focused on workplace health are limited. services in In the process of developing utilization tools for population health. alignment to recent PHR Measure outcome plus process indicators as presented in Healthy community health Living Plan, individual programs develop Logic Models to represent needs individual program services in relation to the overall Health assessment. Promotion Plan. Not able to meet the demand for Chronic Disease Prevention
Working with 100 schools to promote physical activity and healthy eating using a capacity building approach
Despite the use of Language Lines are challenged by the number of new immigrants into region who do not understand English.
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Chronic Disease Prevention: Living Healthy
Opportunities
1. Continue to expand multidisciplinary and multisectoral programming for CDP.
Findings
The Living Healthy Program (LHP), part of Chronic Disease Management services, is a regional program operating out of Brooks and MHRH. It includes Actions for Life, a program providing workshops to all five sites in the Palliser Health Region (PHR). In Medicine Hat the program includes Cardiac Rehab; Community Education and Exercise; Diabetes Education Clinic, Actions for Life; Primary Care Project (PRIISME); Functional Capacity Assessment and Testing; Cardiac Post-op Telehealth Clinic and Telehealth Assessment Clinics. 2. Clarify CDP role CDP is in development mode: moving from traditional programs offered in and mandate with separate physical space to co-located and coordinated program. Moving to respect to chronic new space in 2007 (Medicine Hat). Also moving to a generalist model, disease education consistent with leading practice. in acute and home Work closely with Health Promotion further opportunities exist to integrate care. programming across the continuum from primary and secondary prevention to treatment, across acute, community, public health, etc. For example, 3. Related to CDP obesity/eating disorder programs. role clarification, review and clarify Perceptions raised during consultation that insufficient support is provided to inpatients. role of RNs. Perception raised during consultation that Educators are not sufficiently 4. Examine resources involved. required to enable Resources are limited: this program to Has to purchase acute care therapist hours expand into other Very lean staffing and administrative structure - 1 Supervisor for Clinical Nutrition and areas such as 0.1 for each of 2 rural facilities. vascular clinic, Opportunity to expand services in several areas: To encompass Vascular Clinic/Stroke programming pacemaker To perform pacemaker checks checks, and To support insulin pumps for patients over 18 years (vs. using ER for service) insulin pump To extend the use of telehealth for Living Healthy clinics. support.
90 AHW RHA Efficiency Review Palliser Health Region Property of Alberta Health and Wellness 2007 Deloitte Inc
Environmental Health
Opportunities Findings PHR has a regional Environmental Health service. Program areas are administered by having each Public Health Inspector function at two levels: operational and advisory. This approach improves the region's ability to span across its geographic boundaries, while also providing specific expertise to inspections work.
1. Increase focus on achieving AB Blue Book At the operational level, the inspector is a generalist and is responsible for his/her assigned geographic area. Standards in Environmental At an advisory level, the inspector is a specialist in a program area. Within his/her sphere of specialization, the inspector provides technical expertise, initiates and Health. guides procedure and policy development and in some cases, delivers direct 2. Explore options services. to improve PHI The region faces challenges in its ability to maintain service to Blue Book utilization standards, reporting only a 63% compliance rate in food inspections, and through varied compliance across other areas. This has resulted in key enhanced environmental health risks related to food safety and private water testing technology, in the region. including: Computerized Currently, Public Health Inspectors utilize paper form reports in the field, and clerks the duplicate data entry into computer. Scheduling In-Field The region is in the process of implementing Total Management System Mobile (TMS) for its information system, which will enable computerized Technology scheduling, and facilitate consistent tracking of activity. Consultation with Reduced other regions report some challenges with achieving full functionality in Duplicate TMS, and maintaining strong IT support. Data Entry by Stakeholders identify several recruitment challenges for public health Clerks. inspectors, which are anticipated to increase over the next five years. As part of its strategy to address recruitment challenges, the region works with local colleges to take on student PHIs.
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Physician Findings and Opportunities
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Physician Findings and Opportunities
Introduction
The review process incorporated several direct consultations with physicians, which have yielded a number of findings and opportunities. Physician-related findings and opportunities have been clustered into the following four key areas, which also have linkage to opportunities identified across other areas of the region:
Physician Governance and Leadership Physician Human Resources Planning and Management
Quality, Risk and Performance Management
Physician Findings and Opportunities
Program Review and Organization
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Physician Findings and Opportunities
Governance and Leadership
Findings
As MHRH has evolved and matured from a community to a regional hospital, its physician governance model has continued to undergo change. However, the role distinction of MAC, President and Executive of the medical staff and the office of the VP Medical Services is unclear. Interactions between administration and physicians have been challenging, such as advocacy and operational issues at the MAC.
The PHR MAC tends to focus on advocacy over quality management. Potential conflict of interest is present with respect to advocacy and quality management, as the MAC Chair and President of the Medical Staff is the same person at the same time.
Policies outlining expectations of physicians are lacking. MAC exists but is considered quite ineffective. General perception that the short supply of physicians creates risk in challenging physician behaviour given their risk of departure and the corresponding workload and coverage challenge. However, consultation with physicians suggest that this perception is inflated, and that clearer, higher expectations and accountabilities should be required. Chiefs of Service (department heads) are elected by department members, members of MAC representing the department members, and theoretically report to the VP Medical Services, although this is not clear or adequate. Representatives from the all regional sites sit on MAC. Stakeholders report that discussion is MHRH-centric. Consultations suggest that the physicians and administration are not working together to facilitate tough discussions required for difficult decisions. There are, however, strengths in the relationship to build on. Generally, physicians respect Administration and their work effort.
Opportunities
See next page.
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Physician Findings and Opportunities
Governance and Leadership (continued)
Opportunities
1. Separate the roles of Chair of MAC and President of Medical Staff ,and delineate clear roles for medical staff leadership, such as:
quality through the MAC, advocacy through the President and Executive of the medical staff, and administration through the office of the VP Medical Services. appropriate mechanisms and options should be put in place to address these aspects with identification of processes for follow up.
Revise the Terms of Reference for the MAC Chair to ensure that individual is selected for the position and appointed by the Board. A nomination committee that includes medical staff and administration should be created. 3. The MAC should design and implement policies that contribute to patient care quality and/or safety. 4. The Board, the Executive and the MAC need to establish quality and behaviour standards for physicians in PHR, including outlining expectations of practicing optimal care and policies on disruptive behaviour. 5. The region should consider several changes to its current identification, terms and support for Department Heads, including:
Department heads should be selected (not elected) Set terms (e.g. 3 years), with clear terms of reference that outline expectations and how administration will support their challenges, including education. A stipend that reflects PHR's commitment to physician leadership and their expectation that leadership must be provided.
2.
8.
Mechanisms for joint problem solving with physicians and administration should be created and be based PHR leadership values and the broader principles of organizational justice.
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Physician Findings and Opportunities
Physician Human Resources
Findings
PHR is required to credential physicians practicing in the community, but has little or no responsibility and authority over what they do and how they behave. Recruitment is initiated by each Department and PHR funds the costs of advertising, site visits, moving and incentive packages if required. Candidate approval is departmental. Consultation with several stakeholders indicate that there are times when the need for a specific new recruit is identified by members of another department, but that there is no mechanism in place in the region to manage this process. For example, Family Practice may perceive needs in Internal Medicine, but the need is not supported by Internal Medicine. Recruitment incentives may be required for bringing new people to PHR but it can create retention challenges for the current workforce. Consultation with broader service delivery areas in the region reported mixed involvement in program planning as it relates to physician impact analysis.
Opportunities
Develop a mechanism by which physician recruitment and planning incorporates input from across departments. This process requires a mechanism to resolve real / perceived issues where a department decides not to recruit a new member where a need is identified. 2. Given the payment for recruitment costs, PHR should establish itself as a stronger partner in physician recruitment, and therefore have presence and authority during the recruitment process. 3. Develop a service level agreement model with physicians, such that PHR enters into a contract with MDs outlining their expectations to maintain credentials in the region. 4. Develop a consistent regional Physician Impact Assessment process for physician recruitment needs, workforce planning, and program planning. 1.
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Physician Findings and Opportunities
Quality, Risk, and Performance Management
Findings
Consultation findings suggest the region does not have mechanisms to promote evidence-based practice.
Most departments do not have effective quality management practices, adherence to standards or identification of risk issues. Although some departments do have partial systems in place, very few if any have all components. Lack of availability of specific evidence/data on clinical practice makes it difficult to enforce MD accountability.
Quality management in small departments is complex as it is difficult to assist other members improve suboptimal practice. Some physicians are unwilling to take part in quality programs such as Safer Healthcare Now, whereas others are providing important quality leadership, such as in the MORE Ob program. Quality management has recently been given greater attention by the formation of the Quality committee, co-chaired by the Vice Presidents of Health Services and of Medical Services. PHR has a program to train International Medical Graduates to ensure competence prior to receiving a position in the region.
Opportunities
1. The MAC and administration must take the leadership required to ensure that concerns of quality of care or conflict are managed appropriately.
Create policies to set standards for quality/risk/performance and the evaluation framework and management tools in support of the standards. PHR should establish a mechanism by which Department Heads (in smaller departments) can work with the VP Medical Services so that appropriate action can be taken as required to improve quality and performance. PHR should also consider use of independent, external reviews where specific challenges emerge in physician practice and quality of care, to provide an objective evaluation and recommendations.
2. Administration and physicians should make a commitment to create and use appropriate performance indicators for some selected programs and eventually expand to all programs.
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Physician Findings and Opportunities
Program Review and Organization
Findings
MDs are paid for clinical work as well as administrative leadership. There appears to be confusion between the role of the AMA in negotiating better incomes for MDs vs. the opportunity to take advantage of RHAs to supplement clinical earnings Alternate Funding Packages (AFPs) are not well supported. Currently, Department Heads receive $900 plus additional payments for attending meetings. There are some programs that seem to be progressing reasonably well - these programs tend to have leadership outside PHR that is recognized and then internalized - such as MORE Ob, paediatrics, stroke care - where the external leadership is used as a push to move forward. Nevertheless, uptake and progress in these areas is also based upon internal recognition and leadership with respect to program development. The concepts of Chief of Staff, Regional Chief and Program Medical Director are not clearly worked out. In part, this may relate to the drift / inclination to program management. The number of physicians willing and able to take part in administrative matters may be inadequate to support all these needs.
Opportunities
1. 2. 3. The Department Head stipend should be increased significantly (0.1-0.2 FTE), in conjunction with a clearer definition of the selection process and accountabilities. PHR must determine if it will shift to program management, and this must be supported by a clear plan, leadership and associated leadership organization structure to ensure success. Clarify roles and responsibilities of physician leaders at the regional level (VP Medicine, Regional Chiefs of Services), the local level (local Chiefs of Staff and Chiefs of Services), and where regional and local activities cross over.
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Clinical Support & Allied Health Services
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Clinical Support and Allied Health Services
Peer Staffing Comparison Process Overview
To understand the relative efficiency of the Clinical Support and Allied Health services, we conducted a comparative analysis with a number of comparable health regions from Alberta, British Columbia, Manitoba, and Saskatchewan. Fiscal 2005-06 data for PHR was used for peer comparison, as this represents a full year of staffing, but reference to budgeted 2006-07 staffing levels are also provided. The efficiency analysis assessed peer staffing based on a comparison of actual total paid hours per adjusted patient day (HAPD) for each "discipline" within the organization (based on MIS functional centre alignment).
Although many of the allied health disciplines in the region are aligned to clinical program, an MISbased alignment for comparison was used to ensure an `apples-to-apples' comparison to peers.
The adjustment factor increases the base of inpatient clinical activity to better reflect the span of inpatient, outpatient, continuing care and community clinical activity. The results across the comparator group were considered with the following "rules" applied at the departmental level:
Values among the comparator group that were well outside the range (e.g. outliers) were eliminated from the analysis. For Clinical Support and Allied Health Services, the FTE efficiency opportunity was identified compared to the 50th percentile to reflect a more realistic level of clinical resourcing to support patient care needs.
Staffing opportunities are identified based on comparative analysis and the team's understanding of minimum staffing requirements. Staffing opportunities are not stand alone, however, and need to be considered in the context of other opportunities identified for each area. The benchmarking information should be used as input to management decision-making, rather than as a decision in and of itself.
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Clinical Support and Allied Health Services
Peer Staffing Comparative Analysis Areas Reviewed
MIS Primary Account 71410 71415 71435 71440 71445 71450 71455 71460 71470 71485 Departments and Disciplines Clinical Laboratory Diagnostic Imaging Respiratory Therapy Pharmacy Clinical Nutrition Physiotherapy Occupational Therapy Audiology And Speech/Language Pathology Social Work Recreation
Source: AHW MIS 2004-05, Deloitte Benchmarking Database 2003-04 & 2004-05 & 2005-06, PHR Payroll 2005-06 101 AHW RHA Efficiency Review Palliser Health Region Property of Alberta Health and Wellness 2007 Deloitte Inc
Clinical Support and Allied Health Services
Clinical Laboratory
Opportunities
1. Develop a regional Laboratory Utilization Committee to continue to promote regional collaboration, formally sharing best practices, and supporting lab utilization management. 2. Develop business case to asses cost benefit of integrating Medicine Hat Community Lab Keane lab results into regional Meditech system.
Findings
MHRH provides regional testing for Brooks, Bow Island, Bassano and Oyen, supported by a regional lab courier system. Specialized testing is centralized in Medicine Hat. Brooks also provides on-site testing and referred out service and other sites provide limited lab services. The region has moved to increase point-of-care testing to improve lab efficiencies (e.g. glucose, hemoglobin, cardiac enzymes) PHR has established a good working relationship with a community lab in Medicine Hat, which enables good utilization of lab services for high volume work. The two organizations have focused on building common training, technical standards, procedures and order sets, and also share some purchasing contracts for equipment and reagents. A challenge exists in the information transfer between these two organizations, however, as there is still a need for investment into the integration of the region's Meditech system and the community lab's Keane system. Integration would lead to improved information flow and lab utilization management. Consultation suggests that there is general acceptance of best practices to help drive decision-making, however this is typically driven through an MD peer-to-peer process. There is no regional laboratory utilization committee to support the drive to best practice and utilization management.
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Clinical Support and Allied Health Services
Clinical Laboratory
Opportunities Findings
Consultation findings also identified staffing challenges related to recruitment, retention and workforce planning.
The region is currently running 3.0 FTE vacancies in Labs.
3. Develop targeted strategies for clinical laboratory to address vacancies and increased staff demand as part of regional workforce planning.
Population growth in Brooks has increased demand on Labs.
Given the varied models of lab services across the RHAs, a comparison based on lab costs/procedure was performed.
This comparison found that PHR had the second lowest lab cost per procedure among the Alberta non-metro regions. This finding confirms the efficiencies gained by the region in managing workload across its hospital-based and community based lab service providers.
Area Description
Lab Cost/Procedure 2004-05
Alberta Peer Lab Cost/Procedure MIN $6.34
Alberta Peer Lab Cost/Procedure MAX $19.90
Clinical Laboratory
$7.45
Source: AHW MIS for 2004-05, RHA-Provided GL Data for 2005-06 103 AHW RHA Efficiency Review Palliser Health Region Property of Alberta Health and Wellness 2007 Deloitte Inc
Clinical Support and Allied Health Services
Diagnostic Imaging
Opportunities Findings
DI is a regional service. Fluoroscopy and ultrasound is provided out of both MHRH and Brooks. Mammography, CT, Nuclear Medicine and MRI is provided only out of MHRH. Radiology (basic x-ray) is provided at all sites. The region has focused on standardization of operations and functionality in all five imaging facilities. All sites use a common Radiology Information System (RIS), policy and 1. Explore options to improve procedures, list of routine examinations and protocols, Meditech functionality to regional documentation, and equipment. address identified data PACS implementation is currently in progress. The region has capture issues for DI re-skilled its film library staff to support digital archiving. 2. Integrate DI into PHR has established a preventative maintenance program for community-wide equipment, and current capital plans will result in the majority scheduling. of DI equipment being relatively new. Stakeholder consultation indicates Meditech challenges that have resulted in an overall decrease in functionality for example: requesting MD is not captured, inpatient exams are cancelled when patients are discharged. Further, DI scheduling is not yet well integrated with the community-wide scheduling module in Meditech, which would facilitate service delivery and wait list management.
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Clinical Support and Allied Health Services
Diagnostic Imaging
Opportunities Findings
Stakeholders report staffing challenges in recruitment and retention, specifically related to Brooks staffing, and recruitment of CXLTs to the smaller sites. 3. As part of regional HR planning, Develop a targeted DI recruitment and retention plan to address anticipated staff shortages and increased demand, as part of regional HR planning. Consultation also indicates limited access to radiologist services at Brooks so overflow of patients go to private or public facilities in MHRH or Calgary for fluoroscopy. Currently, there is no permanent radiologist at Brooks to supervise contrast enhancement, so these exams are performed under the supervision of hospital GPs. The continued population growth in Brooks is reported as placing increased workload and staffing demands on DI. Staffing comparison finds that PHR is in line with peers for DI at the 50th percentile.
Area Description
Actual FTEs 2005-06 42.7
Actual HAPD 2005-06 0.30
Alberta Peer HAPD MIN 0.23
Alberta Peer HAPD MAX 0.42
National Peer 50th Percentile HAPD 0.30
Potential FTE (Effic.)/ Re-Invest. 2007 Deloitte Inc
Diagnostic Imaging
105
Source: AHW MIS 2004-05, Deloitte Benchmarking Database 2003-04 & 2004-05 & 2005-06, PHR Payroll 2005-06 AHW RHA Efficiency Review Palliser Health Region Property of Alberta Health and Wellness
Clinical Support and Allied Health Services
Respiratory Therapy
Opportunities
1. Explore service delivery models that includes Respiratory Therapists in the OR, with consideration of balancing related nurse staffing. 2. Continue to explore options to improve Meditech and QHR analysis and reporting capabilities. 3. Consolidate Asthma education into regionally coordinated program.
Findings
Respiratory Therapy is a regional acute service operating 24/7 and is centrally located at MHRH. A small number of acute care visits occur in Brooks and are delivered by the outpatient staff working in the Brooks Asthma Education Program. Acute care visits are also provided to a lesser extent in Bow Island and Oyen by the regional outpatient therapist as time permits. Consultation findings indicate that the Brooks and Medicine Hat Asthma Education programs are currently separated. Respiratory Therapy outpatient staff are cross trained to provide support to the acute care staff during periods of heavy workload or staff shortages. A consistent prioritization mechanism is used to manage RT caseloads. RTs currently work at full scope and are able to drive own clinical decisions. However, RTs are not currently working in the OR, due to historical practice patterns with nursing. This is out of line with leading practice for the OR. The transition to the Meditech and QHR systems has been a challenge for Respiratory Therapy, as stakeholders report that there is currently minimal data available for analysis and quality monitoring during the implementation. Overtime was 2.1% in 2005-06, which is higher than observed across other allied health disciplines. Staffing comparison finds that PHR is in line with peers for Respiratory Therapy, at the 50th percentile. Actual FTEs 2005-06 13.7 Actual HAPD 2005-06 0.10 Alberta Peer HAPD MIN 0.02 Alberta Peer HAPD MAX 0.19 National Peer 50th Percentile HAPD 0.10 Potential FTE (Effic.)/ ReInvest. 2007 Deloitte Inc
Area Description
Respiratory Therapy
106
Source: AHW MIS 2004-05, Deloitte Benchmarking Database 2003-04 & 2004-05 & 2005-06, PHR Payroll 2005-06 AHW RHA Efficiency Review Palliser Health Region Property of Alberta Health and Wellness
Clinical Support and Allied Health Services
Pharmacy
Opportunities Findings
Pharmacy services are coordinated across MHRH and BI, but is not a fully regionalized service. PHR has adopted a regional formulary and some 1. Proceed with standardized medication protocols, but the region is just beginning discussions on regionalizing Pharmacy the process required to regionalize pharmacy. that: facilitates leading Well developed dispensary operations and clinical pharmacy program, although practice limited resources prevent further expansion of clinical pharmacy. PAC-Med optimizes operational currently has additional capacity. However, there are insufficient FTEs to expand efficiencies and dispensary and clinical operations due to both shortages and competition with identifies regional retail pharmacy. The region has started to expand roles of Pharmacy Technicians transportation service to alleviate need for Pharmacists in dispensary. requirements (as a critical enabler). Challenge in utilizing laundry truck 3x/week to transport medication to Bow Island due to outdated medication cards, and an identified need for more 2. Continue to examine frequent delivery. increased role for Pharmacy Technicians Current space challenges will be exacerbated if MHRH is to expand coverage to and innovative payment other sites, however this will be addressed through the Ambulatory Care Tower practices for expansion. Pharmacists (e.g. Significant recruitment issues that has limited Pharmacy's expansion of services. location pay) to address Would also like to develop a Residency training program but there is insufficient current staffing staff to support it. shortages. Implementation of the new Meditech system has resulted in a `step backwards', 3. Explore options to as the new system has created challenges in processing orders, managing improve Meditech inventory and drug control as efficiently as the BDM system. Associated functionality in challenges are reported to have also contributed to recent Pharmacist departures. Pharmacy. Staffing comparison finds that PHR has a staffing investment opportunity relative to peers at the 50th percentile, which is in line with current vacancies. Area Description Pharmacy
107
Actual FTEs 2005-06 21.4
Actual HAPD 2005-06 0.15
Alberta Peer HAPD MIN 0.13
Alberta Peer HAPD MAX 0.25
National Peer 50th Percentile HAPD 0.17
Potential FTE (Effic.)/Re-Invest. 3.0
2007 Deloitte Inc
Source: AHW MIS 2004-05, Deloitte Benchmarking Database 2003-04 & 2004-05 & 2005-06, PHR Payroll 2005-06 AHW RHA Efficiency Review Palliser Health Region Property of Alberta Health and Wellness
Clinical Support and Allied Health Services
Clinical Nutrition
Opportunities Findings
Clinical Nutrition is not currently a regional program, but the region has recently started to provide some service to Oyen and Bow Island. Clinical Nutrition services are provided to MHRH as well as 1 day per month (contracted) to the Alfred Egan Home. The region also provides outpatient nutrition consultations to high risk patients, although there is a 6 8 week waiting list. Community Nutrition services are provided through Health Promotion. At MHRH, Clinical Dieticians screen charts for select diagnosis on a daily basis for acute patients, to identify patients at high nutritional risk. They also participate in multi-disciplinary rounds. Both of these are leading practices. The department is impacted by staff shortages due to maternity leaves, lack of relief or casual staff. Outpatient nutrition services are suspended during vacation or other times of staff absences. Staffing comparison for Clinical Nutrition finds that PHR is in line with peers at the 50th percentile.
Actual HAPD 2005-06 0.05 National Peer 50th Percentile HAPD 0.05 Potential FTE (Effic.)/ Re-Invest. -
1. Regionalize Clinical Nutrition to establish common programming, practice, and staff cross coverage across the continuum.
No opportunity identified.
Area Description
Actual FTEs 2005-06 7.0
Alberta Peer Alberta Peer HAPD MIN HAPD MAX 0.04 0.12
Clinical Nutrition
Source: AHW MIS 2004-05, Deloitte Benchmarking Database 2003-04 & 2004-05 & 2005-06, PHR Payroll 2005-06 108 AHW RHA Efficiency Review Palliser Health Region Property of Alberta Health and Wellness 2007 Deloitte Inc
Clinical Support and Allied Health Services
Physiotherapy and Occupational Therapy
Opportunities Findings
Physiotherapy and Occupational Therapy are regional services that support all sites and communities across the health continuum. Services are provided primarily Monday-Friday, 0800-1615, however PT and OT has some weekend coverage in Medicine Hat. Consultations suggest that there is still further need for PT and OT weekend services, to cover orthopaedic and other services and reduce LOS impacts. This is anticipated to be a further challenge given the change in focus of the 2N unit to rehabilitation.
1. Clarify policies and procedures PT and OT share some aide staff, where appropriate. for accessing Consultation findings suggest that PT and OT services would benefit by Physiotherapy having Medical Leadership to advocate, and provide education. Note: across the health this should be considered pending a program management decision. continuum to ensure The transition to the Meditech and QHR systems has been a challenge for consistency. PT and OT, as stakeholders report that there is currently minimal data available for analysis and quality monitoring during the implementation. Stakeholders across clinical programs also identified some challenges in accessing PT services, and varied models for payment of PT (e.g. global funded for acute vs. pay for service for Chronic Disease Management). With the exception of urgent requests, OT Services uses a Determination of Need form to establish priority for services. Have established standards for acceptable timeframes for patients to be seen.
109 AHW RHA Efficiency Review Palliser Health Region Property of Alberta Health and Wellness 2007 Deloitte Inc
Clinical Support and Allied Health Services
Physiotherapy and Occupational Therapy (continued)
Opportunities
2. Consider increased PT staffing with respect to required support for 2N rehabilitation unit and weekend coverage in MHRH, CHADS program services, and existing contract services.
Findings
Staffing comparison finds that PHR has an investment opportunity for Physiotherapy and is in line for Occupational Therapy, relative to peers at the 50th percentile.
Area Description
Actual FTEs 2005-06 34.9 22.6
Actual HAPD 2005-06 0.24 0.16
Alberta Peer HAPD MIN 0.10 0.11
Alberta Peer HAPD MAX 0.31 0.20
National Peer 50th Percentile HAPD 0.26 0.16
Potential FTE (Effic.)/ Re-Invest. 1.8 -
Physiotherapy Occupational Therapy
Source: AHW MIS 2004-05, Deloitte Benchmarking Database 2003-04 & 2004-05 & 2005-06, PHR Payroll 2005-06 110 AHW RHA Efficiency Review Palliser Health Region Property of Alberta Health and Wellness 2007 Deloitte Inc
Clinical Support and Allied Health Services
Audiology, Speech Language Pathology and CHADS
Opportunities Findings
Acute SLP/Audiology and CHADS are regional services, coordinated centrally in Medicine Hat across the continuum of care. Stakeholders report that transitioning patients within across the continuum is `seamless'. The service has established consistent regional policies and procedures, and active caseload guidelines are used to standardize caseloads. Reports suggest that this has enabled 1. Continue to improved prioritization, and a reduction in service wait times. explore The region also participates in a cross-regional SLP/Audiology Network in Alberta, to support SLP/Audiology new program development, best practice and policy review, and comparative benchmarking. program The region also has a Medical Director for CHADS, who provides important clinical expansion leadership. opportunities SLP/Audiology has identified several opportunities for program expansion, including within existing behavioural work, home care, and increased use of telehealth, among others. resources, in Potential to develop a regional children's service referral/intake program may be useful. alignment Telehealth will be an opportunity to reach smaller communities. with PHR Recruitment challenges for SLPs nationally. Significant number of maternity leaves & community modified schedules to accommodate staff. health needs Consultation findings indicate good equipment support for both SLP and Audiology. assessment. Identified space challenges at MHRH and Brooks are expected to be resolved through current capital plans. Staffing comparison finds that PHR has a potential staffing efficiency opportunity for SLP/Audiology. Given direct funding of several FTEs by SHIP, however, no opportunity exists for operational staffing efficiencies. Area Description Speech Language Pathology and Audiology
111
Actual FTEs 2005-06 24.5
Actual HAPD 2005-06 0.17
Alberta Peer HAPD MIN 0.07
Alberta National Peer 50th Peer HAPD Percentile HAPD MAX 0.18 0.16
Potential FTE (Effic.)/ Re-Invest. (2.3) See Above
Source: AHW MIS 2004-05, Deloitte Benchmarking Database 2003-04 & 2004-05 & 2005-06, PHR Payroll 2005-06 AHW RHA Efficiency Review Palliser Health Region Property of Alberta Health and Wellness 2007 Deloitte Inc
Clinical Support and Allied Health Services
Social Work
Opportunities Findings
Consultation findings indicate that the region does not currently have a regionally managed Social Work program, although several Social Workers are in place supporting discharge planning. A number of the smaller sites in the region identified challenges in accessing social work services. Staffing comparison finds that PHR is in line with peers for Social Work at the 50th percentile.
1. Examine the role and allocation of Social Work resources in the region, to determine ability to improve service access and patient flow across region.
Area Description
Actual FTEs 2005-06
Actual HAPD 2005-06 0.05
Alberta Peer HAPD MIN
Alberta Peer HAPD MAX
National Peer 50th Percentile HAPD 0.05
Potential FTE (Effic.)/ Re-Invest. -
Social Work
7.4
0.01
0.07
Source: AHW MIS 2004-05, Deloitte Benchmarking Database 2003-04 & 2004-05 & 2005-06, PHR Payroll 2005-06 112 AHW RHA Efficiency Review Palliser Health Region Property of Alberta Health and Wellness 2007 Deloitte Inc
Clinical Support and Allied Health Services
Recreation
Opportunities Findings
Recreation primarily supports continuing care settings in the region. 1. Continue to monitor Recreation staffing requirements as part of broader regional continuing care staffing model. Staffing comparison finds that PHR has a staffing investment opportunity for Recreation, relative to peers at the 50th percentile. This opportunity should be considered relative to broader continuing care staffing in the region, especially given the shifting model of continuing care delivery in the region. The region should continue to monitor staffing levels across continuing care disciplines before pursuing this potential investment.
Area Description
Actual FTEs 2005-06
Actual HAPD 2005-06 0.06
Alberta Peer Alberta Peer HAPD MIN HAPD MAX
National Peer 50th Percentile HAPD 0.15
Potential FTE (Effic.)/ Re-Invest. 13.4
Recreation
8.1
0.06
0.21
Source: AHW MIS 2004-05, Deloitte Benchmarking Database 2003-04 & 2004-05 & 2005-06, PHR Payroll 2005-06 113 AHW RHA Efficiency Review Palliser Health Region Property of Alberta Health and Wellness 2007 Deloitte Inc
Corporate & Support Services
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Corporate and Support Services
Peer Staffing Comparison Process Overview
To understand the relative efficiency of the Corporate and Support Services, we conducted a comparative analysis with a number of comparable health regions from Alberta, British Columbia, Manitoba, and Saskatchewan. Fiscal 2005-06 data for PHR was used for peer comparison, as this represents a full year of staffing, but reference to budgeted 2006-07 staffing levels are also provided. The efficiency analysis assessed peer staffing based on a comparison of actual total paid hours per adjusted patient day (HAPD) for each "department" within the organization (based on MIS functional centre alignment). The adjustment factor increases the base of inpatient clinical activity to better reflect the span of inpatient, outpatient, continuing care and community clinical activity. The results across the comparator group were considered with the following "rules" applied at the departmental level:
Values among the comparator group that were well outside the range (e.g. outliers) were eliminated from the analysis. Given the northern geographic challenges faced by the region, the FTE efficiency opportunity for all Corporate, Support, Clinical Support and Allied Health Services was identified compared to the peer 50th percentile level of staffing performance.
Staffing opportunities are identified based on comparative analysis and the team's understanding of minimum staffing requirements. Staffing opportunities are not stand alone, however, and need to be considered in the context of other opportunities identified for each area. The benchmarking information should be used as input to management decision-making, rather than as a decision in and of itself.
115 AHW RHA Efficiency Review Palliser Health Region Property of Alberta Health and Wellness 2007 Deloitte Inc
Corporate and Support Services
Peer Staffing Comparative Analysis Areas Reviewed
MIS Primary Account 71105, 71110, 71205, 71305, 71405, 71505 71115 71120 71840 71125 71135 71145 71150 71153, 71155, 71165, 71175 71190, 71180, 71130 Departments General Administration and Nursing Administration Combined (Combined to ensure comparability to peer reported data) Finance Human Resources/Personnel and Occupational Health & Safety Clinical Affairs and Education Systems Support Regional IT Materiel Management (includes all CSR for the region) Housekeeping Laundry And Linen (excluding any CSR staff) Plant Operations, Maintenance and Biomedical Engineering Combined (Combined to ensure comparability to peer reported data) Health Records, Registration and Telecommunications Combined (Combined to ensure comparability to peer reported data) Patient/Resident and Non-Patient Food Services Combined (Combined to ensure comparability to peer reported data)
2007 Deloitte Inc
71195, 71910
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General and Nursing Administration Combined
Opportunities Findings
The region has established a robust and comprehensive capital planning process:
Stakeholders report good involvement across the clinical, support service and administrative areas of the organization.
No opportunity identified.
A clear set of criteria are used to determine capital priorities, which have been developed and agreed to by a cross-section of stakeholders. Capital needs are identified by stakeholders from across the organization.
Stakeholders report good satisfaction with capital planning and equipment processes. No opportunity identified. Staffing comparison finds that PHR is in line with peers for General and Nursing Administration combined, at the 50th percentile. Note: community services management and clerical support are included in this comparison, to ensure comparability to peers.
Actual FTEs 2005-06 70.1 Actual HAPD 2005-06 0.49 Alberta Peer HAPD MIN 0.42 National Peer 50th Percentile HAPD 0.49 Potential FTE (Effic.)/ Re-Invest. -
Area Description General & Nursing Admin. Combined
117
Alberta Peer HAPD MAX 0.61
Source: AHW MIS 2004-05, Deloitte Benchmarking Database 2003-04 & 2004-05 & 2005-06, PHR Payroll 2005-06 AHW RHA Efficiency Review Palliser Health Region Property of Alberta Health and Wellness 2007 Deloitte Inc
Corporate and Support Services
Finance
Opportunities
1.Consider investment of resources to ensure continued Decision Support functionality in the region. 2.Explore options for expanding Director and Manager involvement in annual budgeting processes, enabled by Decision Support.
Area Description Finance
118
Findings
Finance is a regional service and centralized in Medicine Hat. Consultation across Finance, HR, Materials Management reports good collaboration in coordinated functions such as payroll and accounts payable. The regional budgeting process is described as a top-down approach that uses the previous year's budget with adjustments for such costs as inflation, labour, utilities, drugs, etc. Consultation and comparison to other organizations suggests that limited Director/Manager involvement in budgeting may impact the region's support for program innovation and manager ownership of budgets. The region has a decision support function that has been re-focused on Meditech report writing to support the current implementation. While this is necessary to enable the region to realize the full value of the Meditech Phase 1 implementation, it reduces the functionality of this group to support management decision making across the organization. Staffing comparison finds that PHR has an investment opportunity relative to peers at the 50th percentile. By expanding decision support functionality through this investment, managers could be enabled to have more active involvement in annual budgeting.
Actual HAPD 2005-06 0.13 Alberta Peer HAPD MIN 0.12 Alberta Peer HAPD MAX 0.22 National Peer 50th Percentile HAPD 0.14 Potential FTE (Effic.)/Re-Invest. 1.4
2007 Deloitte Inc
Actual FTEs 2005-06 18.5
Source: AHW MIS 2004-05, Deloitte Benchmarking Database 2003-04 & 2004-05 & 2005-06, PHR Payroll 2005-06 AHW RHA Efficiency Review Palliser Health Region Property of Alberta Health and Wellness
Corporate and Support Services
Human Resources
Opportunities Findings
Human Resources is a regional service including recruitment, workforce planning, labour relations, performance management, classification, occupational health & safety, education (related to management and OHS issues) and disability management. Staff are cross-trained in HR, to enable cross coverage and flexibility in service delivery. Over the last 6 years, priorities have evolved from labour relations and disability management to a greater focus on occupational health and safety and attendance management. Current HR priorities are in leadership development, succession planning, workforce planning and cultural transformation. Consultation with HR and other stakeholders identified challenges in meeting current HR service delivery workload.
HR reports challenges in meeting service requests, which impacts its ability to more strategically support the organization while maintaining service. Several program areas identified recruiting support challenges, and so perform some functions independent of HR, such as reference checking.
1. Target staffing investment in HR to support strategic focus in the region. See HR Strategy and Management section (near end of document) for additional opportunities.
Staffing comparison finds that PHR HR is below peers at the 50th percentile, and has an opportunity for staffing investment in this area.
Area Description Human Resources
119
Actual FTEs 2005-06 14.3
Actual HAPD 2005-06 0.10
Alberta Peer HAPD MIN 0.07
Alberta Peer National Peer 50th Potential FTE HAPD MAX Percentile HAPD (Effic.)/Re-Invest. 0.18 0.12 2.8
2007 Deloitte Inc
Source: AHW MIS 2004-05, Deloitte Benchmarking Database 2003-04 & 2004-05 & 2005-06, PHR Payroll 2005-06 AHW RHA Efficiency Review Palliser Health Region Property of Alberta Health and Wellness
Corporate and Support Services
Education
Opportunities
1. Continue to expand onsite regional education across the rural sites. See HR Strategy and Management section (near end of document) for additional opportunities.
Findings
Stakeholder consultations indicate a good level of satisfaction with broad education in the region, with specific note of the leadership and management development and training in place. Consultation with the rural sites, however, indicate past challenges in accessing regional education on-site. The region has recently instituted Rural Education Days, which are anticipated to address this gap. Staffing comparison finds that PHR Education is in line with peers at the 50th percentile.
Area Description
Actual FTEs 2005-06 11.9
Actual HAPD 2005-06 0.08
Alberta Peer Alberta Peer HAPD MIN HAPD MAX 0.02 0.10
National Peer 50th Percentile HAPD 0.08
Potential FTE (Effic.)/ Re-Invest. -
Education
Source: AHW MIS 2004-05, Deloitte Benchmarking Database 2003-04 & 2004-05 & 2005-06, PHR Payroll 2005-06 120 AHW RHA Efficiency Review Palliser Health Region Property of Alberta Health and Wellness 2007 Deloitte Inc
Corporate and Support Services
Systems Support
Opportunities Findings
Please refer to Staffing comparison finds that PHR IT is in line with peers at Technology section (later the 50th percentile. in document) for additional opportunities. Please refer to Technology section for additional findings.
Area Description
Actual FTEs 2005-06 14.3
Actual HAPD 2005-06 0.10
Alberta Peer HAPD MIN 0.07
Alberta Peer HAPD MAX 0.16
National Peer 50th Percentile HAPD 0.10
Potential FTE (Effic.)/ Re-Invest. -
Systems Support
Source: AHW MIS 2004-05, Deloitte Benchmarking Database 2003-04 & 2004-05 & 2005-06, PHR Payroll 2005-06 121 AHW RHA Efficiency Review Palliser Health Region Property of Alberta Health and Wellness 2007 Deloitte Inc
Corporate and Support Services
Materiel Management
Opportunities Findings
Materials Management is a regional function centrally managed from MHRH. The region has undertaken several initiatives to improve processes (e.g. 1. Continue efforts changing time for top-up cart restocking). to drive product standardization Good progress is reported in standardizing capital equipment and products through a regional Product Evaluation Committee. across the region. However, reports suggest that some physicians still select products by personal 2. Continue efforts to standardize In SPD, while staff are allocated by site, there is flexibility through crossSPD practices at training and some cross-coverage between MHRH and Brooks. Brooks, with PHR has developed common policies and procedures for SPD for consideration of decontamination and sterilization across the region. However, increased stakeholders report challenges with standardizing Brooks SPD practices regional despite regional guidelines. management In part, this has been driven by an inability to fill Brooks SPD Supervisor vacancy, presence onand challenges for regional management to have increased on-site presence. site. Consultation findings indicate challenges in recruiting casual staff into areas such as SPD, and an anticipated need for targeted workforce planning to recruit younger staff.
preference. This is reported as especially a challenge for standardizing SPD trays.
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Corporate and Support Services
Materiel Management (continued)
Opportunities Findings
3. Develop a regional approach to Although the region has established a comprehensive asset management and tracking capital planning process, stakeholder consultation suggests to support capital planning. that there is limited focus on asset management and 4. Develop a targeted workforce tracking. plan for Materiel Management Staffing comparison finds that PHR is in line with peers at as part of regional workforce the 50th percentile for Materiel Management. planning.
Area Description Materiel Management
123
Actual FTEs 2005-06 35.9
Actual HAPD 2005-06 0.25
Alberta Peer Alberta Peer HAPD MIN HAPD MAX 0.20 0.53
National Peer 50th Percentile HAPD 0.25
Potential FTE (Effic.)/ Re-Invest. -
Source: AHW MIS 2004-05, Deloitte Benchmarking Database 2003-04 & 2004-05 & 2005-06, PHR Payroll 2005-06 AHW RHA Efficiency Review Palliser Health Region Property of Alberta Health and Wellness 2007 Deloitte Inc
Corporate and Support Services
Housekeeping
Opportunities Findings
Housekeeping services are decentralized (MHRH & Bow Island are managed together; Brooks, Bow Island & Bassano are managed 1. Consider independently). Foremost, Oyen and Cereal use contracted regionalization of housekeeping services with contracts managed by MHRH. housekeeping services to standardize Although some coordination exists, PHR has not yet adopted regionmanagement, wide policies and procedures in place for Housekeeping, and technology, policies variations exist across sites around technology and management and procedures. enablers (e.g. Task Tracker at MHRH only). 2. Continue development Stakeholders reported isolation cleaning as a potential risk of standardized particularly during the day and night shifts, due to limited policies infection control and communication between housekeeping and nursing staff. The policies across region. region is in process of creating regional policies and procedures aligned to infection control standards.
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Corporate and Support Services
Housekeeping (continued)
Opportunities Findings
Consultations across stakeholder groups identified that high workload 3. Consider identified impacts several service areas, for example: staffing investment to At MHRH, the ability of the bed making team to consistently respond in a increase timely manner. Information systems support to enable better housekeeping service communication to the bed making team was also identified as a need. responsiveness and Quick turnaround for OR cleaning. internal patient portering at MHRH. Although not traditionally a role of housekeeping, stakeholders also identified the need for internal patient porters at MHRH. 4. Investigate options to improve ADT linkage to Housekeeping to improve bed making and room cleaning notification. Payroll analysis identified that Housekeeping sick time was at 4.8% for 2005-06, which is above the support service average in the region. Staffing comparison identified that PHR Housekeeping has a staffing investment opportunity relative to peers at the 50th percentile.
Area Description
Actual FTEs 2005-06 79.1
Actual HAPD 2005-06 0.55
Alberta Peer Alberta Peer HAPD MIN HAPD MAX 0.55 0.75
National Peer 50th Percentile HAPD 0.64
Potential FTE (Effic.)/ Re-Invest. 13.3
Housekeeping
125
Source: AHW MIS 2004-05, Deloitte Benchmarking Database 2003-04 & 2004-05 & 2005-06, PHR Payroll 2005-06 AHW RHA Efficiency Review Palliser Health Region Property of Alberta Health and Wellness 2007 Deloitte Inc
Corporate and Support Services
Laundry and Linen
Opportunities Findings
PHR has a regional laundry service, with central laundry in MHRH providing service to all sites except Oyen. Oyen continues to have on-site laundry facilities due to geography, but utilizes MHRH linen inventory. The region also has some revenue generating service through laundry (e.g. to the Military Base). The service has undertaken several initiative to achieve efficiencies (e.g. chemical delivery system, laundry equipment, etc.). Further plans for technology enhancement include a new shuttle system and dryer system, which are anticipated by department management to drive increased revenue opportunities. Stakeholders report high satisfaction with laundry quality. Successful cross-training of staff has been achieved between housekeeping and laundry, which helps to facilitate ongoing challenges retaining casual staff in these areas. Staffing comparison finds that PHR Laundry is in line with peers at the 50th percentile.
Area Description Actual FTEs 2005-06 29.2 Actual HAPD 2005-06 0.20 Alberta Peer Alberta Peer HAPD MIN HAPD MAX 0.15 0.27 National Peer 50th Percentile HAPD 0.20 Potential FTE (Effic.)/ Re-Invest. 2007 Deloitte Inc
1. Develop a casual recruitment strategy for Laundry and Housekeeping, as part of regional workforce planning.
Laundry and Linen
126
Source: AHW MIS 2004-05, Deloitte Benchmarking Database 2003-04 & 2004-05 & 2005-06, PHR Payroll 2005-06 AHW RHA Efficiency Review Palliser Health Region Property of Alberta Health and Wellness
Corporate and Support Services
Plant Operations, Maintenance and Biomedical Engineering Combined
Opportunities Findings Plant Operations, Maintenance & Biomedical Engineering is a regional service. Day to day operations and maintenance for all sites is the responsibility of the site Maintenance Supervisor who each report to the Regional Manager. Biomedical Engineering is in-house, and some trades (refrigeration, electrical and electronics) are provided out of MHRH. At MHRH, maintenance requests are made via PalliserNet and voicemail. All other sites currently utilize voice mail for maintenance requests. Pallisernet will be made available at all sites as part of CENDEC maintenance software upgrade this Fall. The region reports good ability to keep a consistent preventative maintenance program, to enable good facility management. Stakeholders identify anticipated challenges with the quantity and complexity of new biomedical equipment. Recruiting, training and retaining new staff is especially a challenge in this regard. The current capital planning in the region will bring additional workload to Plant Operations, which stakeholders have identified will be a challenge to current resourcing. Staffing comparison finds that PHR Plant Operations has a staffing investment relative to peers at the 50th percentile..
Actual HAPD Alberta Peer Alberta Peer 2005-06 HAPD MIN HAPD MAX 0.30 0.29 0.41 National Peer 50th Percentile HAPD 0.33 Potential FTE (Effic.)/Re-Invest. 3.6
1.Continue to ensure new version of Cendec is made available to smaller sites to streamline maintenance requests. 2.Consider staffing investments in Plant Operations to support capital projects and facility maintenance in the region.
Area Description Plant Ops, Maint., and Biomed.
127
Actual FTEs 2005-06 43.5
Source: AHW MIS 2004-05, Deloitte Benchmarking Database 2003-04 & 2004-05 & 2005-06, PHR Payroll 2005-06 AHW RHA Efficiency Review Palliser Health Region Property of Alberta Health and Wellness 2007 Deloitte Inc
Corporate and Support Services
Health Records, Patient Registration and Telecommunications Combined
Opportunities Findings
Health Records and Patient Registration is regionally managed, with some cross-coverage of staff across sites. As part of recent portfolio changes, Health Records and Patient Registration are now aligned to regional IMTS department to facilitate the movement towards the EHR. Stakeholders reported significant space constraints for staff as well as storage space for charts in Health Records. The region is planning to utilize a scanning and archiving system to move towards EHR and alleviate the current space challenges, and planned expansion at MHRH may also resolve these challenges.
1. Develop a plan to address Health Records chart storage, with consideration of facilities and technology-based solutions.
2. Consider development of a single multi-site phone system to enable crosscoverage of switchboard and reception functions in the region, as part of capital planning. 3. Explore the business case for establishing centralized booking at MHRH, with consideration of physical vs. technology-based centralization.
128
Phone system is site specific and there is no cross coverage across sites. Stakeholders report challenges in multiple points of booking across MHRH related to coordination. Recent implementation of Meditech Community Wide Scheduling Module may offer improved coordination although stakeholder consultation indicates that this has not been explored.
AHW RHA Efficiency Review Palliser Health Region Property of Alberta Health and Wellness
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Corporate and Support Services
Health Records, Patient Registration and Telecommunications Combined (continued)
Opportunities
4. Target staffing investment in Health Records and Patient Registration to address current backlogs in coding, abstracting and transcription (will need to determine appropriate level of investment given current outsourcing of transcription which is impacting target to some extent).
Findings
Stakeholder consultations indicated challenges in meeting Health Records workload, with backlogs in coding, abstracting and transcription. However, the region has outsourced some transcription service to offset current backlogs.
In part, stakeholders report this backlog has being driven by the increased workload associated with the Meditech implementation.
Patient registration reported current vacancies of approximately 2.0 FTEs in the department. Staffing comparison finds PHR has a staffing investment opportunity for Health Records and Patient Registration, relative to peers at the 50th percentile. In part, this opportunity may be related to the region's recent outsourcing of transcription services.
Area Description Health Rec., Telecom Pt Reg. Combined
129
Actual FTEs 2005-06 52.0
Actual HAPD 2005-06 0.36
Alberta Peer Alberta Peer HAPD MIN HAPD MAX 0.36 0.58
National Peer 50th Percentile HAPD 0.45
Potential FTE (Effic.)/ Re-Invest. 12.3
Source: Alberta H&W MIS 2004-05, Deloitte Benchmarking Database 2003-04 & 2004-05, PHR Payroll Data 2005-06 AHW RHA Efficiency Review Palliser Health Region Property of Alberta Health and Wellness 2007 Deloitte Inc
Corporate and Support Services
Patient and Non-Patient Food Services
Opportunities 1. Consider regionalization of Food Services throughout PHR to achieve common standards, policies and procedures. 2. Develop a business case to examine the potential shift to centralized food service production and distribution. 3. Determine required staffing to support a regionalized food service model, before targeting identified investments.
Area Description Pt. & Non-Pt. Food Services Combined
130
Findings Food services is not yet regionalized in PHR. MHRH Food Services does oversee Bow Island, however, and shared processes and standardization is beginning to occur. All sites operate with raw food production, and MHRH is just beginning to look at trends around cook-chill-retherm options. Because food services is site specific, there are a number of service delivery elements that have not yet been standardized across the region. Examples include:
Regional menus, Regional policies and procedure., Regional job descriptions. Improved communication. Regional staffing and recruitment.
Limited casual staff availability. The region is using the CBORD IT system, but stakeholders reported limited support from IT in maintaining or modifying the system to meet end-user needs. Staffing comparison finds that PHR is below peer staffing levels at the 50th percentile, and has an opportunity for investment.
In part, this is driven by outsourced retail food operations in MHRH, as well as the majority of continuing care facilities in the region being provided by private or voluntary organizations, however this finding requires further exploration. Alberta Peer HAPD MAX 0.86 National Peer 50th Potential FTE Percentile HAPD (Effic.)/Re-Invest. 0.79 36.0
Actual FTEs Actual HAPD Alberta Peer 2005-06 2005-06 HAPD MIN 77.0 0.54 0.48
Source: AHW MIS 2004-05, Deloitte Benchmarking Database 2003-04 & 2004-05 & 2005-06, PHR Payroll 2005-06 AHW RHA Efficiency Review Palliser Health Region Property of Alberta Health and Wellness 2007 Deloitte Inc
Operational Trending and Analysis
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Operational Trending and Analysis
Introduction
Through the peer staffing comparison, this review has already explored opportunities for efficiency and effectiveness across approximately 70% of the organizations operational spending. Other key cost drivers for consideration include:
Sick and Overtime Premium Costs Non-Salary Discretionary Supplies and Sundries Medical/Surgical Supply Costs Drugs and Medical Gas Supply Costs Food Supply Costs
Further examination of each of these costs will be presented over the following slides. In addition, an overall review of where the region is investing its operating dollars across the continuum of care will be presented relative to peers.
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Sick Time and Overtime Summary
Service Area Administration & Support Services Nursing Inpatient Services Ambulatory Care Services Allied Health Community & Social Services Total FTEs 2005-06 446 520 119 257 207 Sick Time % Sick Time % Potential FTE Sick time and over time rates on average increased of Total Paid of Total Paid Savings 2004-05 2005-06 2005-06 slightly from 2004-05 to
2005-06.
2.7% 4.1% 3.7% 1.7% 3.2% 3.1% 4.0% 3.7% 2.0% 3.2% 2.5 2.3 0.9 0.7 0.7
By examining the region's internal sick and overtime averages by service area, opportunities for improvement can be realized by shifting departments to perform at the area-specific sick and overtime averages. Analysis suggests a potential for up to 7.1 FTEs in sick time improvement, and almost $857,659 in overtime premium cost savings, which would need to be explored within a broader HR framework for change.
Service Area Administration & Support Services Nursing Inpatient Services Ambulatory Care Services Allied Health Community & Social Services
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Total FTEs 2005-06 446 520 119 257 207
Overtime % Overtime % of Total Paid of Total Paid 2004-05 2005-06 1.0% 2.5% 1.3% 2.2% 0.7% 1.0% 2.7% 1.2% 2.2% 0.9%
Potential $ Savings 2005-06 $154,259 $322,670 $65,560 $282,277 $32,893
Source: PHR Payroll 2004-05, 2005-06 AHW RHA Efficiency Review Palliser Health Region Property of Alberta Health and Wellness 2007 Deloitte Inc
Non-Salary Discretionary Supplies and Sundries
An analysis of non-salary discretionary accounts was conducted to identify spending variations as well as to understand the large increase in sundry expenses.
Discretionary accounts are identified as those non-salary costs that are not directly related to patient care, and over which management is able to exert a degree of control.
Overall, non-salary discretionary costs increased by over $6.4 million, or 22%, between 2003-04 and 2005-06.
The main drivers of the increase include General Department Supplies and Sundries, Staff Travel, and Data Processing fees.
Although not shown here, it also important to note several other non-salary cost drivers in the region:
The cost for patient transport has increased by over $146,000 (16%) since 2003-04. The cost for building and land rental has increased by over $137,000 (357%) in 2005-06, although this is anticipated to be a temporary cost driver until the Medicine Hat Ambulatory Care Tower is developed. Account General Department Supplies General Sundries Staff Travel Data Processing and Communication Long Distance Printed Forms Sub-Total Other Accounts Total
Source: PHR General Ledger 2003-04, 2004-05, 2005-06. 134 AHW RHA Efficiency Review Palliser Health Region Property of Alberta Health and Wellness 2007 Deloitte Inc
2003-04 $22,154,386 $1,769,631 $707,354 $129,734 $93,378 $157,050 $25,011,533 $4,444,826 $29,456,359
2004-05 $24,892,939 $3,368,954 $749,668 $117,752 $116,914 $165,088 $29,411,315 $4,861,355 $34,272,670
2005-06 $27,049,993 $1,937,222 $825,437 $371,482 $183,531 $234,299 $30,601,964 $5,284,036 $35,886,000
Variance 2003-04 to 2005-06 22% 9% 17% 186% 97% 49% 22% 19% 22%
Med/Surg, Drugs and Food Supply Costs
Medical/Surgical, Drugs and Food Supply expenses were examined relative to adjusted patient days for PHR and other rural RHAs in Alberta. In comparison to Alberta peers, PHR was found to be at the mid-point for Medical/Surgical Supplies and Drugs and Medical Gases Expenses per APD, respectively. For Food and Dietary Supplies, PHR was found to have the lowest costs/APD among the rural Alberta RHAs.
Alberta Peers Expense/APD MIN Alberta Peers Expense/APD MAX
Supply Costs as a % of Total Expenses
2005-06 Actual Expenses
2005-06 Expense/APD
Medical/Surgical Supplies Drugs and Medical Gases Food and Dietary Supplies
$4,332,540 $3,780,446 $1,315,424
$14.91 $13.01 $4.53
$3.94 $4.40 $4.53
$25.14 $19.80 $12.76
Source: AHW MIS for 2004-05, RHA-Provided GL Data for 2005-06
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Financial Profile Across the Care Continuum
A financial profile of PHR relative to other regions in Alberta is presented below, which examines the % of total expenses currently being allocated across different dimensions of the organization. As observed through this analysis, PHR is at the mid-point of peers for its % of total operating expenses in its Corporate Services and Emergency, Day and Ambulatory Services. PHR also has the second highest % of total operating expenses in Acute Nursing, Residential Nursing and Allied Health services. Conversely, PHR is currently spending the lowest % of total operating expenses on Community Health Services, which supports findings about challenges to maintain services in Environmental Health and other community services. Components of Regional Operational Expenses Corporate Services Support Services Acute Nursing Residential Nursing Emergency, Day and Ambulatory Services Telehealth Allied Health Community Health Services Marketed Services Undistributed 2005-06 % of Total Expenses 8.9% 16.1% 23.0% 17.6% 6.7% 0.0% 17.7% 10.1% -0.1% 0.0% Alberta Peers % of Total Operating Expenses MIN 6.3% 12.6% 14.9% 4.6% 4.4% 0.0% 13.8% 10.1% -0.1% 0.0% Alberta Peers % of Total Operating Expenses MAX 12.4% 22.2% 26.4% 18.2% 8.2% 0.3% 17.9% 15.9% 13.7% 5.6%
Source: AHW MIS for 2004-05, RHA-Provided GL Data for 2005-06 136 AHW RHA Efficiency Review Palliser Health Region Property of Alberta Health and Wellness 2007 Deloitte Inc
Human Resources Strategy and Management
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Human Resources Overview
Talented people or shortage of talented people can make or break any organization's strategy. In the past, health care in general has taken the people and talent issues for granted. Our people plans including plans to hire and / or workforce deployment were tactical issues to be addressed once the business strategy was finalized. This approach can no longer stand up to the growing and increasingly complex demands of the health care workforce. What was once tactical has now become strategic. Coming into this review, Deloitte expected that the Health Regions would share the following common healthcare workforce challenges:
Critical shortage of numerous professional and non-professional roles Retention issues as staff leave health care industry for other better paying opportunities Retention issues as staff go to other healthcare organizations for better pay or perceived better role Aging workforce Increased casualization of the workforce Reliance on foreign graduates and the corresponding need for higher level of organizational support for these individuals Need for incentives to recruit and retain Restrictive labour contracts and requirements
Our goal was to assess the extent to which the Region understands these issues and has developed strategy to respond. Specifically, we are looking to see the degree to which the Human Resource Strategy and roles are well positioned to support the growing complex world of people management.
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Human Resources Overview
(continued)
Our findings are based on a review of relevant documentation and consultation. From these, we will identify opportunities for Regions to consider. Our model for review, findings reporting and opportunity identification follows a four part framework: Talent Management the integration of processes,
programs, technologies and staff to Develop, Deploy and Connect workforce. Develop builds individuals' capabilities as required by organization either currently or for the future.
Connect cultivates high quality work relationships and culture that fosters engagement, productivity and innovation.
Human Resources Re-focus efforts to enhance
HR capacity and capability to support service and management priorities of the Region.
Re fo HR cu si ng
Deploy ensures candidates are attracted, and recruited to roles and that recruitment is well aligned to strategic and operational needs.
HR Transformation Strategy Process
Te gy R H olo n ch
Human Resources Technology focuses on the
extent to which technology supports the HR capacity and consistency in practice across Region.
Healthy Work Environment encompasses the
physical work environment and psychosocial work environment. Healthy work environment practices exist where culture and practices converge to create improvements for staff that cascade to the patient and community level.
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H En W ea vi o lth ro rk y nm en t
M
t n t en le m Ta ge a an
Human Resources Strategy and Management
Findings and Opportunities
Opportunities HR Refocusing 1. Continue development of a single, comprehensive health human resources workforce plan for PHR that aligns health human resources needs and priorities to regional strategic objectives, and which includes Physicians in planning. The region has a health human resources strategy that was recently developed in May 2006. To support this strategy, the region is currently in the process of developing a workforce plan that aligns health human resource needs and priorities to the strategic objectives and health services planning. Findings
Stakeholder feedback suggests that because staffing shortages have not been a challenge in the past, this has not been an area of historical strategic focus, however the organization is renewing its focus on HR through several 2. Consider the development of initiatives (e.g. workforce planning, cultural transformation). a senior level HR position to Although Human Resources has been able to focus on some drive the strategic priority of initiatives, reported staff shortage has focused the HR for the organization. department on maintaining transactional workload.
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Human Resources Strategy and Management
Findings and Opportunities
Opportunities Talent Management The region has invested in several elements of talent management to support regional recruitment, operations and culture. Examples include:
A supernumerary program, which supports the mentoring and placement of new graduates.
Findings
1. Develop an Close connections with several colleges, which provide placements for RN, integrated health LPN, OT, PT, SW and other disciplines. human resources Planned implementation of HPNet, a central placement database for nursing recruitment and which facilitates nursing student placements. retention plan, which A cultural transformation initiative is currently underway in the is based on region, which is anticipated to help the region re-focus on talent workforce planning management by building a stronger culture that will continue to and aligned to HR attract and retain health human resources. strategy. These current efforts will contribute to ongoing regional recruitment, retention and broader talent management. However, the region still has areas for improvement in recruitment and retention planning for example an integrated plan that includes physicians, and which considers HHR requirements for physician impact analysis planning.
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Human Resources Strategy and Management
Findings and Opportunities
Opportunities Talent Management (continued) 2. Re-focus efforts on performance management as a regional priority, to ensure individual performance alignment to regional strategies and objectives. The region has invested in creating an online performance management system supported by training, but stakeholders report low compliance with performance management across the organization. This can result in a lack of alignment between regional strategic objectives, operational plans and individual actions that drive regional operations and performance. Although the region has invested in leadership development and training for management and staff, stakeholder consultations suggest a gap in management training for physician leaders. It is anticipated that management training for regional physician leaders would enable further physician engagement in regional clinical operations. Several programs exist that may provide support to regional physician management training, such as those offered through the Physician Management Institute. Findings
3. Explore the development and investment in management training for regional physician leaders.
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Human Resources Strategy and Management
Findings and Opportunities
Opportunities HR Technology 1. Explore options to improve functionality of QHR, supported by management training to leverage HR management at the regional and site levels. The region has adopted QHR as its HRIS, but stakeholders report several challenges with the system's current functionality:
Limited attendance management support for managers. Limited management reporting. Limited ability to modify scheduling rules to fit different contract rules. Limited ability for non-clinical areas to use QHR for schedule development and management.
Findings
2. Continue to build telehealth and elearning as key HR technologies supporting regional education.
The region is starting to use telehealth and e-learning to support remote learning. However, opportunity exists to build on current progress to improve access to telehealth-based education.
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Human Resources Strategy and Management
Findings and Opportunities
Opportunities Healthy Work Environment Stakeholder consultations indicate a generally healthy work environment, supported by:
Good OH&S departmental support to the region. Good relations across management and staff. Good relations between physicians and administration
Findings
1. Establish processes and communication mechanisms to provide staff and physicians with an ability to discuss and resolve inter-professional issues.
Some stakeholders did report challenges in a lack of process to support staff-physician issues.
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Infrastructure
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Regional Infrastructure Alignment
Introduction
Our review of regional infrastructure is intended as a high level assessment of how well infrastructure is aligned to support operations. Where there are opportunities for improvement to infrastructure, these opportunities will be identified for the region's consideration. The review has focused on the key high level opportunities across two dimensions of regional infrastructure, with findings and opportunities based on consultation, document review and related analysis:
Facilities and Equipment Technology
Regional Infrastructure Findings and Opportunities
Alignment to Support Operations
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Facilities and Equipment
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Facilities and Equipment
Facilities Re-Development
High-level consultation findings, on-site observations, and analysis of availability Alberta Infrastructure data for regional facilities and equipment identified the following key findings and opportunities: Opportunities Findings
At MHRH, the current triangle-model for the inpatient units can be a challenge to resource management, as it requires that two nursing stations are staffed, with limited visibility between stations. 1. Ensure alignment of current capital planning to service planning and setting of care requirements (also based on community health needs assessment and leading practices).
The region has, however, re-configured many units to address some of these challenges.
Observations during site tours at MHRH noted several areas with equipment in hallways, but the region has identified a plan to address this impact on physical flow. Several areas reported physical space challenges (e.g. OR, Pharmacy, DI). At MHRH, the physical plant impairs LDRP achievement, because L&D and Post-Partum are physically separated in the current configuration. An MHRH re-development plan in place to address many space issues, which includes the development of an Ambulatory Care tower. At Oyen, an ER/OPD re-development is currently underway to improve overall physical facilities. A full facility replacement is planned at Brooks that will integrate acute care, ambulatory care and community health services. Bow Island and Bassano facility replacements also being considered by the region. The region has recently completed a community health needs assessment.
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Facilities and Equipment
CTAS Standards and Telehealth
High-level consultation findings, on-site observations, and analysis of availability Alberta Infrastructure data for regional facilities and equipment identified the following key findings and opportunities: Opportunities Findings
As identified in the Emergency Program findings and opportunity, some of the smaller sites across the region have challenges in meeting CTAS standards, some of which are driven by physical facility configuration:
2. Examine facility redesign options to At Bow Island, the waiting room is not visible to triage. support CTAS standards in the EDs At Bassano, there is no formal triage space, and the ER Bay and overall facilities are outdated to current standards. at Bow Island and Bassano. CTAS standards are achieved at MHRH and Brooks, however, it is anticipated that the ER/OPD re-development at Oyen will incorporate CTAS standards in facility design. 3. Explore opportunities to expand use of telehealth in the region, with consideration of equipment and operational resource requirements.
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Although the region has invested in telehealth technology across its sites, stakeholders reported some challenges in its use:
There is a perceived need for more administrative and technology support to end-users. There is a reported need to expand telehealth technology to community health clinics in the region (e.g. Living Healthy).
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Facilities and Equipment
Laundry
High-level consultation findings, on-site observations, and analysis of availability Alberta Infrastructure data for regional facilities and equipment identified the following key findings and opportunities: Opportunities
4. Develop a business case for the replacement of aged Laundry equipment and the installation of a new shuttle system.
Findings
Stakeholder consultations identified initial planning to install a shuttle system to drive increased efficiencies and revenue capacity in laundry. Further, stakeholders identified concern about existing dryers being at their end-of-life.
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Technology
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Leveraging the Value of Information Technology through IT Governance
Information and the Technology that supports it often represent the most valuable but least understood asset in an organization. The essential elements of IT governance are to ensure that value is received from spending on technology and then to control and safeguard information. The purpose of an IT governance framework is to institutionalize good practices that ensure an organization's IT investment supports business objectives. These objectives are identified through the Palliser Health Region's goal of ensuring "healthy people in health region."
And involves: ensuring senior management and frontline providers are involved in determining the direction and goals of the IT department evaluation of service delivery from two perspectives, the total cost of technology operations and monitoring of project outcomes ongoing support and maintenance intended to safeguard the value of existing assets and knowledge in the regional facilities.
Available IT resources, including infrastructure, applications, information and people, should be optimized to support goals. Organizations need to satisfy the quality, fiduciary and security requirements of IT information and infrastructure as for all other assets. To discharge these responsibilities, as well as to achieve objectives, the status of evolving enterprise architecture must be known.
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What is IT Governance?
IT governance consists of leadership, organizational structures and processes that are designed to support an organization's strategies and objectives to increase stakeholder value. Clear responsibility for the direction of IT requirements is necessary to successfully deliver services that support the enterprise's strategy. Monitoring success in delivering against business requirements, requires that management put a framework in place to measure achievements against goals. IT governance transforms business goals into IT objectives through consideration of value, risk and control.
Value IT Objectives
IT Governance
Business Goals ...
Risk
Control
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Determination of IT Activities
Align Business Goal and IT Objectives
Organizational Strategic Plan
Defines
Define IT Strategy
Translate IT objectives into specific initiatives
Business Priorities for IT
Defines
Assess resource suitability and gaps
IT Objectives
Identify IT Resources
Infrastructure Applications Information People
Determine ability to fill gaps through acquisition, training, realignment etc. Determine extent to which business priorities for IT can be met
Communicate results and manage expectations
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Technology
Findings and observations for the technology workstream are intended to identify the degree to which IT investments and resulting initiatives support the goals of the region, and the degree to which they are executed efficiently and effectively. The following key documents were reviewed in support of the Technology review for Palliser Health Region:
Profiles Palliser Health Region IT Surveys IS Director, IS Staff, IS End Users Consultation Findings Supplementary Documents from IS department IT Organization Chart
Information has been summarized in five key focus areas, which are also supported by an overall assessment of IT Service Management: Technology Categories Strategic Alignment Key Questions Is the IT strategy aligned to support the business? Is there a clear understanding of how IT is supporting the RHA's business objectives? Is the RHA achieving optimum use of its IT resources? Is the RHA investing in the appropriate IT resources? Does the RHA perceive value from their IT investments? Is IT delivering the promised benefits? Are IT risks understood and being managed? Is the quality of IT systems appropriate for business needs? Is there a framework within which to measure the achievement of IT goals?
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Resource Alignment Value Delivery Risk Management Quality Management
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Technology Service Management Assessment
As part of the Technology workstream, regional IT service management was evaluated relative to a 10-part ITIL framework. Information for this assessment was based primarily on self-reported data from the region, as well as additional data identified through consultation. The diagram below provides a summary of the region's IT service management assessment (highlighted in green). The assessment evaluates the region's performance across 10 key dimensions using a five-point service scale:
0.00: No Service Present 0.25: Reactive 0.50: Proactive 0.75: Service Driven 1.00: Business Driven
Service Level As shown, there are Management opportunities for the region to improve its approach across all 10 dimensions of IT service management, IT Service Continuity Management although the region shows good traction with respect to Financial Management.
0.50 0.25 0.00
Service Desk and Incident Management Financial Management for IT Services
1.00 0.75
Problem Management
Change Management
Configuration Management
Additional opportunities are identified along the five key areas of focus, on the following slides.
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Capacity Management Availability Management
Release Management
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Key Focus Area 1: Strategic Alignment
Leading Practice Attributes The organization focuses on ensuring the linkage of business and IT plans; on defining, maintaining and validating the IT value proposition; and on aligning IT operations with enterprise operations. Palliser currently does not have a regional IT Strategic Plan in place that aligns IT to business objectives. The region does however have an RSHIP business plan that incorporates both RSHIP and non-RSHIP IS initiatives, which guides decision-making. Deloitte Findings and RSHIP has contracted J.J. Wild to assist the region in developing a 36-month tactical plan which will include implementation of RSHIP phase II, and its Observations integration with other regional and provincial initiatives. The region is awaiting the completion of this plan to build into its own planning. For RSHIP implementation, the Region has a monthly executive communication debriefing.
1. Development of a targeted regional IT Strategic Plan is suggested to help guide regional IT initiatives and balance RSHIP vs. non-RSHIP priorities in regional resourcing. 2. Ensure the 36-month tactical plan is finished in time for Phase II and that Potential Opportunities region-specific lessons learned from Phase 1 are incorporated. 3. The new regional 36-month tactical plan should take into account resource allocation, change management, and training concerns raised during Phase I, to ensure a smooth execution of Phase II.
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Key Focus Area 2: Resource Alignment
Leading Practice Attributes The organization is focused on the optimal investment in, and the proper management of critical IT resources: applications, information, infrastructure and people including the optimization of knowledge and infrastructure. IS resources are centralized in Medicine Hat, and travel to sites as needed. The IS department provides a 2-tiered help desk service for non-RSHIP requests. An IT Infrastructure Library (ITIL)-compliant tool is being used to facilitate help desk operations and management. The help desk is supported by knowledgeable and experienced IS staff. The region finds it hard to recruit IS talent who have Meditech experience. IS end-users report relatively good satisfaction with the IS department, but many report concerns of the sustainability of IS and end-user operational resources into Phase II of the Meditech implementation. 1. Continue to expand the compliance with ITIL to optimize service delivery and service support. Potential Opportunities 3. Work with RSHIP and the other non-metro regions to develop a broader resource strategy to support Meditech implementation. 4. Conduct periodic IS resource reviews to incorporate new user needs and priorities, and to align to regional IT Strategic Plan.
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Deloitte Findings and Observations
2. Develop a PHR-specific HR strategy to attract, recruit and retain skilled Meditech IT resources for ongoing implementation.
Key Focus Area 2: Resource Alignment (continued)
Leading Practice Attributes The organization is focused on the optimal investment in, and the proper management of critical IT resources: applications, information, infrastructure and people including the optimization of knowledge and infrastructure. Meditech super users also hold ongoing operational roles across regional departments. As a result, end-users report challenges in maintaining operations throughout the Meditech implementation. The gap analysis during phase I is reported to have been underestimated with respect to workload and resource requirements to support implementation. The standardization process of RSHIP is time consuming: all 7 regions have to agree on every add-in or change request raised by one or more of the regions. Some requests are unique to the region that raised them, consequently other regions have difficulties to understand the changes. While this is expected in this type of collaboration, consultations suggest the need to streamline these processes.
Deloitte Findings and Observations
4. Conduct a region-wide current state assessment of Phase 1 implementation to determine areas for further improvement and support, before initiating Phase II of the RSHIP implementation. 5. Develop a targeted resource allocation strategy that aligns appropriate IT Potential and operational resources to the 36-month tactical plan for RSHIP Phase II. Opportunities 6. Encourage more end-user engagement in the planning and implementation of IS initiatives. 7. Collaborate with RSHIP and the other non-metro regions to review, standardize and streamline processes to implement changes to the Meditech modules currently implemented.
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Key Focus Area 3: Value Delivery
Leading Practice Attributes The organization executes the value proposition throughout the delivery cycle, ensuring that IT delivers the promised benefits against the strategy, concentrating on optimising costs and proving the intrinsic value of IT. Business users report good involvement in the Meditech implementation, and are seeing value from their involvement. This involvement has increased confidence in achieving value upon full roll-out. Although business users from most areas report good involvement in the Meditech implementation, they also note the challenge of the corresponding strain on their resources available for daily operations. Further, end-users reported limited value in the training received for the Meditech implementation. Several operational areas reported challenges in how Meditech is able to support their areas (e.g. reporting functionality, clinical decision support, inventory management), however, which suggests opportunities for improvement. The region had mixed uptake by end-users in identifying the benefits and work process changes that would result from the Meditech implementation. Where this pre-implementation planning was not done by departments, stakeholders reported challenges in implementation. 1. For Phase II implementation, ensure consistent end-user commitment and completion of pre-implementation planning to establish a region-wide benefits realization framework that identifies, promotes, monitors and assesses benefits realization for each key department as the new Meditech system is implemented, as well as identify work process impacts.
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Deloitte Findings and Observations
Potential Opportunities
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Key Focus Area 4: Risk Management
Leading Practice Attributes The organization requires risk awareness by senior corporate officers, a clear understanding of the enterprise's appetite for risk, understanding of compliance requirements, transparency about the significant risks to the enterprise, and embedding of risk management responsibilities into the organization. Processes to control user access, and policies about security and privacy are in place. There is a noted concern of lack of basic PC skills among users. The Meditech implementation required users to use sophisticated integrated applications directly from an environment that was paper-based. The region also has some infrastructure in place to support risk management, but does not have a disaster recovery strategy. Stakeholders report challenges in IT resourcing to support initiatives. This is a risk to continuing the current pace of implementation while also maintaining operations and clinical service delivery. Further, the challenges reported by end-users related to Meditech implementation workload suggest a potential risk to the organization's ability to balance implementation with ongoing operations.
Deloitte Findings and Observations
1. Develop a training plan to provide focused basic computer skills training among users. Potential 2. Develop a disaster recovery strategy and explore the possibility of having Opportunities off-site back up storage. 3. Develop and implement operational resource requirements aligned to an IT risk management framework for both IT and end-users in the Region.
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Key Focus Area 5: Quality Management
Leading Practice Attributes The organization utilizes a system of performance measurement to track and monitor strategy implementation, project completion, resource usage, process performance and service delivery, using, for example, balanced scorecards that translate strategy into action to achieve goals measurable beyond conventional accounting. SLAs exist in the contracts signed between the Region and RSHIP. Although the region has several other quality control mechanisms in place for internal IT operations and service delivery, there appear to be limited quality controls with respect to the region's relationship and ongoing operational requirements with RSHIP. Help desk is monitoring user satisfaction by user surveys. Consultation findings suggest that users tend to go around help desk and contact RSHIP directly for some Meditech requests, and so may not understand the tieredlevel of support across the region, RSHIP and Meditech.
Deloitte Findings and Observations
1. Continue to implement quality management mechanisms, with increased focus on ongoing quality control monitoring related to RSHIP. Potential 2. Consider consolidating the help desk contact point for end-users, to Opportunities facilitate quality control and management of help desk service, supported by clear communication to stakeholders about help desk contact processes.
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Cluster/Provincial Opportunities
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Cluster/Provincial Opportunities
Introduction
Having reviewed the seven non-metro regional health authorities, we have identified opportunities that are common across the seven regions. We have identified common opportunities as `Cluster/Provincial Opportunities', and they are based on of the following three criteria:
Where the opportunity requires a solution larger than 1 Region's capacity (as it may require cross-region collaboration, provincial collaboration or investment). Where a cross region collaboration and solution development will deliver greater value (either qualitative or quantitative) than if pursued by 1 Region independently. Where individual regions are without the current resources or talent and/or will have challenge attracting and recruiting individuals or securing resources independently.
Opportunities identified in the Cluster 1 Review that we feel are specific to the first three regional reviews (Cluster 1), and not common across Cluster 2, are not included in this report.
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Cluster/Provincial Opportunities
Reporting Framework
Cluster/Provincial Opportunities are presented across seven key areas of reporting, which fit within the broader context of health system and regional goals and initiatives. This builds on the previous reporting framework, and separately highlights two additional distinct areas of reporting, given their importance in health service planning and delivery: Health Human Resources Strategy and Management
Initiatives Health System Goals and Initiatives
Cluster-Related Cluster-Related Strategy, Partnerships and Planning Strategy, Partnerships and Planning
Physician Leadership and Management It should be noted that AHW has not yet decided which of the Cluster/Provincial opportunities identified in this report will be acted on, or their related timing.
Service Service Delivery Delivery Model Model
Clinical Clinical Resource Resource Management Management and Practice and Practice
Resource Resource Alignment Alignment
Regional
Human Resources Human Resources Strategy and Management Strategy and Management Physician Leadership and Management Physician Leadership and Management Infrastructure Infrastructure Goals and
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Cluster/Provincial Opportunities
Strategy, Partnerships and Planning
I. Establish a mandated regular community health needs assessment process for RHAs, which is aligned to health service planning, budgeting and reporting with AHW. Develop a transparent and reproducible process for determining service delivery models, care requirements, facility roles, etc., for rural sites, with consideration of community health needs assessments. a. Supporting this, conduct a community economic impact review to determine feasibility and strategies around facility-based health services contraction in the non-metro RHAs. III. Develop a provincial health services plan that is linked to the regional community health needs assessments and community economic impact review. a. As part of this plan, establish clinical utilization guidelines that use population based planning principles, are aligned to a clinical program model, and which are linked to health and system outcomes to determine appropriateness and feasibility of specialty service deployment across the province. IV. Review RHA accountability model and planning frameworks to align to the provincial health services plan and regional community health needs assessments, supported by a validation process that matches planning and accountability to targeted system outcomes. V. Re-examine the governance structure and relationships between regional boards and faith-based institutions with the view to improve transparency, strengthen accountability and ultimately ensure service rationalization and efficiency.
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II.
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Cluster/Provincial Opportunities
Strategy, Partnerships and Planning (continued)
VI. Increase collaboration between AHW and FNIHB to define health service planning and delivery roles and responsibilities for First Nations within Alberta. a. b. A provincial task force made up of representatives from FNIHB, AHW, RHA and the First Nations Band Councils should be established. A provincial assessment of First Nations health care needs and expected impact on RHAs should be conducted.
VII.
Develop and implement education and awareness strategies on risk, quality, rural health service delivery, and efficiency/site rationalization that is targeted to: a. b. MLA's Local communities and broad public
VIII. Increase attention and effort to creating board awareness and education on regional and individual responsibilities and liabilities.
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Cluster/Provincial Opportunities
Service Delivery Model
I. Standardize trauma management, First Responders and EMS protocols as priority areas for provincial focus, given that pre-hospital care is varied across the province and represents significant area of risk. Develop a province-wide formal rural triage strategy to implement CTAS standards, with consideration of related investments in capital, staffing and training required.
II.
III. Standardize regional approaches to self vs. regional pay for service related to Home Parenteral Therapy as this is one of the drivers of increased non-urgent volumes in regional Emergency Departments. IV. Re-evaluate the provincial Mental Health strategy with the view to examining the roles of AMHB, the provincial mental health facilities, AADAC, Social and Housing Services, and their regional role in service delivery. V. Develop provincial standardized criteria and processes to determine resident qualification for DAL, DSL and Long Term Care. Establish funding guidelines and develop a strategy around sustainable resourcing of community living and outcome measurement.
VI. Establish a provincial public health mechanism and/or agency with the view to developing/expanding common standards, programs and resources to support service delivery across regions. VII. Establish provincial standards for Environmental Health to manage growing risks related to population growth, with consideration of the Blue Book and Green Book as key inputs. a. Develop a technology strategy for common system to support inspections. b. Develop and implement workload measurement and reporting for Environmental Health to enable management decision-making and cross-regional comparisons. c. Increase collaboration and partnership with industry to address increasing environmental health workload and associated risks.
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Cluster/Provincial Opportunities
Clinical Resource Management and Practice
I. Leverage the Health Canada initiatives targeted at strengthening Interprofessional Education for Collaborative Patient-Centred Practice (IECPCP), by establishing an interdisciplinary forum that includes physician, nursing, pharmacy and allied health leadership from across the regions, as a new entity or within existing forums, to enhance the development, awareness, education, implementation of clinical leading practices. Develop strategy to promote expanded clinical application and adoption of Telehealth to respond to growing clinical needs (strategy to include sourcing clinical expertise external to regions to support Telehealth delivery).
II.
III. Adopt a stronger standardized approach to Chronic Disease Management, supported by clinical expertise and links to Telehealth, which can be customized within Regions.
IV. Expand opportunities for interdisciplinary teams of medical and other health professionals in the small centres to train and practice.
V.
Establish documentation and coding standards, training and mechanisms to improve health record documentation through regional process and policy changes in order to improve quality of care and coding accuracy, and to decrease risks to patient safety.
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Cluster/Provincial Opportunities
Resource Alignment
I. Explore a shared service model for core corporate services as a strategy to enhance effectiveness, avoid cost, and achieve efficiency: a. Finance b. Decision Support (clinical and administrative) c. Human Resources (includes physician issues) d. Information Systems and Support e. Supply Chain Services II. Leverage the MDS implementation by developing and implementing systems to measure and manage home care caseload to enable management decision-making and crossregional comparisons.
III. Develop and implement systems to measure and manage Public Health program and service delivery to enable management decision-making and cross-regional comparisons.
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Cluster/Provincial Opportunities
Human Resources Strategy and Management
I. Develop a comprehensive approach to Health Human Resources (HHR) strategy, management and implementation that includes physicians and is focused on: a. Workforce/resource gaps, skills management and education; b. Alignment/realignment of current resources to core service delivery needs; c. Attraction/recruitment/retention of a talent workforce; d. Strategies to address casualization of workforces and manage influx of novice staff; e. Enhanced business case approach to cost impact analysis related to physician recruitment and service repatriation; and, f. Define talent strategy to ensure effective leadership in place (from governance to front line delivery) to support change in complex environment.
II.
Collaborate in the development or procurement of leadership and management development and training based on identified need or gaps.
III. Review current agreement language and requirements in the AHW-AMA-RHA Agreement and staffing union labour agreements, which limit the Regions' ability to provide service in an increasingly challenged environment.
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Cluster/Provincial Opportunities
Physician Leadership and Management
Our observations and identified opportunities reflect common and emerging physician practice across the country. Where these opportunities are seen as desirable by AHW, the province will have to explore different remuneration models that support and lever physician behaviour and desired change. I. II. Review MAC governance structure and mechanisms with specific attention to by-law adherence and alignment to legislative requirements for patient safety, quality and risk. Develop a medical leadership accountability framework and leadership requirements (which includes examining current organizational and reporting structures, and current /potential roles and responsibilities for Chiefs in the management and decision-making process at the site and regional levels).
III. Create a Physician accountability framework with evaluation and quality/risk/performance management tools for Physicians which is integrated into the broader regional performance management framework. IV. Explore alternative payment models for physicians with the objective to improve resourcing and linkage to care/service delivery model. (As part of this opportunity, explore alternate staffing models in consideration of physician AFP options e.g., APN/NP model in ER and other primary care models.) V. Develop a comprehensive Physician Impact Assessment process for physician recruitment related to needs planning and service expansion, linked to HHR strategy.
VI. Conduct a review of the availability and deployment of specialists with rural medicine skills across the non-metro locum pools.
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Cluster/Provincial Opportunities
Infrastructure
I. Conduct a comprehensive review of the RSHIP Meditech implementation to ensure success and sustainability, with consideration of: Planning Investments Staffing Training Benefits Module Functionality (e.g. Pharmacy, Materiel Management, Clinical Nutrition) Service Levels Ongoing Maintenance and Operations Integration with Physician EMRs and Alignment with Physician Business Plans
II. Develop a benefits realization approach for the RSHIP Meditech implementation to ensure investments are aligned to intended outcomes, at the RSHIP and RHA levels. III. Enhance broad regional reporting requirements to include ongoing monitoring of IT strategic initiatives, to ensure ongoing alignment of IT to business priorities and objectives. IV. Improve coordination of Alberta Infrastructure, AHW and the RHAs to align facilities capital funding to provincial and regional health services plans and community health needs assessments.
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Regional Opportunity Map and Reference Guide
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Regional Opportunity Map and Reference Guide
Introduction
Regional Opportunities For today's discussion, we have developed a reference guide for the opportunities identified in the region's report. Opportunities have been filtered to facilitate discussion. Cluster-Related Opportunities Filter 1: The overlap of cluster and regional opportunities is one filter.
Cluster Opportunities will be driven by a separate process through a collaboration of AHW and the Cluster 2 regions, and so have not been prioritized for today's discussion. Where Cluster and regional opportunities overlap, the cluster-related regional opportunities have been identified in this reference guide, but not included in this prioritization and sequencing process.
Opportunity Consolidation
Filter 2: Like / related opportunities have been consolidated to facilitate planning and action. Opportunities for Prioritization
Opportunity consolidation is based on interdependencies and linkages, which are highlighted in the reference guide.
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Regional Opportunity Map and Reference Guide
Opportunity Alignment
To facilitate prioritization, opportunities are aligned across five areas, shown in framework below.
Regional Initiatives
This framework will be referenced throughout our discussion, and will facilitate an understanding of the different types of opportunities for prioritization. Also important will be an understanding of how broader system goals and initiatives, and other regional initiatives impact opportunity prioritization.
Cluster-Related Cluster-Related Strategy, Partnerships and Planning Strategy, Partnerships and Planning
Service Service Delivery Delivery Model Model
Clinical Clinical Resource Resource Management Management and Practice and Practice
Resource Resource Alignment Alignment
Infrastructure Infrastructure
He alt h Go Syst als em
em yst h S ives alt t He nitia I
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Cluster-Related Cluster-Related
Palliser Health Region
Strategy, Partnerships and Planning
Key Opportunities Health Human Resources Recruitment and Retention Plan and Processes Regional Senior HR Leader HR Performance Management Description
Strategy, Partnerships and Planning Strategy, Partnerships and Planning
Service Service Delivery Delivery Model Model
Clinical Clinical Resource Resource Management Management and Practice and Practice
Resource Resource Alignment Alignment
Infrastructure Infrastructure
The region is currently developing an HHR workforce plan and strategy. Several opportunities relate to this effort, which identify areas of focus (Physicians, Labs, DI, Materiel Management, etc.) Consider the development of a senior level HR position to drive the strategic priority of HR for the organization. Re-focus efforts on performance management as a regional priority, to ensure individual performance alignment to regional strategies and objectives. Separate the roles of Chair of MAC and President of Medical Staff ,and delineate clear roles for medical staff leadership, such as: quality through the MAC, advocacy through the President and Executive of the medical staff, and administration through the office of the VP Medical Services. Appropriate mechanisms and options should be put in place to address these aspects with identification of processes for follow-up. Clear roles, responsibilities, terms and resources for Chief of Staff, Regional Chief and Program Medical Director need to be defined.
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Separate MAC Chair and MSA President Roles
Physician Leadership Terms and Roles
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Cluster-Related Cluster-Related
Palliser Health Region
Strategy, Partnerships and Planning (continued)
Key Opportunities MAC Policies and Mechanisms on Quality, Patient Safety, and MD Behaviour Description
Strategy, Partnerships and Planning Strategy, Partnerships and Planning
Service Service Delivery Delivery Model Model
Clinical Clinical Resource Resource Management Management and Practice and Practice
Resource Resource Alignment Alignment
Infrastructure Infrastructure
The Board, the Executive and the MAC need to establish quality and behaviour standards for physicians in PHR, including outlining expectations of practicing optimal care and policies on disruptive behaviour, and which focus on the achievement of high patient care quality and safety. Mechanisms for joint problem solving with physicians and administration should be created and be based PHR leadership values and the broader principles of organizational justice. Explore the development and investment in management training for regional physician leaders. Establish processes and communication mechanisms to provide staff and physicians with an ability to discuss and resolve inter-professional issues. Develop and use appropriate performance indicators for some selected programs and eventually expand to all programs.
Physician-Management Joint Problem Mechanisms Physician Leadership Training Interprofessional Conflict Management Process Program Performance Indicators
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Cluster-Related Cluster-Related
Palliser Health Region
Strategy, Partnerships and Planning (continued)
Key Opportunities Brooks Administration And Support Structure Director/Manager Role in Budgeting Coordinated Access Balance Description
Strategy, Partnerships and Planning Strategy, Partnerships and Planning
Service Service Delivery Delivery Model Model
Clinical Clinical Resource Resource Management Management and Practice and Practice
Resource Resource Alignment Alignment
Infrastructure Infrastructure
Revisit the administration structure and administrative support. Explore options for expanding Director and Manager involvement in annual budgeting processes, enabled by Decision Support. Consider the balance of regional vs. local policy and service delivery to create consistent criteria, processes and equitable access. Opportunity exists to create stronger links with AADAC for community addictions support, and to continue to expand community-based mental health services in the region. Consolidate Asthma education into regionally coordinated program. Develop a regional approach to asset management and tracking to support capital planning. There are several points of IT focus for the region, related to RSHIP (current state assessment, benefits realization, planning and resources), development of a regional IT Strategy, and improvements to IT service management.
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Community Mental Health Asthma Education Program Regional Asset Management IT Strategy, Planning, Assessment and Resource Management
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Palliser Health Region
Service Delivery Model
Key Opportunities Regional Organizational Model MHRH LDRP Model and Rooming In ENT Service Review RT Role in OR Description
Strategy, Partnerships and Planning Strategy, Partnerships and Planning
Service Service Delivery Delivery Model Model
Clinical Clinical Resource Resource Management Management and Practice and Practice
Resource Resource Alignment Alignment
Infrastructure Infrastructure
MHRH ER Model
PHR must determine if it will shift to program management, and this must be supported by a clear plan, leadership and associated leadership organization structure to ensure success. Several related opportunities identify the need to define this model for the management of Medicine/ICU, Perioperative, and Perinatal/Pediatric services. Conduct a review to determine feasibility of moving to an LDRP model of care, with consideration of care model, staffing and facilities. Consider "Rooming in" 24/7 to keep in line with evidence-based practice, and as a staging toward LDRP. Review ENT services in the Region to align service to needs, and consider ambulatory service delivery model to align to best practice. Explore service delivery models that includes Respiratory Therapists in the OR, with consideration of balancing related nurse staffing. Explore options to improve management of workflow for CTAS 4 and 5 patients with consideration of: establishment of a dedicated fast track area, shifting of Triage 4/5 volumes to PCN to improve ER flow, involvement of physicians to ensure alignment to ensure alignment of practice to process, liaise with home care to expand evening and weekend services, liaise with Day Medicine to reinforce support for the continued shift of patients to day medicine area. Explore alternative service setting for clinic visits seen in the ER.
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Bow Island ER Visit Alternative Service Setting
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Cluster-Related Cluster-Related
Palliser Health Region
Service Delivery Model (continued)
Key Opportunities Home Care Expansion Description
Strategy, Partnerships and Planning Strategy, Partnerships and Planning
Service Service Delivery Delivery Model Model
Clinical Clinical Resource Resource Management Management and Practice and Practice
Resource Resource Alignment Alignment
Infrastructure Infrastructure
Consider options to increase service delivery, including the potential for: additional respite beds, expanded day programs, and expanded evening and weekend home care service. Examine the role and allocation of Social Work resources in the region, to determine ability to improve service access and patient flow across region. Proceed with regionalizing Pharmacy that facilitates leading practice, optimizes operational efficiencies and identifies regional transportation service requirements (as a critical enabler). Clarify policies and procedures for accessing Physiotherapy across the health continuum to ensure consistency. Regionalize Clinical Nutrition to establish common programming, practice, and staff cross coverage across the continuum. Consider regionalization of Food Services throughout PHR to achieve common standards, policies and procedures, supported by a business case to examine a potential shift to centralized service delivery and required staffing. Consider regionalization of housekeeping services to standardize management, technology, policies and procedures. Continue to build telehealth and e-learning as key HR technologies supporting regional education.
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Social Work Role
Regional Pharmacy Service Physiotherapy Policies Regional Clinical Nutrition Service Regional Food Services Model, Business Case, and Staffing Regional Housekeeping Services Telehealth and eLearning Utilization
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Clinical Resource Management and Practice
Key Opportunities Perioperative Services Team Perioperative Services Performance and Quality Management CDP and Living Healthy Role, Mandate, and Resources CTAS Assessment in Rural Sites Bow Island ACLS and TNCC Staff Training Medical Protocols
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Strategy, Partnerships and Planning Strategy, Partnerships and Planning
Service Service Delivery Delivery Model Model
Clinical Clinical Resource Resource Management Management and Practice and Practice
Resource Resource Alignment Alignment
Infrastructure Infrastructure
Description Formalize an interdisciplinary team for Perioperative Services that oversees planning as well as quality, access and efficient use of resources. Several opportunities were identified related to OR Late Starts and Turnaround Times, OR Case Scheduling Policy, converting all OR's to be Latex-Free, expanding Performance Management and Quality Indicators, mandating CNA Certification, exploring Patient Wheelchair Transportation, and reviewing Colonoscopy Admission Criteria. Clarify CDP role and mandate with respect to chronic disease education in acute and home care, role of RNs in CDP, and examine resources required to enable Living Healthy to expand into other areas such as vascular clinic, pacemaker checks, and insulin pump support. Conduct regional assessment of CTAS use in the ER to determine resources, education support, and policies and procedures required to standardize use across the region. Move to full ACLS and TNCC training for all staff. Palliser should implement medical protocols, as opposed to standing orders.
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Cluster-Related Cluster-Related
Palliser Health Region
Clinical Resource Management and Practice (continued)
Key Opportunities Description
Strategy, Partnerships and Planning Strategy, Partnerships and Planning
Service Service Delivery Delivery Model Model
Clinical Clinical Resource Resource Management Management and Practice and Practice
Resource Resource Alignment Alignment
Infrastructure Infrastructure
Continue to develop strategies for LOS management focused on the following:
Develop and implement policies to increase use of day procedures across
Continued Length of Stay Management
identified areas to achieve improved bed utilization Assess need for improvements to regional coding and abstracting; Continue planning efforts to increase continuing care capacity. Improve discharge planning and coordination across continuum for mental health population to reduce mental health related LOS targets.
Medicine/ICU Review admission and discharge criteria involving the Medicine/ICU Admission/Discharge staff. Redefine definitions for ICU admission and discharge criteria Criteria with the goal of appropriate utilization of this resource. Continuum Software Access Telemetry Practice and Education Ensure all Coordinated Access staff have access to Continuum solutions software. Conduct a review of Medicine unit telemetry practices and develop evidence based indications for the initiation and discontinuation of telemetry. Review skill mix, including the roles of health care aides to ensure that they are operating within an appropriate scope of practice within the acute care setting.
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Skill Mix
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Clinical Resource Management and Practice (continued)
Key Opportunities Obstetrics Data Capture Calgary NICU Preceptorship MHRH Mental Health Bed Utilization, Role, and Mandate Description
Strategy, Partnerships and Planning Strategy, Partnerships and Planning
Service Service Delivery Delivery Model Model
Clinical Clinical Resource Resource Management Management and Practice and Practice
Resource Resource Alignment Alignment
Infrastructure Infrastructure
Ensure that all ambulatory visits are consistently captured and reported in regional statistics (e.g. NSTs). Link with Calgary for preceptorship program to maintain NICU skills. Clarify MHRH Mental Health role and mandate with respect to other hospital services, including clarification and communication of admission criteria. In addition, monitor MHRH inpatient mental health bed utilization. Develop a regional Laboratory Utilization Committee to continue to promote regional collaboration, formally sharing best practices, and supporting lab utilization management. Continue to examine increased role for Pharmacy Technicians and innovative payment practices for Pharmacists (e.g. isolation pay) to address current staffing shortages.
Lab Utilization Committee Pharmacy Technicians and Pharmacist Payments
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Cluster-Related Cluster-Related
Palliser Health Region
Resource Alignment
Key Opportunities Regional Staffing and Scheduling MHRH Unit Clerk Model and Roles MHRH 4 West Skill Mix and Resources MHRH 6 West Scheduling MHRH 5 West Staffing Model Expand Day Medicine MHRH Pediatrics/NICU Cross-Training OR Staff Utilization OR Educator Support
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Strategy, Partnerships and Planning Strategy, Partnerships and Planning
Service Service Delivery Delivery Model Model
Clinical Clinical Resource Resource Management Management and Practice and Practice
Resource Resource Alignment Alignment
Infrastructure Infrastructure
Description Review staffing and scheduling processes as well as schedules to ensure adequate baseline staffing, consistent staffing patterns, and sufficient replacement staff. Review MHRH unit clerk model and roles, and align resources appropriately. Consider enhancing the skill mix, as well as increasing the budget to reflect actual HPPD. Review schedules and assignment practices with the goal of leveling day and night staffing. Revise the care delivery model on 5 West to eliminate the Care Coordinator role, shift some resources to the evening and night shift and enhance skill mix. Investigate feasibility of extending hours of Day Medicine into evenings and weekends. Consider cross-training staff between Paediatrics and NICU. Increase utilization of regularly scheduled hours to improve staffing efficiency. Ensure regular hours and staffing matches surgical demand. Expand Educator support to include OR.
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AHW RHA Efficiency Review Palliser Health Region Property of Alberta Health and Wellness
Cluster-Related Cluster-Related
Palliser Health Region
Resource Alignment (continued)
Key Opportunities Description
Strategy, Partnerships and Planning Strategy, Partnerships and Planning
Service Service Delivery Delivery Model Model
Clinical Clinical Resource Resource Management Management and Practice and Practice
Resource Resource Alignment Alignment
Infrastructure Infrastructure
Target potential MHRH ER staffing investment with focus on: MHRH ER Staffing
Separating Triage from Charge Nurse positions during day/evening shifts; Reviewing nurse assignment practices to ensure equitable workloads and alignment between patient needs and nurse staffing; and Removing patient care responsibilities from paramedic.
MHRH ICU/ER Staff Cross-Training Rural On-Site Education Infection Control Resources Health Promotion Resources Sexual Health Clinic Expansion
ICU nursing staff should be cross trained and expected to support ER during times of low occupancy. Additional clinical educational support required, with consideration of use of simulators to train teams for the rare emergencies that develop, and further leveraging of telehealth to support training. Investigate potential of adding additional resources to infection control. Examine health promotion resources relative to required services in alignment to recent PHR community health needs assessment. Consider expanding sexual health /STD clinic hours to 6 hours per week. Provide some hours in regional facilities as well as MHRH.
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Cluster-Related Cluster-Related
Palliser Health Region
Resource Alignment (continued)
Key Opportunities Description
Strategy, Partnerships and Planning Strategy, Partnerships and Planning
Service Service Delivery Delivery Model Model
Clinical Clinical Resource Resource Management Management and Practice and Practice
Resource Resource Alignment Alignment
Infrastructure Infrastructure
Physiotherapy Staffing
Consider increased PT staffing with respect to required support for 2N rehabilitation unit and weekend coverage in MHRH, CHADS program services, and existing contract services. Consider investment of resources to ensure continued Decision Support functionality in the region. Target staffing investment in HR to support strategic focus in the region. Target staffing investment in Health Records and Patient Registration to address current backlogs in coding, abstracting and transcription (will need to determine appropriate level of investment given current outsourcing of transcription which is impacting target to some extent). Consider identified staffing investment to increase housekeeping service responsiveness and internal patient portering at MHRH. Consider staffing investments in Plant Operations to support capital projects and facility maintenance in the region.
Decision Support Staffing Human Resources Staffing
Health Records Staffing
Housekeeping Resources Plant Operations Resources
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Cluster-Related Cluster-Related
Palliser Health Region
Infrastructure
Key Opportunities MHRH Medication Preparation Perinatal Service Colocation Health Records Chart Storage MHRH Centralized Booking Regional Telecommunications System QHR Functionality and Training Laundry Equipment Business Case
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Strategy, Partnerships and Planning Strategy, Partnerships and Planning
Service Service Delivery Delivery Model Model
Clinical Clinical Resource Resource Management Management and Practice and Practice
Resource Resource Alignment Alignment
Infrastructure Infrastructure
Description Explore a dedicated area for medication preparation within the MHRH units to decrease interruptions. Explore planning opportunities for future co-locating of Perinatal services. Develop a plan to address Health Records chart storage, with consideration of facilities and technology-based solutions. Explore the business case for establishing centralized booking at MHRH, with consideration of physical vs. technology-based centralization. Consider development of a single multi-site phone system to enable cross-coverage of switchboard and reception functions in the region, as part of capital planning. Explore options to improve functionality of QHR, supported by management training to leverage HR management at the regional and site levels. Develop a business case for the replacement of aged Laundry equipment and the installation of a new shuttle system.
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AHW RHA Efficiency Review Palliser Health Region Property of Alberta Health and Wellness
Cluster-Related Cluster-Related
Palliser Health Region
Cluster/Provincial-Related
Key Opportunities Physician Roles and Accountabilities Physician Impact Assessment Description
Strategy, Partnerships and Planning Strategy, Partnerships and Planning
Service Service Delivery Delivery Model Model
Clinical Clinical Resource Resource Management Management and Practice and Practice
Resource Resource Alignment Alignment
Infrastructure Infrastructure
Delineation of physician roles, responsibilities and accountability in the region. Develop a consistent regional Physician Impact Assessment process for physician recruitment needs, workforce planning, and program planning. Develop a service level agreement model with physicians, such that PHR enters into a contract with MDs outlining their expectations to maintain credentials in the region. Explore options to improve PHI utilization through enhanced technology, including:
Computerized Scheduling In-Field Mobile Technology Reduced Duplicate Data Entry by Clerks.
Physician Service Level Agreements
Public Health Inspector Utilization through Technology
Environmental Health Standards Pharmacy Meditech Functionality
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Increase focus on achieving AB Blue Book Standards in Environmental Health. Explore options to improve Meditech functionality in Pharmacy.
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Regional Opportunity Prioritization
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Regional Opportunity Prioritization
Introduction
Based on a facilitated working session with the Region's Senior Management Team, the Project Team have developed an Opportunity Prioritization Map. Opportunity prioritization has focused on sequencing, based on five key factors:
Opportunity Inter-Dependencies Resource Requirements (Leadership, People, Financial, External Support) Identified Risks Timeline Feasibility Priority Level to the Region
The opportunity mapping (timeline) has four phases of effort:
Phase 1: 0-10 months (June 2007 March 2008) Phase 2: 11-22 months (April 2008 March 2009) Phase 3: 23-34 months (April 2009 March 2010) Phase 4: 35-46 months (April 2010 March 2011)
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Regional Opportunity Prioritization
Introduction (continued)
During the working session with the region's Executive Team, opportunities were reviewed by phase of effort to discuss the appropriateness and feasibility of the opportunity prioritization. Throughout the discussion, a "go-forward determination" was also assigned to each opportunity to establish if phasing needs to be changed, deferred and / or not pursued: Priority Opportunities that are considered priorities for achievement by the region over the 46-month planning period. Deferred Opportunities which must be deferred at this stage, but which will be re-considered for pursuit in the future. Not Pursued Opportunities which are not considered as regional priorities, and so will not be pursued. The regional opportunity map is presented on the next page, followed by the Senior Leads identified by the region as being responsible for the achievement of each prioritized opportunity. In addition, information is provided about the opportunities that the region has decided to defer or not pursue.
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Regional Opportunity Prioritization
Final Opportunity Map
Regional Initiatives
Cluster-Related Cluster-Related Strategy, Partnerships and Planning Strategy, Partnerships and Planning
Service Service Delivery Delivery Model Model
Clinical Clinical Resource Resource Management Management and Practice and Practice
Resource Resource Alignment Alignment
Infrastructure Infrastructure
He alt h Go Syst als em
stem Sy s lth tive Hea itia In
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Regional Opportunity Prioritization
Regional Leads Phase 1
Opportunity Name CDP and Living Healthy Role, Mandate, and Resources Health Human Resources Recruitment and Retention HR Performance Management Re-Focus Regional RSHIP Implementation Current State Assessment Responsible Senior Lead Janice Blair
Blaine Ball
Blaine Ball
Cal Niebergall
Expand ITIL Compliance
Cal Niebergall
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Regional Opportunity Prioritization
Regional Leads Phase 2
Opportunity Name OR Late-Starts Turnaround Audit OR Case Scheduling Policy OR Performance Management and Quality Indicators OR Patient Wheelchair Transportation Colonoscopy Admission Criteria 4 West Skill Mix and Resources OR Staff Utilization Asthma Education Program Brooks Administration and Support Structure Regional Staffing and Scheduling
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Responsible Senior Lead Linda Iwasiw Linda Iwasiw Linda Iwasiw Linda Iwasiw Linda Iwasiw, Dr. Vince Di Ninno Linda Iwasiw Linda Iwasiw Janice Blair Linda Iwasiw Linda Iwasiw
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Regional Opportunity Prioritization
Regional Leads Phase 2 (continued)
Opportunity Name Skill Mix Sexual Health Clinic Expansion MHRH Pediatrics / NICU Cross-Training Calgary NICU Preceptorship Regional Clinical Nutrition Service Director / Manager Role in Budgeting Telehealth and eLearning Utilization Telemetry Practice and Education MHRH 5 West Staffing Model MHRH Medication Preparation
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Responsible Senior Lead Linda Iwasiw Janice Blair Linda Iwasiw Linda Iwasiw Janice Blair Seamus O'Fuarthain Linda Iwasiw Linda Iwasiw Linda Iwasiw Linda Iwasiw
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Regional Opportunity Prioritization
Regional Leads Phase 2 (continued)
Opportunity Name MHRH ER Staffing Home Care Expansion Laundry Equipment Business Case Health Records Chart Storage Physician Leadership Team and Roles MAC Policies and Mechanisms on Quality, Patient Safety, and MD Behaviour. Interprofessional Conflict Management Process Physician Leadership Training Interdepartmental MD Recruitment Process QHR Functionality and Training
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Responsible Senior Lead Linda Iwasiw Linda Iwasiw Cal Niebergall Cal Niebergall Dr. Vince Di Ninno Dr. Vince Di Ninno Dr. Vince Di Ninno, Linda Iwasiw Dr. Vince Di Ninno Dr. Vince Di Ninno, Blaine Ball Blaine Ball, Seamus O'Fuarthain
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Regional Opportunity Prioritization
Regional Leads Phase 3
Opportunity Name Perioperative Services Team Responsible Senior Lead Linda Iwasiw
Latex-Free OR CNA Perioperative Certification Respiratory Therapy Role in OR CTAS Assessment in Rural Sites Community Mental Health Lab Utilization Committee
Linda Iwasiw Linda Iwasiw Linda Iwasiw Linda Iwasiw, Dr. Vince Di Ninno Linda Iwasiw, Janice Blair Linda Iwasiw, Dr. Vince Di Ninno
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Regional Opportunity Prioritization
Regional Leads Phase 3 (continued)
Opportunity Name Physician-Management Joint Problem Solving Mechanisms Medical Protocols Separate MAC Chair and MSA President Program Performance Indicators Benefits Realization Framework ADT Linkages with Housekeeping Regional Telecommunication System Responsible Senior Lead Tom Seaman, Dr. Vince Di Ninno
Linda Iwasiw, Dr. Vince Di Ninno Tom Seaman, Dr. Vince Di Ninno Dr. Vince Di Ninno Cal Niebergall Cal Niebergall Cal Niebergall
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Regional Opportunity Prioritization
Regional Leads Phase 4
Opportunity Name MHRH Centralized Booking Responsible Senior Lead Cal Niebergall
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Regional Opportunity Prioritization
Opportunities Deferred or Not Pursued
The following opportunities were identified by the region as being either `Deferred' or `Not Pursued'. Regional commentary for these decisions is also provided.
Opportunity Name MHRH Unit Clerk Model and Roles Status Commentary The region reports that it has added some resources in 2007/08. Due to resource implications, however, any further changes are deferred The region notes that they have made some minor changes but that any further change requires significant capital, and is deferred pending approval by AHW The region notes that further change requires significant capital, and is deferred pending approval by AHW Due to resource implications, the region has deferred this opportunity at the present time The region reports that since the time of review, the MHRH ICU has significantly increased its utilization, and is facing staffing challenges, so this opportunity may be considered at a future date
2007 Deloitte Inc
Deferred
MHRH LDRP Model and Rooming In
Deferred
MHRH Perinatal Service Collocation Expand Day Medicine
Deferred
Deferred
MHRH ICU/ER Staff Cross-Training
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Deferred
AHW RHA Efficiency Review Palliser Health Region Property of Alberta Health and Wellness
Regional Opportunity Prioritization
Opportunities Deferred or Not Pursued (continued)
The following opportunities were identified by the region as being either `Deferred' or `Not Pursued'. Regional commentary for these decisions is also provided.
Opportunity Name Rural On-Site Education Status Deferred Commentary Due to resource implications, the region has deferred this opportunity at the present time The region has decided to defer this opportunity to a future date, due to current physician practice The region reports that it has made investment in related areas, and so will not be pursuing this specific opportunity The region reports that a previous fast-track business case, physician practice and other challenges will prevent opportunity pursuit The region reports that physician practice and other challenges prevent opportunity pursuit at the present time
ENT Services Review
Deferred
Decision Support Staffing Not Pursued
MHRH ER Model
Not Pursued
Bow Island ER Visit Alternative Service Setting
Not Pursued
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Regional Opportunity Prioritization
Opportunities Deferred or Not Pursued (continued)
The following opportunities were identified by the region as being either `Deferred' or `Not Pursued'. Regional commentary for these decisions is also provided.
Opportunity Name Regional Asset Management Status Commentary The region identifies that it has what it feels is needed in this area, and so will not pursue the opportunity The region identifies that it assesses resource adequacy on a regular basis and so will not pursue this opportunity at the present time The region identifies that it is sufficiently staffed in this area, and so will not pursue the opportunity The region has identified that this is not a priority at this time, and so will not pursue the opportunity.
Not Pursued
Plant Operations Resources Not Pursued
Housekeeping Resources
Not Pursued
Regional Housekeeping Services
Not Pursued
Regional Food Services The region has identified that this is not a priority Model, Business Case , and Not Pursued at this time, and that it is sufficiently staffed in this Staffing area, so it will not pursue the opportunity.
203 AHW RHA Efficiency Review Palliser Health Region Property of Alberta Health and Wellness 2007 Deloitte Inc
Deloitte & Touche LLP and affiliated entities. Deloitte, one of Canada's leading professional services firms, provides audit, tax, consulting, and financial advisory services through more than 6,100 people in 47 offices. Deloitte operates in Qu bec as Samson B lair/Deloitte & Touche s.e.n.c.r.l. The firm is dedicated to helping its clients and its people excel. Deloitte is the Canadian member firm of Deloitte Touche Tohmatsu. Deloitte refers to one or more of Deloitte Touche Tohmatsu, a Swiss Verein, its member firms, and their respective subsidiaries and affiliates. As a Swiss Verein (association), neither Deloitte Touche Tohmatsu nor any of its member firms has any liability for each other's acts or omissions. Each of the member firms is a separate and independent legal entity operating under the names "Deloitte," "Deloitte & Touche," "Deloitte Touche Tohmatsu," or other related names. Services are provided by the member firms or their subsidiaries or affiliates and not by the Deloitte Touche Tohmatsu Verein.
Member of Deloitte Touche Tohmatsu
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AHW RHA Efficiency Review
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Palliser Health Region
Performance Management Overview Final Report
July 13, 2007
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AHW RHA Efficiency Review Palliser Health Region Property of Alberta Health and Wellness
Property of Alberta Health 2007 Deloitte Inc and Wellness
Performance Management Overview
Key Components of Performance Management
The framework below is used to assess performance management alignment. There are seven components used in this assessment. For each of these seven components (except Culture), Leading Practice Attributes from industry have been identified to guide discussion.
Leadership
Vision and Strategy
Organization Structure People Infrastructure
Measurement
Operating Processes
Opportunities
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AHW RHA Efficiency Review Palliser Health Region Property of Alberta Health and Wellness
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1. Leadership
Leading Practice Attributes
Visible leadership; vision and strategy focused; systems thinking and planning; Transparent and timely management processes related to decision-making; Demonstrated commitment to standardization; Role mentorship and succession planning; Multi-stakeholder relationships management
Findings Documentation Review
3 Year Health Plan; Annual Business Plan; Annual Report Organization Charts
Stakeholder Feedback
Significant challenges foreseen with succession planning due to gap in candidates interested and readiness for leadership roles. Require more visible and active Medical Leadership to support various Clinical Support Services.
Deloitte Observations
Leadership roles will be critical to the evolving organizational model and associated structure. Leadership needs to collectively determine the organizational model and structure, with respect to considerations of program management. The Region has invested in Leadership training for senior leaders and should continue to develop leaders to build competencies and `bench-strength' for support required succession. Increase focus on physician leaders is needed. Board, MAC and Administration need to come to terms and accept that retention of Physicians will be based on defined quality and behaviour standards and any deviation will not be accepted. Defined roles and responsibilities for physicians and physician leaders will be critical to this success.
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2. Vision and Strategy
Clearly articulated Mission, Vision, and Value Statements (or Guiding Principles)
Leading Practice Attributes
Current Strategic Plan with supportive structure and processes to cascade to operational level; prioritization process to focus organizational initiatives and decision-making Performance management processes and structure aligned to support strategy; Focused on direction; Cross RHA collaboration; integration mindset.
Findings
Documentation Review
3 Year Health Plan; Annual Business Plan; Annual Report. Community Health Needs Assessment
Stakeholder Feedback
Stakeholders identify that operations do map to strategy, and are able to identify operational initiatives in their areas that support regional planning. Quality and patient safety are key focal points for region. PHR has developed a number of innovative initiatives in primary care to support health system sustainability, which stakeholder see as actively progressing
The region has a clearly articulated mission, vision and principles, which are supported by the three-year plan and annual business plan. Three-year plan show alignment to AHW requirements, and performance indicators are in place to track progress to plans. Each strategic focus has been clearly articulated with corresponding tactical approaches, measures and timeline. As well, they have each been clearly cross referenced to AHW expectations. The region's longstanding history provides a strong foundation on which to build strong vision and strategy. Supporting this, the region's commitment to a regular community health needs assessment every 5 years is an important success factor. One consideration for continued management attention is the balance of how many strategies can be tackled relative to the resource requirements across regional initiatives.
3 AHW RHA Efficiency Review Palliser Health Region Property of Alberta Health and Wellness 2007 Deloitte Inc
Deloitte Observations
3. Organization Structure
Leading Practice Attributes
Organizational structure reflects unique requirements of organization, service delivery; supports changing service and people requirements; Supports timely decision-making and efficient work flow; role accountability and communication Minimizes role duplication and confusion Strategic portfolios instead of service management ones
Documentation Review
Organization Structure / Charts Role descriptions (select management roles)
Findings Stakeholder Feedback
The Chair of MAC is also the President of the Medical Staff (elected by Medical Staff) which results in a conflict of interest with respect to advocacy and quality management. The organization is in a state of transition, as it considers a shift to program.
Deloitte Observations
The job descriptions for the Medical Directors indicates they are co-leaders but consultation found they generally are less involved. Further clarity on the roles and relationships of the Medical Directors to the VP Medicine is suggested. Overlap with the Chief role and the Medical Director role and acceptance of accountability is often described as "a lot of push and pull". A separation of the President of the MSA and MAC Chair is suggested to facilitate the distinction and focus on regional issues. Implementation of Regional structure is moving slowly in some areas, which suggests that further focus on regionalizing services would support efficiency and effectiveness of service delivery. As the region continues to evolve its organization model, further consideration should be given to align senior team portfolios and management structure to service delivery. For example, three areas for suggested ongoing focus include:
The emerging role of the Regional Rural Director suggests a review of the required management support on-site at select sites such as Brooks. The higher level of workload associated with the Senior VP Health Services portfolio vs. VP Community Services. Nursing management structure is in transition and there are opportunities to streamline several areas given existing points of role overlap and nurse manager vacancies.
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4. People
Current Human Resources Strategic Plan; HR planning and management from a regional perspective (move from local to central)
Leading Practice Attributes
Standardized performance review process with regular application Identified competencies for roles particularly at leadership level Sufficient HR staffing support across organization to support management and staff Supportive staff development and education program / process in place / career paths / laddering opportunities
Findings Documentation Review Stakeholder Feedback
There are limited HR resources to assist programs with developing an integrated workforce planning strategy. HR Recruitment Challenges identified across organization with succession planning, recruitment of and Retention Plan casual staff and retention of younger staff. Organization Structure A performance management review process, exists, but there is low compliance across the organization. The region is embarking on a cultural transformation initiative that is anticipated to help increase the region's retention and attraction of new talent. Although stakeholders report that staff shortages has not been as challenging as observed in other regions, nursing recruitment and retention is still observed to be an issue compounded by the insufficient HR staff providing services. The region's current workforce planning initiative should help to drive change in this area, and focus should include physician workforce planning to ensure alignment across regional HHR planning. There is an opportunity to review nursing schedules and rotations to enhance coverage, decrease reliance on casual staff and enhance staff satisfaction. A program that is supporting this is the initiation of New Grad program, which allows for new staff members to be supernumerary on the nursing units.
2007 Deloitte Inc
Deloitte Observations
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AHW RHA Efficiency Review Palliser Health Region Property of Alberta Health and Wellness
5. Infrastructure
Leading Practice Attributes
Current and integrated information management, technology and facility plans Sufficient and appropriate technology to support efficient and effective operations Capital replacement plan (current and integrated); Facility development processes and plans to support care requirements and efficient operations Metrics to assess value of investment (economic and social value, linking service to infrastructure) Assessment of new business models to enable infrastructure investment
Findings
Documentation Review Stakeholder Feedback
Stakeholders report good access to funding and regional process for capital equipment acquisitions. Equipment across the organization is in fairly good condition and age. The region's IT initiatives are resource-intensive but are expected to provide a good information foundation for operations. Experiencing challenges with recent implementation of Meditech due to decreased functionality and time consuming reporting in many areas. Some areas are experiencing space issues (e.g. Pharmacy, Patient Registration, Health Records) that will be addressed in future capital projects.
IT planning documents Capital Redevelopment Submissions
The Capital Equipment approval processes and resources observed in the region are strong and effective in supporting regional planning in a coordinated and collaborative manner. Although the RSHIP is an important investment by the region, the region needs to Deloitte evaluate the level of time and resource investment required for Phase II before proceeding, to ensure the sustainability of current IT infrastructure and to prepare for the Observations impact on end-user operational stakeholders. Further, it is equally important for the region to balance other IT initiatives to support service delivery. Key to this is the development of a regional strategic plan that guides alignment of IT initiatives to regional business objectives.
6 AHW RHA Efficiency Review Palliser Health Region Property of Alberta Health and Wellness 2007 Deloitte Inc
6. Measurement
Leading Practice Attributes
Existence of a comprehensive performance management system in place (people, financial, operations, satisfaction, and other key processes) Development of performance metrics and targets to manage care and service; linkage of measurement to action and communication; Consistent, standardized measures Performance measurement linked to quality and risk management
Findings
Documentation Review
3 Year Health Plan; Annual Business Plan; Annual Report, Annual Reports
Stakeholder Feedback
The region's performance management framework for individuals is not consistently used across the organization. There is mixed traction in applying performance management and measures across operational initiatives. For example, stakeholders report that infection control reports are being responded to at MAC and Administration, which is good. But other issues, e.g. disruptive MDs, not being responded to. The region's implementation of Continuum has achieved good progress in improving clinical utilization performance management.
Deloitte Observations
The region has performance management in place through the three-year and annual planning processes. The Region has invested effort into performance management, including the development of a quality framework. A Regional Coordinator is responsible for quality improvement, balanced scorecard, accreditation and patient safety. Important to the success of regional performance management is the integration of clear roles, responsibilities and accountabilities for physicians. Given the investments made by the region in creating an online performance management system and framework, this is an area for renewed focus of senior management attention. A key focus for ongoing senior management attention in this area is that `measurement should lead to change'.
2007 Deloitte Inc
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7. Operational Processes
Leading Practice Attributes
A formal, organization-wide risk identification and management process is in place; Established processes in place to support standardization and development of practice Established processes, initiatives to support standardization of care and service Established resources to support initiative implementation and monitoring Assessment of new or different business models to support service delivery and integration Management processes that support accountability
Findings
Documentation Review Stakeholder Feedback
Process standardization is variable across the region, where a mix of regionalized and site-based services, policies and procedures exist. Managers report a good understanding of their budgets, and alignment of their Annual Business Plan operational initiatives to regional plans. Accreditation Report Care documentation (charts) Board reports a good understanding of regional risks, and this cascades throughout the organization which was observed through consultations in Policy/Procedure which stakeholders were readily able to identify operational risks and related Risk Management Framework strategies. Multi-disciplinary approach required to address needs and understand impacts of program expansion and practices of new physician.
Although some services are regionalized, the region has not fully explored business case based opportunities across several areas (e.g. Housekeeping, Pharmacy, Food Services). The region should continue efforts to standardize policies, procedures, roles, etc., with consideration of geographic and operating differences between sites. Deloitte Observations To support ongoing management decision-making and operational planning, the regionto be should attempt to protect the existing Decision Support resources, and not allow them pulled into the RSHIP Meditech report writing needs. To ensure strong program planning, the region needs to further build on its analysis for program, operational support and physician impact analysis.
8 AHW RHA Efficiency Review Palliser Health Region Property of Alberta Health and Wellness 2007 Deloitte Inc
Summary Remarks
Strengths to build on include: Strengths to build on include:
Good alignment between the Good alignment between the three-year plan and annual three-year plan and annual program planning process program planning process Community Health Needs Community Health Needs Assessment approach to Assessment approach to informed health services informed health services planning planning Comprehensive capital planning Comprehensive capital planning processes processes Existing online Performance Existing online Performance Management system for Management system for individual performance individual performance
Areas for further consideration: Areas for further consideration:
Determination of organization Determination of organization model with respect to program model with respect to program model considerations and model considerations and associated management portfolios associated management portfolios Delineation of physician roles, Delineation of physician roles, responsibilities and accountability responsibilities and accountability in the region in the region Creation of a regional IT Strategy Creation of a regional IT Strategy that is aligned to regional that is aligned to regional objectives objectives Improved balance across Meditech Improved balance across Meditech vs. other IT initiatives vs. endvs. other IT initiatives vs. enduser operations user operations
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AHW RHA Efficiency Review Palliser Health Region Property of Alberta Health and Wellness
2007 Deloitte Inc
Deloitte & Touche LLP and affiliated entities. Deloitte, one of Canada's leading professional services firms, provides audit, tax, consulting, and financial advisory services through more than 6,100 people in 47 offices. Deloitte operates in Qu bec as Samson B lair/Deloitte & Touche s.e.n.c.r.l. The firm is dedicated to helping its clients and its people excel. Deloitte is the Canadian member firm of Deloitte Touche Tohmatsu. Deloitte refers to one or more of Deloitte Touche Tohmatsu, a Swiss Verein, its member firms, and their respective subsidiaries and affiliates. As a Swiss Verein (association), neither Deloitte Touche Tohmatsu nor any of its member firms has any liability for each other's acts or omissions. Each of the member firms is a separate and independent legal entity operating under the names "Deloitte," "Deloitte & Touche," "Deloitte Touche Tohmatsu," or other related names. Services are provided by the member firms or their subsidiaries or affiliates and not by the Deloitte Touche Tohmatsu Verein. 10 AHW RHA Efficiency Review Palliser Health Region Property of Alberta Health and Wellness
Member of Deloitte Touche Tohmatsu 2007 Deloitte Inc